Does AUBURN POST ACUTE have any serious inspection findings?

Yes, AUBURN POST ACUTE has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 123 total deficiencies from recent inspections.

What are the staffing levels at AUBURN POST ACUTE?

AUBURN POST ACUTE has a two-star staffing rating from CMS with 0.53 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is AUBURN POST ACUTE located?

AUBURN POST ACUTE is located in AUBURN, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does AUBURN POST ACUTE have?

AUBURN POST ACUTE has 96 certified beds.

Who owns AUBURN POST ACUTE?

AUBURN POST ACUTE is a for profit - limited liability company facility and operates independently (not part of a chain).

What questions should families ask when visiting AUBURN POST ACUTE?

Families visiting AUBURN POST ACUTE should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does AUBURN POST ACUTE compare to other nursing homes?

AUBURN POST ACUTE has a 1-star overall rating, which is below average compared to other nursing homes in WA. Families should carefully review inspection findings and consider alternatives.

AUBURN POST ACUTE

Q: What is AUBURN POST ACUTE's CMS rating?

AUBURN POST ACUTE has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is AUBURN POST ACUTE safe?

AUBURN POST ACUTE has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Q: Do nurses at AUBURN POST ACUTE stick around?

AUBURN POST ACUTE has high staff turnover at 56%. High turnover can mean less continuity of care as staff change frequently.

Q: Was AUBURN POST ACUTE ever fined?

Yes, AUBURN POST ACUTE has been fined $392,410 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is AUBURN POST ACUTE on any federal watch list?

No, AUBURN POST ACUTE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

414 - 17TH SOUTHEAST, AUBURN, WA 98002 · (253) 833-1740

For profit - Limited Liability company 96 Beds Independent Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

0/100

#162 of 190 in WA

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AUBURN POST ACUTE nursing home in AUBURN, WA - Photo 1 of 4

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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Auburn Post Acute has received a Trust Grade of F, indicating poor performance with significant concerns about resident care and safety. It ranks #162 out of 190 nursing homes in Washington, placing it in the bottom half of facilities in the state, and #42 out of 46 in King County, meaning there are only a few local options that are better. The facility's trend is worsening, with issues increasing from 10 in 2024 to 21 in 2025. Staffing is rated at 2 out of 5 stars, and the 56% turnover rate is around average, which may impact the continuity of care. Additionally, the home has accumulated $392,410 in fines, which is concerning as it is higher than 99% of other facilities in Washington. There are critical incidents that highlight serious deficiencies, including a failure to ensure safe smoking practices that placed residents at risk for fire, and not properly administering wound care for residents, leading to severe complications like infections and delayed healing. While the facility does have some RN coverage, it is less than 76% of other facilities in the state, which raises concerns about the level of medical oversight. Overall, families considering this nursing home should weigh these significant weaknesses against any potential strengths before making a decision.

Trust Score: F
In Washington: #162/190
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $392,410 in fines. Higher than 53% of Washington facilities. Some compliance issues.
Skilled Nurses: Each resident gets 31 minutes of Registered Nurse (RN) attention daily — about average for Washington. RNs are the most trained staff who monitor for health changes.
Violations: 123 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 10 issues

2025: 21 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Washington average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 56%

Near Washington avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $392,410

Well above median ($33,413)

Significant penalties indicating serious issues

Staff turnover is elevated (56%)

8 points above Washington average of 48%

The Ugly 123 deficiencies on record

1 life-threatening 7 actual harm

Aug 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide adequate supervision to 1 (Resident 1) of 3 residents reviewed for elopement and accidents. The facility failed to provide supervision to Resident 1. These failures placed Resident 1 at a potential risk of harm, injury, and avoidable accidents. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; there was sufficient evidence the facility corrected the supervision failures after it was identified) and is no longer outstanding. Findings included.Review of the facility policy, titled Elopements and Wandering Residents, dated 2025, showed the facility would ensure residents who exhibited wandering behavior and/or was at risk for elopement would receive adequate supervision to prevent accidents. The policy showed door and wander guard alarms were not a replacement for necessary supervision and staff should be vigilant in responding to alarms in a timely manner. When a resident was missing the elopement/missing resident emergency procedure code white (missing resident) would be initiated. The procedure included searching the facility and the outdoor premises. If the resident was not located the facility would notify the Director of Nursing (DON), the Administrator, the resident representative, the physician, and local law enforcement. <Resident 1>Review of Resident 1's quarterly Minimum Data Set (MDS, an assessment tool), dated 07/31/2025, showed Resident 1 had severe cognitive impairment and was not able to make their own decisions. The MDS showed Resident 1 had diagnoses including dementia, high blood pressure, anxiety, and muscle weakness. The MDS showed Resident 1 used a wheelchair for mobility and required staff supervision with transfers and toileting.Review of physician orders, dated 04/09/2024, directed staff to perform safety checks on Resident 1 every shift for elopement and wandering risk.Review of a facility elopement assessment, dated 05/01/2025, showed Resident 1 was at high risk for an elopement. The assessment showed Resident 1 had a history of wandering and exit seeking, with a history of an elopement from the facility.Review of Resident 1's elopement Care Plan (CP), revised on 08/03/2025, showed Resident 1 had a history of attempts to leave the facility unsupervised. The CP directed staff to distract the resident from wandering by offering pleasant diversions, such as activities, food, conversation, television, or a book. The CP showed Resident 1 had a wander guard (bracelet device that sets an alarm off when close to an unsafe area like the elevator or exit door) to the left wrist and directed staff to perform safety checks every two hours, and document Resident 1's location.Review of a facility investigation, dated 08/03/2025, showed on 08/02/2025 at 8:32 PM Resident 1 who resided on the second floor with a wander guard in place, when they eloped from the facility front door unnoticed, went missing for nine hours before staff noticed, was found in the community thirteen hours later, and was alone and unsupervised in the community for twenty two hours. The investigation showed Staff B (DNS) was notified at 5:52 AM, nine hours later that Resident 1 could not be located in the facility by Staff C (Licensed Practical Nurse, LPN). The investigation showed that Staff D (Certified Nurse's Assistant assigned to Resident 1 on 08/02/2025 from 2pm to 08/03/2025 at 6 am) were interviewed and stated they last saw Resident 1 around midnight in the resident's room. (Review of the security footage did not show Resident 1 returning to the facility.) The investigation showed on 08/03/2025 at 7:10 PM Staff B was notified that a phone call was received that a person that fit the description of the resident was found down the street in a residential backyard. A neighbor confirmed Resident 1 was seen on 08/02/2025 at 9:15 PM in the same spot where they were discovered on 08/03/2025 at 7:10 PM. The investigation showed Resident 1 was sent to the hospital for an evaluation that showed a minor skin issue.Review of Resident 1's clinical record showed on 08/02/2025, Staff C documented every half hour from 6:30 PM to 6:00 AM on 08/03/2025 that safety checks were performed on Resident 1.In an observation and interview on 08/11/2025 at 2:00 PM, Resident 1 was observed sitting in their wheelchair in their room with a wander guard bracelet on the left wrist. When asked what happened to their upper right arm, Resident 1 stated they did not recall. Resident 1's right upper arm was observed with slightly red discoloration and scabbed areas. When asked about the elopement Resident 1 was not able to give any details or information as they did not recall the incident. Attempts to interview Resident 1's collateral contact were unsuccessful.During an interview on 08/18/2025 at 11:42 AM, Staff A (Administrator) stated the facility front doors were locked and an alarm was triggered when the door push bar was engaged and someone exited the facility. Staff A stated when a resident was not located in the facility, they would expect staff to follow the facility's protocol and activate a code white. When the resident was not found within fifteen minutes staff were expected to call the DNS, Administrator, local authorities, the facility medical director, and the resident representative. Staff A stated Staff C and Staff D were primarily responsible for the care and safety for Resident 1 and both failed to monitor the residents' location. Staff A stated security measures, such as the locked and alarmed door and the residents' wander guard were all functioning properly at the time of the incident, but staff failed to investigate the front door wander guard alarm which enabled Resident 1 to leave the facility unattended. Attempts to interview Staff C and Staff D who were responsible for Resident 1 during the time of the incident was unsuccessful as both were unavailable. REFERENCE: WAC 388-97- 1060(1)(3)(g) .

Jan 2025 20 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

<Standing While Feeding> <Resident 4> According to an 11/26/2024 Significant Change MDS, Resident 4 had a functional limitation in range of motion to one side of their upper arms and requi...

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<Standing While Feeding> <Resident 4> According to an 11/26/2024 Significant Change MDS, Resident 4 had a functional limitation in range of motion to one side of their upper arms and required substantial assistance from staff for eating. Review of Resident 4's Self-Care care plan showed the resident required one person assistance with eating their meals. Observations on 01/28/2025 at 12:40 PM showed Staff C (Resident Care Manager) standing next to Resident 4 in the dining area. Staff C was assisting Resident 4 with their fluids during lunch by holding the cup while the resident would drink in between taking bites of food. Staff C continued to stand at Resident 4's side assisting with fluids until 1:05 PM, 25 minutes later, at which time Staff C grabbed a nearby chair. In an interview on 01/31/2025 at 1:06 PM, Staff F stated it was their expectation staff sit down next to a resident when assisting them with their meal. Staff F stated it would feel intimidating if staff stood while assisting a resident with eating or drinking.Based on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity for 6 (Residents 1, 52, 4, 17, 15, & 12) of 20 sample residents and 2 (26 & 29) supplemental residents reviewed. The facility staff failed to provide Residents 52 & 12 with a privacy bag for their catheter, sit while feeding Resident 4, completely cover Residents 12, 17, & 29 while transporting them to the shower room, knock on Resident 1's room prior to entering, and remove items from Resident 1, 26, 15, & 29's room with permission. These failures placed residents at risk for feelings of diminished self-worth and embarrassment. Findings included . <Facility Policy> Review of the facility's 2024 Promoting/Maintaining Resident Dignity policy showed the facility would treat each resident with respect and dignity. The policy showed all staff members involved in providing care would provide care in a manner that promoted and maintained resident dignity. <Catheter Bag> <Resident 52> According to the 11/18/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 52 had some cognitive impairment. This MDS showed Resident 52 had an indwelling catheter (device that drained urine from the body to an external bag). Observation on 01/27/2025 at 12:27 PM showed Resident 52 on their bed. Their catheter bag contained urine and was hooked to the bed frame. The catheter bag was not covered with a privacy bag and the resident's urine filled bag was visible from the hallway. Similar observations were made on 01/28/2025 at 8:23 AM, 01/29/2025 at 8:26 AM, and 01/30/2025 at 10:18 AM. In an observation and interview on 01/30/2025 at 11:40 AM, Staff F (Resident Care Manager) confirmed the catheter bag was visible from the hallway and stated Resident 52 should have a privacy bag for their catheter bag. In an interview on 01/31/2025 at 9:31 AM, Staff B (Director of Nursing) stated catheter bags should have privacy bags to ensure resident dignity. <Shower Transportation> <Resident 12> Observations on 01/28/2025 at 12:25 PM showed Staff W (Certified Nursing Assistant -Shower Aid) pushing Resident 12 in a reclined shower chair through the hallway. Resident 12 only had a couple of towels placed on top of their body to cover them. Resident 12's upper chest, sides of both thighs, and legs were exposed. Resident 12's buttocks was observed through the hole in the shower chair and their catheter bag, without a cover, was hanging in the front with urine collected inside. Staff W took Resident 12 to a weight scale in the dining area and raised them onto the ramp, allowing more visibility of Resident 12's buttocks to the residents waiting for their lunch and family sitting in the dining area. Staff W finished weighing Resident 12 and then pushed them in the chair to the shower room. <Resident 17> Observations on 01/30/2025 at 8:18 AM showed Staff W pushing Resident 17 in a reclined shower chair through the hallway. Resident 17's sides of both thighs were exposed, and their buttocks area was observed though the hole in the shower chair. Staff W took Resident 17 to a weight scale in the dining area and raised them onto the ramp, giving more visibility of Resident 17's buttocks. Another staff member quickly approached Staff W and Resident 17 and began trying to tuck some of the edges of the resident's bath blanket underneath them to help cover the exposed areas. Staff W then took Resident 17 into the shower room. In an interview on 01/31/2025 at 9:34 AM, Staff F stated it was their expectation catheter bags be covered for dignity and staff should ensure a resident is fully covered when being transported for showers or weights through the hallway. Staff F stated it could be, embarrassing for a resident if they were uncovered and exposed to others. <Resident 29> Observation on 01/28/2025 at 8:47 AM showed Resident 29 being transported by Staff W through the hallway in a shower chair. Resident 29's bare legs, arms, and both sides of their buttocks were exposed and not contained within the bath blanket. In an interview on 01/31/2025 at 1:49 PM, Staff B stated staff should make sure residents were covered when going to and from shower rooms to promote dignity. <Privacy> <Resident 1> According to the 01/22/2025 admission MDS, Resident 1 had a diagnosis of an unhealed pressure wound, partial paralysis to one side of their body, and blindness in one eye. The MDS showed Resident 1 was dependent on staff for toileting hygiene and mobility assistance. Review of the revised 09/06/2024 Activities of daily living self-care performance deficits care plan showed Resident 1 had limited mobility, needed two-person assistance for toileting hygiene, and used incontinence briefs. In an interview on 01/28/2025 at 8:13 AM, Resident 1 stated staff did not knock on their door before coming into their room and stated they felt like they did not have any privacy. Observation on 01/28/2025 at 1:44 PM showed Staff L (Licensed Practical Nurse) provided wound care to Resident 1's left foot. Staff L did not close Resident 1's bedroom door and wound care treatment was visible from the hallway. In an interview on 01/29/2025 at 8:23 AM, Resident 1 stated the nursing aids come into their room and do not always knock on their door first before entering. In an interview on 01/31/2025 10:40 AM, Staff F stated their expectation was for staff to provide dignity and privacy. Staff should knock on residents' doors first, introducing themselves and not just going into resident's room as this was their home. <Resident Supplies > In an interview on 01/28/2025 at 8:13 AM, Resident 1 stated the staff went through their closet and took their specially ordered incontinence bed pads without asking them. Resident 1 stated they could not use the blue bed pads the facility regularly used because it irritated their skin. Because of this the facility provided them with a special incontinent bed pad that did not irritate their skin. In an interview on 01/29/2025 at 8:49 AM, Resident 1 stated their incontinent bed pads should be kept at their bedside so staff could not take them. Resident 1 stated staff came into their room closet again last night to take their incontinence bed pads without Resident 1's consent. Resident 1 stated they needed this pad for their care and staff should not be taking items from their closet. Observed Resident 1 tell Staff N (Certified Nursing Aid) to hide their incontinence bed pads in the bottom of their closet or put the pads on their bed so other staff could not find them. In an interview on 01/30/2025 at 2:34 PM resident council members (Residents 26, 15, & 29) stated they reported to the facility that extra-large incontinent supplies were taken from their rooms and staff were going through their personal closets to obtain these supplies without their approval. In an interview on 01/31/2025 at 8:54 AM, Staff K (Staffing Coordinator/Supplies) stated they were aware Resident 1 had specially ordered bed pads that were missing and Staff K was aware other residents had reported incontinence supplies being taken from their room. Staff K stated there were enough supplies and staff should not be taking items from resident's room for other residents because of dignity and the potential of cross contamination. In an interview on 01/31/2025 at 10:40 AM Staff F stated staff should not be going into resident's rooms and taking anything for dignity reasons. Staff F stated this was the resident's home and things in their room were the resident's belongings. REFERENCE: WAC 388-97-0180(1-4). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medication Consent> <Resident 64> According to the 01/09/2025 admission MDS, Resident 64 was assessed with progress...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medication Consent> <Resident 64> According to the 01/09/2025 admission MDS, Resident 64 was assessed with progressive neurological conditions and care needs that included dementia, depression, impaired memory, and the use of antipsychotic and antidepressant medications. Review of Resident 64's January 2025 Medication Administration Record (MAR) showed physician orders for three psychotropic medications. The MAR showed all three medications were started the day after admission and administered as ordered thereafter. Review of Resident 64's record showed no documentation indicating the resident or their representative were provided with the risks and benefits or consented to the use of the antipsychotic and antidepressant medications. In an interview on 01/31/2025 2:03 PM, Staff F (Resident Care Manager) stated consents for the use of psychotropic medications should be signed by either residents or their representatives prior to administration, and included in the resident's record. Staff F was unable to locate Resident 64's consent for the use of the psychotropic medications ordered. Staff F stated that this failure placed Resident 64 at risk for loss of the resident's right to be informed of medication use, adverse side effects, and the right to refuse. <Resident 419> Record review of the 01/21/2025 admission MDS showed Resident 419 was assessed with neurological conditions and care needs including stroke, dementia, seizures, impaired memory, and had a history of mental and behavior disorders. The MDS showed Resident 419 used psychotropic medications. Review of Resident 419's January 2025 MAR showed physician orders for three psychotropic medications. The MAR showed all three medications were started on the date of admission and administered as ordered thereafter. Review of Resident 419's record showed no documentation demonstrating Resident 419's representative were provided with an explanation of the risks and benefits or consented to the use of the psychotropic medications prior to administration. In an interview on 01/31/2025 at 2:05 PM, Staff F was unable to locate Resident 419's consents for the use of the psychotropic medications ordered. Staff F stated that this failure placed Resident 419 at risk for loss of resident's right to be informed of medication use, adverse side effects, and the right to refuse. <Resident 33> According to the 10/30/2024 Quarterly MDS, Resident 33 had severe cognitive impairment. The MDS showed Resident 33 had diagnoses including brain dysfunction, anxiety, depression, and a mood disorder. The MDS showed Resident 33 was administered an antidepressant medication during the assessment period. Review of a 01/28/2025 Order Summary showed Resident 33 was receiving an antidepressant medication twice daily. Review of a 09/20/2024 Psychotropic Medication Therapy consent showed the resident was being treated with an antidepressant medication. Section D of this form showed two check boxes, one checkbox indicating the resident consented to the medication and the other checkbox indicating the resident did not consent to the use of the medication. Both boxes were blank and unchecked. Section D also included a space indicating Responsible Party Informed. This box was blank and did not show the resident and/or their responsible party were informed of the medication or its potential risks and benefits. In an interview on 01/20/2025 at 12:55 PM, Staff B confirmed the consent for the antidepressant medication was incomplete. Staff B stated the consent should capture whether the resident accepted or declined the treatment, but the consent did not. REFERENCE: WAC 388-97-0260. . <Resident 44> According to a 12/17/2024 Quarterly MDS, Resident 44 admitted to the facility on [DATE], had multiple medically complex diagnoses including anxiety, depression, and schizophrenia (a serious mental health condition affecting how people think, feel, and behave), and required the use of an antidepressant and antipsychotic medication during the assessment period. Review of the January 2025 MAR showed Resident 44 was receiving an antidepressant, an antianxiety, and an antipsychotic medication daily. Review of three 07/06/2024 Psychotropic Medication Therapy consents for the antidepressant, antianxiety, and antipsychotic medication showed each form had a section, Responsible Party Informed that was left blank by staff. There was no resident signature from the resident and/or a representative to show they reviewed the form and were informed of the risks and benefits for the use of the psychotropic medications. In an interview on 01/31/2025 at 9:34 AM, Staff F stated consents were important to show staff communicated the risks and benefits with the resident and/or representative prior to the use of any psychotropic medications. Staff F stated the consents gave the opportunity for the resident to acknowledge they have been informed and accept or decline the use of the medications. Staff F stated the psychotropic medication consents should be signed by the resident and/or the representative. Based on observation, interview, and record review the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits was provided) for the use of a device for 1 (Resident 48) of 4 residents reviewed for positioning and failed to provide informed consent regarding high-risk medications for 3 (Residents 64, 44, & 33) of 5 sample residents and 1 (Resident 419) supplemental resident. These failures placed residents at risk for loss of autonomy and the opportunity for alternative treatment options. Findings included . <Facility Policy> The facility's undated Restraint Free Environment Policy showed residents had the right to be treated with respect and dignity, including the right to be free from chemical restraints. <Device Consent> <Resident 48> According to the 11/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 48 was assessed to have modified independence for daily decision making and required substantial to maximal assistance with transfers, rolling left to right in bed, sitting to lying, and sitting to standing. The MDS showed Resident 48 used a manual wheelchair. The MDS showed Resident 38 had diagnoses including a history of stroke, dementia, and muscle wasting. Observation on 01/27/2025 at 10:46 AM showed Resident 48 used a tilt-in-space wheelchair (a type of specialty wheelchair that allowed the resident to be tilted while sitting and could potentially restrict a resident's ability to walk independently). According to the 07/13/2024 Safety Device: Tilt and Space Wheelchair . care plan, Resident 48's goal was to have no complications from using the wheelchair. The CP included an intervention instructing staff to monitor the resident for complications from use of the wheelchair. Record review showed a 09/14/2024 Consent - Safety Device form was completed related to Resident 48's tilt-in-space wheelchair. This form showed the wheelchair was needed to assist with locomotion (in or out of wheelchair) and was necessary due to Resident 48's weakness. The form did not identify any potential risks from the use of the tilt-in-space wheelchair for Resident 48 and increased ability for locomotion as the sole benefit. In an interview on 01/31/2025 at 1:34 PM, Staff B (Director of Nursing) stated Resident 48 benefited from the tilt-in-space wheelchair as it reduced their fall risk. Staff B stated the 07/13/2024 consent form was inaccurate by showing the wheelchair assisted Resident 48 with walking as a standard wheelchair provided the same benefit. Staff B stated the form did not address the risk of restraint from the chair. Staff B stated there was no risk of restraint as Resident 48 could not walk themselves independently regardless of their positioning in a wheelchair, and this should be reflected on the consent form.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an effective program to ensure resident Advanced Directives (ADs - legal documents describing treatment wishes for when a resident is incapacitated) were included in the record and residents without ADs were offered assistance to formulate one for 2 (Residents 120 & 49) of 6 residents reviewed for ADs. This failure placed residents at risk for not having their treatment goals met and other negative health impacts. Findings included . <Facility Policy> According to the facility's 2024 Residents' Rights Regarding Treatment and Advance Directives policy, the facility would determine on admission if a resident had an AD in place, and if not, determine of the resident wanted to formulate one, and provide information on how to formulate an AD. The policy showed the facility would identify, clarify, and review with the resident any changes related to ADs during the care planning process. The policy showed the facility would review AD with the resident quarterly, at each care conference. <Resident 120> According to the 12/24/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 120 had a moderate memory impairment. The MDS showed Resident 120 had medically complex diagnoses including multiple infections. Record review showed no AD available in Resident 120's record. There was no documentation showing Resident 120 was offered assistance to formulate an AD, or whether they wished for such assistance. There was no care plan addressing Resident 120 AD status. In an interview on 01/31/2025 at 9:07 AM Staff M (Social Services) stated ADs were important to capture residents' wishes for treatment should they become incapacitated. At that time Staff E (Social Services Director) stated ADs and facility efforts to assist with formulating an AD would be documented in the record, either in the care plan, the care conference documentation, or directly scanned into the chart. Staff E indicated that Staff M completed a care conference on 12/21/2024. Staff M and Staff E reviewed the care conference documentation and agreed it did not address Resident 120's stats regarding ADs.<Resident 49> According to a 05/01/2024 Annual MDS, Resident 49 admitted to the facility on [DATE]. The MDS showed Resident 49 had no memory impairment. Review of Resident 49's health records showed an AD Acknowledgment dated 05/05/2023. Review of the health records showed no other documentation of an AD being discussed or offered to Resident 49 since the initial admission to the facility in May 2023. In an interview on 01/31/2025 at 10:42 AM Staff E stated Resident 49 was only offered assistance to formulate an AD once upon admit, on 05/05/2023. Staff E stated facility process was to discuss and offer assistance with AD within 48 hours of admission and then review with the resident quarterly at their care conference. Staff E stated AD were important to ensure the resident had a durable power of attorney appointed to carry out their wishes when the resident was unable to. REFERENCE: WAC 388-97-0280(3)(c)(i-ii). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to thoroughly investigate an injury accident for 1 (Resident 6) of 8 residents reviewed for accidents, rule out abuse for 1 (Resident 38) of 3 sampled residents reviewed for abuse and investigate a fall for 1 (Resident 419) of 2 reviewed for falls. Facility failure to complete thorough investigations placed residents at risk for further injuries, potential abuse, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 2023 Incidents and Accidents policy, an accident was any unexpected or unintentional incident . which resulted or could result in injury or illness to a resident. The policy showed accidents must be entered into the incident report log and thoroughly investigated within five days of the incident. According to the facility's undated Abuse, Neglect, and Exploitation policy, the facility would identify, provide an ongoing assessment, and care plan for appropriate interventions. The facility would provide feedback regarding the concerns that were expressed and make efforts to ensure all residents were protected from physical, psychosocial harm, and additional abuse, during and after the investigation by increasing supervision of the alleged victim. The facility would make room changes as necessary, provide emotional support to the resident during and after the investigation, and revise the care plan if the resident's medical, physical, mental, or psychosocial needs changed as a result of an incident of abuse. <Resident 6> According to the 12/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 6 used a power wheelchair. The MDS showed Resident 6 could use their power wheelchair independently for a distance of at least 150 feet. The MDS showed Resident 6 had medically complex diagnoses including a history of stroke and one-sided paralysis. The MDS did not include an assessment of Resident 6's cognition, both the resident cognitive interview and staff cognitive assessment were incomplete. There was no determination of Resident 6's cognition at the time of the assessment. According to the Activities of Daily Living self-care deficit care plan, revised 08/03/2024, Resident 6 used a power wheelchair. The care plan showed Resident 6 could operate their power wheelchair independently. A 09/30/2024 nursing progress note showed a nursing assistant charted Resident 6 had bruising on their right ankle. The note showed Resident 6 reported they ran into a wall while operating their power wheelchair and felt some tenderness to their right lower leg. A 10/01/2024 nursing progress note showed Resident 6 continued to express discomfort regarding their right ankle area. A 10/04/2024 provider note showed Resident 6 was referred for a lump on their right leg. The note showed Resident 6 hit their right leg using their power wheelchair. A 10/05/2024 nursing progress note showed Resident 6 continued to report right ankle pain. Record review showed the facility's September 2024 Incident Log did not include an entry documenting Resident 6's right ankle injury Observation on 01/28/2025 at 1:17 PM showed Resident 6 crying out in pain by the right, second floor elevator door. Resident 6 had an accident with their power wheelchair and the elevator door. Nursing staff assisted Resident 6 back to their room. According to a 01/29/2025 progress note, Resident 6 was sent to the hospital and assessed with a right femur fracture. In an interview on 01/31/2025 at 2:42 PM Staff B (Director of Nursing) stated they did not know about the other wheelchair accident. Staff B stated if facility staff notified them of the accident, as expected, they would have logged and investigated the accident and reassessed Resident 6 for safe us of their power wheelchair.<Resident 38> According to the 11/26/2024 Quarterly MDS, Resident 38 was assessed with some memory deficit, could be understood, and understood others. The MDS showed Resident 38 had medically complex diagnoses including heart failure, depression, and muscle weakness. In an interview on 01/27/2025 at 9:27 AM, Resident 38 stated there was a nurse that was not so nice to them. Resident 38 stated they could not recall the nurse's name but could describe when they worked last and what they looked like. Resident 38 stated the nurse had threatened to take their medicine away from them and stated they hated the resident. Resident 38 stated they were scared and did not feel comfortable with that nurse around them. In an interview on 01/28/2025 at 12:47 PM Resident 38 stated no one had come back to provide follow up to them. Review of the facility's 01/27/2025 incident report showed alert charting was to be put into place for staff to document and assess Resident 38 for psychosocial harm. Review of Resident 38's progress notes from 01/27/2025 through 01/31/2025 showed only one progress note dated 1/31/2025 by Staff C (Resident Care Manager) regarding the incident. No other documentation from alert charting was found regarding assessing Resident 38 for psychosocial harm. In an interview on 01/31/2025 at 10:55 AM Staff F (Resident Care Manager) stated follow up should have occurred for Resident 38 so they were aware of the outcomes of the investigation and staff could assess Resident 38's psychosocial behavior, but this did not happen. In an interview on 01/31/2025 at 9:42 AM Staff B stated they did not talk to Resident 38 yet regarding the incident. Staff B stated there were no other interventions put into place for Resident 38 to feel safe and to express their feelings regarding the incident, but there should be. <Resident 419> A provider progress note dated 01/27/2025 at 2:41 PM, showed Resident 419 had a fall on 01/25/25 from trying to get up from bed. The provider noted showed scattered swelling and bruising of the resident's left ankle, 2nd/3rd/4th toes, and the underside of the left foot. The provider ordered a left foot and ankle x-ray and instructed staff to monitor for any changes or spontaneous bruising and bleeding. Review of the facility's incident log showed Resident 419 had a non-injury fall on 01/22/2025. There was no entry on the incident log of the injury fall on 01/25/2025. In an interview on 01/31/2025 at 2:10 PM, Staff F reviewed Resident 419's medical record and stated it did not appear that an incident report was initiated specifically related to Resident 419's fall on 01/25/2025. Staff F stated it was important to investigate to ensure resident's safety. REFERENCE: WAC 388-97-0640(6)(a)(b). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 25> According to a 08/29/2024 Annual MDS Resident 25 admitted [DATE]. The MDS showed Resident 25 had their natur...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 25> According to a 08/29/2024 Annual MDS Resident 25 admitted [DATE]. The MDS showed Resident 25 had their natural teeth without any issues. Review of a 06/27/2024 Activities of Daily Living CP, Resident 25 had no natural teeth and had an upper denture but no lower denture. The CP showed Resident 25 required staff assistance with cleaning the denture and the residents' mouth/gums twice daily. In an interview on 01/31/2025 at 9:27 AM Staff P stated Resident 25's MDS showed they had their natural teeth without issues. Staff P stated the MDS should show that the resident has the upper denture and no natural teeth. Staff P stated it was important for the MDS to be accurate to plan residents care appropriately. REFERENCE: WAC 388-97-1000 (1)(b). .Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-an assessment tool) accurately reflected the status for 5 (Resident 44, 36, 4, 6, & 25) of 20 residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 44> According to the 12/17/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 44 had multiple medically complex diagnoses including anxiety. This MDS did not indicate Resident 44 was taking any antianxiety medications during the assessment period. Review of Resident 44's December 2024 medication administration record showed Resident 44 was receiving an antianxiety medication three times daily during the 12/17/2024 MDS assessment period. In an interview on 01/31/2025 at 11:28 AM, Staff P (MDS Nurse) stated it was their expectation an MDS be accurate as the MDS was an important part of a establishing the resident's plan of care. According to the 12/17/2024 Quarterly MDS, Resident 44 was taking the following high-risk drug class medications: a hypoglycemic (used to lower blood sugar levels); an anticonvulsant (used to control seizures); an antidepressant, and an antipsychotic. There was a second column on the MDS to identify if there was an indication noted for all medications being used in these high-risk drug classes. None of the boxes in the second column were selected by staff. In an interview on 01/31/2025 at 11:28 AM, Staff P stated they missed marking the second column on Resident 44's 12/17/2024 Quarterly MDS. Staff P stated there were indications noted in Resident 44's records for all of the high-risk drug class medications being administered. According to a 12/17/2024 Quarterly MDS, Resident 44 did not receive the influenza (a contagious respiratory illness) vaccine in the facility for this year's influenza vaccination season and included an indication the vaccination was not received because it was offered and declined by Resident 44. Review of Resident 44's vaccination records showed staff documented the resident refused the influenza vaccine in 2023 but did receive the influenza vaccine for the current season on 10/03/2024. In an interview on 01/31/2025 at 11:28 AM, Staff P reviewed Resident 44's records and stated the MDS was inaccurate and should have, but did not include the influenza vaccine administered to Resident 44 for this year's influenza vaccination season. <Resident 36> According to an 11/28/2024 Quarterly MDS, Resident 36 received the influenza vaccine in the facility for this year's influenza vaccination season. Staff listed the date the influenza vaccine was received as 10/25/2023, which was the year prior to the current influenza season. Review of Resident 36's immunization records showed staff documented the resident's most recent influenza vaccine was administered on 10/10/2024, not 10/25/2023 as documented on the 11/28/2024 Quarterly MDS. In an interview on 01/31/2025 at 11:34 AM, Staff P reviewed Resident 36's records and stated the MDS was inaccurate and should have, but did not include the most recent vaccination administered for this year's influenza vaccination season.<Resident 4> According to the 11/26/2024 Significant Change MDS, Resident 4 had diagnoses including a spinal cord disorder and dementia. This MDS did not include an assessment of Resident 4's cognition, both the resident interview for cognition and the staff cognitive assessment were incomplete In an interview on 01/31/2025 at 10:45 AM Staff P stated Resident 4's cognition should have been completed. Staff P stated the completion of the cognitive assessment was the responsibility of the Social Services department. <Resident 6> According to the 12/30/2024 Quarterly MDS Resident 6 had medically complex diagnoses including a history of stroke and one-sided paralysis. The MDS did not include an assessment of Resident 6's cognition, both the resident cognitive interview and staff cognitive assessment were incomplete. There was no determination of Resident 6's cognition at the time of the assessment. In an interview on 01/31/2025 at 10:45 AM Staff P stated Resident 6's cognition should be completed and included.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 44> According to a 12/17/2024 Quarterly MDS, Resident 44 admitted to the facility on [DATE], had multiple medica...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 44> According to a 12/17/2024 Quarterly MDS, Resident 44 admitted to the facility on [DATE], had multiple medically complex diagnoses including anxiety, depression, and schizophrenia (a serious mental health condition that affects how people think, feel, and behave), and required the use of an antidepressant and antipsychotic medication during the assessment period. Review of the January 2025 medication administration records showed Resident 44 was receiving an antidepressant and antipsychotic medications daily. Review of a 07/03/2024 Level 1 PASRR showed Resident 44 had no serious mental illness indicators identified, and a Level II evaluation was not indicated. In an interview on 01/30/2025 at 1:54 PM, Staff E stated upon admission the Level 1 PASRR should be assessed by staff for accuracy. Staff E reviewed Resident 44's records and stated the Level I PASRR was inaccurate and should be, but was not updated as required.Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed for 5 (Residents 33, 44, 25, 38, & 64) of 7 residents reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> Review of the facility's 2024 Resident Assessment - Coordination with PASRR Program showed all applicants to the facility would be screened for serious mental disorders, intellectual disabilities, and related conditions. The policy showed PASSR Level I was an initial pre-screening and was completed prior to admission. The policy showed a positive Level I screen necessitated a PASRR Level II evaluation prior to admission. A record of the pre-screening would be maintained in the resident's medical record. <Resident 33> Review of the 10/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 33 admitted to the facility on [DATE]. This MDS showed Resident 33 had diagnoses including anxiety, depression, and a mood disorder. The MDS showed Resident 33 received an antianxiety medication, antipsychotic medication, and an antidepressant medication during the assessment period. Review of Resident 33's record showed a PASSR was not included as part of the resident's record. In an interview on 01/29/2025 at 12:09 PM. Staff E (Social Services Director) reviewed Resident 33's record and confirmed the resident did not have a PASRR. Staff E stated the PASRR should be obtained and in the resident's record, but it was not. <Resident 25> According to a 08/29/2024 Annual MDS Resident 25 admitted [DATE]. The MDS showed Resident 25 had diagnoses of, but not limited to, anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, and post-traumatic stress disorder. Review of Resident 25's health records showed no PASRR screening for the 03/22/2024 admission. In an interview on 01/31/2025 at 10:42 AM Staff E stated Resident 25 did not have a PASRR I completed prior to the 03/22/2024 admission but should have. Staff E stated Resident 25 should have been referred for a level II PASRR for the 03/22/2024 admission for their listed serious mental disorders. Staff E stated it was important to complete PASRR's prior to admission, per regulation, so they identified behaviors and managed them appropriately to best care for residents with mental health disorders.<Resident 38> According to an 11/26/2024 Quarterly MDS, Resident 38 had multiple complex conditions including anxiety disorder and major depression. Review of a revised 01/27/2025 Behavior CP showed Resident 38 had depression, anxiety and behaviors of refusing medications and meals. Review of Resident 38's January 2025 Medication Administration Records (MAR) showed Resident 38 received an antidepressant medication. Review of Resident 38's medical record showed a PASSR Level 1 form was completed on 02/09/2022. The form showed a check mark in the box indicating a PASSR II referral was required due to Resident 33 having depression and anxiety. A PASSR Level II form was requested from the facility but was not provided. In an interview on 01/30/2025 at 10:33 AM Staff E stated they were not aware Resident 38 needed a PASSR Level II. Staff E stated the facility was still working on getting PASSR Level II forms completed and was behind on getting these done. Staff E stated a PASSR II evaluation was important because it helped identify behaviors that needed to be addressed for resident's with mental health issues. <Resident 64> Record review of the 01/09/2025 admission Minimum Data Set (MDS - an assessment tool) showed Resident 64 was admitted to the facility on [DATE] and assessed with progressive neurological conditions and care needs included dementia, depression, impaired memory and the use of antipsychotic and antidepressant medications. Review of Resident 64's January 2025 MAR showed physician orders for three psychotropic medications. The MAR showed all three medications were started on the day after admission and administered as ordered thereafter. Review of Resident 64's 12/18/2024 Level 1 PASRR form showed no serious mental illness indicators were identified, and no referral was indicated for Level II evaluation. In an interview on 01/30/2025 at 1:38 PM, Staff F (Resident Care Manager) reviewed the Level 1 PASRR form in Resident 64's medical records and stated it does not appear to be complete. Staff F stated they were trying to educate hospital staff on the importance of accuracy on the form. Staff F stated the error on the form should be identified during the facility's admission process, corrected, and resubmitted for review. REFERENCE: WAC 388-97-1915(1)(2)(a-c)(4). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure physician orders were clarified for 4(Residents 38, 64, 44 & 33) of 20 sample residents reviewed and physician parameters were followed for 2 of 5 residents (Resident 44, & 49) reviewed for unnecessary medications with 1 supplemental resident (Resident 50) reviewed. These failures placed residents at risk for ineffective treatments, medications errors, and delayed treatment. Findings included . <Facility Policy> The facility's undated Medication Orders Policy showed the elements of the medication order should be clarified for accuracy. The facility's undated Medication Administration Policy showed staff were to compare medication source (bubble pack, vial, etc.) with the Medication Administration Records (MAR) to verify resident name, medication name, form, dose, route, and time. The policy showed staff were to correct any discrepancies and report to nurse manager. <Clarifying Orders> <Resident 38> Observations on 01/29/2025 at 1:41 PM showed Staff R (Registered Nurse) preparing to administer Intravenous (IV) antibiotic medication for Resident 38. Staff R compared the physician's order in Resident 38's health record to the dual-compartment antibiotic IV bag. After preparing IV bag and tubing for infusion, Staff R connected tubing to Resident 38's left wrist IV site. Staff R set the infusion pump to a flow rate of 100 milliliters per hour as indicated on the medication label and started the infusion. Staff R did not apply tubing label indicating date and time changed, and staff initials. Review of Resident 38's January 2025 MAR showed an IV antibiotic order entered with medication name, time, route, and defined the dose concentration in milligram per milliliter; however, the order failed to specify the IV flow rate required for safe administration. The MAR showed this order was administered as written on 01/28/2025 and 01/29/2025, then discontinued on 01/30/2025. The MAR showed an order starting on 01/21/2025 instructed staff to change IV tubing every 24 hours for IV maintenance. In an interview on 01/30/2025 at 8:39 AM, Staff Q (Licensed Practical Nurse) opened Resident 38's MAR and stated the order for IV antibiotics did not include instructions for flow rate and the MAR should match instructions on the IV bag label. Staff Q stated Resident 38's IV tubing attached to the IV bag hanging at bedside had no label attached and was not dated. On 01/30/2025 at 8:52 AM, Staff Q stated they had clarified with Staff B (Director of Nursing) staff should have labeled tubing with the date and time it was changed. <Resident 64> Record review of the 01/09/2025 admission Minimum Data Set (MDS, an assessment tool) showed Resident 64 was admitted to the facility on [DATE] and assessed with progressive neurological conditions and care needs included always incontinent of bowel. The comprehensive Care Plan (CP) revised on 01/06/2025 showed Resident 64 had constipation due to decreased mobility and the use of medications with a side effect of constipation. The CP showed staff would follow the facility's bowel protocol for bowel management. Review of Resident 64's January 2025 MAR showed a 01/03/2025 physician order for an enema as needed for constipation when there were no results from the suppository. The MAR did not include a physician order for suppository. The MAR showed an order for a powdered laxative to be given twice daily for bowel management. This order was administered between 01/03/2025 and 01/22/2025, and discontinued on 01/22/2025. The MAR showed a second order for the same powdered laxative to be administered twice daily which Resident 64 received between 01/03/2025 and 01/28/2025. In an interview on 01/31/2025 at 1:42 PM, Staff F (Resident Care Manager) reviewed Resident 64's MAR and identified the lack of suppository order. Staff F stated staff should have clarified the order but failed to, which placed Resident 64 at risk of ineffective bowel management. Staff F identified the order for the powdered laxative was duplicated during order entry and administered twice daily between 01/03/2025 and 01/22/2025. Staff F stated the nurse was expected to identify order duplications and bring them to the nurse manager for clarification. During record review of the January 2025 Bowel and Bladder Elimination report, Staff F stated the record showed Resident 64 had loose stools and diarrhea correlating with the dates of duplicate administration. Staff F stated this error placed Resident 64 at increased risk for dehydration and skin breakdown.<Following Parameters> <Resident 49> According to a 12/02/2024 Quarterly MDS Resident 49 had no memory impairment. The MDS showed Resident 49 experienced no constipation. The MDS showed Resident 49 had diagnoses of, but not limited to, left leg amputation above the knee and difficulty walking. Review of an 11/10/2024 pain medication CP, Resident 49 received an opioid pain medication with a side effect of constipation. The CP showed staff would monitor and report for any constipation Resident 49 experienced. Review of Resident 49's physician orders showed 08/23/2023 orders for a laxative regimen if Resident 49 experienced no Bowel Movement (BM) in 3 days. Resident 49's laxative orders were to administer a liquid laxative if no BM in 3 days, then a suppository if no results from the liquid laxative, then an enema if no results from the suppository, and if no results from the enema staff were to notify the physician for further orders. Review of Resident 49's health records showed no BM on 01/15/2025, 01/16/2025, 01/17/2025, 01/18/2025, then a small BM on 01/19/2025, then no BM on 01/20/2025, 01/21/2025, 01/22/2025, and 01/23/2025. Resident 49's health records showed no laxatives administered per physician orders. In an interview on 01/31/2025 at 1:31 PM Staff F stated nurses were expected to administer the laxatives as ordered for Resident 49 per the facilities bowel protocol of no BM in 3 days. Staff F stated they did not even count the small BM because that could be a sign of constipation or worse a bowel obstruction. Staff F stated the nurses should have initiated the bowel protocol on 01/17/2025 for Resident 49 but did not. Staff F stated it was important to follow the bowel protocol to ensure residents don't become impacted which could lead to a bowel obstruction, nausea, vomiting, or being sent to the hospital when they could have prevented this. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii). <Clarifying Orders> <Resident 33> Review of Resident 33's 01/28/2025 order summary showed an order for an as needed antacid medication. The order directed staff to administer two wafers of the medication and not to exceed 3000 milligrams per day. The order did not specify how often staff were able to administer the wafers. Review of Resident 33's 01/28/2025 order summary showed an order directing staff to administer an as needed enema for constipation. This order directed staff to administer the enema if no results from a suppository. Review of Resident 33's comprehensive order summary showed the resident did not have an order for a suppository. In a joint interview on 01/30/2025 at 1:19 PM, Staff B and Staff F reviewed Resident 33's orders for the antacid and enema medications. Staff B and Staff F confirmed the orders needed to be clarified. <Clarifying Orders> <Resident 44> According to a 12/17/2024 Quarterly MDS, Resident 44 had frequent pain and received pain medications on an as needed basis during the assessment period. Review of Resident 44's January 2025 MAR showed the resident had four orders for pain medications to be administered as needed for pain. Two of those orders were for the same narcotic pain medication and provided pain scales to determine which dose to administer, one tablet every eight hours was to be given for a pain level of 5-7 out of a 0-10 pain scale, and two tablets every eight hours were to be administered for a pain level of 8-10 out of a 0-10 pain scale. This medication was not administered in January 2025. Resident 44 had a third narcotic pain medication order to be given every eight hours as needed for pain management with no parameters identified. This medication was not administered in January 2025. Resident 44 had a fourth order for a non-narcotic pain medication to be given every four hours as needed for general pain. This medication was administered for a pain level of five or greater out of a 0-10 pain scale on 19 of 28 times. In an interview on 01/31/2025 at 9:34 AM, Staff F stated it was their expectation pain medication parameters be followed and clarified when needed. Staff F stated Resident 44's pain medications orders needed to be clarified with the physician. <Following Parameters> <Resident 44> According to a 12/17/2024 Quarterly MDS, Resident 44 had multiple medically complex diagnoses including high Blood Pressure (BP). Review of Resident 44's MAR showed the resident was receiving a medication for high BP with directions to staff to hold the dose if SBP [Systolic BP - a measure of the pressure in your arteries when your heart beats] < [less than] 100 or Pulse < 60. The November 2024 MAR showed staff administered this medication outside of parameters on three occasions when Resident 44's SBP was < 100. The December 2024 MAR showed staff administered this medication outside of parameters on four occasions. The January 2025 MAR showed staff administered this medication outside of parameters on two occasions when Resident 44's SBP was < 100. <Resident 50> According to an 11/04/2024 Quarterly MDS, Resident 50 had multiple medically complex diagnoses including high BP. Review of Resident 50's MAR showed the resident was receiving a medication for high BP with directions to staff to hold the dose if SBP was less than 110. The November 2024 MAR showed staff administered this medication outside of parameters on six occasions when Resident 50's SBP was < 110. The December 2024 MAR showed staff administered this medication outside of parameters on four occasions. The January 2025 MAR showed staff administered this medication outside of parameters on two occasions when Resident 50's SBP was < 110. In an interview on 01/31/2025 at 9:34 AM, Staff F stated it was their expectation staff follow physician orders and hold medications as directed when outside of parameters. Staff F reviewed Resident 44 and Resident 50's MARs and confirmed staff administered the medications outside of the ordered parameters.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide nailcare and assistance with shaving facial hair for residents dependent on staff for Activities of Daily Living (ADLs - grooming, oral hygiene, nail care etc.) for 3 of 6 (Residents 120, 36, & 21) residents and 1 supplemental resident (Resident 169) reviewed for ADLs. This failure placed residents at risk for poor hygiene, skin impairment, and a diminished sense of self-worth. Findings included . <Facility Policy> According to the facility's 2024 ADLs policy, the facility would provide cares and services to residents who depended on staff for ADL assistance including bathing, dressing, grooming, and oral care. <Resident 120> According to the 12/24/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 120 had a moderate memory impairment and medically complex diagnoses including multiple infections. The MDS showed Resident 120 required substantial to maximum assistance with personal hygiene. According to the 12/19/2024 ADL self-care performance deficit . Care Plan (CP) Resident 120 required one-person assistance with all personal hygiene needs. Review of the Certified Nursing Assistant (CNA) documentation from 01/09/2025 through 01/31/2025 showed no nail care was documented to be provided. There were no documented refusals of nail care assistance. Observation on 01/31/2025 at 8:40 AM showed Resident 120's fingernails were long, sharp, and dirty with black-brown debris under the nail. At 8:43 AM Staff L (Licensed Practical Nurse) observed Resident 120's fingernails and stated they were long, dirty, and needed trimming.<Resident 36> According to a 11/28/2024 Quarterly MDS, Resident 36 had clear speech, was able to understand and be understood by others, and had no memory impairment. This MDS showed Resident 36 required substantial assistance from staff for personal hygiene and bathing and had no rejection of care during the assessment period. Review of a revised 09/09/2024 self-care performance CP showed Resident 36 required extensive staff assistance for bathing twice weekly. Observations on 01/28/2025 at 8:36 AM showed Resident 36 with scattered long chin hairs. In an interview at this time, Resident 36 stated they preferred to have the chin hairs shaved. On 01/30/2025 at 9:26 AM Staff R (Registered Nurse) observed and confirmed Resident 36 had long chin hairs. In an interview on 01/31/2025 at 9:22 AM, Staff U (CNA) stated daily care for a resident should include assisting them with shaving as needed. Staff U stated shaving was most often done during showers. According to Resident 36's January 2025 ADL records, staff documented the resident received a shower on 01/27/2025. <Resident 169> According to a revised 01/23/2025 self-care performance CP showed Resident 169 required one-person extensive assistance for all personal hygiene needs. Observations on 01/27/2025 at 2:54 PM showed Resident 169 with long chin hairs. In an interview at this time, Resident 169 stated they would like the chin hairs shaved off. On 01/30/2025 at 9:26 AM Staff R observed and confirmed Resident 169 had long chin hairs. In an interview on 01/31/2025 at 9:22 AM, Staff U stated daily care for a resident should include assisting them with shaving as needed. Staff U stated shaving was most often done during showers. Review of Resident 169's January 2025 ADL records showed staff documented no bathing was done between the resident's admission on [DATE] and 01/30/2025, seven days later. In an interview on 01/31/2025 at 9:34 AM, Staff F (Resident Care Manager) stated it was their expectation staff keep a resident clean and shaved. Staff F stated shaving was often done with showers, but would expect it done if a resident required shaving more often.<Resident 21> Review of the 12/18/2024 admission MDS showed Resident 21 had severe cognitive impairment and had diagnoses including a progressive memory loss disorder and a chronic autoimmune disorder affecting their brain and spinal cord. This MDS showed Resident 21 required substantial/maximal assistance with personal hygiene. Review of Resident 21's 12/13/2024 ADL self-care performance deficit CP showed staff were to check the resident's nail length and trim and clean on bath days and as necessary. Review of Resident 21's January 2025 Medication Administration Record (MAR) showed a 12/17/2025 order directing staff to perform fingernail care every Tuesday during the night shift. The MAR showed staff documented they completed fingernail care for Resident 21 on 01/28/2025. In an observation on 01/27/2025 at 9:35 AM, Resident 21 was lying in bed. Their fingernails on both hands were long and the nails on their right hand had dark debris underneath. Observation and interview on 01/28/2025 at 11:59 AM showed Resident 21 with long nails and debris under the nails, Resident 21 stated they received a shower that day. Similar observations were made on 01/29/2025 at 1:05 PM. In an interview on 01/28/2025 at 1:01 PM Staff W (CNA) stated they gave Resident 21 a bath that day. Staff W stated they forgot to offer to assist Resident 21 with their nail care that day. In an observation and interview on 01/30/2025 at 11:41 AM, Staff F confirmed Resident 21's nails were long and had debris under them. Staff F asked Resident 21 if they would allow staff to trim their nails, Resident 21 stated yes. In an interview on 01/31/2025 at 9:30 AM, Staff B (Director of Nursing) stated it was their expectation staff did not document that a task was done unless staff actually completed the task. REFERENCE: WAC 388-97-1060-(2)(c). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 36> According to a 11/28/2024 Quarterly MDS, Resident 36 had clear speech, was able to understand and be underst...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 36> According to a 11/28/2024 Quarterly MDS, Resident 36 had clear speech, was able to understand and be understood by others, and had no memory impairment. This MDS showed staff assessed Resident 36 to be at risk of developing pressure ulcers and had no ulcers, wounds, or skin problems. In an interview on 01/28/2025 at 8:36 AM, Resident 36 stated they had a rash on their abdomen and thighs which developed after they received a recent vaccination. Resident 36 stated the doctor ordered some medications that were helping to decrease the itching. Review of Resident 36's records showed the resident received a vaccination on 01/16/2025. Review of a 01/23/2025 communication form to the provider showed staff documented Resident 36 complained of increased itching which started on 01/16/2025 and had, some kind of dermatitis [swelling, redness, and itching]. According to a 01/23/2025 provider progress note, Resident 36 had some superficial scratches to both thighs and indicated the plan was to add a medication to help reduce itching and do daily skin checks. Review of Resident 36's records showed no daily monitoring of the resident's skin. The only skin assessment completed was on 01/27/2025, four days later, at which time staff did not identify the newly identified rash to their abdomen and thighs from 01/16/2025. Observations on 01/30/2025 at 9:24 AM, with Staff R (RN) showed Resident 36 had a pin-point red rash on both thighs and across their abdomen with several dried scratch marks to the left side. In an interview on 01/31/2025 at 9:34 AM, Staff F stated it was their expectation staff monitor skin as directed and document any findings accurately on the weekly skin assessments. Staff F stated Resident 36's new rash should have, but was not identified on the 01/27/2025 skin assessment.Based on observation, interview, and record review the facility: Failed to ensure residents' skin was assessed, monitored, and treated as required for 2 (Residents 269 & 36) of 4 residents reviewed for non-pressure skin, failed to ensure nonpharmacological pain interventions were in place for 1 of 5 residents (Resident 49) reviewed for unnecessary medications, and failed to ensure residents were monitored for latent injuries after falls for 1 of 2 resident (Resident 419) reviewed for falls. These failures placed all residents at risk for delay in treatment, worsening of condition, unmet care needs, and decreased quality of life. Findings included . <Facility Policy> Review of the facility's 08/16/2024 Wound Management policy showed the physician's order would specify the type of dressing and frequency of dressing changes for a resident's wound. This policy showed wound assessments would be documented upon admission, weekly, and as needed for changes in the wound's condition. Review of the facility's undated Incidents and Accidents policy showed licensed staff were required to utilize both PCC Risk Management and the Incident Investigation Folder to report incidents of resident falls within 24 hours of the occurrence and assist in completing an investigation within five days of the incident. Any injuries were to be assessed and reported by the licensed nurse to the resident's provider, implement new orders, care plan interventions and document in resident's record. <Resident 269> According to the 12/16/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 269 did not have cognitive impairment, was understood, and able to understand others in conversation. This assessment showed Resident 269 did not have any wounds or skin problems. In an observation and interview on 01/27/2025 at 8:58 AM, Resident 269 stated they had a sore on their stomach. Observation showed a wound dressing to the lower right side of their abdomen. A dime-sized amount of drainage was visible on the outside of the dressing. Resident 268 stated they thought they had the wound for a couple of weeks. A similar observation of the dressing was made on 01/28/2025 at 12:18 PM. Review of Resident 269's 01/28/2025 physician orders showed there were no orders directing staff to treat the wound to the resident's abdomen. Review of a 01/28/2025 Weekly Skin Evaluation form showed staff performed a head-to-toe skin assessment on Resident 269. This assessment showed staff did not identify any skin impairments to Resident 269. In an interview on 01/30/2025 at 10:26 AM, Staff T (Registered Nurse - RN) stated Resident 269 did have a wound to their right lower abdomen. Staff T stated the wound was improving and they completed a dressing change yesterday. Staff T reviewed Resident 269's physician orders and confirmed there was no order directing staff on how to treat the resident's wound. In an interview on 01/30/2025 at 11:45 AM, Staff F (Resident Care Manager - RCM) stated there should be an order directing staff on how to care for Resident 269's wound, but there was not. In an interview on 01/31/2025 at 9:39 AM, Staff B (Director of Nursing) stated it was their expectation staff notify the RCM of any new skin issues, evaluate and document the newly identified skin issue, and, notify and obtain orders from the physician. <Resident 49> According to a 12/02/2024 Quarterly MDS Resident 49 had no memory impairment. The MDS showed Resident 49 experienced pain frequently and the pain occasionally affected their sleep during the assessment period. The MDS showed Resident 49 had a diagnosis of, but not limited to, left leg amputation above the knee. Review of an 11/10/2024 Pain Medication Care Plan (CP), Resident 49 received an opioid pain medication for left leg amputation pain. The CP showed no nonpharmacological pain interventions for Resident 49's pain. Review of Resident 49's health records showed a 01/04/2024 physician order for an opioid pain medication administered as needed for complaint of pain. Resident 49's health records showed no nonpharmacological pain interventions. In an interview on 01/31/2025 at 8:12 AM Staff F stated Resident 49 did not have any nonpharmacological pain interventions but should. Staff F stated it was important staff assessed Resident 49's pain and offered nonpharmacological pain interventions first to ensure they were not masking something or causing harm to the resident. <Resident 419> Record review of the 01/21/2025 admission MDS showed Resident 419 was admitted to the facility on [DATE] and assessed with other neurological conditions including dementia, stroke, seizures, impaired memory, a risk for falls associated with the use of psychotropic medications. The MDS showed Resident 419 had no falls since admission and no skin problems or injuries were present during the assessment period. Observation on 01/27/2025 at 10:23 AM showed Staff CC (Medical Doctor) and Staff C (RCM) entered Resident 419's room to assess resident's left foot and ankle. Staff CC instructed Staff C to notify them when the results for Resident 419's left foot and ankle x-ray were available and to continue monitoring for worsening symptoms. According to the provider progress note dated 01/27/2025 at 2:41 PM, Resident 419 had a fall on 1/25/2025 from trying to get up from bed. The provider noted scattered swelling and bruising of left ankle, 2nd/3rd/4th toes, and the underside of the left foot. Provider ordered a left foot and ankle x-ray and monitoring for any changes or spontaneous bruising and bleeding. Review of Resident 419's health record between 01/25/2025 and 01/30/2025 showed no progress notes, skin assessments, or alert charting entries specific to Resident 419's left foot injuries were completed either immediately after the fall or as directed by the provider once discovered and noted in their 01/27/2025 progress note. In an interview on 01/31/2025 at 2:10 PM, Staff F reviewed Resident 419's health record and stated it did not appear that skin assessments or alert charting were conducted specifically related to Resident 419's left foot or ankle. Staff F stated nursing staff should have monitored specific skin areas for latent injuries and the areas should be clearly indicated in Resident 419's CP and progress notes. Staff F stated it was important to capture worsening symptoms. REFERENCE: WAC 388-97-1060(1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure residents were assessed for the need, ability, and safety of devices, and movement in bed for 2 of 5 residents (Residents 25 & 49) reviewed for accident hazards, and 1 supplemental resident (Resident 6). The failure to reassess use of a power wheelchair when required placed residents at risk for power wheelchair accidents. The failure to complete safety assessments for beds against the wall placed Residents 25 & 49 at risk of entrapment and injury. Findings included <Facility Policy> The facility's undated Motorized Chair Policy showed use of a power wheelchair was a right, rather than a privilege, and a resident must have the mental and physical capacity to safely operate a motorized chair as assessed by the Rehabilitation Department. The policy showed the resident must be trained by the Rehabilitation Department prior to authorization of motorized chair use. The policy showed a resident must sign a written agreement showing they would abide by safety rules related to use of a power wheelchair. The policy showed a resident using a power wheelchair must avoid contact with fixed and movable objects. The policy showed residents returning from the hospital would use a manual wheelchair until reassessed by the Rehabilitation Department. The policy showed if a resident's ability to safely operate their motorized chair was in question at any time based on staff observation or a reported incident, an assessment by the care team would be initiated. The policy showed in the event of injury to staff, self, or others, even if first occurrence the power wheelchair would be removed until assessed by facility staff. The policy showed if a resident showed signs of cognitive changes, the resident must not utilize a power chair until determined safe by the Director of Nursing (DON). <Resident 6> According to the 12/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 6 used a power wheelchair. The MDS showed Resident 6 could use their power wheelchair independently for a distance of at least 150 feet. The MDS showed Resident 6 had medically complex diagnoses including a history of stroke and one-sided paralysis. The MDS did not include an assessment of Resident 6's cognition, both the resident cognitive interview and staff cognitive assessment were incomplete. According to the Activities of Daily Living self-care deficit care plan, revised 08/03/2024, Resident 6 used a power wheelchair. The care plan showed Resident 6 could operate their power wheelchair independently. The 08/08/2024 Annual MDS showed Resident 6 was assessed with intact cognition. The 08/28/2024 discharge assessment - return anticipated MDS showed Resident 6 discharged to the hospital on that date, with a readmission to the facility anticipated. A nursing progress note dated 09/30/2024 showed a nursing assistant charted Resident 6 had bruising on their right ankle. The note showed Resident 6 reported they ran into a wall while operating their power wheelchair and felt some tenderness to their right lower leg. A nursing progress note dated 10/01/2024, showed Resident 6 continued to express discomfort regarding their right ankle area A provider note dated 10/04/2024 showed Resident 6 was referred for a lump on their right lateral leg. The note showed Resident 6 hit their right leg using their power wheelchair. A nursing progress note dated 10/05/2024 showed Resident 6 continued to report right ankle pain. The 10/17/2024 Quarterly MDS showed Resident 6 was assessed with moderately impaired cognition. The 11/13/2024 discharge assessment- return anticipated MDS showed Resident 6 discharged to the hospital on that date, with a readmission to the facility anticipated. Record review showed no reassessment of Resident 6's ability to use their power wheelchair after their two hospitalizations on 08/28/2024 and 11/13/2024 per the facility's policy; no reassessment after their cognition was shown to have diminished on the 10/17/2024 MDS's interview for mental status; no reassessment after Resident 6 injured their right ankle on 09/30/2024. On 01/28/2025 at 1:17 PM Resident 6 was heard screaming from the facility's second floor elevator door. Observation immediately afterward showed Resident 6 half in the elevator doorway with their right leg close to the right door frame of the elevator door. Resident 6 cried out in pain. Staff C (Resident Care Manager - RCM) ran over to check on Resident 6. Resident 6 then drove their left front wheel of their chair onto the foot of another staff member who came to assist. Resident 6 was assisted to their room. According to a nursing progress note dated 01/29/2025, Resident 6 was transported to a nearby hospital. This note showed Resident 6 sustained a a fracture to the lower end of their right thigh bone. The note showed the fracture required surgery. In an interview on 01/31/2025 at 1:40 PM, Staff B (DON) stated facility staff should have reassessed Resident 6 after their cognition changed from intact to moderately impaired on the 10/17/2025 Quarterly MDS. In an interview on 01/31/2025 at 2:05 PM Staff D (Rehab Director, Speech Therapist) stated they were unable to provide any power wheelchair safety assessments for Resident 6. Staff D stated since the current therapy provider started providing therapy services for facility residents in August 2024, no such assessments were completed for Resident 6. Staff D stated after initial assessments were completed, reassessment was done annually, and as needed. Staff D stated a change in cognition would be a good rationale for reassessment as diminished cognition could be a risk factor. In an interview on 01/31/2025 at 2:42 PM Staff B stated they did not know of the 09/30/2024 incident where Resident 6 hurt their right ankle while using their chair, but if they had, would have reassessed Resident 6's use of the wheelchair at that time. <Resident 25> According to the 11/15/2024 Quarterly MDS, Resident 25 had no memory impairment. The MDS showed Resident 25 was independent with rolling side to side in bed. The MDS showed no physical restraints were used in bed for Resident 25. The MDS showed Resident 25 had diagnoses of, but not limited to, stroke, oxygen dependent respiratory disease, and morbid obesity. Observation on 01/27/2025 at 1:17 PM showed Resident 25 in bed with the left side of their bed against the wall. Review of Resident 25's health records showed a 03/13/2024 physician order for the left side of the bed to be placed against the wall but no safety assessment for the placement of the left side of the bed against the wall. <Resident 49> According to 12/02/2024 Quarterly MDS Resident 49 had no memory impairment. The MDS showed Resident 49 was independent with rolling side to side in bed. The MDS showed no physical restraints were used in bed for Resident 49. The MDS showed Resident 49 had diagnoses of, but not limited to, a left leg amputation above the knee, muscle wasting and atrophy (deterioration of muscles), general weakness, and difficulty in walking. Observation on 01/27/2025 at 1:17 PM showed Resident 49 in bed with the right side of their bed against the wall. Review of Resident 49's health records on 01/28/2025 showed no safety assessment for the placement of the right side of bed against the wall. In an interview on 01/31/2025 at 8:21 AM Staff F (RCM) stated Residents 25 and 49 did not have safety assessments completed for their beds against the wall but should have. Staff F stated it was important to complete safety assessment for beds against the wall to ensure no entrapment occurred and for the overall safety of the resident. REFERENCE: WAC 388-97-1060(3)(g). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure 2 (Residents 120 & 38) of 5 sampled residents reviewed for nutrition received adequate weight monitoring. The failure to ensure a reweigh occurred after a significant weight change placed residents at risk for weight changes, and inaccurate assessment of nutritional status. <Facility Policies> According to the facility's 2023 Nutritional Management policy, the facility provided care and services to ensure resident maintained acceptable parameters of nutritional status . The facility's 2022 Weight Monitoring policy showed weight was a useful indicator of nutritional status and significant weight loss could indicate a nutritional problem. The policy showed a weight loss of greater than five percent (%) in one month represented a significant weight loss. <Resident 120> According to the 12/24/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 120 had a moderate memory impairment and medically complex diagnoses including multiple infections. According to a 01/05/2025 progress note, Resident 120 was transferred to the hospital on that date. The note showed Resident 120 had respiratory symptoms. According to a 01/14/2025 progress note, Resident 120 returned to the facility on that date. Record review showed Resident 120's weight fell from 146.5 Pounds (Lb.) on 12/24/2024 to 131.5 Lb. on 01/22/2024, representing a loss of -10.24 % in 29 days. Resident 120's weight on 01/14/2025, the date of their return from the hospital, was 139 Lb. Resident 120 lost 7.5 Lb. between 01/14/2025 and 01/22/2025, representing a 5.4% weight loss over 8 days. Resident 120 was not weighed again until 01/30/2025. In an interview on 01/31/25 at 12:07 PM, Staff Z (Registered Dietician) stated if nursing staff documented a weight representing a significant weight loss, they would ask staff to reweigh the resident. Staff Z stated it could be that Resident 120 refused to be reweighed. Staff Z stated they did not see any documentation of a refusal. <Resident 38> According to the 03/20/2024 Annual MDS, Resident 38 had medically complex conditions, including heart failure and depression. The MDS showed Resident 38 had a therapeutic diet due to a heart condition and needed set up assistance in order to eat. Review of a revised 1/27/2025 Poor Nutrition CP showed Resident 38 had a decreased appetite and used an antidepressant medication to stimulate their appetite. The CP showed staff were to monitor the use of the antidepressant medication and Resident 38's appetite and report weight loss. The CP did not show staff interventions on what staff would do when Resident 38 refused to have their weights taken or refused their meals. Review of physician progress note dated 1/24/2025 showed Resident 38 refused meals and the facility provider ordered an antidepressant medication that also acted as an appetite stimulant. The note showed staff were to monitor oral intake and weekly weights. Review of progress notes dated 1/30/2025 showed Staff Q (LPN) documented Resident 38 chronically refused their appetite stimulant medication and Staff Q was unable to evaluate the effectiveness. Review of December 2024 and January 2025 caregiver task sheets showed Resident 38 refused weekly weights from December 2024 through January 2025, with the last recorded weight taken on 11/17/2024. The nutrition caregiver task sheet showed from 01/01/2025 through 01/31/2025 Resident 38 refused breakfast 19 times, refused lunch 14 times and refused dinner 12 times. Review of the most recent nutritional assessment completed on 11/25/2024 showed Resident 38 was at moderate risk for nutritional needs and ate 50% to 100% of meals. In an interview on 01/27/2025 at 12:53 PM Resident 38 stated they thought they lost weight, but they refused to be weighed because the Hoyer lift used to get them up was very painful. In an interview on 01/31/2025 at 11:05 AM Staff F (Resident Care Manager) stated there should be other interventions in place to monitor Resident 38's weight and additional interventions in place on what staff were to do when Resident 38 refused meals. In an interview on 01/31/2025 at 9:47 AM Staff B (Director of Nursing) stated when Resident 38 refused their meals, staff should reapproach and try to assist Resident 38 with eating if they refused meals. Staff B stated the facility should try other interventions such as measure Resident 38's hip and waist to help assess changes in body mass if Resident 38 continued to refuse to be weighed. Staff B stated the interdisciplinary team should evaluate Resident 38's nutritional needs and make a plan to help Resident 38. REFERENCE: WAC 388-97-1060 (3)(h). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach) was administered in accordance with physician orders and professional standards of practice for 1 of 1 sampled resident (Resident 23) reviewed for enteral nutrition. The facility failed to accurately document the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive and deliver per physician orders. This failure placed the residents at risk for inadequate nutrition, dehydration, and other adverse outcomes. Findings included . <Facility Policy> According to an undated facility policy titled, Appropriate Use of Feeding Tubes, showed the facility would accurately document food and fluid intake. According to an undated facility policy titled, Flushing a Feeding Tube, showed the nurse would verify and accurately infuse water per physician orders. An undated facility policy titled, Care and Treatment of Feeding Tubes, showed the facility would ensure that the administration of enteral nutrition was consistent with and follows the physician orders. <Resident 23> According to a 12/27/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 23 admitted to the facility on [DATE]. The MDS showed Resident 23 had moderate memory impairment. The MDS showed Resident 23 had diagnoses of, but not limited to, Multiple Sclerosis (progressive neurological condition), Quadriplegia (paralyzed from waist down), Contracture of both hands (deformities), Dysphagia (difficulty swallowing), and enteral nutrition delivery through a stomach tube. Review of Resident 23's physician orders showed a 07/09/2024 order for enteral nutrition to be delivered via pump at 90 Milliliters (ml) an hour (/hr) with water at 65 ml/hr over 18 hrs. The physician order showed Resident 23 was to have enteral nutrition and water started at 3:00 PM and off at 9:00 AM. Review of Resident 23's November 2024, December 2024, and January 2025 Medication Administration Records (MAR) showed inaccurate calculations documented for formula infused each day. The MAR showed Resident 23 received 1080 ml of formula daily, but the physician order showed to infuse 1620 ml/day. The MAR showed Resident 23 received 585 ml of water, but the physician order showed to infuse 1170 ml/day. Observation and interview on 01/30/2025 at 2:58 PM showed Staff H (Licensed Practical Nurse) set tube feeding pump to deliver water at 90 mls/0 hr. During this observation Staff H did not review or reset the pumps enteral formula delivered from previous days. Staff H stated they set the water pump incorrectly and should have set per physician orders of 65 ml/hr. Staff H stated they never reviewed or cleared the pump to document the previous day's amount of formula and water infused. Staff H stated it was important to accurately document enteral nutrition intake, water intake, and administer per physician orders to ensure Resident 23 received adequate nutrition and hydration. In an interview on 01/31/2025 at 9:04 AM Staff B (Director of Nursing) stated they expected staff to administer enteral nutrition and hydration per physician order. Staff B stated it was important to accurately administer and document enteral nutrition and hydration to ensure the resident received adequate nutrition and hydration. REFERENCE: WAC 388-97-1060(3)(f). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

<Resident 419> Observations of medication pass on 01/29/2025 at 9:11 AM showed Staff R (Registered Nurse) prepare and administer multiple medications by mouth to Resident 419, including a multiv...

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<Resident 419> Observations of medication pass on 01/29/2025 at 9:11 AM showed Staff R (Registered Nurse) prepare and administer multiple medications by mouth to Resident 419, including a multivitamin with minerals. Review of Resident 419's January 2025 MAR revealed directions to staff to administer a standard multivitamin, rather than the multivitamin with minerals that was administered. In an interview on 01/29/2025 at 12:49 PM, Staff R verified the orders, located the different bottles of vitamins on the medication cart, and stated Resident 419 should have but did not receive the medication dose as ordered. In an interview on 01/31/2025 at 1:49 PM, Staff B stated it was their expectation staff administer medications as ordered. REFERENCE: WAC 388-97-1060 (3)(k)(ii). Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 2 of 25 medications for 2 of 6 residents (Resident 10 & 419) observed during medication pass resulted in a medication error rate of 8 %. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> The facility's undated Medication Orders Policy showed the elements of the medication order should be clarified for accuracy. The facility's undated Medication Administration Policy showed staff were to compare medication source (bubble pack, vial, etc.) with Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route, and time. <Medication Error> <Resident 10> Observations of medication pass on 01/29/2025 at 1:08 PM showed Staff S (Licensed Practical Nurse) prepared medications for Resident 10. Staff S identified the eye lubricant plus drops ordered were not present in the medication cart. Staff S went to the medication supply room and returned with dry eye relief drops, which contained different ingredients. Staff S compared Resident 10's physician order in the January 2025 MAR to the dry eye relief drops packaging, labeled the box with Resident 10's name and proceeded with administration preparation. Staff S entered Resident 10's room and explained medications to be administered. Resident 10 stated she self-administered eye drops; however, commented the bottle seemed larger than usual. Staff S observed the total number of drops self-administered by Resident 10, returned bottle to the labeled box and returned the box to the medication cart. Review of Resident 10's January 2025 MAR showed directions for staff to administer one drop of eye lubricant plus drops in both eyes four times per day. A review of active ingredients showed the dry eye relief drops offered temporary relief of eye burning and irritation and the eye lubricant plus drops offered the same benefits in addition to longer lasting and advanced moisturizing. In an interview on 01/30/2025 at 1:51 PM, Staff B (Director Of Nursing) confirmed the dry eye relief drops in the cart labeled with Resident 10's name were administered in error and contained different ingredients from the eye lubricant plus drops ordered by the physician. Staff B stated the facility mistakenly ordered the wrong eye drops to stock the medication supply room and the expectation was the medications administered should match the provider's order. Staff S should have identified the discrepancy prior to administering the eye drops and contacted the nurse manager for clarification.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to maintain intact resident room doorways, keep resident walls free of chipping paint, scuffs, and stains, keep hallways free of clutter, and ensure resident rooms were personalized for 3 of 4 units (Long Term 1, Short Term 1, & Short Term 2) left residents at risk for a less-than homelike environment. Findings included . <Facility Policy> According to the facility's 2024 Safe and Homelike Environment policy, the facility would provide residents with a safe, clean, comfortable, and homelike environment in accordance with resident rights. The policy showed the facility would prevent the spread of disease-causing organisms by keeping resident care equipment clean. The policy showed any unresolved environmental concerns would be reported to the administrator. <Long Term 1> Observation on 01/27/2025 at 10:49 AM showed room [ROOM NUMBER] had scuff marks on the bathroom door trim panel. The trim panel on the lower half of the door leading into the room was separating from the door and a sharp edge was exposed. The door frame had chipped and peeling paint at the hinges and the flashing was separated from door. The walls of the room had scuff marks. The room appeared barren and contained nothing of personal significance or interest for Resident 48 who resided in this room. In an interview on 01/29/2025 at 12:54 PM Resident 48 nodded that they would like their room to be more personal and homelike. Observation on 01/29/2025 at 1:09 PM of the shower room opposite room [ROOM NUMBER] showed trim in the shower room was missing and the flashing for the door was broken along the edge. Observation on 01/29/2025 at 8:30 AM on the Long Term 1 hallway showed 3 motorized scooters, one manual wheelchair, and one laundry cart against the wall. Dust was observed on one of the motorized scooters around the back of the seat. The manual wheelchair was soiled with dirt around the handles and seat. The laundry cart contained linens not completely folded and hanging from the cart was in front of the wheelchair. Behind the manual wheelchair was a bedside table crowded together up against a mechanical lift which was in front of another motorized scooter. An isolation cart containing personal protective equipment, had a green activity basket with markers and crayons on top of it. Observation on 01/30/2025 at 8:59 AM on the the Long Term 1 hallway showed the left side of the hallway had a multi layered laundry cart with linens, a manual wheelchair, a bedside table, a large, motorized scooter, and a mechanical lift crowded along the wall between rooms [ROOM NUMBERS] making it difficult for tray carts and residents to navigate the hallway. Similar observations on 01/30/2025 at 1:24 PM showed the Long Term 1 hallway had a large, motorized scooter, a mechanical lift and a nurse's cart blocking the hallway between rooms [ROOM NUMBERS]. Observed Resident 5 with their four wheeled walker trying to walk down the hallway but had to wait for approximately 2 minutes for staff to remove items out of the way so Resident 5 could continue walking. <Short Term 1> Observation of room [ROOM NUMBER] on 01/27/2025 at 10:29 AM showed the room door would not close because a piece of plastic floor trim was torn and detached from the floor, presenting a potential tripping hazard. On 01/27/2025 at 1:07 PM a nursing assistant was observed tripping on the detaching floor trim. Similar observations on 01/28/2025 at 8:17 AM showed the floor trim remained unfixed. Observation of room [ROOM NUMBER] on 01/27/2025 at 1:04 PM showed the threshold at the door was separated from the floor at door and presented a tripping hazard. Observation of room [ROOM NUMBER] on 01/27/2025 at 11:55 AM showed the door frame of the room was very worn and chipped around the hinges and the panel of the door was in poor repair. Observation of the ceiling on the second floor between the resident care managers' office and the nurse's station on 01/27/2025 at 12:58 PM showed stains on four ceiling tiles . <Short Term 2> <room [ROOM NUMBER]> Observation on 01/30/2025 at 12:42 PM showed room [ROOM NUMBER] with a missing strip of threshold between the room and hallway flooring. The gap exposed chipped, dirty linoleum tile in room [ROOM NUMBER]. The wall under the television of Bed A showed black scuffs along the wall. The shared sink in the room showed rust-colored drip marks running down the wall under the sink. <room [ROOM NUMBER]> Observation on 01/30/2025 at 12:45 PM showed room [ROOM NUMBER] with rust-colored drip marks running down the wall, under the shared sink. In an interview and walk-through of the facility on 01/31/2025 at 2:14 PM, Staff A (Administrator) stated it was important to provide a safe, comfortable, homelike environment to ensure quality of life for residents. Staff A stated it was important for maintenance needs to be addressed timely. Staff A stated the trims and thresholds for the resident room doors should be repaired and the rusty stains under sinks addressed. Staff A stated they were aware of the need to provide a more personalized room for Resident 48. REFERENCE: WAC 388-97-0880. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 120> According to the 12/24/2024 admission MDS, Resident 120 had a moderate memory impairment, and medically com...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 120> According to the 12/24/2024 admission MDS, Resident 120 had a moderate memory impairment, and medically complex diagnoses, including a multiple infections. According to a 01/05/2025 nursing progress note Resident 120 was observed to be congested with thick mucus and unable to expectorate. The note showed the doctor was called and the resident was transferred to the hospital. Record review showed no proof Resident 120 was provided a transfer notice as required after the 01/05/2025 hospitalization. There was no evidence the LTCO office was notified of the transfer, as required. In an interview on 01/31/2025 at 9:01 AM, Staff E (Social Services Director) stated they could not provide evidence a transfer notice was provided in person to Resident 120 or their representative, and there was no transfer notice in Resident 120's chart. Staff E stated transfer notices were important to help orient the resident to the cause of the transfer and notify them of their rights.Based on interview and record review, the facility failed to implement a system to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable, and ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information for 5 (Residents 36, 120, 25, 19, & 52) of 5 residents reviewed for hospitalizations. The failure to ensure written notifications were provided to residents and/or their representatives, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about transfers/discharges. The failure to ensure required notifications were completed, prevented the LTCO office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Policy> According to the facility's 2023 Transfer and Discharge policy, in the event of an emergency transfer, the facility would provide the resident a transfer form. The policy showed the original copy of the form should be sent with the resident and a copy provided to the resident representative as appropriate. The policy showed the Social Services Director (SSD) was responsible for for providing copies of emergency transfer notices to the State LTCO. <Resident 36> According to a 02/26/2024, 03/24/2024, and 09/11/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 36 was discharged emergently to an acute care hospital on [DATE], 03/24/2024, and 09/11/2024 with return anticipated. Record review showed no documentation staff provided written notification to Resident 36 and/or the resident's representative regarding their discharge as required for the 02/26/2024 and 03/24/2024 transfers to the hospital. Review of a 09/11/2024 Transfer/Discharge (Bed Hold) form showed staff completed some sections but left the Notice Provided To: section blank under the Notice of Transfer or Discharge section. Record review showed no documentation indicating the LTCO was notified of the transfer as required for either the 02/26/2024, 03/24/2024 or 09/11/2024 transfers.<Resident 19> Review of Resident 19's 01/26/2025 Discharge MDS showed the resident was discharged to the hospital on [DATE] with their return anticipated. Review of Resident 19's record showed there were no documents or progress notes indicating the resident received a written notice of transfer with their rights at the time of these transfers. <Resident 52> Review of Resident 52's 04/08/2024 and 11/09/2024 Discharge MDS's showed the resident was discharged to the hospital with their return anticipated. Review of Resident 52's 12/06/2024 Discharge MDS showed the resident was discharged to the hospital and their return was not anticipated. Review of Resident 52's record showed there were no documents or progress notes indicating the resident received a written notice of transfer with their rights at the time of these transfers. In an in interview on 01/29/2025 at 1:42 PM, Staff M (Social Services) stated they were unfamiliar with the regulation regarding notifying the LTCO when residents discharged to the hospital. Staff M was unable to provide documentation they notified the LTCO of resident's hospital transfers. In a joint interview on 01/29/2025 at 1:51 PM, Staff E and Staff M stated they were not familiar with the regulation for providing residents with written notices including their rights, at the time of transfer to the hospital. In an interview on 01/29/2025 at 2:00 PM, Staff A (Administrator) stated it was not the facility's current practice to send written notices when residents transferred to the hospital. In an interview on 01/31/2025 at 9:33 AM, Staff B (Director of Nursing) confirmed the LTCO should be notified of resident discharges and residents should be provided with written transfer notices. REFERENCE: WAC 388-97-0140(1)(a)(b)(c)(i-iii). <Resident 25> According to an 11/15/2024 Quarterly MDS Resident 25 had no memory impairment. The MDS showed Resident 25 had diagnoses of, but not limited to, stroke and heart failure. Review of Resident 25's health records showed they were hospitalized on [DATE], 01/02/2024, 01/19/2024, and 03/14/2024. Resident 25's health records did not have documentation of written transfer notifications being provided for any of the hospitalizations. In an interview on 01/27/2025 at 1:22 PM Resident 25 stated they went back to the hospital a few times over the last year. Resident 25 stated they did not receive written transfer notifications for the rehospitalizations.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 120> According to the 12/24/2024 admission MDS, Resident 120 had a moderate memory impairment, and medically com...

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CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received and/or participated in care conferences for 6 (Residents 50, 57, 23, 25, 49, & 38) of 20 residents reviewed and failed to ensure Care Plans (CP) were updated and/or revised to reflect person-centered care for 1 (Residents 36) of 22 sample residents whose CPs were reviewed. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's undated Resident Participation - Assessments/Care Plans Policy, the resident/and or their representative had a right to participate in the resident assessment and development of the person-centered CP. This policy showed residents/representatives would receive seven-day advance notice of care conference meetings. The social services director or designee was responsible for maintaining care conference records. <Care Conferences> <Resident 50> According to an 11/04/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 50 had clear speech, was understood, able to understand others, and had no memory impairment. In an interview on 01/27/2025 at 12:10 PM, Resident 50 stated they did not have a care conference for a long time and stated they were frustrated the meeting had not happened yet. Review of Resident 50's records showed the last care conference was from 05/23/2024, eight months earlier. In an interview on 01/31/2025 at 9:34 AM, Staff F (Resident Care Manager) stated care conferences were important as they give the opportunity for residents and/or families to share concerns and team members to review current plans and updates. Staff F stated care conferences should be done quarterly and indicated they were behind and trying to get caught up on the quarterly conferences. <Resident 57> Review of Resident 57's 11/07/2024 Annual MDS showed the resident had impaired memory and thinking processing. The MDS showed Resident 57 had diagnoses including a memory loss disorder, chronic pain, and high blood pressure. Review of Resident 57's records showed their last documented care conference was 03/07/2024. The care conference evaluation showed issues discussed included Resident 57's low back and knee pain. Resident 57 requested more clothing and the possibility of discharging from the facility. The summary of the document showed Resident 57's discharge plan was to go to an adult family home. Review of Resident 57's progress notes from March 2024 to January 2025 and evaluations showed the resident did not have a care conference since 03/07/2024, over 10 months prior. In an interview on 01/31/2025 at 8:31 AM, Staff E (Social Services Director) confirmed Resident 57 did not have a care conference since 03/07/2024. Staff E stated care conferences were important to track a resident's progress. Staff E stated care conferences allowed for the facility, the resident, and/or their representative to be collaborative in the resident's care, set goals for therapy, discharge planning, and work towards a successful stay at the facility. <Resident 23> According to a 12/27/2024 Quarterly MDS Resident 23 admitted to the facility 12/07/2018. The MDS showed Resident 23 had moderate memory impairment. The MDS showed Resident 23 had diagnoses of, but not limited to, Quadriplegia (paralysis from the neck down), Multiple Sclerosis (progressive neurological disorder), and depression. Review of Resident 23's records showed their last documented care conference was 11/29/2023. <Resident 25> According to a 11/15/2024 Quarterly MDS Resident 25 admitted to the facility on [DATE]. The MDS showed Resident 25 had no memory impairment. The MDS showed Resident 25 had diagnoses of, but not limited to, stroke, anxiety disorder, depression, and post traumatic stress disorder. Review of Resident 25's health records showed their last documented care conference was 01/28/2024. <Resident 49> According to a 12/02/2024 Quarterly MDS Resident 49 admitted to the facility on [DATE]. The MDS showed Resident 49 had no memory impairment. The MDS showed Resident 49 had diagnoses of, but not limited to, anxiety disorder, depression, and left leg amputation. Review of Resident 49's records showed their last documented care conference was 02/07/2024. In an interview on 01/31/2025 at 9:38 AM Staff F stated Residents 23, 25, and 49 did not have care conference per facility policy or regulation. Staff F stated they expected care conferences to be conducted 48 hours after admission to the facility, quarterly, and as needed. Staff F stated care conferences were important to include the resident in their plan of care. <Resident 38> According to the 11/26/2024 Quarterly MDS, Resident 38 had medically complex conditions, was understood, could understand by others, and had some memory impairment. Record review showed the last documented care conference for Resident 38 occurred on 4/05/2024. No other care conference was documented for Resident 38. In an interview on 01/27/2025 at 12:51 PM Resident 38 stated they did not have a recent conversation with the staff about their care. In an interview on 01/28/2025 at 12:47 PM Resident 38 stated no one talked to them about their care. In an interview on 01/30/2025 at 10:26 AM, Staff M (Social Services) stated the facility provided quarterly care plan meetings with the Interdisciplinary Team (IDT-Nursing, Social Worker, Food Director, Activities, etc). Staff M stated care conferences were held in the resident's room and the IDT team asked the resident how everything was going with their care and how they were doing. Staff M stated they did not always document completed care conferences and they did not routinely keep notes from the care conferences. Staff M stated they did a care conference for Resident 38, but did not have documentation to show this was completed recently. In an interview on 01/31/2025 at 11:06 AM Staff F stated they invited the legal guardian to Resident 38's care conferences, but they did not always show up for these. Staff F stated care conferences should happen with Resident 38 even if the guardian was not present. In an interview on 01/31/2025 at 9:47 AM Staff B (Director of Nursing) stated we discuss care as an IDT with the social worker during care conferences. Staff B stated care conferences should be quarterly and agreed Resident 38 did not have their last quarterly care conference. Staff B stated care conferences were important for everybody to have a plan, to know where care was going and to know what the resident's goals were. <Care Plan Revision> <Resident 36> According to an 11/28/2024 Quarterly MDS, Resident 36 used a wheelchair for mobility and walking was not attempted due to medical conditions or safety concerns. Review of a revised 09/09/2024 ADL [Activities of Daily Living] self-care performance CP showed Resident 36 used a wheelchair for mobility. Review of Resident 36's January 2025 ADL documentation showed a restorative nursing program for the resident to walk up to 20 feet three days a week. Staff documented Resident 36 was not doing the walking program. Observations on 01/27/2025 at 11:55 AM and 01/29/2025 at 12:47 PM showed Resident 36 in a wheelchair during activities. In an interview on 01/31/2025 at 1:38 PM, Staff FF (Restorative Nursing Assistant) stated Resident 36 was not currently doing a walking restorative program. Staff FF stated Resident 36 walked with therapy previously but stated the resident would not continue due to complaints of leg pain. Staff FF stated they did not observe Resident 36 doing a walking program, in some time. In an interview on 01/31/2024 at 9:34 AM, Staff F stated it was their expectation care plans be updated and revised as needed to reflect the current conditions of the resident. REFERENCE: WAC 388-97-1020(2)(c)(d), (4)(c)(i-ii). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure resident meals were prepared following the menu as directed for 1 of 1 meal preparations observed. The failure to prepare meals according to the dietician approved spreadsheet placed residents at risk of unmet nutritional needs, and other potential negative health/nutritional outcomes. Findings included . The menu for lunch service on 01/30/2025 showed the facility was serving a main entree of mandarin chicken that day. The menu showed residents requiring a regular menu would be served a scoop of the regular preparation of the mandarin chicken and residents requiring controlled carbohydrate (lower sugar) and renal (kidney) diets would be served a scoop of the diet preparation of the menu. Observation of lunch service on 01/30/2025 from 11:24 AM through 12:52 PM showed Staff Y (Kitchen Cook) serving meals for residents. Staff Y served a scoop of orange chicken from the same pan for residents requiring regular, controlled carbohydrate, and renal diets. There was no second pan of the diet specific main course on the steam table. In an interview on 01/30/2025 at 12:52 PM Staff X (Dietary Supervisor) stated the kitchen staff prepared only the diet version of the mandarin chicken. Staff X provided the recipe for the diet preparation and stated they were unsure the exact nutritional difference of the two different preparations of the mandarin chicken. In an interview on 01/30/2025 at 3:25 PM Staff X stated they spoke with the Staff Z (Registered Dietician) who stated the substitution of the diet mandarin chicken for residents requiring regular meals was not a big deal. Staff X provided the recipes for both the regular and diet preparations of the mandarin chicken. The recipes showed the diet preparation provided 15 fewer kilocalories, 26 fewer grams of carbohydrate, and 33 fewer grams of sugar. In an interview on 01/31/2025 at 12:14 PM Staff Z stated it was important to follow the menu. Staff Z stated there was a nutritional difference in the two different recipes. REFERENCE: WAC 388-97-1160 (1)(a)(b). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

<Resident 4> According to the 11/26/24 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 4 had diagnoses including a spinal cord dysfunction, a history of stroke, and respi...

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<Resident 4> According to the 11/26/24 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 4 had diagnoses including a spinal cord dysfunction, a history of stroke, and respiratory failure. The MDS showed Resident 4 had a prognosis of less than six months and received hospice services. Record review showed an 11/26/2024 physician's order for hospice services. According to the 01/21/2025 Hospice Plan of Care, Resident 4 would continue with hospice services This Hospice Plan of Care showed hospice visits were scheduled once weekly and as needed. Record review showed in total only four hospice documents were scanned into Resident 4's record: an 11/26/2025 hospice visit note, a 12/09/2024 hospice change of physician's orders document, a 01/08/2025 hospice visit note, and the 01/21/2025 Hospice Plan of Care. In an interview on 01/31/2025 at 10:31 AM Staff F stated coordination between the facility and the hospice provider was effective. Staff F stated the hospice provider came as scheduled and as needed, and the facility had no concerns with the provision of Resident 4's hospice care. Staff F stated they expected the hospice records to be scanned into Resident 4's record. Staff F stated there could be a backlog in the facility's medical records department. In an interview on 01/31/2025 at 11:17 AM Staff BB (Medical Records) stated making sure the residents' records was comprehensive was important and stated they were a little bit behind in their scanning. Staff BB stated it could take a couple of weeks to scan records in residents' charts. <Resident 120> According to the 12/24/2024 admission MDS Resident had medically complex diagnoses including multiple infections. The MDS showed Resident 120 used a urinary catheter (tubing to help facilitate urinary drainage for residents with conditions making urination more difficult). In an interview on 01/31/2025 at 10:24 AM Staff F stated the rationale for Resident 120's urinary catheter was a prostate condition that was identified in the discharge documentation from the hospital at the time of admission. Staff F stated that this condition should be reflected in the resident's record, and it was the responsibility of the medical records department to ensure diagnoses were reflected accurately in the record. <Resident 44> Review of Resident 44's records showed pharmacy progress notes on 12/18/2024 and 01/15/2025 indicating the resident's medications had been reviewed. Review of a binder provided by Staff B showed a 07/18/2024 pharmacy recommendation to decrease a medication for anxiety, this was addressed by staff, but the recommendation information was not found in Resident 44's records. There were no recommendations in the binder for December 2024. Staff B was able to reprint the pharmacy recommendations and provide one for Resident 44 which recommended to decrease a medication used to treat heartburn. This recommendation was addressed by staff but was not found in Resident 44's records. In the binder was a 01/16/2025 pharmacy recommendation to reduce Resident 44's antidepressant medications, this was addressed by staff, but the recommendation information was not found in Resident 44's records. In an interview on 01/31/2025 at 1:49 PM, Staff B stated it was their expectation staff scan the pharmacy recommendations into the resident records promptly so they would be readily available for access. <Resident 33> Review of Resident 33's 10/30/2024 Quarterly MDS showed the resident had diagnoses including anxiety, depression, and a mood disorder. This MDS showed Resident 33 received antipsychotic, antidepressant, and antianxiety medications during the look back period. Review of Resident 33's records showed no pharmacy records were available in the resident's record for August 2024 and December 2024. In an interview on 01/30/2025 at 12:49 PM, Staff B confirmed that pharmacy recommendations should be available in Resident 33's records but were not. <Resident 25> Review of Resident 25s health records on 01/29/2025 showed no pharmacy recommendations. <Resident 49> Review of Resident 49s health records showed no pharmacy recommendations. In an interview on 01/30/2025 at 9:38 AM Staff B stated Residents 25 and 49 did not have the pharmacy MRRs in their health records but should. Staff B stated they had a binder in their office with copies of all resident's pharmacy recommendations. Staff B stated all pharmacy recommendations should be scanned into the residents' records to show the pharmacy recommendations and physician orders. <Resident 23> Observation and interview on 01/30/2025 at 2:58 PM Staff H (Licensed Practical Nurse) walked away from the medication cart with the computer screen open to Resident 23's medication administration records. Staff H stated they understood they should lock the computer screen prior to leaving it for resident privacy but forgot too. In an interview on 01/31/2025 at 8:04 AM Staff B stated they expected staff to lock computer screens prior to leaving them to ensure resident privacy. Staff B stated it was important to protect resident's records for resident rights and privacy. REFERENCE WAC 388-97-1720 (2)(a-m). Based on interview and record review, the facility failed to ensure resident records were maintained comprehensively and readily accessible for 8 of 20 sample residents whose records were reviewed (Residents 1, 4, 120, 44, 33, 25, 49, & 23). The failure to ensure health records were added to the chart timely placed residents at risk for incomplete medical records, delays in treatment, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's undated Dialysis (a process for filtering the blood policy, the facility would assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice, including ongoing assessment of the resident's condition, and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The policy included the monitoring of the resident's condition during treatments, monitoring for complications, and for implementation of appropriate interventions. <Resident 1> According to the 01/22/2025 Annual MDS, Resident 1 was dependent on dialysis due to end stage renal (kidney) disease and had a history of blood transfusions. Review of the revised 06/18/2024 Hemodialysis Care Plan (CP) showed staff would send a dialysis transfer form with Resident 1 when they went to dialysis for treatments. Interventions on the CP showed the dialysis form would contain initial and pre-treatment health information filled in on the form. The dialysis center would return the dialysis form with treatment information and the nurse at the facility would enter information into the electronic medical record. Observation on 01/29/2025 at 10:01 AM showed the facility kept a dialysis binder on the wall near the 2nd floor north hallway nurse's station. Within the binder, there were handwritten notes on the dialysis transfer forms with observations and questions from the dialysis center to the facility as well as lab reports with results. A note dated 1/24/2025 showed the dialysis center notified the facility that Resident 1's blood pressure was dropping and asked if Resident 1 received any medication that would cause the resident to sleep more and for their blood pressure to decrease. Original copies of the lab report card results 10/1/2024-12/09/2024 and 11/1/2024-1/09/25 and a lab report from 12/4/2024 from the kidney dialysis center for Resident 1 were in the binder. Review of Resident 1's medical record showed the dialysis center lab report card with lab results dated 10/1/2024-12/09/2024 and 11/1/2024-1/09/25 were not in the medical record. Lab results report from a lab completed on 12/4/2024 were not found in the medical record. Notation that the dialysis center asked a question about Resident 1 sleeping more and had a lower blood pressure was not found in the medical record. Interview on 01/29/2025 at 10:13 AM, Staff A (Administrator) stated all the dialysis notes and lab results from the dialysis center should have been scanned into Resident 1's medical record but were not. In an interview on 01/31/2025 at 10:57 AM Staff F (Resident Care Manager) stated nurses should enter the dialysis dates, lab information and information such as blood transfusions information and the paperwork into the electronic medical record. Staff F stated the paperwork from the dialysis center should be scanned in right away to the medical record by the medical record staff. Staff F stated if the paperwork did not get into the medical record, this would create a problem as other providers would not have access to review Resident's 1's notes for care. In an interview on 01/31/2025 at 9:52 AM, Staff B (Director of Nursing) stated dialysis treatment information should be scanned immediately into the medical record. Staff B stated nurses, providers, and the pharmacy all needed to be able to review the dialysis treatment notes. Staff B stated they were aware scanning information into the medical record was an issue at the facility.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <HH in the Dining Room> Observation of the lunch service in the facility's main dining room on 01/27/2025 11:52 AM showed ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <HH in the Dining Room> Observation of the lunch service in the facility's main dining room on 01/27/2025 11:52 AM showed Staff AA (Activity Aide) helping to distribute lunch trays to residents in the dining room. At 11:59 AM, Staff AA was observed to open a bag of chips for a resident, then hand a plate to a neighboring resident. Staff AA retrieved a ketchup packet from a second table and gave it to the resident they helped with the chips. Staff AA did not perform HH between residents and between tables. At 12:01 PM Staff AA repositioned a resident in their wheelchair using the handle of the wheelchair to change the angle of the seat. Staff AA helped reattach the resident's footrests, entered the Activity Department office using the door handle, then returned, putting on gloves before assisting the resident they recently repositioned with their socks and providing a blanket. Staff A then removed their gloves and performed HH. At 12:13 PM Staff AA put on gloves without first performing HH, then brought a coffee from a resident to the dirty cart. Staff AA then returned to cleaning up more soiled dishes, changed gloves without HH, then while wearing a right glove only, carried a dirty tray to the cart, placing it at the bottom. Staff AA then took a clean tray to a resident waiting outside the dining room. The clean tray came from the top of the same cart in which Staff AA was placing dirty dishes In an interview on 01/31/2025 at 12:47 PM Staff J stated it was their expectation staff performed HH between handling clean and dirty dishes, and between helping different residents. Staff J stated their expectation was staff not place dirty trays on the same cart as clean trays. <Uncleanable Surfaces> Observations on 01/27/2025 at 9:15 AM and 01/28/2025 at 1:42 PM showed a chair lined up against the wall near room [ROOM NUMBER]. The chair had torn material on the arm rests, exposing the cushion underneath. Next to the chair were three wheelchairs with torn arm rests with some tape hanging off one of the armrests. In an interview on 01/30/2025 at 10:00 AM, Staff J stated torn material was uncleanable and increased the risk of spreading infections. Staff J stated the arm rests should be replaced. Based on observation, interview, and record review the facility failed to ensure staff performed Hand Hygiene (HH) in accordance with standard precautions and/or remove Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measures used to reduce the spread of multidrug-resistant organisms) for 1 supplemental resident (Residents 269), maintain clean resident equipment, cleanable surfaces throughout the facility, and establish a water management program that assessed and monitored measures to prevent the growth of Legionella (bacteria that could cause a serious lung infection), and other opportunistic waterborne pathogens in the facility's water systems. These failures placed residents at risk for the development and transmission of communicable diseases and an unclean environment. Findings included . <Facility Policies> The facility's undated Resident Rights Policy showed that resident had a right to a safe, clean, comfortable and homelike environment. The facility's undated Cleaning and Disinfection of Resident-Care Equipment Policy showed staff were responsible for the cleaning and disinfection of multi-resident use equipment after each use and before use by another resident. <Water Management Program> In an interview on 01/29/2025 at 8:41 AM, Staff G (Maintenance Director) stated they were recently hired and were unable to locate documents to demonstrate the facility's water management plan. Staff G stated they thought the facility performed a Legionella test prior to Staff G being hired but Staff G was unable to provide testing documentation. Staff G was unaware of high-risk areas in the facility's water systems where Legionella had the potential to grow. Staff G stated each week they checked hot water in random resident rooms, kitchen, laundry, rehab gym, and facility showers but they did not keep a log of their work. Staff G confirmed they should have a water management plan to prevent water borne pathogens, but they did not. In an interview on 01/29/2025 at 1:46 PM, Staff A (Administrator) stated the facility should have a water management plant in place to prevent Legionella, but they did not. <HH/PPE> <Resident 269> Review of Resident 269's 12/31/2024 revised EBP care plan showed the resident was on EBP due to having a multidrug resistant organism in their urine. This care plan directed staff to wear a gown and gloves when providing care. Observation on 01/28/2025 at 12:18 PM showed Staff I (Certified Nursing Assistant) providing incontinence care to Resident 269. Staff I had a gown and gloves on. Staff I cleaned Resident 269 with a wipe and applied barrier cream to the resident. Staff I grabbed the resident's blankets and opened the resident's closet using their soiled gloves. Staff I did not remove their gloves or perform HH before touching the resident's blankets or closet handle. Staff I then removed their personal protective gown with their soiled gloves on. Staff I removed their soiled gloves last and washed their hands. In an interview at that time, Staff I confirmed they should have removed their gloves prior to touching Resident 269's blankets and closet handle and should have removed their soiled gloves before removing their personal protective gown. In an interview on 01/31/2025 at 11:28 AM, Staff J (Infection Preventionist) confirmed staff should perform HH and change their gloves when going from dirty to clean and staff should remove PPE in the correct order. <Dirty Resident Equipment> Observations on 01/27/2025, 01/28/2025, 01/29/2025 and 01/30/2025 showed a mechanical lift (assistive equipment used to transfer residents) was positioned along the wall near the 2nd floor dining area and had dried, brown, liquid-like splatter on its base and mast. Observation on 01/30/2025 at 1:25 PM showed Staff V (Certified Nursing Assistant) took the lift into room [ROOM NUMBER], used the lift to transfer the resident to a shower chair, and returned the lift to its previous location near the 2nd floor dining area without sanitizing it. In an interview on 01/30/2025 at 2:14 PM, Staff J stated they expected all staff to sanitize assistive equipment with germicidal disposable wipes after each use. They stated these wipes were available in designated locations throughout the facility and staff were trained on procedures to perform equipment sanitization. In an interview on 01/30/2025 at 2:26 PM, Staff H (Licensed Practical Nurse) confirmed the mechanical lift had dried, brown, liquid-like splatter on the base and mast. Staff H stated the debris placed residents at risk for cross contamination and should have been cleaned if you don't want [an infection]. REFERENCE: WAC 388-97-1320 (1)(a)(c), (5)(c). .

Aug 2024 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident 1) reviewed for sexual abuse. Resident 1 experienced psychological harm, applying the reasonable person approach (how a reasonable person would respond under the same circumstances), when they were inappropriately touched on their breast by Resident 2. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding. Findings included . Review of the facility Abuse, Neglect and Exploitation policy, dated 2023, showed the facility would provide protection for the health, welfare and rights of each resident by developing and implementing policies that prohibit abuse. The facility would keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This included freedom from verbal, mental, sexual, or physical abuse, corporal punishment, and involuntary seclusion. The policy showed sexual abuse, defined as non-consensual sexual contact of any type with a resident. <Resident 1> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 08/07/2024, showed Resident 1 was not able to make their own decisions due to severely impaired cognition, needs known, and was rarely or never understood by others. The MDS showed Resident 1 had short and long term memory problems, was not able to recall the current season, location of their room, where they were, and staff faces and names. The MDS showed Resident 1 had no behaviors and diagnoses including a history of a stroke (brain bleed), Alzheimer's disease, aphasia (a communication disorder caused by damage to the brain that controls language, expression, and comprehension), depression, and schizophrenia (a mental health disorder that affects how people think, feel, and behave). The MDS showed Resident 1 used a wheelchair, and required staff assistance for wheelchair mobility, transfers, and hygiene care needs. Review of Resident 1's Activities of Daily Living (ADL) and communication problem care plan (CP), revised 07/23/2024, showed Resident 1 preferred female caregivers. The CP directed staff to anticipate Resident 1's needs and ensure a safe environment as Resident 1 was not able to communicate effectively. Review of an impaired cognition CP, revised 07/23/2024, showed Resident 1 had an impaired thought process due to dementia and directed staff to cue, re-orient, and supervise as needed. Review of a Nursing Progress Note (NPN), dated 08/09/2024, showed Resident 1 was placed on alert charting to monitor for signs and symptoms of distress from being touched inappropriately. Review of a facility investigation, dated 08/09/2024, showed Resident 1 was sitting in their wheelchair in the hallway when Resident 2 was observed rubbing and touching Resident 1's breast. Staff D (Licensed Practical Nurse) separated the residents and staff redirected Resident 2 away from Resident 1. During an observation and interview on 08/16/2024 at 4:00 PM, Resident 1 was observed sitting on the edge of their bed. Resident 1 stated doing good, but was unable to answer questions related to the incident with Resident 2. <Resident 2> Review of a quarterly MDS, dated [DATE], showed Resident 2 was not able to make their own decisions, needs known, and was rarely or never understood by others. The MDS showed Resident 2 had physical behavioral symptoms that were directed at others and other behavioral symptoms that were not directed at others, the behaviors occurred one to three times during a seven day look back period. The MDS showed the behaviors significantly interfered with Resident 2's care and participation in activities and social interactions, significantly intruded on the privacy and activity of others, and disrupted the care and living environment. The MDS showed Resident 2 had diagnoses including non-traumatic brain dysfunction, dementia, and a cognitive communication deficit (trouble reasoning and making decisions while communicating). The MDS showed Resident 2 ambulated independently with a walker and required staff assistance with bathing and personal hygiene. Review of Resident 2's medical record showed a NPN, dated 04/19/2023, the NPN showed a staff member saw Resident 2 touching a female resident's breast. The staff asked Resident 2 to stop and separated both residents. A NPN, dated 04/19/2023, showed Staff D, (Social Services Director) followed up with Resident 2 who denied touching another resident's breast. The NPN showed the SW identified through resident interviews another female resident who was inappropriately touched on the breast by Resident 2. Review of a NPN, dated 08/09/2024, showed staff witnessed Resident 2 ambulating with their walker, and was found Resident 2 rubbing and touching the breast of Resident 1. Review of Resident 2's behavior CP, dated 10/24/2023, showed Resident 2 had sexually inappropriate behaviors that included touching female residents, exposing their genitals and masturbation. The CP directed staff to re-direct Resident 2 to their room for privacy when observed masturbating in public, monitor for behaviors, re-direct or remove Resident 2 from situations, and intervene as necessary to protect the rights and safety of other residents. Review of a NPN, dated 08/09/2024, showed Resident 2 was observed by a Staff D walking over to Resident 1, asked if they could touch Resident 1's breast, and proceeded to rub Resident 1's breast. The staff member stopped Resident 2 and reported the incident to Staff B (Director of Nursing Services). Review of a facility investigation, dated 08/09/2024, showed Resident 2 was re-directed to their room after being observed by Staff D rubbing Resident 1's breast. The investigations showed both Resident 1 and Resident 2 had dementia, and Resident 2 did not recall touching Resident 1's breast. In an interview of 08/16/2024 at 3:45 PM, Staff B stated Resident 2 had a history of sexually inappropriateness, was not aggressive, and did not recall the incident with Resident 1. Staff B stated both Resident 1 and Resident 2 had dementia and were not able to recall the incident. Staff B stated Resident 2 needed increased supervision and should be kept away from female residents. In an observation and interview on 08/16/2024 at 3:55 PM, Resident 2 was observed sitting in a chair in the hallway next to the nursing station. Resident 2 was asked about the incident but did not recall what happened. When asked if Resident 2 was touched inappropriately, they responded, not yet, darn it. I wish they would. Resident 2 asked repeatedly for a kiss during the interview. During an interview on 08/16/2024 at 4:05 PM, Staff C (Nursing Assistant Certified), stated Resident 2 made sexual statements to the staff, either asking for a kiss or asking they lay in the bed with the resident. Staff C stated Resident 2 could be difficult to re-direct at times and was reminded the behavior was inappropriate. Staff C stated it was not okay for another resident to touch another resident's breast as it would be considered sexual abuse. The facility corrected the failed practice prior to the investigation by having only male caregivers work with resident 2 to decrease and remove the triggers or stimulation from females .This was past non-compliance and is no longer outstanding. REFERENCE: WAC 388-97-0640(1).

Jul 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) to include teeth brushing, transfers out of bed, and assistance with eating for 1 of 3 dependent residents (Residents 1) reviewed for ADL's. The failure to provide assistance with teeth brushing, transfers out of bed and eating to dependent residents, placed residents at risk for decreased intake, weight loss, poor hygiene, skin breakdown, embarrassment, and a diminished quality of life. Findings included . Review of the facility policy titled, ADL Care for Dependent residents, undated, showed the facility would provide appropriate treatment and services for dependent residents to ensure all ADL needs were met on a daily basis while attaining or maintaining the resident's highest practicable physical, mental and psychosocial well-being. Each resident's physical functioning would be assessed, included in the Care Plan (CP), and the CP interventions would be monitored on an on-going basis for effectiveness and would be reviewed as necessary. <Resident 1> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 05/01/2024, showed Resident 1 admitted to the facility on [DATE]. The MDS showed Resident 1 was able to make their needs known, had no behaviors of rejection of care, and had diagnoses including a history of a brain bleed with left sided weakness, heart failure, high blood pressure, diabetes, disease of the stomach, and acid reflux. The MDS showed Resident 1 was assessed with loss of liquids or food from their mouth when eating or drinking, had no weight loss, and required moderate assistance with eating meals and oral hygiene. Review of a functional abilities and goal assessment, dated 01/31/2024, showed Resident 1 was assessed to require supervision or touching assistance with eating and the had ability to use utensils to bring food and liquids to the mouth. The assessment showed Resident 1 required maximum assistance with oral hygiene and was dependent on staff for bed to chair transfers. Review of Resident 1's Physicians Orders (PO) showed a PO, dated 02/02/2024, that directed staff to get Resident 1 out of bed for all meals and assist with feeding during each meal. Review of a PO, date 02/06/2024, showed Resident 1 was referred to speech therapy for coughing during eating related to a history of a brain bleed. Review of a Nursing Progress Note (NPN), dated 02/02/2024, showed staff documented that Resident 1 to be out of bed for each meal and assisted with feeding to prevent aspiration (inhalation of food or liquids into the lungs). Review of a Provider Progress Note (PPN), dated 02/14/2024, showed the provider noted Resident 1 with clear lungs and a cough. The PPN showed Resident 1 had dysphasia (difficulty swallowing), was seen consistently coughing during eating meals and directed staff Resident 1 was to be out of bed for all meals, sitting upright to prevent aspiration. Review of an ADL, self-care deficit Care Plan (CP), initiated on 01/29/2024, showed Resident 1 required limited assistance, by staff, for help with meals, was dependent on two staff assistance with a mechanical lift to transfer out of bed and into the wheelchair. The CP did not identify the amount of assistance Resident 1 required for oral hygiene. Review of Resident 1's ADL CP, revised on 05/13/2024, showed Resident 1 was able to feed themselves after set-up assistance when sitting up in the wheelchair and should be up in the wheelchair during all mealtimes. The CP showed Resident 1 required one person extensive assistance with oral care and directed staff to brush Resident 1's teeth and assist with rinsing their mouth after meals as needed. Review of ADL documentation, dated 02/2024, showed on 02/04/2024, 02/08/2024, and 02/20/2024 staff documented Resident 1 was independent with hygiene needs and required set up assistance only for teeth brushing. Review of the ADL documentation showed multiple nursing staff documented not applicable, indicating a transfer did not occur or left the documentation blank for transfers on 02/05/2024, 02/06/2024, 02/07/2024, 02/10/2024, 02/12/2024, 02/14/2024, 02/15/2024, 02/18/2024, 02/19/2024, 02/20/2024, 02/22/2024, 02/24/2024, 02/25/2024, 02/26/2024, and 02/29/2024. Review of the ADL documentation showed staff documented Resident 1 was independent with eating and required set up tray help from staff or left the documentation blank on 02/01/2024, 02/02/2024, 02/05/2024, 02/06/2024, 02/07/2024, 02/10/2024, 02/12/2024, 02/13/2024, 02/14/2024, 02/15/2024, 02/18/2024, 02/20/2024, 02/23/2024, 02/24/2024, 02/25/2024, 02/26/2024, 02/28/2024, and 02/29/2024. Similar findings were identified when 03/2024, 04/2024, and 05/2024 ADL documentation was reviewed and showed Resident 1 was not assisted as required on multiple occasions with oral hygiene, transfers out of bed, and supervision and assistance with meals. In an interview on 07/18/2024 at 1:30 PM, Staff C (Restorative Nursing Assistant) stated Resident 1 had difficulties swallowing, would cough and sneeze during meals, and staff had to remind Resident 1 to use a chin-tuck method (induces swallowing by bending the head, neck, and pulling the chin towards the body) when eating meals. Staff C stated Resident 1 would come down to the main dining room so staff could assist the resident and if Resident 1 did not come to the main dining room, they would request staff get Resident 1 up but the resident didn't always come down to the main dining room for meals. In an interview on 07/18/2024 at 1:45 PM, Staff D (Certified Nursing Assistant) stated the resident's CP should direct staff on the amount of assistance a resident required with teeth brushing, transfer and meals. Staff D stated residents should be offered teeth brushing twice daily. During an interview on 07/18/2024 at 2:00 PM, with Staff A (Administrator) and Staff B (Director of Nursing), Staff A stated Resident 1 had challenges with eating and was an aspiration (inhalation of food into the lungs) risk. Staff B stated if Resident 1 had a physician's order to be out of bed for all meals, they would expect Resident 1 to be out of bed for all meals and assisted by staff. Staff B stated the CP should reflect the amount of assistance a resident needed for ADL's and would expect staff to follow the CP. REFERENCE: WAC 388-97-1060(1)(c) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed received the necessary care and services in accordance with professional standards of practice. The facility failed to ensure Physician Orders (PO) were reviewed, clarified and implemented upon admission and after a physician visit, and failed to document on new pressure ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure on the skin). These failures caused Resident 1 to experience skin breakdown, and placed all residents at risk for skin breakdown, pain, and diminished quality of life. Findings included . <Resident 1> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 05/01/2024, showed Resident 1 admitted to the facility on [DATE] after transferring from another nursing facility. The MDS showed Resident 1 was able to make needs known, able to make themselves understood, and able to understand others. The MDS showed Resident 1 had no behaviors, was incontinent of bowel and bladder, and had diagnoses including a history of stroke (brain bleed) with left sided upper and lower extremity paralysis, heart failure, diabetes, hypothyroidism, liver failure, diseases of the stomach, and dementia. The MDS showed Resident 1 was dependent on staff assistance for transfers out of bed with a mechanical lift, bed mobility, bathing, and toileting. Review of facility discharge transfer PO, dated 01/24/2024, showed no treatment orders were included on the transfer orders. Review of transfer PO's showed a 01/23/2023 PO for Resident 1 to receive a high protein diabetic snack nightly and directed staff to give half a sandwich or a protein shake, a 07/10/2023 PO for Resident 1 to receive a liquid nutritional supplement four times daily for weight management, and a 01/23/2023 PO for heel protectors to both feet when in bed to promote skin integrity during the day and evening shift. Review of Resident 1's PO's, dated 01/29/2024, showed staff did not implement or clarify resident 1's PO for a high protein diabetic snack nightly, liquid nutritional supplement four times daily, or for heel protectors to prevent skin breakdown. A 02/05/2024 PO showed staff put in a PO for Resident 1 to have a nightly diabetic snack, the snack did not include high protein, and was implemented six days after Resident 1 admitted to the facility. A PO, dated 02/22/2024, showed staff put in a PO for liquid protein supplement one time daily for wound healing, the PO was put in 23 days after admission and was one fourth of the dose they previously received prior to admission to the facility. A PO, dated 02/28/2024, showed staff were directed to use moon boots (special heel protectors) on Resident 1's feet, the PO was put in place 29 days after Resident 1 admitted to the facility. Review of a facility admission assessment, dated 01/29/2024, showed Resident 1 was assessed with no skin injuries upon admission. Review of a Braden Scale (predicts PU risk), dated 01/29/2024, showed Resident 1 was assessed at moderate risk for PU development Review of a physician progress note, dated 02/01/2024, showed the physician ordered baseline thyroid lab testing and directed staff to completed with the next set of labs. Review of Resident 1's record showed no labs were completed while Resident 1 resided at the facility. Review of a skin and wound evaluation, dated 02/20/2024, showed Resident 1 was identified with a new PU, assessed as a stage two (an open area involving deeper layers of skin) to their buttocks that was acquired at the facility three weeks after admission. Review of a PO, dated 02/27/2024, directed staff to provide wound care to Resident 1's first and second toe on their right foot. The PO did not identify the type of wound present. Review of a PO, dated 03/26/2024, directed staff to provide wound care to Resident 1's fifth toe on the left foot. Review of a PO, dated 05/17/2024, directed staff to monitor an open area on Resident 1's left heel and to ensure Resident 1 is wearing heel protectors when in bed. Review of a PO, dated 05/19/2024, showed two days after the wound was discovered, PO's were put in that directed staff to provide wound care to Resident 1's left heel. Review of Resident 1's nursing progress notes (NPN), dated 02/02/2024 through 03/05/2024, showed no documentation from staff when Resident 1 was discovered with a new PU. During an interview on 07/18/2024 at 2:00 PM, Staff B (Director of Nursing Services), stated they were not sure why all the PO's were not implemented and would expect all PO's to be implemented or clarified as needed when a resident is transferred to the facility. Staff B stated the facility did baseline labs and would expect staff to implement PO's after a physician visit. Staff B acknowledged there was no NPN for Resident 1's PU's and would expect staff to document a NPN that included potential cause of the wound, preventative measures implemented, and notification to the physician, and Resident 1's collateral contacts. REFERENCE: WAC 388-97-1060(b)(3)(b) .

May 2024 5 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide consistent supervision and ensure a safe environment that was free from dangerous accident hazards for 6 of 14 residents (Resident 1, 4, 8, 3, 9 & 5) reviewed for smoking. The failure to: timely and accurately assess resident's ability to safely smoke; secure smoking paraphernalia; implement, and enforce the facility smoking policy when Resident 1 was found smoking in the facility and a common area repeatedly, including near a resident who required and was wearing oxygen, placed all residents at risk for serious adverse outcomes with the potential for fire and an explosion and/or serious bodily injury, and constituted an Immediate Jeopardy (IJ). On 04/18/2024 an IJ was identified in F-689 and the provider was informed. The IJ was determined to begin on 04/13/2024. The facility removed the immediacy that was confirmed with an on-site visit by ensuring all residents were accurately assessed to smoke, educated all residents who smoked on the facility smoking policy, consequences for not abiding to the policy, and secured all smoking paraphernalia. Findings included . Review of the facility's undated policy titled, Smoking Policy, showed the facility would provide a safe environment while ensuring resident safety as it related to the residents who smoked. The policy showed smoking was prohibited in all areas of the facility except the designated smoking area. The policy showed residents who wished to smoke would be assessed to determine if they were safe to smoke by using the resident safe smoking assessment, all safe smoking measures would be documented on the resident's Care Plan (CP), and communicated to staff. Review of the facility's undated policy titled, Accidents and Supervision showed the resident environment would remain free of accident hazards and each resident would receive adequate supervision to prevent accidents. All facility staff would be involved in the observation and identification of potential hazards in the environment. The policy showed the facility would use specific interventions to reduce the risk from hazards in the environment that included; communicating the interventions to all relevant staff, provide training, document, and ensure interventions were put into place. The interventions would be monitored and modified to ensure interventions were implemented correctly, consistently, and evaluated for effectiveness. Review of the facility, Smoking Tobacco and Marijuana Notice and Agreement, that was part of the resident admission agreement, showed residents are permitted to smoke cigarettes, marijuana, and the use of any/all tobacco products, as well as electronic cigarettes and vaping devices in certain designated outdoor areas of the facility. The smoking agreement showed the resident must be assessed first to safely smoke, assessed to safely go outside independently, and the assessment would verify if the resident was capable of maintaining their own smoking supplies, if not deemed safe to maintain their smoking supplies the resident would agree to have smoking supplies stored at the nurse station. The agreement showed if a resident failed to adhere to the policy, they may be issued a 30-day discharge notification. <Resident 1> Review of the 01/11/2024 admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility on [DATE], was not able to make their own decisions, and had a decision maker to assist with decisions. The MDS showed Resident 1 had medically complex conditions and diagnoses including a traumatic brain injury, pneumonia (respiratory infection) that required intermittent oxygen use, adult failure to thrive, altered mental status, and restlessness with agitation. The MDS showed Resident 1 used a wheelchair to ambulate, had behaviors of delusions (misconceptions or beliefs), was prescribed an antipsychotic (used to treat mental disorders) medication and, an antidepressant (used to treat depression). Review of an admission assessment, dated 11/16/2023, showed Resident 1 had a history of smoking one pack of cigarettes daily for 45 years and smoked marijuana. Review of a Nursing Progress Note (NPN), dated 03/07/2024 at 4:16 PM, showed Staff C (Registered Nurse, RN) documented another staff member found Resident 1 smoking marijuana in their room, the room smelled of marijuana but Resident 1 denied smoking in their room. The NPN showed Resident 1's roommate requested to be out of the room, and Staff C notified the Physician, Director of Nursing (DON), and the Resident Care Manager (RCM) of Resident 1's incident. A NPN on 03/07/2024 at 5:28 PM showed Staff C found a lighter and marijuana on Resident 1 who gave Staff C the lighter but refused to provide staff with the marijuana, instead put it in their mouth when staff tried to confiscate the marijuana. Staff C documented they informed Staff B (DON) of the incident and placed Resident 1 on alert monitoring. Review of a NPN, dated 03/08/2024, showed Staff E (RN) documented Resident 1's roommate stated they witnessed Resident 1 smoking in the room and when staff asked Resident 1, they denied smoking in their room. Review of a NPN, dated 03/16/2024, showed Staff D (Licensed Practical Nurse, LPN) was called to Resident 1's room because smoke was observed coming from the room and found Resident 1 smoking marijuana in the bathroom. Staff D explained the fire risks related to smoking indoors and Resident 1 refused to give Staff D the lighter but did relinquish the marijuana to staff. Staff D documented they informed Staff A (Administrator) and the Physician. Review of a NPN, dated 03/17/2024 11:49 AM, showed Staff C found Resident 1 smoking in their room and initially refused to give up their lighter. Staff C documented they informed their supervisor of Resident 1's behavior. An additional note on 03/17/2024 at 1:15 PM showed Staff C asked Resident 1 who provided the cigarette. Resident 1 stated, Resident 3 gave it to them. Staff C asked Resident 3 why they gave Resident 1 a cigarette and Resident 3 replied, they said they wanted to smoke. Review of a NPN, dated 03/28/2024 at 12:12 PM, showed Staff E documented they smelled smoke coming from Resident 1's room. Resident 1 was asked if they were smoking. Resident 1 denied smoking in their room but gave Staff E their lighter. Review of a NPN, dated 03/29/2024 at 7:56 PM, showed Staff C was notified that Resident 1 and their roommate were seen smoking in the atrium (common area) of the facility. Staff C documented they informed Staff A, Staff B, and the facility Social Worker (SW). Review of a smoking assessment, dated 04/10/2024, showed Resident 1 indicated: they wished to smoke; was assessed as cognitively intact to smoke independently; had a history of smoking in their room and other areas of the facility; and a history of non-compliant behavior regarding the smoking policy. The assessment showed the recommendations based on the data gathered was the resident denies smoking, according to the RN there have been reports of the resident and roommate smoking in room unwitnessed. There were no adjustments made to Resident 1's Care Plan (CP) to reflect the resident's smoking. Review of a NPN, dated 04/12/2024, showed Staff F (RN) documented they caught Resident 1 smoking a cigarette in their bathroom. Staff F documented they reminded Resident 1 not to smoke inside the building due to fire hazards and other residents using oxygen. Review of a NPN, dated 04/13/2024 at 9:31 AM, showed Staff G (Administrative Assistant) documented they found Resident 1 smoking a cigarette in the atrium. When Staff G told Resident 1 they could not smoke in the atrium, Resident 1 responded, I'm not. Staff G observed a lit cigarette Resident 1 had dropped on the ground. Resident 1 apologized to Staff G, and Staff G educated Resident 1 about the dangers of smoking with other residents using oxygen nearby. Staff G stated they informed Staff A and Staff B that Resident 1 was found smoking in the atrium. An additional note on 04/13/2024, four minutes later at 9:35 AM, Staff G found Resident 1 smoking again in the atrium area with another resident, possibly Resident 2 who was actively receiving oxygen from an oxygen tank with a nasal cannula delivering oxygen to their nose. Staff G stated the charge nurse was aware and went and removed the lighter from Resident 1. During an interview on 04/17/2024 at 2:07 PM Staff A (Administrator) stated that another resident might be sharing their cigarettes with Resident 1 because they had no way to get cigarettes. Staff A stated residents were allowed to keep cigarettes on them but lighters were stored in a locked box in the resident's room. In an interview on 04/17/2024 at 3:20 PM Staff J (Infection Preventionist/RN) stated they did not see Resident 1 smoking in the atrium but Resident 1's roommate (Resident 5) was seen sneaking out to smoke in the atrium. Staff J stated Resident 5 had a Collateral Contact (CC) bringing them cigarettes and when staff tried to remove the cigarettes or lighter, Resident 5 would become combative with staff. During an interview on 04/17/2024 at 3:32 PM Staff I (LPN) stated when a resident smoked their lighter and cigarettes should be kept secured on the nurse's cart but it was hard to regulate because the residents could sign out and return with more smoking supplies than staff knew about. In an interview on 04/17/2024 at 3:55 PM Staff H (Certified Nursing Assistant, CNA) stated the facility did not store resident cigarettes or lighters. During an interview on 04/17/2024 at 4:20 PM Staff C stated Resident 1 did not have access to get cigarettes from outside the facility, they were not sure where Resident 1 obtained cigarettes, but last week Staff C smelled smoke coming from Resident 1's room. Staff C could not be sure if it was Resident 1 or their roommate (Resident 5) smoking. In a follow up interview on 04/18/2024 at 5:25 PM Staff C stated they were not sure where Resident 1 obtained marijuana or smoking supplies. Staff C stated Resident 1 continued to ask staff to go outside to smoke. During an interview on 04/17/2024 at 5:45 PM Staff A stated the smoking agreement was in the admission paperwork that informed residents upon admission of the smoking policies. Review of the admission smoking agreement showed the smoking assessment would determine if the resident was able to maintain their own smoking supplies. Review of the smoking assessment showed no area to address where or if a resident could maintain their own smoking supplies. Staff A stated the admission smoking agreement was not correct, residents were not allowed to smoke marijuana in the smoking area, and the facility needed to change the smoking admission agreement. Staff A stated the admission agreement paperwork was not always completed timely and the residents were not always informed of the smoking policies in a timely manner. Staff A stated after Resident 1 was found smoking in the facility numerous times the Interdisciplinary Team (IDT) had conversations about Resident 1's non-compliance with smoking and discussed a plan. Staff A was asked to provide that documentation, as Resident 1's medical record did not show any IDT notes discussing the resident's non-compliance with the smoking policy, and no documents were provided. During an interview on 04/18/2024 at 5:15 PM Staff A stated they believed the other resident who was wearing oxygen when Resident 1 was in the atrium smoking was possibly Resident 2 who worked with Physical Therapy (PT) and would walk through the atrium when exercising with PT. Staff A stated the stated the staff that witnessed Resident 1 smoking in the atrium did not get a good look at the other resident but could see their oxygen tank on the back of the wheelchair and the nasal cannula around the resident's ears and was connected to the oxygen tank. In an interview on 04/18/2024 at 5:32 PM Staff I stated they have never seen lock boxes in rooms of residents who smoked. In an observation and interview on 04/18/2024 at 5:31 PM Resident 1 was observed sitting on their bed and stated yes, they smoked. Resident 1 stated facility staff told them they had to smoke outside and off the facility property. Resident 1 stated they never smoked in the facility and asked if they could go buy cigarettes or have someone buy them cigarettes as they reached and pulled cash out of their shirt pocket. During an interview and observation on 04/18/2024 at 5:35 PM Resident 6's room was observed with a window that looked out into the atrium. Resident 6 stated they observed Resident 1 smoking in the atrium three or four times. Resident 6 stated they observed Resident 1 with another resident one time but was not sure if the resident had oxygen on, and stated they could not always see who was out in the atrium smoking but could smell the smoke. Review of a smoking assessment, dated 04/19/2024, showed staff assessed Resident 1 as not safe to smoke independently. Review of a Smoking Cessation CP, dated 04/19/2024, showed Resident 1 is on a smoking cessation medication due to being assessed as not safe to smoke and the charge nurse should be notified immediately if Resident 1 violates the smoking policy. In an interview on 05/02/2024 at 2:45 PM Staff B stated smoking assessment should be completed upon admission if the resident was identified as a smoker, should be re-assessed every 90 days, and a CP in place to ensure safe smoking. <Resident 4> Review of the admission MDS, dated [DATE] showed Resident 4 was admitted to the facility on [DATE], had some impairments with their decision making ability, and had verbal behaviors directed towards others. The MDS showed Resident 4 had medically complex conditions including chronic obstructive lung disease, end stage renal disease that required dialysis (process of removing excess toxins when kidneys no longer work), depression, and tobacco use. The MDS showed Resident 4 was dependent on staff for transfers and used an electric wheelchair to move around the facility. Review of an admission assessment, dated 01/30/2024, showed Resident 4 was assessed as a current smoker and used alcohol. Review of a smoking assessment, dated 01/30/2024, showed Resident 4 wished to smoke, was assessed to be cognitively intact to smoke, had no disease or medical conditions that disqualified them from smoking per the assessment, and was assessed as able to safely smoke independently. The smoking assessment showed when a resident had certain medical conditions, such as neuropathy, the resident may not smoke at that time. Review of Resident 4's Physicians Orders (PO) showed Resident 4 was prescribed a medication for neuropathy. Review of an Active Smoker CP, dated 01/31/2024, showed Resident 4 was instructed about the facility policies on smoking locations, times, and safety concerns. Review of a NPN, dated 02/04/2024, showed Staff K was informed that staff could not enter Resident 4's room because their motorized wheelchair was blocking the door. Staff K documented they observed Resident 4 unresponsive with irregular breathing. Emergency responders were able to gain access into Resident 4's room and while working on Resident 4, a crack pipe, lighter, used foil pieces, used cut straws, a baggie with what appeared to be crack, and six tablets of a narcotic 30 milligram medication were found. Staff K documented Resident 4 transferred to the hospital, informed Staff A of the incident, and requested instructions on what to do with the drug paraphernalia. Review of a signed behavior contract between the facility and Resident 4, dated 02/09/2024, showed Resident 4 would; refrain from the possession or use of illicit drugs and paraphernalia while residing in the facility, if there was concern about paraphernalia Resident 4 would agree to their belongings and room being searched, no smoking in the community, and no smoking in the with oxygen on. The behavior contract showed if Resident 4 failed to meet these expectations it would result in an immediate termination of the relationship between the facility and Resident 4. Review of a NPN, dated 02/26/2024, showed staff observed Resident 4 in the front lobby, with a cigarette and lighter in their hand. Resident 4 was observed with a runny nose, a white residue above their lip, and constricted eye pupils. The NPN showed Resident 4 consented to have their bag being searched, no items were found, but Resident 4's clothing and jacket pockets were not searched. The NPN did not mention if the cigarette or lighter was removed from Resident 4 at that time. Review of a NPN, dated 02/29/2024, showed Resident 4 appeared to be under the influence of a recreational substance and gave consent for staff to search their room. Upon searching Resident 4's room, an electrical heating pad, heat gun, cut pieces of aluminum foil, a cut straw, and a cigarette butt were found. The documentation showed no further interventions were indicated at this time. Review of Resident 4's NPN's showed no documentation to support the facility enforced Resident 4's behavior contract after being found with drug paraphernalia twice in three days. Observations and interviews on 04/17/2024 at 2:45 PM showed Resident 11 self-propelling in the hallway, upset, screaming, and swearing that they wanted their lighter back so they could go smoke. At this time Staff B came into the hallway and stated Resident 11 was new to the facility and was not able to safely smoke or go outside independently. Observations and interviews on 04/17/2024 at 4:50 PM showed two working lighters, one with a torch like flame sitting on Resident 4's bedside table. Resident 4 was not observed in their room or in the facility. On 04/17/2024 at 4:55 PM Staff B stated lighters should be stored in the lock box and should not be accessible to other residents because it was a safety issue, especially when Resident 11 was previously looking for a lighter earlier that day. Staff B was not able to locate a lock box or key in Resident 4's room and stated they would expect Resident 4 to have a lock box and key to secure their smoking supplies. During an interview on 04/24/2024 at 4:10 PM Staff B acknowledged the smoking assessment for Resident 4 was not marked for neuropathy although they were being treated with medication for neuropathy and stated the nursing management and administration reviewed and revised the resident smoking assessments eliminating certain medical diagnoses, such as neuropathy. Staff B stated because a resident was treated for neuropathy does not mean they are not safe to smoke. Staff B stated the smoking assessment included a visual assessment to watch the resident smoke to determine if they were safe. <Resident 8> Review of a 04/12/2024 significant change MD'S showed Resident 8 admitted to the facility on [DATE], was able to make their own decisions and needs known. The MDS showed Resident 4 had medically complex conditions including cancer, diabetes, anxiety, and bipolar disorder. The MDS showed Resident 8 used a wheelchair to ambulate and had no behaviors. Review of an admission Assessment, dated 03/15/2024, showed Resident 8 was identified as a current smoker on admission to the facility. Review of a NPN, dated 03/16/2024 at 2:35 AM, showed Resident 8 demanded staff take them outside to smoke. Staff documented they informed Resident 8 of the facility smoking policy and that staff cannot assist in facilitating smoking. An additional NPN, dated 03/16/2024 at 6:17 PM showed Resident 8 was found smoking cigarettes in their bed. Resident 8 put their cigarette out and gave staff one pack of cigarettes, 1/2 smoked cigarette, and a lighter. Review of a smoking assessment, dated 04/04/2024, showed Resident 8 wished to smoke, was unable to access the smoking area independently, was dependent on staff for all smoking needs, and should not smoke unassisted. A second smoking assessment was completed on 04/19/2024 showed Resident 8 preferred not to smoke and was currently prescribed a smoking cessation to stop smoking. Review of a NPN, dated 04/16/2024, showed Resident 8 was heard yelling about wanting to go outside to smoke. The NPN showed staff reminded Resident 8 that it was past the smoking time. Staff were able to re-direct the resident. During an interview and observation on 04/17/2024 at 4:45 PM Resident 8 stated they were a current smoker and kept their cigarettes and lighter on their person. Resident 8 was observed with a pack of cigarettes and a lighter on them and stated they did not have a lock box with a key to store their cigarettes and stored their smoking supplies in their pocket. Observations showed no lock box in Resident 8's room to secure smoking supplies. Review of Resident 8's CP showed on 04/19/2024, a smoking cessation CP was initiated and directed staff to notify the nurse immediately if Resident 8 violated the facility smoking policy. During an interview on 04/24/2024 at 4:22 PM Staff B stated all smokers were re-assessed and Resident 8 was assessed as no longer safe to smoke independently, wished not to smoke, and was started on a smoking cessation medication. Staff B stated they would expect all residents who smoked to have a lock box and key in their room to secure smoking supplies. <Resident 3> Review of a quarterly MDS, dated [DATE], showed Resident 3 admitted to the facility on [DATE], was not able to make their own decisions, and had behaviors of wandering that put Resident 3 at significant risk of getting to a potentially dangerous place. The MDS showed Resident 3 had medically complex diagnoses including epilepsy (brain disorder that causes seizures), dementia, and nicotine dependence. Review of an admission assessment, dated 12/12/2023, showed Resident 3 was identified as a current smoker with a history of smoking for 20 years and currently used smokeless tobacco. Review of Resident 3's CP, initiated 12/13/2023, showed no CP in place that addressed Resident 3's smoking or a smoking assessment completed upon Resident 3's admission after being identified as a current smoker. Review of a NPN, dated 12/15/2023, showed Resident 3 went outside to smoke with their roommate and later returned to the unit. Additional NPN's dated 12/30/2023 and 12/31/2023 showed Resident 3 was reminded not to go smoke by themselves and a staff member assisted them outside to smoke a cigarette. A NPN, dated 01/02/2024 showed Resident 3 triggered the wanderguard alarm (a system to alert staff if a resident attempted to exit the facility) because they wanted to go outside to smoke. Staff C documented they were informed by staff that another resident gave Resident 3 a cigarette and Resident 3 made multiple attempts to go outside to smoke, eventually staff escorted Resident 3 outside to smoke their cigarette. Review of a Social Services Assistant (SSA) note, dated 02/04/2024, showed Staff L (SSA) spoke with Resident 3 and requested they be supervised when leaving the building to go smoke or go to the corner store. Staff L documented Resident 3 had a history of confusion and wandering. Review of a NPN, dated 02/17/2024, showed Staff D was notified by a staff member leaving the building that the wanderguard alarm was ringing and they saw Resident 3 walking down the street towards the facility. Resident 3 told Staff D they went to the corner store to have a cigarette. Review of a smoking assessment, dated 03/06/2024, showed Resident 3 preferred not to smoke, was independent with their cognition, judgement, and safety decision making. The smoking assessment showed staff documented that Resident 4 was able to smoke independently, acknowledged the smoking policy, and agreed to follow the smoking policy. Review of a NPN, dated 03/16/2024, showed Resident 3 requested to go outside to smoke but when staff brought Resident 3 outside the resident wanted to go to the corner store. A NPN, dated 04/15/2024, showed Staff M (Resident Care Manager, RN) documented a smoking assessment was completed supporting Resident 3 was assessed as not safe to smoke unassisted. Staff M requested an order for nicotine patches for Resident 3. During an observation and interview on 04/17/2024 at 4:34 PM, Resident 3 stated they were a current smoker and they usually had a lighter on them, was unable to locate one, and stated that it was probably in their room. Review of a smoking assessment, dated 04/19/2024, showed Resident 3 wished to smoke, had impaired cognition, judgement, and unsafe decision making. The assessment showed Resident 3 was deemed unsafe to smoke and smoking cessation was in progress. Review of a NPN, dated 04/20/2024, showed Staff C documented they were informed that Resident 3 got money from another resident and left the facility to go to the corner store and returned with a pack of cigarettes, a lighter, and three cans of beer. A staff member found Resident 3 smoking a cigarette in the parking garage, Resident 3 refused to give staff the cigarettes and lighter, and was difficult to re-direct. The documentation did not include any reassessment to new interventions the facility would take to ensure the resident's safety and non-compliance with smoking. Review of Resident 3's PO showed a 04/24/2024 PO for a smoking cessation medication was ordered five days after Resident 3 was deemed unsafe to smoke on 04/19/2024. In an interview on 04/25/2024 at 3:00 PM Staff B stated if a resident was assessed not safe to smoke, they should not be smoking. <Resident 9> Review of a quarterly MDS, dated [DATE], showed Resident 9 re-admitted to the facility on [DATE], was able to make their own decisions, and had no behaviors. The MDS showed Resident 9 had medically complex diagnoses including chronic respiratory failure, heart failure, history of brain bleed, anxiety, schizophrenia, and post traumatic stress disorder. The MDS showed Resident 9 had impairments to both lower extremities and used an electric wheelchair to move around the facility. Review of an admission assessment, dated 01/09/2024, showed staff documented Resident 9 was a current smoker. Review of a smoking CP, initiated on 01/31/2024, showed Resident 9 had a history of smoking marijuana and used a vape pen (electronic cigarette). The CP directed staff to instruct Resident 9 on the facility smoking policy and to notify the charge nurse if the resident violated the facility smoking policy. Review of a smoking assessment, dated 03/06/2024, showed staff documented Resident 9 indicated they did not wish to smoke, they were assessed cognitively intact to smoke independently, and had diagnoses that included neuropathy that automatically disqualified them from being able to smoke at that time, per the smoking assessment directions. The smoking assessment concluded that Resident 9 continued to smoke, had plans to stop in the future, and declined smoking cessation medications. Review of a smoking assessment, dated 04/19/2024, showed staff documented Resident 9 wished to smoke, was assessed to be safe to smoke independently, and had diagnoses that included neuropathy that automatically disqualified them from being able to smoke at that time, per the smoking assessment directions. The smoking assessment concluded that Resident 9 continued to smoke at this time. Review of a smoking assessment, dated 04/24/2024, showed Resident 9 wished to smoke, was assessed as cognitively intact, able to smoke independently, and the smoking assessment no longer contained the section that reviewed conditions or medical diagnoses automatically disqualifying a resident to smoke if they had one or more of those conditions. Review of a NPN, dated 03/06/2024, showed staff spoke with the physician about Resident 9 continuing to smoke while having a PO for a nicotine patch, the physician discontinued the order for the nicotine patch. A NPN, dated 04/18/2024, showed Resident 9's lighter was removed from them and put in the nurses cart to keep secure. During an observation and interview on 04/23/2024 at 3:18 PM, Resident 9 was observed sitting on the edge of their bed and stated they had not smoked a cigarette in a week but did still use a vape pen to smoke. Review of a NPN, dated 04/24/2024, showed staff documented that Resident 9 was aware they could not keep marijuana or any smoking paraphernalia in their room, and if they did not abide by the facility smoking policy they may be subject to a 30 day discharge notice. <Resident 5> Review of the admission MDS, dated [DATE], showed Resident 5 admitted to the facility on [DATE], was not able to make their own decisions, and had no behaviors. The MDS showed Resident 5 had a non-traumatic brain dysfunction, dementia with behavioral disturbances, restlessness with agitation, and tobacco use. The MDS showed Resident 5 was able to ambulate independently with no assuasive devices. Review of an admission assessment, dated 03/21/2024, showed Resident 5 was assessed as a previous smoker. Review of a smoking assessment, dated 03/21/2024, showed Resident 5 did not wish to smoke, was not cognitively independent to safely smoke. The assessment concluded that an order for smoking cessation medications were ordered. Review of Resident 5's history of tobacco use CP, dated 04/15/2024, directed staff to monitor for non adherence to the smoking policies and report to the provider with each occurrence. Review of a NPN, dated 03/29/2024 at 4:08 PM, showed Resident 5's Collateral Contact (CC) requested staff look at Resident 5's belongings and staff found a lighter on Resident 5, who was not willing to have their smoking items secured. An additional NPN, dated 03/29/2024 at 4:45 PM showed Staff C was informed that Resident 5 had a lighter in their hand, refused to give Staff C the lighter, and Staff C informed Staff B. Staff C documented they were notified after an hour that Resident 5 was smoking in the atrium with their roommate (Resident 1), and Resident 5 gave Staff C the cigarettes but refused to give them the lighter. A NPN, dated 03/30/2024 showed Resident 5's CC came to the facility and staff were able to obtain and secure the lighter in the nurses cart. Review of a NPN, dated 04/09/2024, showed Staff K documented at 7:45 PM Resident 5 was observed smoking a cigarette in the atrium, was educated not to smoke in that location, put their cigarette out, and refused to relinquish their lighter to staff. Staff K re-attempted to obtain the lighter but Resident 5 became aggressive and refused to give up their lighter. Staff K documented they informed Staff A, Staff G, and Staff B of the incident. Resident 5 continued on 15 minute checks for safety. Review of a NPN, dated 04/14/2024 at 11:00 PM, Resident 5 was observed pacing the hallway with clenched fists and stated I want out, just out!. Staff K asked Resident 5 if they had cigarettes and Resident 5 stated, you can't have mine. Staff K escorted Resident 5 outside and the resident pulled out a cigarette lit their cigarette with their lighter. The NPN did not indicate if staff removed or attempted to remove Resident 5's smoking supplies from them as they were not assessed to be able safely to smoke independently. During an interview on 04/17/2024 at 3:20 PM Staff J stated Resident 5 was new to the facility and was sneaking out to the atrium to smoke. Staff J stated there was no clear directions from management on how to manage Resident 5's non-compliant behaviors. In an observation and interview on 04/17/2024 at 4:22 PM, Resident 5 stated yes they were a smoker, kept their cigarettes in their pocket as they pointed at their pocket and a shape of a small box was observed. Resident 5 stated they had a lighter but it was almost empty. No lock box was observed in Resident 5's room. In an observation and interview on 04/18/2024 at 5:30 PM, Resident 5 was observed in their

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure residents were provided a comfortable homelike environment for 3 of 5 residents (Resident 1,12, 6) reviewed. The failure to ensure the facility boiler was repaired timely and water temperatures were maintained at comfortable levels, placed all residents at risk for decreased cleanliness, quality of life, dignity, and a homelike environment. Findings included . Review of the facility policy titled, Safe and Homelike Environment, dated 04/2023, showed the facility would provide a safe, clean, comfortable, and homelike environment. This included ensuring the residents received care and services safely. In an interview on 04/17/2024 at 2:07 PM, Staff A (Administrator) stated the facility had two boilers upstairs that supplied hot water to the shower and resident rooms, one of the boilers was leaking. Staff A stated one side of the facility's upper level was affected. Only warm water was available to wash hands, faces, provide showers, and baths. Staff A stated on Friday 04/12/2024 there was no hot water available for less than an hour while a vendor came to assess the malfunctioning boiler. Staff A stated three different vendors came to assess the boiler and a part needed to be replaced. Staff A stated the facility was waiting on an electrician to give a quote to complete the electrical portion of work on the boiler. During an interview on 04/17/2024 at 2:25 PM Staff N (Maintenance) stated on 04/01/2024 a vendor came to the facility to service the boiler and on 04/06/2024 one of the two boilers was observed leaking. Staff N stated the north and east part of the upper level hot and cold water were available but the south and west part of the upper level had warm and cold water was available. In an interview on 04/17/2024 at 3:32 PM Staff I (Licensed Practical Nurse) stated they worked over the weekend and the water was lukewarm. Staff I stated the staff was able to use the lukewarm water to wash their hands and provide care. <Resident 1> During an observation and interview on 04/17/2024 at 4:20 PM, Resident 1 was observed sitting in their bed. Resident 1 stated there is something wrong with the water, it is not getting hot. Resident 1 stated they were not sure why the water wasn't getting hot. Temperature readings of Resident 1's sink water showed 73.7 degrees Fahrenheit, 26.3 degrees cooler than the required temperature range. <Resident 12> In an observation and interview on 04/17/2024 at 4:25 PM showed Resident 12 resting in bed. Resident 12 stated the water from their room sink was cold and they could not wash their face. Resident 12 stated they could not wash their hands after toileting and did not receive a shower in over two weeks. Resident 12 stated they heard that the facility boiler broke. Temperature readings of Resident 12's sink water showed 77.4 degrees Fahrenheit, 22.6 degrees cooler than the required temperature range. During an interview on 04/23/2024 at 4:15 PM, Staff A stated Resident 12 was offered a room move to a different room with hot water available but declined to move rooms. Review of a Nursing Progress Note (NPN), dated 04/18/2024 at 10:11 AM showed Staff G (Administrative Assistant) documented they went to speak to Resident 12 about a room move but the resident did not feel well and asked if Staff G could return later. Review of NPN's between 04/18/2024-05/08/2024, showed no documentation that facility staff returned to speak to Resident 12 about a room move. In an interview on 05/02/2024 at 1:55 PM Staff G stated when they went to speak to Resident 12 it was not a good time, they were off the next day, and did not follow up with Resident 12 on a room move. During an interview on 05/02/2024 at 2:05 PM Resident 12 stated facility staff did not offer them a room move due to no hot water available in their room. <Resident 6> In an observation and interview on 04/18/2024 at 5:35 PM Resident 6 stated they were not able to participate with Physical Therapy (PT) because there was a water leak that made it's way to the outside of their door. Resident 6 stated they attempted to walk with PT but their foot kept slipping on the water that was on the floor. Observations of Resident 6's room showed right outside the doorway was a wet floor sign and a saturated towel on the floor. Water was observed seeping through the wood floor when pressure was applied. Resident 6's room was located on the upper level of the facility next to the boiler room. In an interview of 04/18/2024 at 5:40 PM Staff A stated the electrician had not gotten back to the facility with their quote, they had authorization to purchase the needed parts, and was told the electrician had to consult with their partner and the boiler leak would potentially be repaired next week. During an interview on 04/23/2024 at 4:00 PM Staff A stated the boiler was still leaking a little and the facility was still waiting for the electricians quote. Staff A acknowledged that 17 days passed since the boiler leak was discovered and the lack of hot water on one side of the upper level did not create as a homelike environment for the residents affected by no hot water. In an interview on 04/25/2024 at 2:00 PM, Staff A stated the boiler will be replaced starting tomorrow and the leak has stopped. In an electronic mail (e-mail) communication on 04/30/2024 at 4:53 PM with Staff B (Director of Nursing) showed Staff B confirmed the new boiler was in, the contractors were completing their work, and the work would be completed today. The boiler was replaced after 24 days without hot water to one side of the upper level of the facility. In an interview on 05/02/2024 at 3:10 PM Staff A stated water temperatures should be maintained at 110 degrees Fahrenheit plus or minus 10 degrees. Staff A stated maintenance performed water temperatures after the boiler was replaced. Documentation of water temperatures after the boiler was replaced and no documents were received. Refer to F677- ADL Care provided for dependent residents REFERENCE: WAC 388-97-0880(1)(2) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs-bathing, grooming, eating) received the assistance they required for 6 of 6 residents (Residents 12, 14, 9, 1, 3, & 10 ) reviewed for bathing and showers. The failure to provide bathing or showers placed all residents at risk for poor hygiene, embarrassment, and diminished quality of life. Findings included . Review of a facility Shower policy, date 05/2024, showed the facility would offer residents the preference of shower days and times and the resident's preference would be documented on the Care Plan (CP). When a resident refused a shower staff would re-approach the resident and notify the nursing leadership. <Resident 12> Review of an Annual Minimum Data Set (MDS, an assessment tool) dated 02/14/2024, showed Resident 12 was able to make their own decisions and had diagnoses including a neurological disease, cancer, diabetes, anxiety, depression, and history of a brain bleed. The MDS showed Resident 12 experienced delusions (misconceptions or beliefs, contrary to reality) and had behaviors of rejecting care. The MDS showed Resident 12 used a wheelchair and required maximum assistance from staff for showering. Review of an ADL self-care deficit CP, revised 10/01/2023, showed Resident 12 required one-person extensive assistance with showers and preferred showers twice weekly on Monday and Wednesday. In an observation and interview on 04/17/2024 at 4:25 PM Resident 12 was observed lying in bed and stated they did not receive a shower in over two weeks. Resident 12 stated they liked to take a shower two times weekly but staff did not offer them a shower in the past two weeks because they heard the boiler was out. During an observation and interview on 05/02/2024 at 2:05 PM Resident 12 was observed sitting in their wheelchair and stated staff did not offer them showers but they would like to be asked and offered a shower twice weekly. Review of ADL bathing documentation, dated 04/01/2024-04/30/204, showed Resident 12 received a shower on 04/01/2024 and 04/22/2024 and refused a shower on 04/03/2024. The ADL documentation showed 3 instances where staff offered or provided a shower but no documentation that Resident 12 was offered or provided a shower six out of nine opportunities. <Resident 14> Review of an admission MDS, dated [DATE], showed Resident 14 admitted to the facility on [DATE], had no behaviors, and was able to make their own decisions and needs known. The MDS showed Resident 14 had medically complex conditions and diagnoses including heart failure, anxiety, and depression. The MDS showed Resident 14 was assessed to require maximum assistance with showers and transfers. Review of an self-care deficit Care Plan (CP), dated 04/04/2024, showed Resident 14 required one person assistance with a shower or bath and preferred a shower or bath at least one time weekly on Thursday day shift. In an observation and interview on 05/02/2024 at 2:25 PM, Resident 14 was observed in bed, their hair appeared greasy and unwashed. Resident 14 stated they were not receiving showers and after a month at the facility they have only had one shower. Resident 14 stated staff did not offer them showers or bed baths and they would prefer a shower twice a week. Resident 14 stated going without showers made them feel gross especially when they were sweating after working with physical therapy or sometimes woke up sweaty after sleeping. Review of ADL bathing documentation, dated 04/01/2024-04/30/2024, showed Resident 14 received a shower on 04/23/2024, 19 days after admitting to the facility, and refused a shower on 04/21/2024. The ADL documentation showed the facility staff did not offer or provide Resident 14 with the option for bathing four out of six opportunities. <Resident 9> Review of a quarterly MDS, dated [DATE], showed Resident 9 had no behaviors and was able to make their own decisions and needs known. The MDS showed Resident 9 had medically complex conditions and diagnoses including chronic respiratory failure, heart failure, diabetes, anxiety, and depression. The MDS showed Resident 9 had impairments to both lower extremities, used an electric wheelchair, and was assessed to require moderate staff assistance with showers and bathing. Review of an self-care deficit Care Plan (CP), revised 10/21/20236, showed Resident 9 preferred showers two times weekly and required physical help of one staff member with bathing. In an observation and interview on 05/02/2024 at 2:25 PM, Resident 9 was observed sitting on their bed and stated they didn't received their showers twice weekly as they preferred. Resident 9 stated they were a larger person and not having showers made them feel dirty. Review of ADL bathing documentation, dated 04/01/2024-04/30/2024, showed Resident 9 received a shower on 04/10/2024, 04/23/2024, and 04/24/2024, and was not available for a shower on 04/19/2024. The ADL documentation showed the facility staff did not offer or provide Resident 9 with the option for bathing four out of four opportunities. <Resident 1> Review of quarterly MDS, dated [DATE], showed Resident 1 had some impairments to their decision making and had no behaviors. The MDS showed Resident 1 had dementia, a story of a traumatic brain injury, anxiety, and lung disease. The MDS showed Resident 1 had no impairments to their upper or lower extremities, used a wheelchair for mobility and was assessed to require maximum assistance from staff for showers. Review of an self-care deficit Care Plan (CP), dated 11/23/2023, showed Resident 1 required one person extensive assistance with showers. The CP did not show how many showers Resident 1 preferred weekly. In an observation and interview on 05/02/2024 at 2:40 PM, Resident 1 was observed sitting on their bed eating a snack. Resident 1 stated staff did not offer them showers, they preferred to shower daily, and stated they liked to maintain a clean body. Resident 1 stated they were not sure how they felt about not getting showers and stated they just have to wait for staff to offer. Resident 1's facial hair was observed to be long and Resident 1 stated they preferred a shorter beard or shaved off but did not have a razor to manage their facial hair. Review of ADL bathing documentation, dated 04/01/2024-04/30/2024, showed Resident 1 received only two showers on 04/19/2024 and 04/23/2024, during a 30 day period. The ADL documentation showed the facility staff did not offer or provide Resident 1 with a shower six out of six opportunities. <Resident 3> Review of a quarterly MDS, dated [DATE], showed Resident 3 had impairments to their decision making and had behaviors of wandering that placed Resident 3 in potentially dangerous places. The MDS showed Resident 3 had medically complex conditions and diagnoses including a seizure disorder, dementia, and chronic pain syndrome. The MDS showed staff assessed Resident 3 to required one person assistance with showers. Review of an self-care deficit Care Plan (CP), dated 04/23/2024, showed Resident 3 required assistance of one staff member for showers and preferred showers or bathing twice weekly. In an observation and interview on 05/02/2024 at 2:00 PM, Resident 3 was observed sitting in a common area socializing with other residents and stated they used to shower twice daily when working but since being retired would prefer a shower every other day. Review of ADL bathing documentation, dated 04/01/2024-04/30/2024, showed Resident 3 received five showers in thirty days on 04/05/2024, 04/08/2024, 04/11/2024, 04/18/2024, and 04/24/2024. The ADL documentation showed facility staff did not offer or provide a shower to Resident 3 three out of three opportunities. <Resident 10> Review of a quarterly MDS, dated [DATE], showed Resident 10 was able to make their own decisions, needs known, and had no behaviors. The MDS showed Resident 10 had vascular disease, an amputation of the left leg , weakness, anxiety, and depression. The MDS showed Resident 10 was assessed with an impairment to the left lower extremity, used a wheelchair to ambulate, and required assistance of one staff member for showering. Review of an self-care deficit Care Plan (CP), dated 04/26/2024, showed Resident 10 required extensive assistance of one staff member for showers and preferred showers twice weekly. In an attempt to interview Resident 10 on 05/02/2024 at 2:30 PM, they were observed sleeping in bed and did not want to participate in the interview at that time. Resident 9, who was Resident 10's roommate stated Resident 10 liked to have their showers religiously. Review of ADL bathing documentation, dated 04/01/2024-04/30/2024, showed Resident 10 had four showers in 30 days on 04/10/2024, 04/17/2024, 04/23/2024, and 04/26/2024. The ADL documentation showed facility staff did not offer or provide Resident 10 with a shower four out of four opportunities. In an interview on 05/02/2024 at 2:10 PM Staff O (Staff Scheduler) stated the facility used two shower aides Monday through Friday. Staff O stated the facility has not pulled the shower aides to work as aides on the floor because they had to catch up on showers. During an interview on 05/02/2024 at 2:50 PM, Staff B (Director of Nursing) stated they would expect showers be completed per the residents preference, if a resident refused staff should document the refusal, and inform a nurse manager. Staff B stated they would expect the documentation to be in the resident's record that they were offered or provided with a bath and acknowledged six out of six residents relived did not receive showers per their preference. REFERENCE: WAC 388-97-1060(1)(c)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment to prevent placing residents at risk for facility acquired infections. The failure to have an effective system of surveillance to identify possible contagious infections, prevent the spread of infection to there residents and staff, reporting a suspected outbreak, and controlling the spread of a Gastrointestinal (GI) infection to other residents for 3 of 3 residents (Residents 15, 18, & 19 ) reviewed for infections. The failure to ensure staff used appropriate Personal Protective Equipment (PPE), to ensure proper Hand Hygiene (HH) was performed, and failed to have an effective Water Management Policy (WMP), plan, and implementation of that plan placed all residents at risk for facility-acquired or healthcare-associated infections and related complications. Findings included . Review of the facility policy titled, Transmission-Based Isolation Precautions, dated 04/2023, showed the facility would take appropriate precautions to prevent transmission of pathogens (germs), based on the pathogens mode of transmission. The policy showed contact precautions referred to measures that were intended to prevent transmission of infectious agents that were spread by direct or indirect contact with the resident or the environment. The policy showed that nursing placed residents with suspected or confirmed infectious diarrhea on transmission-based precautions while waiting for confirmation. The policy showed the signage would include and specify the specific Personal Protective Equipment (PPE, used to protect staff from infectious disease), would be placed in a conspicuous location outside the resident's room, near the entrance of the residents room. The policy showed facility staff would don (put on) appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. Review of the facility policy, titled Hand Hygiene, dated 04/2023, showed facility staff would perform hand hygiene when indicated, using proper technique, and consistent with accepted standards of practice. The policy showed a hand hygiene table that directed staff to use soap and water for instances of suspected or likely Clostridium Difficile (C.diff, contagious loose stools and abdominal symptoms) and when caring for a resident with known or suspected infectious diarrhea. <Gastrointestinal (GI) Outbreak> Review of a facility GI Outbreak Line List, dated 04/2023, showed a list of all residents and staff, including symptoms, onset date, and if the person was hospitalized . The line list included a total of 33 residents and 5 staff members with GI like illness, for a total of 38 people affected by the facility GI outbreak. <Resident 15> Review of an admission Minimum Data Set (MDS, an assessment tool), dated 02/28/2024, showed Resident 15 admitted to the facility on [DATE] and was able to make their own decisions and needs known. The MDS showed Resident 15 had diagnoses including the history of a brain bleed, weakness to the right side of the body, heart failure, diabetes, and a history of a Urinary Tract Infection (UTI) with sepsis (infection moves into the bloodstream). The MDS showed Resident 15 received antibiotics while residing at the facility. Review of a facility provided GI Outbreak line list, dated April 2024, showed Resident 15 was the first resident identified with loose stools, cramps, and vomiting on 04/06/2024. The line list showed Resident 15 went to the emergency room (ER) for abdominal pain on 04/10/2024 and was sent out to ER again on 04/11/2024 where they passed with a GI bleed and pneumonia with sepsis. Review of Resident 15's comprehensive Care Plan (CP), dated 02/22/2024, showed no documentation of a CP developed for Resident 15's diarrhea, cramping, or vomiting related infection or antibiotic use. Review of a Nursing Progress Note (NPN) dated 04/09/2024, showed Staff K (Licensed Practical Nurse, LPN) documented for Resident 15, reviewed labs drawn on 04/08/2024 for CBC with Diff (Complete Blood Count with Differential) and CMP (Complete Metabolic Profile). Values noted within range. An additional NPN, dated 04/09/2024, showed Staff J (Infection Preventionist) spoke with the Resident 15's physician who ordered a stool sample to be collected to rule out Clostridium Difficile (C. diff, an inflammation of the colon caused by the bacteria c.diff and results in abdominal pain, loose stools, and was contagious), because Resident 15 was having loose stools. Staff J documented Resident 15 was placed on contact precautions (intended to prevent transmission of infections which are spread by direct or indirect contact with the resident or the environment). Review of Resident 15's lab results, dated 04/09/2024, showed the lab report was flagged for abnormal results inconsistent with Staff K's reporting. Resident 15's labs showed indication of abnormal values for liver and kidney malfunctioning, and elevation of white blood cells which was an indication of a possible infection. The lab results showed Resident 15 was negative for C.diff. Review of a NPN, dated 04/10/2024, showed Resident 15, at their request, was sent to the emergency room (ER) the night of 04/09/2024 to be evaluated for lethargy (deep unresponsiveness), low blood oxygen saturation levels at 80%, coughing up bloody mucous NPN notes dated 04/10/2024 showed Resident 15 was given Morphine (pain medications) in the emergency room. The NPN showed Resident 15 returned to the facility. A NPN, dated 04/10/2024 at 11:53 AM showed staff documented that Resident 15 was barely arousable, took their medications, and shortly after became nauseous and vomited. The NPN showed the physician placed an order for intravenous fluids for hydration for Resident 15. Review of a NPN, dated 04/11/2024 at 12:50 AM showed staff documented that Resident 15 was experiencing lethargy, had brown discolored vomit, and diarrhea that was black in color. Resident 15 was sent out to the ER to be evaluated. An NPN, dated 04/11/2024 at 12:03 PM showed staff documented that Resident 15 was admitted to the Intensive Care Unit with sepsis. A NPN, dated 04/12/2023, showed staff documented they were informed that Resident 15 passed away on 04/11/2024. Review of Resident 15's Activities of Daily Living (ADLs, bathing, eating, toileting) documentation for bowel movements, dated 04/01/2024-04/11/2024, showed Resident 15 had loose stools on 04/01/2024, 04/02/204, 04/04/2024, and no bowel movements were documented for 04/06/2024. There was no documentation to support the facility initiated infection control measures when Resident 15 first presented with diarrhea. Review of 04/10/2024 Physician's Orders (PO) showed after nine days of diarrhea, Resident 15 was to ordered be started on contact precautions and to rule out C.diff. <Resident 18> Review of a quarterly MDS, dated [DATE], showed Resident 18 had some impairments to their decision making ability, had no behaviors, and was incontinent of bowel. The MDS showed Resident 18 had medically complex conditions and diagnoses including malnutrition and lung disease. Review of a facility provided GI Outbreak line list, dated April 2024, showed Resident 18 was the second of four residents with GI symptoms including diarrhea, vomiting, and cramps that started on 04/06/2024. Review of Resident 18's comprehensive CP, dated 01/11/2024, showed showed no CP developed for Resident 18's suspected GI infection or isolation precautions. Review of NPNs, dated 03/04/2024 through 04/09/2024, showed no documentation of when Resident 18 experienced symptoms, when the resident was isolated, who was notified, daily monitoring of symptoms or Resident 18's response. There was no NPN entry to indicate when Resident 18's symptoms resolved, if isolation precautions were implemented, or when isolation precautions were removed. Review of Resident 18's PO's dated 04/06/2024-04/13/2024 showed no PO for contact isolation or for stool testing to rule out infectious pathogens. Review of Resident 18's Activity of Daily Living (ADL) documentation for bowel movements, dated 04/01/2024-04/11/2024, showed Resident 18 had loose stools on 04/01/2024, and not 04/06/2024 as indicated on the facility GI line list. This data supported staff did not implement infection control for a minimum of five days after development of symptoms. <Resident 19> Review of a quarterly MDS, dated [DATE], showed Resident 19 was rarely or never understood, had a decision maker, no behaviors, and used a wheelchair to self propel around the facility. The MDS showed Resident 19 had medically complex conditions including dementia, weakness, and heart failure. The MDS showed Resident was assessed as frequently incontinent of their bowels. Review of a facility provided GI Outbreak line list, dated April 2024, showed Resident 19 was the third resident on 04/06/2024 to present with symptoms of diarrhea. Review of Resident 19's ADL documentation for bowel movements, dated 04/01/2024-04/11/2024, showed Resident 19 had loose stools that started on 04/04/202, not 04/06/2024 as indicated on the facility GI line list. Review of Resident 19's comprehensive CP, dated 01/19/2024, showed Resident 19 had behaviors of wandering but there was no CP developed for Resident 19's suspected GI infection or isolation precautions. Review of NPN's dated 04/01/2024 through 04/17/2024, showed no documentation when Resident 19 experienced symptoms, when the resident was isolated, who was informed, or when the responsible party or physician were notified. There was no documentation staff daily monitored Resident 19's symptoms or the resident's response. There was no documentation to support when Resident 19's symptoms resolved or when isolation precautions were removed. Review of Resident 19's PO's dated 04/05/2024-04/18/2024 showed no PO for contact isolation or for stool testing. During an interview on 04/17/2024 at 3:00 PM Staff J stated 20 or more residents and staff experienced GI illness symptoms. Staff J stated the diarrhea, nausea, and vomiting started on 04/06/2024, despite clear evidence residents experienced diarrhea on 04/01/2024, and was told to put symptomatic residents on contact precautions. Staff J stated Resident 15 was tested for C.diff, which was negative and one other resident had a stool culture (a test that detects and identifies bacteria that cause infections of the lower digestive tract) that results were still pending. Staff J stated they did not feel it was a foodborne illness and did not complete Norovirus (the most common cause of infectious diarrhea, characterized by diarrhea, vomiting, and stomach pain) testing because it had a short duration of 24-48 hours and it usually wouldn't show up. Staff DJ stated they first identified the increase of GI illness when reviewing a 24 hour nursing report, they were directed by management to report to the local health jurisdiction but was not aware they had to make a state report which was why the GI outbreak was not reported until 10 days after it was identified. <PPE Use, and Handwashing> In an interview on 04/17/2024 at 2:40 PM Staff N (Maintenance) stated the ice machine was cleaned last month, they did not know often the ice machine was emptied and cleaned. Staff N stated they were newly hired and needed to learn how to empty and clean the ice machines. In an observation and interview on 04/17/2024 at 3:45 PM, showed an ice machine behind a closed door, that was not locked, and accessible to anyone who tried to enter the room. A sign was posted on the ice machine that showed, Please wait for employee assistance. No gloves were observed in the ice machine room. An ice scoop was observed sitting in a plastic container on a shelf. At 3:47 PM Staff B stated they did not see any gloves in the ice room and would expect staff to always wear gloves when scooping ice. Staff B did not know how often the ice scoop or the container holding the ice scoop was cleaned. No additional information was provided. Observations on 04/17/2024 at 3:40 PM, showed room [ROOM NUMBER] with a posted contact precautions sign that directed staff to put on an isolation gown and gloves before entering the room. Observations of the isolation cart supplies showed no gloves available for staff use. Observations on 04/17/2024 at 3:47 PM, showed room [ROOM NUMBER] with a posted contact precautions sign that directed staff to put on an isolation gown and gloves before entering the room. Observations of the isolation cart supplies showed no gloves available in the cart. Observations at 3:48 PM showed Staff P (Certified Nursing Assistant, CNA) in room [ROOM NUMBER], with no isolation gown, only gloves assisting Resident 17 out of the bathroom. Staff P removed their gloves in the room, exited and used hand sanitizer in the hallway instead of washing their hands in the resident's room before exiting. During an interview on 04/17/2024 at 3:50 PM Staff P Resident 17 was not on isolation precautions. When asked about the contact isolation sign, Staff P stated they did not see that and yes, if the resident was on isolation an isolation gown and gloves should be worn. During an interview on 05/02/2024 at 3:12 PM Staff B (Director of Nursing) stated if a resident was symptomatic with illness they would expect staff to place the resident on isolation precautions when the diarrhea started, document the resident's symptoms, what actions were taken to decrease the spread of infection, who was notified, and put them on alert charting. Staff B stated if a resident was on posted isolation precautions they would expect the isolation carts to have necessary supplies and expected staff to follow the posted signs for directions on what PPE to wear. <Water Management Program (WMP)> Review of facility Water Management April 2023-April 2024 documents, provided 04/17/2024, showed a table of contents that included; inspect eyewash stations, Legionella water management plan review-upload your plan to TELS (a platform designed specifically for senior care living to create a safe environment), and testing and monitoring of water management plan for Legionnaires disease. The documents showed a generic step by step instructions on how to create a WMP that included establishing a water management team, have a written plan, a charted plan, a risk assessment, a water monitoring plan, verification and validation of the program, and documentation and communication of the water management team activities. The documents provided did not include any specific information for the facility and documentation of a water management plan as specified in the provided documents. In an interview on 04/17/2024 at 2:07 PM Staff A (Administrator) stated the facility had two water boilers upstairs and one was leaking. One side of the upper level of the building had cold and hot water, while the other side had cold and luke warm water. Staff A stated on 04/12/2024 or 04/13/2024 the facility had no hot water for less than a half hour. During an interview on 04/17/2024 at 2:25 PM Staff N (Maintenance Director) stated they were new to the facility, Legionella water testing should be completed weekly, and water temperatures she be at 110 degrees Fahrenheit, give or take 10 degrees Fahrenheit. Staff N looked for documentation of previous water testing, did not found anything. Staff N stated they were not educated on water testing policy. Staff N stated they were not sure if the facility koi pond/water feature was tested for Legionella in the past, they were educated by the previous maintenance man to clean the koi pond when needed. In an interview on 04/17/2024 at 3:15 PM Staff DJ stated they were not involved or familiar with the WMP and not sure if they were supposed to be involved. Observations of water temperature testing on 04/17/2024 at 4:25 PM, showed room [ROOM NUMBER] with sink water at 77.4 degrees Fahrenheit, room [ROOM NUMBER] with sink water at 91.4 degrees Fahrenheit, and room [ROOM NUMBER] with sink water at 93.8 degrees Fahrenheit, During an interview on 04/17/2024 at 5:00 PM Staff A stated facility water temperatures should be checked and documented weekly and if a problem existed with water temperatures residents should be notified. The facility did not notify resident representatives of the hot water being out and affecting one side of the resident rooms Review of a facility policy titled, Legionella Water Management Program, undated, and provided on 04/18/2024. The policy showed the facility was committed to the prevention, detection and control of water-borne contaminants, including Legionella (a bacteria that caused Legionnaires disease (lung infection) when small contaminated droplets are breathed in and can be found in human man-made water systems, such as showerheads, sink faucets, decorative fountains, and water features. The water management team would consist of the Infection Preventionist (IP), administrator, medical director, and the director of maintenance. The purpose of the WMP was to; identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risk of Legionnaires disease. The WMP would include a detailed description and diagram of the water system in the facility, identification of areas in the water system that could encourage growth and spread of water borne illness, identification of situations that could lead to Legionella growth, such as water temperature fluctuations, inadequate disinfectant, and construction. The WMP would use specific measures to control the introduction and/or spread by use of a disinfectant or temperature control, a diagram of where the control measures are applied, a plan when the control measures were not met, and documentation of that plan. The policy showed the facility would conduct annual testing and active management of biological populations (including Legionella). Review of additional WMP documents, provided 04/18/2024 showed the facility had a map of the water flow diagram, areas where Legionella could grow, and controls measures used included checking temperatures and disinfectant levels. The documentation did not include a risk assessment, a written plan, and verification validation of the program. Review of a facility document titled, Tap Water Temperature checks dated 03/06/2024 and 04/03/2024, showed the requirement was; water temperature gauges and the temperature of the tap water in each water heater circuit would be checked weekly; random check of 10 sources (resident room, shower); temperatures shall be no more than (left blank) degrees Fahrenheit, and discrepant findings would be remedied immediately. The documentation showed on 03/06/2024 a resident room temperature read 100 degrees Fahrenheit, and on 04/03/2024 two separate room, one being the shower room had lower temperatures at 102 degrees Fahrenheit. In comparison to previous months water temperatures was at the lowest 108 degrees Fahrenheit or above. The document showed after 03/06/20204 through 04/03/2024 weekly water temperatures were not completed. In an interview on 05/02/2024 at 3:10 PM Staff A stated when water temperatures were identified lower on 04/03/2024 the maintenance man should have done an assessment to identify the cause and notify them abut the temperature. Staff A stated they were not sure but would check to see about additional water testing such as pH (a measure of how acidic water is) levels and disinfectants, if used. No additional documents were provided. Staff A stated after the facility had a new water boiler replaced the facility did perform monitor checks but did not conduct any water testing after the construction and interruption of water. REFERENCE: WAC 388-97-1320(1)(a)(c)(2)(a)(5) .

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0941 (Tag F0941)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure direct care staff were provided the mandatory effective communication training. Failure to ensure the required effective communication training was provide placed all residents at risk of unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, training Requirements, undated, showed the facility would develop, implement, and maintain an effective training program for all new and existing employee's consistent with their role. Training would include at a minimum, effective communication for all direct care staff. Review of a facility Licensed Nurse (LN) 2024 training/inservice proposal showed no documentation of a communication training required or provided for LN's. Review of a facility Nursing Assistant Certified (NAC) 2024 training/inservice proposal showed no documentation of a communication training required or provided for NAC's. During an electronic mail (e-mail) communication on 05/10/2024, Staff A documented staff received Communication tracing as part of their Relias (health care education provider) training. Review of received education documents showed no documentation of Effective Communication tracing provided to direct care staff through the facilities training. Reference WAC 388-97-1680(2)(a)(b)(ii) .

Feb 2024 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 2 residents (Residents 16 & 15) reviewed for resident-to-resident incidents. This failed practice resulted in psychological harm, applying the reasonable person approach (a reasonable person in this situation would be upset, angry, and feel violated), for Resident 16 who experienced inappropriate sexual touching by Resident 14, and for Resident 15 who was inappropriately slapped by Resident 14. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. Findings included . Review of the facility Abuse, Neglect, and Exploitation policy, undated, showed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy showed the facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The policy showed examples to protect residents included; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, and increased supervision of the alleged victim and residents. The policy showed abuse prevention would include establishing a safe environment that supported, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. <Resident 16> Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/30/2023, showed Resident 16 was not able to make their own decision, and was assessed as rarely or never understood by others. The MDS showed Resident 16 had behaviors of wandering that occurred daily that placed the resident at significant risk of getting to a unsafe place and significantly intruded on the privacy and activities of others. The MDS assessed the wandering behaviors as worse when compared to prior assessments. The MDS showed Resident 16 had medically complex conditions including fracture, seizure disorder, anxiety, and depression. Review of an impaired cognition Care Plan (CP), revised 09/15/2023, showed Resident 16 had an impaired thought process due to being developmentally delayed (progression through developmental stages slows, stops, or reverses) and the goal was Resident 16 would develop skills to cope with their mental decline and to maintain the residents safety. Review of an elopement risk CP, revised 11/23/2023, directed staff to monitor Resident 16's location every 30 minutes and distract the resident from wandering with activities. Review of a Nursing Progress Note (NPN), dated 02/07/2024 at 5:15 PM, showed Resident 16 was touched inappropriately in the breast area by another resident (Resident 14) in the hallway by the main nurses station, the residents were immediately separated, and Resident 14 was placed on 15-minute checks. The NPN showed Resident 16 was interviewed and acknowledged the incident occurred. Review of Resident 16's medical record showed no documentation the facility completed an assessment of Resident 16's skin after the incident. Review of a facility investigation, dated 02/09/2024, showed Resident 14 was observed by Staff L (Licensed Practical Nurse, LPN) putting their hands up Resident 16's shirt and touching their breasts. Review of a witness statement, dated 02/07/2024, showed Staff L was able to separate the two residents and re-direct Resident 14. The investigation concluded that Resident 14's behaviors were a result of their progressing diagnoses and they were not aware that the behaviors were inappropriate. The investigation showed that Resident 16 stated they were okay, Resident 14 continued on 15 minute checks, and both residents were at their baseline without signs of psychological harm. In an interview and observation on 02/14/2024 at 2:37 PM, Resident 16 was observed self propelling their wheelchair near the main nurses station. Resident 16 had a hard time focusing on questions and when asked if they were touched inappropriately, Resident 16 could not provide any information on the incident. <Resident 15> Review of a Quarterly MDS, dated [DATE], showed Resident 15 was able to make their own decisions and needs known. The MDS showed Resident 15 had diagnoses including history of a brain bleed, dementia, anxiety, and depression. Review of a social services note, dated 02/07/2024 at 6:51 PM, showed Staff F (Social Services Assistant) documented that resident was tapped on the behind while passing another resident (Resident 14) and the resident wants the behavior addressed. Review of facility investigation documents, dated 02/08/2024, showed Staff A (Administrator) documented the facility actions as; Resident 15 was safe, both residents placed on alert monitoring, and possible medication increase for Resident 14. Review of a investigation document, dated 02/12/2024, showed Staff A documented Resident 15 sustained no injuries and exhibited no psychological harm, and Resident 14 was placed on 15 minute checks. Review of Resident 15's medical record, dated 02/06/2024-02/13/2024, showed one NPN documentation entry for monitoring Resident 15 for psychological abuse, no other NPN were found that showed Resident 15 was monitored for psychological harm as indicated in the investigation documents. Review of Resident 15's record showed no documentation to support the facility assessed Resident 15's skin for injury after being slapped on the buttocks by Resident 14. During an interview and observation on 02/14/2024 at 2:45 PM, Resident 15 was observed in bed and stated that they were standing in line with a Certified Nursing Assistant (CNA) when Resident 14 slapped their buttocks really hard, and it hurt. Resident 15 stated that facility staff told them not to tell their significant other (Resident 17) because they would be upset. Resident 15 stated they were embarrassed, it hurt, and the resident (Resident 14) slapped the CNA's buttocks as well. Resident 15 stated no one from the facility came down to talk to them, interview them, or check or ask to see the skin on their buttocks for injury. Resident 15 stated that they heard from other residents that Resident 14 had hit other residents before, I hope they are gone, and no one here at the facility is doing anything about Resident 14. In an interview on 02/14/2024 at 2:51 PM, Resident 17 stated, I think I was more mad then them (Resident 15), I almost went down there to punch them (Resident 14), but I didn't. During an interview on 02/14/2024 at 3:45 PM, Staff F stated they interviewed Resident 15 after overhearing Resident 15 telling Resident 17 what happened in the hallway. Staff F stated, Resident 15 stated they stepped out of their room, the hall was crowded, and when they passed by Resident 14, they reached out and felt their buttocks. Resident 15 stated they told Resident 14 don't do that and what if I did that to you. Resident 15 told Staff F they wanted this behavior addressed. When asked what was done with this information, Staff F stated they documented in Resident 15's record and informed the clinical team. Staff F stated the process was to direct reports to the administrator to make the report to the state agency and stated it was late when the allegation occurred. Staff F stated they were a mandated reporter and the allegation should have but was not reported immediately. <Resident 14> Review of a Quarterly MDS, dated [DATE], showed Resident 14 had a non-English language preference and required an interpreter to communicate with healthcare staff. The MDS showed Resident 14 could not make their own decisions, could rarely understand or be understood by others, and had no behaviors. The MDS showed Resident 14 had medically complex conditions including dementia without behavioral disturbances, traumatic brain injury, anxiety, depression and a cognitive communication deficit. Review of a dementia CP, revised on 01/11/2024, showed Resident 14 had a history of sexual gestures towards female residents. The CP directed staff to offer the resident activities they preferred and monitor for changes in the resident's behavior or mood. Review of a wandering CP, dated 04/03/2023, directed staff to re-direct the resident to activities of interest and place a stop sign at the entrance of the resident's room. Review of a NPN, dated 02/07/2024, showed Resident 14 had touched another resident (Resident 16) inappropriately, the residents were immediately separated and Resident 14 was placed on 15 minute checks. Review of a NPN, dated 02/10/2024 showed Resident 14 continued to roam around the facility. A NPN, dated 02/12/2024, showed Resident 14 was found sleeping in another residents bed. Review of a NPN, dated 02/13/2024 showed Resident 14 was found in another residents room trying to use the toilet and staff assisted the resident to their own room. Review of Resident 14's medical record showed no documentation that Resident 14's behaviors of wandering or inappropriate sexual touching were being monitored consistently by facility staff. In an observation and attempted interview on 02/14/2024 at 2:40 PM, showed Resident 14 asleep in their wheelchair sitting near the nurses station. On 02/14/2024 at 3:00 PM, 3:10 PM, and 3:30 PM Resident 14 remained in the same spot, sleeping with their eyes closed. At 3:30 PM attempted to interview Resident 14 but they did not respond. During an interview on 02/14/2024 at 3:15 PM, Staff M (Registered Nurse) stated they were familiar with Resident 14 and took care of them often. Staff M stated Resident 14 needed an interpreter when communicating with staff and Resident 14's representative would be called to communicate or assist in re-directing Resident 14. Staff M stated Resident 14 was hard to direct at times, after explaining to the resident they would stop their behavior but then continue with the behavior. When asked how do staff complete 15 minute checks on Resident 14, Staff M stated it was not easy to do, especially during medication pass. On 02/14/2024 at 3:32 Staff M stated Resident 14 would sometimes not respond or open their eyes when they were sleeping, had a hard time sleeping at night, and recently had a medication increased to help with their behaviors. In an interview on 02/14/024 at 4:45 PM, Staff A stated they would expect an allegation of inappropriate sexual touching to be reported immediately to them and the required entities in a timely manner. Staff A stated the purpose of a investigation was to rule out harm and put a plan in place to prevent reoccurrence. Staff A stated Resident 14 was being followed by a mental health provider and was currently being monitored for medication changes related to Resident 14's behaviors. REFERENCE: WAC 388-97-0640(1) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement their abuse and neglect policies and procedures regarding prevention, identification, investigation, and reporting of abuse. The facility failed to thoroughly investigate incidents and allegations of abuse, neglect, and misappropriation of residents property for 8 of 12 residents (Resident 1, 3, 5, 7, 8, 9, 12, 15) reviewed for incidents, failed to timely report incidents of abuse to the required entities for 1 of 2 residents (Resident 15) reviewed for allegations of sexually inappropiate touching, failed to identify incident as abuse for 2 of 2 residents (Resident 9, 10), and failed to ensure facility staff were trained on and implemented abuse policies and procedures for 2 of 4 staff (Staff C, D) involved in incidents, and the facility allowed Staff D to continue to render care to facility residents despite an allegation of verbal abuse. These failures placed the residents at risk for abuse by caregivers, and placed all residents at risk for for unidentified and on-going abuse/neglect, and a diminished quality of life. Findings included . Review of the undated facility, Abuse, Neglect, and Exploitation policy, showed the facility would implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of resident's property. The policy showed policies and procedures were established to investigate any such allegations and would include training for new and existing staff on activities that constitute abuse, neglect, exploitation, misappropriation of resident property, reporting procedures, and resident abuse prevention. The facility would provide on-going oversight and supervision of staff to ensure abuse policies and procedures were implemented as written. An immediate investigation would be warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurred. The staff responsible for the investigation would identify and interview all persons involved, including the alleged victim, alleged perpetrator, witnesses, and others that may have knowledge of the allegations. The investigation would focus on determining if abuse or neglect occurred, the cause, the extent of abuse, and would include thorough documentation of the investigation. The facility would make efforts to ensure all residents were protected from physical and psychological harm, as well as additional abuse, and protect the resident(s) from the alleged perpetrator. The facility would report all alleged violations to the state agency and other required agencies. <Resident 1> Review of the admission Minimum Data Set (MDS, an assessment tool), dated 12/08/2023, showed Resident 1 was able to make their own decisions and needs known. The MDS showed Resident 1 had diagnoses including a fracture, anxiety, and depression. Review of a Nursing Progress Note (NPN), dated 01/14/2024 at 7:14 AM, showed Staff C (Agency Registered Nurse) documented that Resident 1 complained about Staff D's (Certified Nursing Assistant, CNA) rough tone all night long. Resident 1 told Staff C that their roommate pressed the call light and Staff D assumed it was me and I don't want them in my room ever again. The documentation showed Staff C relayed the information to Staff D, who agreed not to go back into the room. Review of a facility investigation, dated 01/14/2024, showed Staff A (Administrator) documented that Resident 1 stated Staff D yelled about a few things, cut the resident off before they could finish their sentence, and stood outside the door, and came back in yelling about pain medications not being due. Staff A documented that Resident 2 (Resident 1's roommate) did not mention yelling but stated Staff D did cut Resident 1 off when talking, and Resident 1 cried and was upset. The investigation showed Staff D was suspended pending the investigation results and Staff D stated that Resident 1 was always concerned about receiving their medications and asked for them often. The investigation concluded that abuse was not able to be substantiated and Staff D seems to have acted with professional standards. Review of a witness statement written by Resident 1, dated 01/15/2024, showed Resident 1 documented the incident as employee verbally abusing resident on 01/13/2024, and no time was documented on the form. Resident 1 documented their call light went off accidentally and suggested the CNA (Staff D) check the roommates light. Resident 1 documented that Staff D yelled at me, stating do you know how long they have been here? They know better! Resident 1 documented that Staff D told them your pain medication isn't due, but I was requesting Tums, and they began yelling before I was able to finish talking. Resident 1 documented when their pain medications were due, Staff D yelled, you already had them! My roommate then requested medication and Staff D began yelling, I am not the nurse!. Resident 1 documented that Staff D left the room but stayed outside the doorway to listen and came back in the room yelling do you know how many times I have been in this room because of you hitting your button!. Resident 1 documented they responded to Staff D by saying, once and then asked Staff D what they had done wrong and documented, I just cried, I wasn't sure what to say or do. Review of a witness statement written by Resident 2, dated 01/15/2024, showed Resident 2 documented the incident was verbal abuse that occurred on 01/13/2024 around 10:00 PM. Resident 2 documented that around 10:00 PM they put their call light on for pain medications, Staff D came in the room, and proceeded to put her hand in Resident 1's face and stated your medication was not due yet. Staff D then turned to Resident 2 and told them how many times they were in the room since they were sleeping. Resident 2 documented that Staff D cut off Resident 1 when all they wanted was some Tums, Staff D made Resident 1 bust into tears and was upset throughout the night. Review of a witness statement, dated 01/18/2024, showed Staff D, documented Resident 1 called for pain medications, went to the nurse who stated it was not time, and told Resident 1 that it was not time for their medications. During an observation and interview on 01/19/2024 at 2:05 PM, Resident 1 was observed in their room standing with their walker. Resident 1 stated Staff D was rude, abrasive, and they yelled at me until I cried. Resident 1 stated the call light was hit accidentally and when Staff D responded, they rolled their eyes, put their hands on their hips, was very abrupt and it caught Resident 1 off guard. Resident 1 stated when they asked for Tums, Staff D cut them off, put their hand up, and stated, I am not the nurse. Resident 1 stated Staff D then left the room and as Resident 1 and Resident 2 were talking, Staff D stormed back in the room and started screaming and yelling at me about how many times they responded to call light. Resident 1 stated they told Staff C about the incident, and continued to cry, was terrified of Staff D, and did not want them back in their room. Resident 1 stated in the morning on 01/14/2024, around change of shift Staff C came to their room with a nurse from the facility to talk with Resident 1 about what occurred with Staff D. Review of Staff D's timecard, dated 01/13/2024, showed Staff D started work on 01/13/2024 at 1:54 PM and left work on 01/14/2024 at 6:19 AM. The timecard showed Staff D was allowed to continue to work with other residents at the facility after an allegation of verbal abuse was received on 01/14/2024 around 10:00 PM. In an interview on 02/01/2024 at 4:42 PM with Staff A and Staff E (Corporate resource Nurse), Staff A stated verbal abuse was something that negatively affected the resident and could be yelling, cursing, being rude or demeaning. Staff E stated both Resident 1 and Resident 2 were alert, oriented, able to make their own decisions and needs known. Staff A was asked who interviewed Resident 2 and if the resident was asked if Staff D yelled at Resident 1, because the facility investigation showed that Resident 2 did not mention yelling. Staff A stated they thought Staff F (Social Services Assistant) interviewed the Resident 2 about the incident and would have to look. No additional documents were provided. Staff A stated when agency nursing staff started at the facility they would attend an orientation that included abuse training and mandated reporting education. Staff A was asked to provide documentation of abuse training for Staff C, no documents were provided. Staff A was asked to provide documentation of abuse training for Staff D, a document was provided that showed a abuse training test, that had no answers circled, was not signed by Staff D, was not dated, or was noted who provided the training to Staff D. Staff A stated they would have to check, it could be how the form printed out, and would look into it. No additional documents were provided. Staff A was asked how they determined abuse was not substantiated, as they concluded the investigation as Staff D seems to have acted with professional standards. Staff A stated yelling is not a professional standard and did not substantiate abuse because of the CNA statement of events and both residents were at their baseline. Staff A stated they would expect facility staff to remove staff member from the floor immediately when a resident had an allegation of abuse. Staff A stated they were not aware of the incident until Monday 01/15/2024 and Staff D was suspended at that time. During an interview on 02/14/2024 at 3:02 PM Staff H (Agency Licensed Practical Nurse, LPN) stated they started working at the facility a few weeks ago and did not receive abuse training when they started their contract at the facility. <Resident 3> Review of the 11/24/2023 Quarterly MDS, showed Resident 3 had a memory problem due to severe mental impairment and was not able to make their own decisions. The MDS showed Resident 3 had hallucinations, delusions, and wandering behaviors that significantly intruded on the privacy and activities of others at the facility. The MDS showed Resident 3 was able to ambulate independently with a walker and did not require staff assistance. The MDS showed Resident 3 had medically complex conditions including dementia, Alzheimer's disease, and a cognitive communication deficit. Review of an Elopement Risk Care Plan (CP), revised on 11/27/2023, showed Resident 3 was at risk for elopement due to impaired safety awareness. The CP directed to staff to distract Resident 3 from wandering by offering activities, food, conversation, and television. The CP showed the residents preference for distraction and/or activities was left blank. The CP directed staff to identify the pattern of wandering and monitor Resident 3's location every 60 minutes. Review of an Elopement Screen, dated 11/29/2023, showed Resident 3 was screened as a high risk for elopement because they had a diagnosis of dementia, a history of wandering, exit seeking, and elopement from the facility. Review of Resident 3's Physician Orders (PO), dated 02/12/2024, showed a PO for a wanderguard (a device a resident wears that activates an alarm if close to exit doors) to the left wrist. Review of a facility incident investigation, dated 01/29/2024, showed Resident 3 was located in the facility parking garage at 5:45 PM on 01/29/2024. The investigation showed the door alarm sounded at approximately 5:45 PM, an employee responded immediately and brought Resident 3 back into the building. The investigation showed the physician and state hotline were notified on the incident and a skin assessment was completed with no injuries found. The investigation concluded that based on witness statements and the incident report, staff acted immediately to the alarm and brought Resident 3 back into the facility. The investigation documents did not include staff statements and failed to determine how Resident 3 made it onto the elevator on the second floor that was alarmed and responds to a wanderguard, down to the first floor, and out the facility door. The investigation did not include details on when the resident was last seen, by whom, who located the resident outside, and a plan to prevent reoccurrence. Review of Resident 3's medical record showed no documentation of the elopement on 01/29/2024, no alert monitoring after the elopement, no documentation of a post elopement screen, no documentation of CP updated post incident with a plan to prevent reoccurrence, and no documentation that staff assessed Resident 3's skin for injuries after being found outside in the parking garage. Observations on 02/01/2024 at 3:00 PM showed Resident 3 sleeping in bed, a wanderguard was observed to the right wrist, and Resident 3 refused to wake up for an interview. During an interview and observation on 02/01/2024 at 4:30 PM with Staff I (Maintenance) showed a resident with a wanderguard approaching the elevator and the wanderguard did not respond until the resident was right in front of the elevator. Staff F said they recently replaced the batteries and the alarm should sound when a resident with a wanderguard is within an eleven foot radius and at times it does not alarm until the resident is within a six feet radius. A wanderguard sensor was observed on and operating near the elevator area and a small panel to turn off the alarm was observed on the opposite of the wall, across from the elevator and right outside Resident 4's room door. During the interview and observation, the alarm sounded, and Resident 4 was observed walking outside their room and turned the alarm off. Staff F stated the alarm sounding must bother them. In an interview on 02/01/2024 at 5:15 PM Staff A stated they did not know Resident 4 was turning off the alarm and Resident 4 would be offered a room move immediately. During an interview on 02/14/2024 at 3:47 PM Staff A stated they would expect the investigation to be thorough and include details to determine how Resident 3 made it onto the elevator without staff knowledge and with a wanderguard. Staff A stated the investigation should include documentation of events, staff interviews, skin assessment, and the investigation should rule out abuse or neglect, and a plan developed to prevent reoccurrence. <Resident 5> Review of a 12/11/2023 Quarterly MDS, showed Resident 5 had some impairments to their decision making ability and exhibited no behaviors. The MDS showed Resident 5 had medically complex conditions, including fracture and depression. Review of a verbal aggression CP, dated 05/12/2023, showed Resident 3 had a history and the potential to be verbally aggressive, occasionally yelling out, and falsely accused peers with allegations. The CP directed staff to assess the resident's understanding of the situation, allow time for the resident to express themselves and feelings about the situation, and intervene before agitation escalates. Review of a NPN, dated 12/18/2023 at 9:43 PM, showed Resident 3 approached and informed the nurse that them that they and their roommate (Resident 6) got into a verbal altercation when the roommate started cussing at them to turn the volume on their television down, both residents used curse words and racial slurs against each other. The NPN showed Resident 5 did not want to sleep in the same room as Resident 6 and was put them in a different room. Review of a facility incident investigation, dated 12/18/2023, showed the incident was documented as residents had a verbal altercation with name calling, a spoon was thrown by Resident 6 at Resident 5 that hit them on the left side of the face, Resident 5 threw the spoon back at Resident 6 but missed, and Resident 5 exited the room. Staff A documented the investigation's data analysis included Resident 5 being relocated to a different room, a skin assessment completed with no injury, and no residents presented with psychosocial harm. The investigation concluded that based on witness statements and the incident report, Resident 5 was easily agitated, struggled to maintain relationships with other residents, and no further altercations occurred between the residents. Review of the investigation documents did not include statements from staff , and the investigation failed to rule out abuse. Review of Resident 5's NPN's, dated 12/19/2023 through 01/03/2024, showed no staff documentation that supported Resident 5 was monitored for psychological harm related to the incident. Review of Resident 6's NPN, dated 12/19/2023, Showed Staff B spoke with Resident 6 regarding their roommate who was recently relocated to a different room. Resident 6 stated they were called a derogatory name and threw their spoon at Resident 5, who turned around and threw the spoon back but it landed on the floor. Review of a 12/21/2023 NPN, showed Resident 6 was on alert for a resident to resident altercation, and Resident 6 had made no mention of the resident to resident incident and denied psychological harm. No additional notes were found related to the incident. Review of a facility investigation, dated 12/29/2023, showed Resident 5 had informed staff they were missing $20 and suggested it was a CNA. The investigation showed the data analyzed included; a CNA came into the room five times during the night to change Resident 8's roommate and did not touch any of Resident 8's personal items. The investigation concluded abuse could not be substantiated, and other caregivers matched Resident 8's description of the CNA. In an interview on 02/14/2024 at 3:50 PM, when asked why did Resident 5 and Resident 6 have an altercation, and Staff A stated, I think one was upset, maybe about the television. Staff A stated the reason for the altercation was not but should be included in the investigation. When asked how psychological harm was ruled out for Resident 5, as Resident 6 first cussed at Resident 5 about the television volume and then threw the spoon at them, Staff A stated they would have to look into this. Staff A stated there should be but was not two separate investigations for both Resident 5 and Resident 6, that the investigation should be thorough and include all information, including staff statements, follow up with both residents and alert monitoring for psychological harm. Staff A stated they would expect facility staff to notify them of incidents at anytime of the day and would provide direction to the staff if they were unsure what to do during incidents. Staff A stated for Resident 8's missing money staff did not but should have interviewed other residents for missing money or items, should have interviewed other staff working the date of the allegation, and should have searched the resident's room or made efforts to look for the missing money. <Resident 7> Review of the admission MDS, dated [DATE], showed Resident 7 admitted to the facility on [DATE] for a non-traumatic brain bleed, increased fluid on the brain, and had a Cerebro-Spinal Fluid (CSF, fluid that is surrounds the brain and spinal cord) drainage device (a permanent device implanted inside the head to drain excess fluid away from the brain). The MDS showed Resident 7 had severe impairments to their decision making ability, had difficulty focusing attention, and disorganized thinking. The MDS showed Resident 7 had highly impaired vision, did not use corrective lenses, and required staff supervision for transfers and toileting. Review of a baseline CP, dated 01/24/2024, showed Resident 7 was alert with confusion, had impaired vision and could only see shadows. The CP directed staff to use one person when assisting Resident 7 with transfers and toileting, and do not leave Resident 7 alone in the bathroom. Review of an actual fall CP, revised on 01/28/2024, directed staff to continue interventions on the at risk for falls CP. Review of Resident 7's CP's showed no at risk for fall CP. Review of a fall assessment, dated 01/24/2024, showed Resident 7 was assessed at high risk for falls due to a history of falls, the use of a walker, impaired balance, and showed staff documented Resident 7 knew their own limitations when asked if they were able to ambulate. Review of a facility investigation, dated 01/25/2024, showed Resident 7 experienced a fall on 01/25/2024 at 7:02 PM and was found on the floor of their room on their buttocks. The investigation showed data analyzed included; Resident 7 was found sitting on the floor after attempting to self transfer to the bathroom, the licensed nurse assessed the resident with no injuries, the resident was placed on alert charting, the CP was updated, a fall assessment was completed, and the physician and facility management were notified of the fall. The investigation concluded that based on interviews and the incident report, it was evident the resident overestimated their abilities and attempted to self transfer to the bathroom, Resident 7 was reminded to use their call light for assistance, the CP was updated to check on resident hourly to ensure needs are met, and no signs of latent injury from the fall. The investigation documents did not include a statement from the resident, staff statements, documentation of a skin assessment, documentation of neurological checks for the unwitnessed fall. Review of a NPN, dated 01/26/2024, showed the resident was found sitting on the bathroom floor at 6:15 PM on 01/25/2024, resident denied pain or discomfort through the shift and would continue to monitor the resident. The NPN did not show documentation if Resident 7 was assessed for injury, if the resident hit their head, vital signs, what the resident said about the fall, what the staff did in response to the fall and/or who was notified about the fall. Review of Resident 7's medical record showed no documentation of a post fall assessment, as indicated in the investigation. No documentation could be found in Resident 7's record that showed staff performed and recorded the results of neurological checks or that staff placed Resident 7 on alert charting as no documentation was observed monitoring Resident 7 after their fall. Documents were requested and no additional documents were provided. In an interview on 02/01/2024 at 3:20 PM, Staff G (LPN) stated they performed neurological checks on Resident 7, they were good but Resident 7's collateral contacts (CC) were very concerned about the brain shunt. Staff G stated Resident 7 was sent to the emergency room to be evaluated, the resident could not ambulate by themselves because they were blind, and needed staff assistance to the bathroom. During an interview and observation on 02/01/2024 at 3:26 PM, Resident 7 was observed sleeping in bed. Resident 7 stated they had a fall on the second day at the facility in the bathroom. Resident 7 stated , I can't see because there is no light going into the bathroom, and complained that the lighting was too dark in the room, and with being blind the resident needed good lighting. In an interview on 02/14/2024 at 4:00 PM, Staff A stated they would expect the fall to be thoroughly investigated and include all details about the fall, if call light was used, last time assisted to the toilet, documentation of a skin assessment, documentation of neurological checks, hospital paperwork and documentation in Resident 7's record of the incident and a post fall assessment. Staff A stated the investigated did not but should have included staff and resident statements about the fall. <Resident 8> Review of a Quarterly MDS, dated 12/202023, showed Resident 8 was able to make their own decisions and needs known. The MDS showed Resident 8 had diagnoses including a history of a brain bleed with left sided weakness, anxiety, and depression. Review of a facility investigation, dated 12/20/2023, showed Resident 8 stated they were missing money, the date of the incident was 12/20/2023 and the time of the incident was unknown. The investigation showed data analyzed included, a CNA helped Resident 8 look for the missing money, and a few days later Resident 8 notified a manager, and blamed the CNA for the missing money. Staff A documented that Resident 8 had stated different amounts of money were missing and was unsure of when the money went missing. The investigation concluded that based on the incident report and staff statements the facility was unable to substantiate abuse and the exact amount of missing money was not established. Review of a social services note, dated 12/24/2023, showed Resident 8 stated money was missing from their belongings, $40 and then another $10, and the resident was unsure of the timeline of the missing money. Staff F documented they would follow up with the resident after the holidays to see if they remember. Review of a grievance form, dated 12/26/2023, showed Staff F documented Resident 8 stated on 12/20/2023-12/21/2023 they noticed $40 missing, and on 12/21/2023-12/22/2023 another $10 went missing. Staff F documented this was elevated to an incident and filed with the state hotline. In an interview and observation on 01/19/2024 at 3:52 PM, Resident 8 was observed in bed and stated the person that took the money knew I slept hard, they reported the missing money the same day it was discovered missing on 12/24/2023, Staff F came down and took a report but the follow up was slow. Resident 8 stated they thought that Staff J (CNA) took the money because they had a recent disagreement. In an interview on 02/14/2024 at 4:10 PM when asked why the allegation of stolen money was not reported on 12/24/2023 when Staff F was aware and spoke with the Resident 8, Staff A stated it should have been reported on 12/24/2023 when staff were aware of the allegation. When asked if other residents were interviewed for missing money or items, Staff A stated they were not sure but would look, no additional documents were provided. When asked how the facility investigated, Staff A was not sure if staff searched Resident 8's room for the missing money, and stated staff should have but did not interview other residents for missing money or items, and should have searched the resident's room for the missing money. <Resident 9> Review of an admission MDS, dated [DATE], showed Resident 9 was not able to make their own decisions and had diagnoses including hip fracture, seizure disorder, anxiety, and depression. Review of a Discharge Plan CP, dated 12/15/2023, showed the discharge plan was for Resident 9 to go home with a CC. Review of a NPN, dated 01/07/2024, showed Resident 9 left the facility with a CC, stated they were discharging from the facility, Staff B was notified, and social services were informed and would follow up the next day. Review of a NPN, dated 01/08/2024, showed Staff B documented that they received a call from facility staff about Resident 9 and spoke with the CC who stated Resident 9 should have only been at the facility for three weeks, facility staff never call the CC back, and they can't get in touch with anyone at the facility. Staff B documented Resident 9 was taken out of the facility before paperwork was signed. In an interview on 02/01/2024 at 5:00 PM Staff A stated they were not aware of Resident 9's CC's allegations of facility neglect of never calling the CC back or answering the facility telephone and would expect that to be identified as neglect, should be investigated, and reported. Staff A stated they did report Resident 9's against medical advice (AMA) discharge but did not investigate into why Resident 9 wanted to leave the facility AMA. <Resident 10> Observations on 02/01/2024 at 3:18 PM showed Resident 10 wheeling down the hall and stopped at a resident door to say hello to the resident in the second bed, when Resident 11, who was in the first bed, yelled at Resident 10 and stated, Shut up! Because I need to go home! Staff K was present in the same area, and laughed it off. When asked if that was okay for the resident to tell the other one to shut up, Staff K stated they (Resident 11) are always like that. Resident 10 was observed going back to their room and stated, they (Resident 11) always yell, are rude, and all I wanted to do was say hi to the roommate. During an interview on 02/01/2024 at 4:45 PM Staff G stated they were not informed by staff about Resident 11 telling Resident 10 to shut up and would follow up. <Resident 12> Review of a Quarterly MDS, dated [DATE], showed Resident 12 was able to make their own decisions and needs known. Resident 12 had medically complex conditions including diabetes, anxiety, depression, and open wounds to the left foot. Review of a verbally aggressive CP, dated 01/25/2024, showed Resident 12 had behaviors of cursing, swearing, yelling, making threats, and was verbally hostile. The CP showed Resident 12 had a history of resident to resident altercations and the CP directed staff to analyze key times, places, circumstances, triggers, and what deescalates behavior, and document. Review of a facility investigation, dated 0105/2024, showed an incident occurred between Resident 12 and Resident 13 outside the facility and was described as Resident 12 stated Resident 13 was aggressive towards them. Review of investigation documents showed data analyzed was Resident 12 expressed they were afraid of Resident 13 during smoke breaks outside of the facility. Resident 12 stated Resident 13 birddogged (to seek out or monitor closely) me and prevented me from coming back to the facility. Staff A concluded the investigation that based on the incident report, witness statements both Resident 12 and 13 are their own responsible party, the day after Resident 12 expressed concern about Resident 13 they were observed outside smoking together and no additional concerns were brought up. Review of investigation documents showed witness statements from Resident 12, no witness statements were provided for Resident 13 or any other witness to the incident. There was no documentation to show what interventions were put in place to protect Resident 12, to prevent reoccurrence, if other residents were interviewed, and the investigation failed to rule out abuse. Review of Resident 12's medical record showed no documentation on 01/05/2024 of the incident in Resident 12's record or alert charting to monitor Resident 12 for psychological harm related to the incident with Resident 13. Review of Resident 13's medical record showed no documentation of the 01/05/2024 incident. During an interview on 02/14/2024 at 4:45, Staff A stated the investigation should be thorough and include documentation in the resident's records, psychological abuse monitoring documented in the record, statements from both resident's involved in the incident and any potential witnesses. When asked how the facility protected Resident 12 from further incidents with Resident 12 and ruled out abuse, Staff A stated they would need to look into that. No additional documents were provided. Staff A stated the purpose of an investigation is to try to determine what happened, determine the root cause, if any resident was harmed, determine if it is a pattern or widespread, and how to prevent the incident from reoccurring in the future. Staff A stated they would expect facility staff to able to identify abuse or neglect, report the abuse or neglect in a timely manner, report to the state hotline as a mandated reporter, and if they were unsure if an incident was reportable they would expect staff to notify them so they could assist in the decision making. <Resident 15> Review of a Quarterly Minimum Data Set (MDS, an assessment tool), dated 12/21/2023, showed Resident 15 was able to make their own decisions and needs known. The MDS showed had diagnoses including history of a brain bleed, dementia, anxiety, and depression. Rev[TRUNCATED]

Nov 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision for 3 of 3 residents (Resident 1, 2 & 3) reviewed for accidents. The facility failed to provide supervision to Resident 1, who resided on the second floor with a wander guard in place, when they eloped from the first floor of the facility unnoticed, and experienced harm when they fell from their wheelchair and sustained a head injury, an abrasion to the head, and required an evaluation at a local hospital. The facility failed to implement fall prevention measures after Resident 1 experienced harm from a fall and after that fall , experienced a suspected fall that caused a leg fracture and a laceration to their forehead that required suture repair. Additionally, the facility failed to implement their elopement policies and procedures for 2 residents (Resident 2 & 3) who eloped and went missing from the facility, this failure resulted in the facility taking no action for 17 hours for Resident 2 and almost 10 hours for Resident 3. These failures placed Resident 2 & 3 at serious risk for harm and injury, and placed all residents at risk for accidents, and avoidable injury. Findings included . Review of the facility's, Wandering and Elopement policy, revised 03/2019, showed residents who were identified at risk for wandering or elopement would have a care plan (CP) that would include strategies and interventions to maintain the resident's safety. When a resident was found missing from the facility, staff would initiate the elopement/missing resident emergency procedure and determine if they resident is out of the building on a leave or pass. If the resident was not out of the facility on a leave or pass the facility staff would initiate a search of the building and premises. If the resident was not located the Administrator, Director of Nursing Services (DNS), the resident's legal representative, the physician, and law enforcement would be notified. If the resident returned to the facility, the facility staff would examine the resident for injuries, inform the physician of the findings and condition of the resident, notify the legal representative, complete an incident report and document all relevant information in the resident's medical record. Review of the facility's, Safety and Supervision of Residents policy, revised 07/2017, showed the facility would take an individualized, person-centered approach to safety, and accident hazards for individual residents. The interdisciplinary team would analyze information obtained from assessments and observations of the resident to identify any specific accident hazards or risks for individual residents. The policy showed resident supervision was a core component of the systems approach to safety and the type and frequency of supervision was determined by the individual resident's assessed needs and identified hazards in the environment. <Resident 1> Review of a 09/01/2023 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was not able to make their own decisions, could usually understand and be understood by others. The MDS showed Resident 1 had medically complex conditions that included a neurological disorder that affected movement and muscle tone, seizure disorder, and muscle weakness. The MDS showed Resident 1 was assessed to require one-person physical assistance and supervision with moving to and from locations in the building, had no impairments to their upper extremities, and used a wheelchair for mobility. Review of Section E, Behaviors, showed Resident 1 did not exhibit behaviors of wandering and behaviors were assessed to have remained the same. Review of a Wander Risk CP, dated 05/23/2023, showed Resident 1 had increased wandering behaviors and made statements of wanting to go home. The CP directed staff to monitor Resident 1's location every 60 minutes, invite and encourage the resident to engage in activities, and distract the resident from wandering by offering diversions, activities, television, food, or conversation. Review of a Fall Risk CP, revised 08/31/2023, showed Resident 1 was high risk for falls. The CP directed staff to anticipate Resident 1's needs and offer toileting before and after meals, before bed, and as needed. A new 11/12/2023 intervention showed a tilt in space wheelchair was added to aide in positioning and decrease fall risk. Review of an Elopement Screen, dated 07/13/2023, showed Resident 1 was assessed as a five, indicating Resident 1 was high risk for an elopement due to diagnoses, a history of wandering, and a history of exit seeking. Review of a Fall Assessment, dated 11/04/2023, showed Resident 1 was assessed at high risk for falls due to a history of falls, weakness, and overestimating their own ability to ambulate. Review of a 07/13/2023 Nursing Progress Note (NPN) showed Resident 1 was witnessed by facility staff trying to exit the lobby door, Resident 1 stated they had an appointment and needed to go, or stated they wanted to go home. The facility staff documented the medical director ordered a wander guard (bracelet that alarms when the resident is close to exit doors to alert staff) for the resident's safety. Review of a 07/20/2023 and 07/27/2023 physician encounter note showed the Medical Director documented Resident 1 frequently wandered and agreed with Resident 1 being fitted for a wander guard for their safety. Review of a 07/28/2023 Psychiatric physician encounter note showed Resident 1 was assessed with poor safety awareness, wandering, and anxiety, and would be appropriate for a wander guard. Review of a 08/02/2023 Physician Order (PO) showed a PO to place a wander guard on Resident 1 and directed staff to place the wander guard on Resident 1's left side of the wheelchair, and to check placement and functioning of the wander guard twice daily. Staff were directed to inform appropriate personnel if the wander guard was not functioning. Review of a 11/07/2023 NPN showed Staff C (Licensed Practical Nurse, LPN) was called down to the front lobby at 11:10 AM and observed Resident 1 laying on the ground outside in front of the facility. Emergency Medical Service personnel were observed assisting Resident 1 when they stated another visitor observed the resident fall out of their wheelchair and notified the front desk. Staff C documented Resident 1 stated they were trying to leave the facility when asked what happened. Resident 1 sustained an abrasion to the right side of their forehead and was sent to the ER to be evaluated for a head injury. Review of a 11/07/2023 hospital After Visit Summary (AVS) showed Resident 1 was seen for a mechanical fall from their wheelchair and a facial abrasion. The AVS instructed Resident 1 to return to the emergency room of worsening or new concerning symptoms of dizziness, fever, bad headache, and repeated vomiting. Resident 1 was prescribed antibiotics for a urinary tract infection and discharged back to the facility. Observations on 11/08/2023 at 3:15 PM showed a visitor waiting at the reception area with no staff present. After a few minutes staff who were just feet away having a meeting acknowledged visitors waiting at the reception area. Observations of the front lobby and first floor showed no wander guard censors and a keypad used to enter a code to exit the front door. Observations showed the front lobby door was not armed and visitors could enter and exit the facility without entering a code. In an interview on 11/08/2023 at 3:20 PM Staff D (Registered Nurse, RN) stated there was supposed to be a staff member at the reception desk, but they left to use the bathroom. In an interview on 11/08/2023 at 3:30 PM Staff B (Director of Nursing Services) stated there was not a wander guard censor on the front door and on 11/07/2023 Resident 1 was last seen at 10:40 AM on the second floor near the elevator doors but was re-directed to the nurse's station. Staff B stated they reviewed the security cameras, and it showed Resident 1 followed two emergency medical service personnel out the front door at 11:01 AM. Staff B stated they were notified at 11:10 AM of Resident 1 being found outside of the facility, falling out of their wheelchair, and hit their head. During an interview and observation on 11/08/2023 at 5:05 PM Resident 1 stated yesterday I wasn't feeling good. My head hurt when I fell down and it hurts now in the back (of the head). I feel really dizzy now; my head feels funny. Resident 1 was observed in bed and an abrasion was observed to the right side of their forehead. Review of a 11/10/2023 NPN showed staff documented the resident had to be brought back upstairs once because they were wanting to leave. Review of a 11/11/2023 at 10:58 PM NPN showed Staff E (Licensed Practical Nurse, LPN) documented they were notified by staff that Resident 1 was observed with an injury to their forehead, assessed the injury as a laceration 5 centimeters (cm) long by 0.5 cm deep, and applied a pressure dressing to stop the bleeding. Resident 1 was not able to tell Staff E how they obtained the injury to their forehead. Staff E documented that Resident 1 was last toileted at 9:30 PM by staff and was transferred to a local hospital to be evaluated for a fall with head injury. Review of a 11/11/2023 hospital AVS showed Resident 1 was found with a fracture to the right leg and a laceration to their forehead was repaired with stitches. Resident 1 was diagnosed with dizziness, fall, closed head injury, closed fracture of the right leg, and a laceration to the forehead. Review of a 11/11/2023 facility investigation showed at 9:30 PM staff assisted Resident 1 to the bathroom and then to bed, at 9:47 PM a staff member found Resident 1 sitting up in their bed, near the head of the bed, with a bleeding injury above the left eyebrow and redness to their right cheek. Staff B documented that hospital visit notes showed Resident 1 complained of feeling dizzy before the fall and drops of blood were observed on the bathroom floor. The investigation showed staff who assisted Resident 1 on 11/11/2023 to the bathroom, prior to the suspected fall asked another staff member to help assist them because Resident 1, who normally required one staff for transfers, was not the same when transferring after the fall on 11/07/2023. The investigation showed Resident 1 reported to the social services director that they fell, hospital reports showed Resident 1 complained of feeling dizzy before the fall, and Staff B concluded that an unwitnessed fall likely happened. Review of Resident 1's medical record showed Resident 1 had experienced falls on 05/12/2023, 06/27/2023, 10/13/2023, and on 11/04/2023 that were all unwitnessed and Resident 1 was found at the bedside. Resident 1 experienced additional falls on 11/07/2023, and the most recent fall on 11/11/2023. Review of Resident 1's medical record showed the facility performed a fall assessment after each of Resident 1's falls that showed staff assessed Resident 1 to be high risk for falling. The fall assessment instructions showed; fall risk is based on fall risk factors and is more than a total score, determine fall risk factors and target interventions to reduce risks. Review of Resident 1's fall risk CP, revised 08/31/2023, showed no documentation of new fall prevention interventions added to the CP after Resident 1's fall on 05/12/2023 and 06/27/2023. The CP showed a new intervention added a month later, on 07/21/2023 that directed staff to provide re-direction as needed for safety during episodes of confusions and behaviors and allow resident to express their feelings and thought process for support when agitation is expressed. The CP showed no documentation to support new fall prevention measures care planned or implemented after Resident 1 fell on [DATE], 11/04/2023, 11/07/2023, until the 11/11/2023 fall when staff added a new intervention on 11/12/2023 for Resident 1 to use a tilt in space wheelchair (wheelchair reclines back) to aide in positioning and decrease fall risk, although Resident 1's falls usually occurred at the bedside, except the 11/7/2023 fall outside the facility, and the 11/11/2023 fall that was suspected to occur during a transfer with facility staff. In an interview on 11/21/2023 at 10:15 AM, Staff B stated that after a resident fell, the interdisciplinary team would review and determine the root cause of the fall and discuss and implement interventions to prevent further falls. Staff B reviewed Resident 1's fall CP and stated there should be updated interventions and acknowledged that a fall mat was added on 10/30/2023 but no new interventions were added after Resident 1's falls on 11/04/2023, 11/07/2023, and 11/11/2023. When asked about a PO for a tilt in space wheelchair, Staff B stated Resident 1 had been using a tilt in space for a while and had updated the PO as part of an audit, not a new intervention. <Resident 2> Review of a 07/16/2023 admission MDS showed Resident 2 was able to make their own decisions, needs known, and was able to understand and be understood by others. The MDS showed Resident 2 had diagnoses that included heart disease, history of a stroke (brain bleed), weakness, and history of substance abuse disorder. Facility staff assessed Resident 2 with no behaviors and the resident required one person staff assistance to move to and from locations in the facility. Review of a facility Elopement Screen, dated 07/10/2023, showed Resident 2 was assessed at a three, indicating a moderate elopement risk due to their ability to ambulate and being aware enough to deactivate exit alarms. Review of a 07/10/2023 PO showed resident may leave the center with an escort. Review of an Activities of Daily Living (ADL) CP, revised 10/02/2023, showed Resident 2 was able to transfer and ambulate independently. Review of an Incident progress note, dated 10/13/2023 at 11:21 AM, showed staff documented what happened as Resident 2 was missing. The note showed the writer was informed by the previous night nurse that Resident 2 was not in their room when the night nurse went to administer medications and has not returned. The note showed the DNS was notified of the incident. Review of the October 2023 Medication Administration Record (MAR) showed staff documented that Resident 2 received medications scheduled at 2:00 PM and staff documented a 9 for medications due at 6:00 PM and 8:00 PM. Review of the MAR chart codes showed 9 indicated other/see progress notes. Review of Resident 2's medical record showed no documentation from staff in progress notes on why Resident 2 did not receive their medications on 10/12/2023 at 6:00 and 8:00 PM. During an interview on 10/17/2023 at 12:18 PM Staff G (Previous Administrator) stated Resident 2 did not return to the facility and after a few days the facility considered the resident an Against Medical Advice (AMA) discharge. Staff G stated they attempted to reach the resident but did not make contact, Staff G did eventually get a hold of a case manager and a collateral contact (CC), who informed Staff G Resident 2 was with family. Resident 2 did show back up to the facility and was sent back to the hospital to be evaluated. Staff G stated Resident 2 had recently tested positive for Covid-19 (a contagious respiratory illness), had finished isolation precautions, and was not sure if Resident 2 would be returning to the facility. <Resident 3> Review of a 10/12/2023 admission MDS showed Resident 3 was able to make their own decisions, needs known, and was able to understand and be understood by others. The MDS showed Resident 3 had diagnoses that included a disease that altered the brain's function, high blood pressure, alcoholic cirrhosis of the liver (alcohol induced liver disease), anxiety, and a dependence on alcohol. Resident 3 was assessed with no behaviors. Review of a 10/06/2023 ADL CP showed Resident 3 required one person staff assistance for ambulation and limited assistance for transfers. The CP showed goals that Resident 3 would have needs met and safety maintained. Review of a facility Elopement screen, dated 10/06/2023, showed Resident 3 was assessed at a three, indicating a moderate elopement risk due to their ability to ambulate and being aware enough to deactivate exit alarms. Review of a 10/13/2023 NPN at 11:33 PM showed Staff F (LPN) documented during shift change report they were informed that Resident 3 was not in the building and staff did not know Resident 3's whereabouts. The NPN showed Resident 3 received their 11:00 AM medications and did not receive their 1:00 PM scheduled medications. Staff F notified the administrator, attempted to make contact with Resident 3 and listed contacts. Staff F spoke with Resident 3's collateral contact who wanted to be updated when the resident was found. Staff F filed a missing person report with the local police, this occurred almost 10 hours after the resident was not found in the building to receive their 1:00 PM medications. Review of a 10/14/2023 social services note at 10:36 AM showed staff documented, the resident was seen leaving the facility with roommate the afternoon of 10/13/2023. The documentation did not show who witnessed Resident 3 leave the facility, if other staff were aware of where Resident 3 was going, the time they planned to return, or if Resident 3 signed out of the facility. An additional note was added on 10/14/2023 at 1:27 PM showed staff spoke with Resident 3 who would not be returning to the facility, if the resident returned to the facility staff were directed to send the resident to the hospital because Resident 3 was not cognitively intact (has sufficient judgement, planning, organizing, and self-control to manage the normal demands in the environment). Review of a 10/14/2023 at 8:20 PM NPN showed the facility was contacted by a local hospital requesting medication information on Resident 3, as they were at the hospital. Facility staff faxed over Resident 3's medications and documents as requested by hospital staff. During an interview on 10/17/2023 at 12:18 PM Staff G stated Resident 3 left the facility with an older gentleman and spoke with a CC that stated Resident 3 was with family. Staff G stated the facility received a call from a local hospital requesting medical documents for Resident 3, but Staff G was not sure why Resident 3 was being admitted to the hospital. Staff G stated the facility considered Resident 3 to be an AMA discharge and was not sure if Resident 3 would be re-admitted back to the facility. In an interview on 10/17/2023 at 1:15 PM Staff G stated the facility did not do an investigation on Resident 2 and Resident 3 leaving the facility because they were considered AMA discharges and the facility made reports to adult protective services. During an interview on 11/08/2023 at 3:45 PM Staff A (Administrator) stated an AMA discharge would be when the facility was aware the resident wanted to leave, and staff would explain the risks and benefits of leaving AMA. Staff A stated they would expect staff to respond immediately and follow the facility procedure of a missing resident and not wait a prolonged period of time. Staff A stated the facility took this seriously, would expect an investigation to be completed, and they would look into the incidents. No additional documents were provided to support the facility reviewed the incidents. REFERENCE: WAC 388-97-1060(3)(g) .

Sept 2023 44 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Tube Feeding (Tag F0693)

A resident was harmed · This affected 1 resident

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Based on observation, interview, and record review the facility failed to implement care for 2 of 2 (Residents 24 & 37) residents reviewed for Tube Feeding (TF) management including: (1) timely action re: Resident Dietician (RD) recommendation to change the type of TF formula, (2) the administration TF rate consistent with and that followed the practitioner's orders; (3) the periodic evaluation of the amount of TF being administered for consistency with the practitioner's orders, (4) the maintenance of TF pumps consistent with manufacturer's instructions to ensure proper TF delivery, and (5) the implementation of proper resident positioning during TF administration to prevent the risk of aspiration (inhaling food contents into lungs). Resident 24 experienced harm when the facility failed to assess their nutritional needs, and placed residents at risk for developing TF complications and a decreased quality of life. Finding included . <Facility Policy> The undated Appropriate Use of Feeding Tubes facility policy showed any decision regarding the use of a feeding tube was based on the resident's clinical condition and residents who were fed by enteral (a way of delivering nutrition directly to the stomach) means received the appropriate treatment including the prevention of complications such as aspiration. The policy outlined Interdisciplinary Team (IDT) involvement, with the support and guidance of the physician, would ensure the ongoing review, evaluation, and decision-making regarding the initiation, continuation, or discontinuation of a feeding tube. The policy incorporated the plan of care to address the use of feeding tubes including strategies to prevent complications. <Resident 24> The 05/15/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 24 made their own decisions and required extensive assistance of two people to meet their daily needs. The MDS showed Resident 24 had a progressive neurological condition with the need for artificial nutrition through a surgically implanted tube directly into the stomach. Review of the 04/22/2021 Care Plan (CP) showed interventions that instructed staff to record intake on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), provide/serve diet as ordered, monitor intake and record the percentage consumed, and provide and maintain good oral hygiene. Review of the weight summary report showed Resident 24 weighed 172 Pounds (LB) on 03/17/2023 and on 09/13/2023 Resident 24 weighed 158 LB for a 7.06% weight loss in one month. Observation on 09/19/2023 at 9:05 AM showed Resident 24 lying in bed resting while receiving TF from a feeding pump. The pump was running at 85 milliliters per hour (ML/HR). The bag containing the formula had the rate written as 90 ML/HR. Resident 24 was noted to have a white film on their tongue and there were no oral care supplies observed in the room. Additional observations of the feeding pump running at 85 ML/HR and no oral care supplies were noted on 09/20/2023 at 8:54 AM, and on 09/21/2023 at 11:42 AM. A 09/12/2023 Physicians Order (PO) showed the pump should be set to 90 ML/HR. Observation and record review on 09/21/2023 at 12:15 PM showed Resident 24 had a wound to the coccyx (tailbone). Review of the 08/30/2023 RD note showed Resident 24's weights were decreasing. The note indicated maintaining a stable weight was desired and recommended increasing the TF pump rate by 5 ML/HR to total 90 ML/HR and recommended a multivitamin and protein powder supplement for Resident 24's wound healing. Review of the 09/08/2023 RD note showed the recommendation on 08/30/2023 was not carried out, and a recommendation to increase the tube feed pump by 5 ML per hour to total 90 MLs was made. In an observation and interview on 09/21/2023 at 12:15 PM Staff H (Resident Care Manager - RCM) confirmed Resident 24 had a white film on their tongue. Staff H stated the film was likely due to poor oral care. In an observation and interview on 09/22/2023 at 8:01 AM, Staff X (License Practical Nurse - LPN) confirmed the pump running at 85 ML/HR. Staff X stated the rate should be 90 ML/HR and adjusted the pump as ordered. Review of the September 2023 MAR and TAR showed intake were not being monitored. In an interview on 09/27/2023 at 9:27 AM, Staff B (Director of Nursing) stated they expected ample oral care supplies to be readily available to encourage oral care. Staff B stated they expected oral care to be offered by staff in the morning and evening daily. Staff B stated not doing so could result in oral yeast infections. Staff B stated they expected all physician's orders to be followed as they were written, and that not following the prescribed tube feeding rate could result in unintended weight loss and delayed wound healing. <Resident 37> According to the 07/26/2023 admission MDS, Resident 37 had multiple medical conditions including memory impairment, heart failure, and difficulty swallowing. The MDS showed Resident 37 was provided nutrition via a TF inserted through their stomach. The 07/20/2023 TF CP showed Resident 37 was not to receive anything by mouth because of swallowing difficulty. The CP outlined an intervention to keep Resident 37's Head of Bed (HOB) elevated at least 30 to 45 degrees during and 30 minutes after their TF. The CP instructed the nursing staff to provide good oral care and maintain Resident 37's oral health. On 09/19/2023 at 10:09 AM, Resident 37 was observed asleep, lying flat on the bed while their tube feeding was infusing, their mouth was open to show multiple, diffuse whitish spots over their tongue. The nutrition bag was not dated to determine when the TF was initiated. A hand-written note was observed taped on top of the pole holding the feeding pump that read TF on at 1pm, off at 9am daily (20-hours run). On 09/19/2023 at 10:16 AM, Staff U (Resident Care Manager) validated the TF was ongoing and that Resident 37 was lying flat in bed. Staff U stated they expected the nursing staff to elevate the HOB when the TF was on. Staff U acknowledged the TF bag did not have a date, time, or staff initial and stated they expected the nurse who initiated the process to label the bag with the items identified as lacking. Staff U read the note taped on top of the pole and stated, .the TF should be stopped by this time. Staff U reviewed Resident 37's TF order in the MAR to validate the times as written on the note. The 09/11/2023 TF order in the MAR did not indicate the time(s) as to when to start and end the TF. Staff U stated, .from my assumption, the intention was for the nurse to start the TF at 1 PM and end at 9 AM of the following day. Staff U stated the PO was not clear because there were no start and end times written for Resident 37's TF order. Staff U stated the hand-written note/directions found taped on the pole did not constitute a PO. Review of the 2023 September MAR showed Resident 37's TF PO was changed on 09/19/2023. The revised PO instructed nursing staff to administer a total of 1600 ML in 20 hours, to start the TF at 4:00 PM and end at 12:00 PM the following day. Observation on 09/20/2023 at 11:05 AM showed Resident 37's TF bag was empty, the TF tubing had multiple air pockets, and the feeding pump showed feed error on the monitor. There was no audible sound heard to alert the staff of the feeding pump malfunction. At 11:36 AM, Staff N (LPN) was alerted that more than half an hour passed since the feeding bag was observed empty. Staff N stated Resident 37's TF should be continuous until 12:00 PM as ordered, and a physician notification was warranted to make up for the time when Resident 37 did not receive any TF. In as observation and interview on 09/20/2023 at 11:58 AM, observed a new TF bag was hung at 11:45 AM by Staff N. The feeding pump showed 2190 ML. as the total amount administered at that time, 590 ML over the prescribed daily total TF amount as ordered. Staff B stated they expected the nursing staff to administer the TF amount as ordered, to document the amount in the MAR, and to clear the feeding pump when a new bag was stated in order to get an accurate reading for the benefit of the interdisciplinary team including the physician and RD. Staff B stated the feeding pump's alarm settings, noted the audible sound was muted, and stated, .that was probably why the nurse was not alerted when the feeding bag became empty. Review of Resident 37's 08/02/2023 Nutrition Assessment form showed the RD recommended a change of feeding formula that considered Resident 37's diabetes. A 08/30/2023 nutrition/dietary progress note completed by the same RD showed they re-recommended the feeding formula change, and again as noted on their 09/02/2023 follow-up progress note. The 2023 September MAR showed the feeding formula was changed on 09/11/2023, one month and nine days after the RD's initial recommendation date on 08/02/2023. The 09/02/2023 nutrition/dietary progress note showed Resident 37's last recorded weight was on 08/11/2023. A 07/28/2023 PO showed an order to obtain Resident 37's weight every Friday. Review of Resident 37's weights summary report showed there was no recorded weight between 08/11/2023 and 09/08/2023. The 2023 August TAR showed staff did not obtain Resident 37's weight on 08/04/2023, 08/18/2023, and 08/25/2023 as ordered. In an interview on 09/26/2023 at 1:44 PM, Staff B stated they expected the nursing staff to notify the physician within 24 hours of receiving an RD recommendation, most importantly for residents on TF. Staff B stated Resident 37's weights should have but were not obtained as ordered. Staff B stated the delay in action to address the RD's recommendation to change the feeding formula was unacceptable, .it should have been done sooner than that. Refer to F686- Treatment/Services to Prevent/Heal Pressure Ulcers. Refer to F692- Nutrition/Hydration Status Maintenance. REFERENCE: WAC 388-97-1060 (3)(f). .

SERIOUS (H)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 24> According to the 05/15/2023 Quarterly MDS Resident 24 made their own decisions and required extensive assist...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 24> According to the 05/15/2023 Quarterly MDS Resident 24 made their own decisions and required extensive assistance of two people to meet their daily care needs. Resident 24 had a progressive neurological condition that resulted in the need for artificial nutrition through a surgically implanted tube going directly into the stomach, and a Stage 4 PU to the coccyx (tailbone). Review of the 04/22/2021 CP showed treatments were to be administered as ordered and assessed including measuring the wound weekly. Review of the 08/04/2023 PO showed Resident 24 was to receive daily dressings to their coccyx, which included a brown medicated paste to the wound bed. Observation and interview on 09/21/2023 at 12:15 PM showed a wound to the coccyx. The wound was covered with a dry dressing but the medicine that was ordered was not observed. Staff H stated they did not see the wound had medicine in it. Staff H stated the medicine should be there, not administering the medicine as prescribed could lead to worsening of the wound. Review of the weekly skin assessments showed Resident 24's wound was not assessed on 04/26/2023, 5/3/2023, 5/10/2023, 5/17/2023, 5/24/2023, 6/21/2023, 7/12/2023, 08/10/2023, and 08/16/2023. Review of Resident 24's TAR showed no treatment was administered on 07/15/2023, 08/04/2023, 08/13/2023, 08/15/2023, 08/18/2023, and 09/07/2023. In an interview on 09/27/2023 at 9:32 AM, Staff B stated they expected wounds to be assessed weekly. Staff B stated wound nurses were recently hired to meet the facility needs but when they could not provide treatments or assess, then direct care staff should deliver wound care. Staff B stated not providing care to the coccyx PU could result in worsening wounds. Refer to F610- Investigate/Prevent/Correct Alleged Violation. REFERENCE: WAC 388-97-1060(3)(b). . <Resident 53> According to a 06/13/2023 admission MDS, Resident 53 had no memory impairment and had limited range of motion on one side of their body. This assessment showed Resident 53 was at risk for developing PUs but did not have PUs upon admission. Review of a 07/19/2023 incident report showed Resident 53 was identified to have a PU on their buttock, right ankle, and left elbow. The incident report showed interventions implemented were a referral to a contracted wound specialist, nutritional supplements to promote wound healing, and regular position changes for pressure reduction. Review of a 07/26/2023 assessment from the contracted wound specialist showed recommendations to always use pillows to float Resident 53's heels and left elbow. This assessment showed Resident 53 should be repositioned for pressure relief. This assessment showed Resident 53's left elbow PU should have a new bandage applied daily. A 09/10/2023 PO showed Resident 53 was to have a specialty air mattress in place. An 08/07/2023 Air Mattress CP showed Resident 53 used an air mattress to promote wound healing. The CP directed staff to notify maintenance or the RCM if the air mattress malfunctioned. A 09/20/2023 Registered Dietician (RD) note recommended Resident 53 start a liquid protein supplement to promote healing of Resident 53's PU. Review of Resident 53's records on 09/27/2023 showed the RD recommendation was not implemented. Facility staff were not providing the protein supplement to promote healing to Resident 53's PUs. Observation on 09/21/2023 at 9:04 AM showed Resident 53 lying on their side, no pillows were under their feet or under their left elbow. Resident 53 was not lying on an air mattress. Observations on 09/22/2023 at 8:40 AM and 09/25/2023 at 8:08 AM showed Resident 53 on their back, no pillows were under their feet or left elbow and an air mattress was not in place. In an observation and interview on 09/25/2023 at 12:19 PM, Resident 53 was on their back, not on an air mattress as ordered. There were no pillows under Resident 53's feet or left elbow. There was no bandage covering Resident 53's PU to the left elbow. At that time, Staff H confirmed Resident 53 should have pillows under their feet and left elbow. Staff H confirmed Resident 53 should have a dressing on their left elbow and an air mattress in place as ordered. In an interview on 09/27/2023 at 10:21 AM, Staff B stated Resident 53 often removed the pillows from under their feet and elbows. Staff B stated these refusals of care should be documented, care planed, and a risk versus benefits should be in place, but there was not. Staff B stated it was their expectation the RD recommendations for the protein supplement should be implemented by the following day of the recommendation. Staff B stated an air mattress should be in place as ordered over two weeks prior, for Resident 53 but was not. <Resident 65> According to the 07/23/2023 admission MDS, Resident 65 admitted to the facility on [DATE] and was assessed to have clear speech with moderate memory impairment due to a brain injury. The MDS showed Resident 65 had multiple diagnoses including kidney failure and was dependent on dialysis (a treatment that cleaned the blood), a medical condition characterized by elevated levels of blood sugar in the body, and weakness to one side of the body from their brain injury. Review of the 07/17/2023 admission Nursing Evaluation form showed Resident 65 was identified to have two skin issues: A right ankle scar, and a right heel PU. The Braden scale skin assessment completed by the admission nurse the same day assessed Resident 65 to be at risk for skin breakdown because of their complex medical conditions, bowel and bladder incontinence, and limited mobility. Review of a 07/17/2023 nursing progress note showed Resident 65 had dry/flaking scar tissue observed to their sacral area. The progress note did not identify any open area on Resident 65's tailbone or upper buttocks area. Review of a 07/19/2023 facility incident report showed Resident 65 was identified with a PU and was categorized as a Stage 3 (full-thickness loss of the skin that extended to the fat tissue) wound, two days after Resident 65's facility admission date on 07/17/2023. Review of the July 2023 Treatment Administration Record (TAR) showed a 07/20/2023 order to cleanse Resident 65's sacral PU with normal saline (a sterile solution used for cleaning wounds) and to apply skin protectant as needed. The TAR showed no documentation to demonstrate the treatments were performed from 07/20/2023 until 07/26/2023; (seven days). Review of the 07/21/2023 skin CP showed Resident 65 had actual skin impairments including the identified stage 3 PU to their sacral area. A CP intervention listed showed an air mattress was implemented for Resident 65 on 08/07/2023, 19 days after their Stage 3 PU was identified. Observation on 09/19/2023 at 12:10 PM, showed Resident 65 wearing a foam boot to their right lower leg/foot. At the same date and time, Resident 65 stated they have a sore on their bottom. When asked if treatments were being provided for the sore on their bottom, Resident 65 stated, .sometimes, not every day though . Observation on 09/25/2023 at 11:18 AM of Resident 65's Stage 3 PU with Staff H (Resident Care Manager) and Staff N (LPN) during wound care treatment showed exposed fat tissue and macerated (softened skin from being soaked) wound edges. The old dressing showed a moderate amount of serosanguinous (mixed blood and body fluids) drainage. In an interview on 09/27/2023 at 11:18 AM, Staff B stated Resident 65's Stage 3 PU was identified during the facility's skin sweep. Staff B stated they expected the nursing staff to assess and identify skin issues during admission, and to implement preventative measures timely to avoid development of and/or worsening skin condition. Staff B stated a skin breakdown could occur almost instantly, within a matter of hours especially for residents with multiple risk factors. Staff B reviewed Resident 65's records and stated there were no documentation to support the existence of the sacral Stage 3 PU prior to Resident 65's facility admission on [DATE]. Based on observation, interview, and record review the facility failed to ensure residents received wound care consistent with professional standards of practice that prevented skin breakdown and the development and/or worsening of Pressure Ulcers (PUs) for 5 of 6 (Residents 55, 65, 32, 53 & 24) residents reviewed for treatment and services for PUs. Three residents (Residents 55, 65, & 32) experienced harm when the facility failed to identify, consistently assess, monitor changes in skin condition, and implement preventative measures and interventions timely, follow Physician Orders (PO) for treatment, and complete weekly documentation of PU progress to promote healing and prevent new or avoidable PUs from developing or existing PU from worsening. These failed practices placed additional residents at risk for worsening of skin integrity, potential for developing PUs, and infections. Findings included . <Facility Policy> Review of the facility's undated 2022 Pressure Injury Prevention and Management policy, the facility was committed to the prevention of avoidable PUs and would provide treatment and services to heal PUs. This policy defined avoidable as a resident developing a PU and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define, and implement interventions that were consistent with resident needs, goals, and professional standards of practice; monitor and evaluate the effectiveness of interventions, or revise interventions as needed. According to the National Pressure Injury Advisory Panel (NPIAP) PU staging definitions include: a Stage 4 PU was a wound with full thickness skin and tissue loss with exposed connective tissue, muscle, tendon, ligaments, cartilage, or bone; a Stage 3 PU with full thickness loss of skin, in which fat was visible on the ulcer and rolled wound edges were present; an Unstageable PU was defined as a full thickness skin and tissue loss where the base of the wound was obscured by slough (dead skin cells) and/or eschar (dead tissue) where until sufficient slough and/or eschar could be removed to expose the base of the wound, the true depth, and therefore stage, could not be determined; Deep Tissue Injury (DTI) was intact or non-intact skin with localized area of persistent non blanchable deep red, maroon or purple discoloration. Pain and temperature change often preceded skin color changes. <Resident 55> According to the 07/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 55 was admitted on [DATE] and had multiple medically complex diagnoses that included an impairment in motor or sensory function of their lower legs, malnutrition, and a Stage 4 PU on their sacrum (the triangular area located below the waist and above the tailbone). The MDS showed Resident 55 was at high risk for new PU development and required extensive assistance for bed mobility, toileting, and transfers. A review of the Resident 55's records showed the resident's wounds were assessed by an outside wound provider on 08/30/2023 for the sacrum PU and left lower leg PU. No additional assessments by the wound provider were found in the records. Review of Resident 55's record showed the resident was transferred to the hospital on [DATE] for a condition change and readmitted to the facility on [DATE]. Review of the 09/13/2023 readmission skin assessment showed Resident 55 readmitted with PUs to their sacrum and to their left lower leg. A Braden scale (a tool that identified the risk for forming PUs) was completed on 09/13/2023 with a score of 13, showing Resident 55 was at moderate risk for developing PUs. Review of a 09/13/2023 revised Skin Integrity Care Plan (CP) showed Resident 55 had a Stage 4 sacrum PU, right heel with a DTI, and a PU to their left outer lower leg. Interventions included instructions for staff to follow wound care as ordered, monitor and document the location, size, and treatment of the skin injury, and to report any abnormalities to the provider. The interventions directed the staff to complete the weekly treatment documentation with wound measurements, and any other observations noted. Review of the weekly skin check assessment for 09/18/2023 -09/25/2023 showed no new skin issues were observed by staff during that period. Observations on 09/19/2023 at 10:28 AM and 2:07 PM, 09/20/2023 at 9:37 AM and 2:18 PM, 09/21/2023 at 8:51 AM, 10:01 AM, 12:37 PM, and 1:50 PM showed Resident 55 lying in bed on their back. In an interview on 09/21/2023 at 2:05 PM, Resident 55 stated they had a big wound on their bottom, and one on their left lower leg. Resident 55 stated they were unable to reposition themselves in bed and that staff assisted them with repositioning in bed once or twice a day. Resident 55 stated staff were busy helping other residents. Resident 55 stated staff used to get them up in the wheelchair but they have stayed in bed since they returned from the hospital. In an interview on 09/21/2023 at 2:08 PM, Staff R (Certified Nursing Assistant - CNA) stated they tried to reposition Resident 55 in bed at times and Resident 55 refused to be on their side. Staff R stated they did not document the refusals. An observation on 09/22/2023 at 2:25 PM showed Staff O (Licensed Practical Nurse - LPN) and Staff P (LPN) providing wound care to Resident 55. Resident 55's sacral wound was covered with a bordered gauze dressing. Staff O removed the dressing, assessed the wound which measured 10 x 11 x 0.2 centimeters (cm). The wound had mild drainage and no odor. At this time, Staff O and Staff P observed two new open wounds on Resident 55's right buttock that measured 3.5 x 1.5 x 0.1cm and 1.0 x 1.0 x 0.1cm with light bloody drainage, no odor, and no dressings in place. In an interview on 09/22/2023 at 2:48 PM, Staff O and Staff P stated they were not aware of these two wounds on Resident 55's right buttock. Staff O stated there was no documentation or treatment orders for these open wounds in Resident 55's record. Staff O stated the facility process for new skin issues was for CNAs report to the nurse, and for the nurse to assess the skin, make appropriate notifications, and investigate the origin of the wound. Staff O stated they were unaware of the open wounds on Resident 55's right buttock area. Review of Resident 55's POs dated 09/13/2023 showed orders for staff to to cleanse the sacrum PU with normal saline, apply a medicated dressing to the wound bed and cover with a foam dressing daily, and as needed, and cleanse the left lower leg with normal saline, apply a medicated dressing, and change daily and as needed. In an interview on 09/22/2023 at 2:53 PM, Staff O stated staff did not follow the PO to cover the sacrum PU with the foam dressing as ordered, and instead applied a different dressing. Staff O stated the foam dressing was not available in the facility for a few days and they notified their supervisor. In an interview on 09/22/2023 at 2:43 PM, Staff Q (Registered Nurse - RN) stated they were not aware of Resident 55's wound status because a wound nurse provided the daily wound care. Staff Q stated a CNA told them about the right buttock PUs last week, but they were busy and did not get time to look at Resident 55's right buttock PUs. Staff Q stated they reported the newly identified PU to the wound nurse. The wound nurse was not available for interview throughout the survey. In an interview on 09/26/2023 at 10:34 AM, Staff R stated they took care of Resident 55 since their readmission on [DATE]. Staff R stated Resident 55 admitted with a big wound on their sacrum and small wounds on their right buttock. Staff R stated they reported that these wounds were getting bigger to a nurse and that nurse responded they would inform the wound nurse. In an interview on 09/26/2023 at 10:47 AM, Staff S (LPN) stated they knew Resident 55 had a sacral PU. Staff S stated the prior week one of the CNAs reported to them about the right buttock PUs but they misunderstood and thought the CNA was discussing the sacral wound. Staff S stated they did not evaluate the wounds. Staff S stated they were busy and passed the information on to the wound nurse who was assigned to assess the PUs and provide daily wound care. In an interview on 09/26/2023 at 12:02 PM, Staff B (Director of Nursing) stated they expected staff to provide wound care as ordered by the provider. Staff B confirmed the facility was out of the ordered treatment supply for Resident 55's wounds temporarily. Staff B stated they found out about Resident 55's right buttock wounds on 09/22/2023 and interviewed CNAs because CNAs provided personal care to Resident 55 every shift. Staff B stated staff should have repositioned Resident 55 every two to three hours while in bed, and if the resident refused, staff should have documented the refusal. Staff B reviewed Resident 55's record and was unable to find documentation about Resident 55's refusal of care. Staff B stated the facility missed to identify and assess the PUs, initiate interventions and treatment to resolve the wounds, and prevent reoccurrences. Staff B stated the nursing staff should have assessed the PUs when CNAs reported to them, but did not. On 09/28/2023 at 9:22 AM, Staff B stated nurses were expected to identify, and assess changes in skin condition, notify the provider to obtain orders for treatment, and complete weekly documentation of wound status. Staff B acknowledged the nurses did not follow these instructions and this resulted in Resident 55's new open wounds on their right buttock. <Resident 32> According to the 08/06/2023 Quarterly MDS, Resident 32 had medically complex conditions including heart failure, peripheral vascular disease, diabetes, a bone infection, and an amputated right leg. The MDS showed Resident 32 was at risk for PU but had no current PU. Resident 32's POs included: a 05/02/2023 PO to cleanse Resident 32's heel with normal saline; a 05/10/2023 order to check Resident 32's skin weekly for new skin impairments. Review of the May 2023 TAR showed nurses did not cleanse Resident 32's left heel on four of 29 opportunities. Review of the June 2023 TAR showed nurses did not cleanse Resident 32's left heel on two of 30 opportunities. Review of the July 2023 Tar showed nurses did not cleanse Resident 32's left heel on three of 31 opportunities. Review of the August 2023 TAR showed nurses did not cleanse Resident 32's left heel on five of 27 opportunities prior to discovery of a DTI/unstageable PU on 08/28/2023. Review of the weekly skin checks showed Resident 32's weekly skin check was not documented as completed on 08/25/2023 (for the week of 08/21/2023 - 08/25/2023) as ordered and scheduled. Review of a 05/02/2023 nursing progress note showed Resident 32 was observed with a non-blanchable area (an indicator of a potential skin impairment) to their left heel. The note showed staff applied skin prep (a skin treatment) to the area. There were no other progress notes between 05/02/2023 and 08/28/2023 documenting Resident 32's left heel. Review of an 08/28/2023 nursing progress note showed Resident 32 had a DTI on their left foot. The note showed the wound was intact and directed staff to continue to float heel. The note did not show how the wound developed. An 08/30/2023 wound consult with an outside wound provider showed Resident 32 had two wounds on their left lower leg: The wound to their left foot, and a wound on the left heel. The documentation showed the foot wound was a diabetic foot wound, and not caused by pressure. The documentation described the left heel wound as an unstageable PU (a PU whose depth and condition could not be assessed due to the presence of eschar - a type of scab that prevents assessment of the wound base). The consult recommended to relieve pressure from the heel by repositioning/offloading (a positioning technique that reduced the risk of ongoing pressure to an area at risk for pressure), and to apply lotion to all areas of dry skin. Record review showed Resident took a leave of absence from the facility beginning on 09/14/2023. Resident 32 returned to the facility on the evening of 09/20/2023 and discharged to the community on 09/21/2023. The wound was not observed by the surveyor. Review of the 05/02/2023 Potential for Impairment to Skin Integrity related to Diagnosis of Diabetes CP showed Resident 32's diabetic foot ulcer was noted in this CP. There was no documentation of the left heel unstageable PU. No CP was developed to address Resident 32's risk for pressure injury documented in the MDS, and the CP did not include instructions on how to care for the left heel wound, and did not include the suggested interventions listed in the 8/30/2023 wound consult. In an interview on 09/26/2023 at 2:43 PM Staff H, stated the purpose of weekly skin checks was to ensure resident skin remained intact. Staff reviewed Resident 32's CP and stated the interventions identified by the wound specialist were not on the CP. Staff H stated the interventions should have been but were not added.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide care in a manner that promoted resident respect and dignity for 4 (Residents 25, 429, 580, & 14) of 4 Residents reviewed for dignity concerns. Facility staff failed to obtain consent prior to sorting through and organizing Resident 25's personal belongings, treat Resident 429 in a dignified manner, provide silverware that was consistent with a homelike environment for Resident 580, and provide adaptive utensils for Resident 14. These failures placed residents at risk for feelings of diminished and disrespected. Findings included . <Room Organizing> <Resident 25> According to a 05/29/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 25 admitted to the facility 02/09/2018 and had intact cognition. Resident 25 was able to understand others and be understood in conversation. Observation on 09/19/2023 at 9:51 AM showed Resident 25 lying in bed. Their over-the-bed table was in front of them and contained several tissue boxes, papers, and various personal items. Resident 25's nightstand was heavily cluttered with personal items. Resident 25 acknowledged they had a lot of items on their over-the-bed table and nightstand but stated they preferred to clean it themselves. In an observation and interview on 09/22/2023 at 11:14 AM, Resident 25 was in their wheelchair in their room. Resident 25 was extremely upset stating staff came to their room the previous night and threw away a bunch of my stuff because the inspector is coming. Resident 25's over-the-bed table and nightstand were tidied and free from the personal items observed on 09/19/2023. Resident 25 stated their room was dark when staff went through the resident's items so Resident 25 did not know what staff were taking. Review of an 08/25/2022 revised activities of daily living self-care participation Care Plan (CP) showed Resident 25 preferred to keep several boxes of gloves and tissues on the over-the-bed table. Review of a 09/21/2023 progress note showed documentation that Staff Y (Social Services Assistant) and a certified nurse's assistant cleaned and decluttered Resident 25's room. The progress note did not show if staff obtained permission from Resident 25 or if Resident 25 was involved in the process of deciding which items would be removed or kept. In an interview on 09/27/2023 at 11:02 AM, Staff B (Director of Nursing) stated a consent should be obtained and the resident should be aware of their room being cleaned. Staff B stated there should be a discussion with the resident fist. In an interview on 09/27/2023 at 11:17 AM, Staff Y stated Resident 25 had a lot of clutter and boxes in their room so they did some spring cleaning. Staff Y stated Resident 25 was very upset when first approached by staff wanting to clean their room but calmed down when Staff Y explained to Resident 25 that the resident oversaw what was kept and what was removed. Staff Y stated they should have documented consent was obtained and that Resident 25 was involved in the process, but they did not. <Plasticware and Adaptive Utensils> <Resident 580> According to an 08/22/2023 admission MDS, Resident 580 had intact cognition. Resident 580 was able to understand others and be understood in conversation. In an interview on 09/25/2023 at 9:53 AM, Resident 580 stated they wished the kitchen would provide real silverware. Resident 580 stated they got plastic ware over the weekend. <Resident 14> According to the 07/14/2023 Quarterly MDS, Resident 14 was assessed to have clear speech, was able to understand and be understood by others during communication, and their memory was intact. The MDS showed Resident 14 had multiple medical diagnoses including arthritis (inflammation or swelling of one or more joints). Review of Resident 14's 12/02/2023 nutrition and hydration CP showed they were at risk for malnutrition and dehydration because of their current medical conditions. The CP outlined a 09/20/2023 nursing intervention indicating Resident 14 used adaptive silverware. Observations on 09/22/2023 at 1:19 PM showed Resident 14 upset and yelling out at staff regarding receiving plastic silverware. Observations showed the resident was served a regular metal fork, plastic spoon, and a plastic knife. Resident 14 stated they had bought their own built-up silverware, wanted to know where it was, and stated, I guess that was not permitted. On 09/22/2023 at 1:23 PM, Staff A (Administrator) came to the kitchen during lunch service, asked the kitchen staff where the adaptive utensils were for Resident 14, and stated Resident 14 was acting belligerent, and was shouting along the hallway outside of their room. Resident 14 was very upset because they could not eat using the plastic utensils that came with the meal tray. Staff J (Dietary Supervisor) was observed searching through the kitchen drawers to find Resident 14's adaptive silverware. In an interview on 09/25/2023 at 1:12 PM, Resident 14 stated they bought their own personal adaptive spoon and fork to use in the facility for eating because they could not use the tiny, plastic ones being provided. Resident 14 stated they had arthritis to their hands and their right hand had trouble with grasping things. Resident 14 stated this was not the first time their adaptive spoon and fork were not provided to them. In an interview on 09/26/2023 at 1:53 PM, Staff BB (Kitchen Cook) stated Resident 14's adaptive silverware was sent to the kitchen for washing and sanitation after each meal. Staff BB stated Resident 14 had issues with their grip and needed their adaptive spoon and fork to allow ease with eating their meals. REFERENCE: WAC 388-97-0180(1-4). <Treatment in a Dignified Manner> <Resident 429> According to an 08/14/2023 admission MDS Resident 429 had multiple medically complex diagnoses including malnutrition, anorexia, an eating disorder, and depression. This MDS showed Resident 429 required limited assistance from staff with eating. Observations on 09/22/2023 at 12:50 PM, showed Staff LL (Certified Nursing Assistant) bringing a lunch tray to Resident 429. Staff LL placed the tray on the resident's bedside table. On the tray was rice, cooked vegetables, a roll, apple juice, a Styrofoam cup labeled health shake and plastic silverware. Resident 429 started to tell staff they were unhappy with the food and Staff LL looked around the room and stated, where is your bib? Staff LL found a clothing protector in a pile on the bedside table and placed it on the resident. Resident 429 started to object, but then shrugged their shoulders while staff placed it on them. Staff LL then stated, enjoy your lunch. In an interview on 09/22/0223 at 1:06 PM, Resident 429 indicated they did not eat much and stated, I was not terribly hungry. When asked about the clothing protector, Resident 429 stated, I do not prefer to have a clothing protector, it feels a bit childish, but you have to pick your battles. In an interview on 09/27/2023 at 2:04 PM, Staff B stated residents should be treated in a dignified manner. Staff B was unsure why residents were receiving plastic silverware and Styrofoam cups, and stated it was their expectation staff follow resident preferences with using clothing protectors.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

<Resident 5> According to the 06/19/2023 Annual MDS Resident 5 had moderate cognitive impairment. This assessment showed Resident 5 had diagnoses including depression, anxiety, and post-traumati...

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<Resident 5> According to the 06/19/2023 Annual MDS Resident 5 had moderate cognitive impairment. This assessment showed Resident 5 had diagnoses including depression, anxiety, and post-traumatic stress disorder and required the use of AP and AD medications. Review of Resident 5's records showed no consent was obtained for two psychotropic medications. In an interview on 09/25/2023 at 6:12 AM Staff B stated there was no documentation for consent at the time of order for two psychotropic medications for Resident 5. Staff B stated they should have obtained consent prior to implementing the medications for Resident 5, but they did not. REFERENCE: WAC 388-97-0260(1)(a)(b)(i)(ii)(iii). Based on interview and record review, the facility failed to inform residents in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 Residents (Residents 30 & 5) reviewed for unnecessary medications. The failure of facility staff to obtain consent for psychotropic medications prior to administration detracted from the residents' ability to exercise their right to make an informed decision about proposed treatments and prevented the residents from exercising their right to decline the treatments/therapies. Findings included . <Facility Policy> The facility's 2023 Psychotropic Medication policy showed residents who used psychotropic drugs would be educated on the risks and benefits of psychotropic drug use. <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had moderately impaired cognition (impaired memory and problem solving), experienced hallucinations and delusions, exhibited verbal behavior towards others, and had diagnoses that included non-traumatic brain disorder (brain damage), anxiety, and depression. The MDS showed Resident 30 regularly used Antipsychotic (AP) and Antidepressant (AD) medications. Record review showed a 03/14/2023 Psychotropic Drugs Disclosure and Consent was completed for Resident 30 by facility staff. The form listed classifications and names for various kinds of psychotropic medications and included a place to identify what drug consent was obtained. The form listed the different risks and benefits for the various classes of psychotropic medications identified. The form showed Resident 30 checked a box stating they accepted treatment with the medication and signed the form. The form did not identify for which medication or which class of medication Resident 30 provided consent. In an interview on 09/28/2023 at 10:39 AM Staff B (Director of Nursing) stated they expected psychotropic consent forms to identify the medication in question in order to ensure residents were able to make an informed decision about the use of a medication.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

<Resident 27> Review of the 05/09/2023 Quarterly MDS showed Resident 27 had no memory impairment, was able to understand and be understood in conversation. This assessment showed Resident 27 req...

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<Resident 27> Review of the 05/09/2023 Quarterly MDS showed Resident 27 had no memory impairment, was able to understand and be understood in conversation. This assessment showed Resident 27 required assistance from staff with bathing and did not reject care. In an interview on 09/19/2023 at 9:25 AM, Resident 27 stated they were supposed to receive showers on Tuesdays and Fridays but stated the staff were only giving her showers on Tuesdays. Review of a 02/06/2023 revised Care Plan showed Resident 27 required staff assistance for bathing. This CP showed Resident 27 preferred two showers per week. According to the facility bathing schedule provided by staff on 09/20/2023 at 9:53 AM, staff were only providing bathing to Resident 27 on Tuesdays. Resident 27 was scheduled once per week, not twice weekly as the resident preferred. Review of Resident 27's July 2023, August 2023, and September 2023 bathing records showed staff provided bathing assistance once per week. Staff did not provide bathing twice weekly as Resident 27 preferred. In an interview on 09/27/2023 at 10:50 AM, Staff B stated staff should provide showers to Resident 27 per their preference, but they did not. REFERENCE: WAC 388-97-0900(1). Based on interview and record review the facility failed to allow 2 (Residents 62 & 27) of 20 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/or type of bathing. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life. Findings included . <Bathing> <Resident 62> According to a 06/01/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 62 had clear speech, no memory impairment, and was able to understand and be understood by others. This MDS showed Resident 62 was assessed to require extensive physical assistance from staff for bathing and had no rejection of care. In an interview on 09/19/2023 at 9:47 AM, Resident 62 indicated they only got one shower each week and stated they were begging staff for showers twice weekly. Resident 62 stated, it was unsanitary to be bathed only one time a week and indicated it was, disgusting. On 09/25/2023 at 12:25 PM, Resident 62 stated, I only get bathing on Tuesdays, I would like another day. Review of a 06/08/2023 Activities of Daily Living (ADL) Care Area Assessment showed staff documented Resident 62 required extensive assistance for ADLs and was at risk for skin impairment and decline in ADLs. Staff documented they would assist and encourage Resident 62 with all their daily activities as needed. Review of Resident 62's Individual Service Plan (ISP - directions to staff regarding how to provide care) on 09/20/2023 showed the resident's bathing preference as, SPECIFY. Staff did not identify Resident 62's actual bathing preferences. A 09/01/2023 physician order gave directions to staff for Resident 62 to have a shower twice weekly on Tuesdays and Fridays to prevent developing yeast infections. According to the facility bathing schedule provided by staff on 09/20/2023 at 9:53 AM, Resident 62 was only scheduled for bathing one time a week. Review of September 2023 bathing documentation showed Resident 62 only received bathing once weekly. In an interview on 09/27/2023 at 2:04 PM, Staff B (Director of Nursing) stated it was their expectation staff would accommodate resident preferences. Staff B confirmed staff failed to provide bathing twice weekly for Resident 62 as directed by the provider and the resident's preferences.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 24> According to the 05/15/2023 Quarterly MDS, Resident 24 admitted to the facility on [DATE]. The MDS showed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 24> According to the 05/15/2023 Quarterly MDS, Resident 24 admitted to the facility on [DATE]. The MDS showed they were cognitively impaired and was dependent on staff to meet their Activities of Daily Living needs due to the diagnosis of Multiple Sclerosis (a nerve muscle disease). Review of the 01/26/2022 AD Acknowledgment form showed Resident 24 provided the office with a copy of their advance directive. The form indicated a Durable Power of Attorney (DPOA - a document that indicated who made decisions on behalf of a person who cannot make their own decision). In an interview on 09/26/2023 at 10:06 AM, Staff C stated they could not locate Resident 24's AD in the medical records. <Resident 373> According to the 09/13/2023 admission MDS, Resident 373 was cognitively intact. The MDS showed Resident 373 had extensive liver disease that required a medication to assist them in maintaining conditions that would affect their ability to make decisions. Review of the undated AD Acknowledgement form showed Resident 373 executed an AD and would provide a copy to the office. In an interview on 09/26/2023 at 10:06 AM, Staff C stated they could not locate Resident 373's AD in the medical records. Staff C stated residents' ADs should be collected to ensure provision of care was consistent with the resident's own needs. Staff C stated ADs should be uploaded into the medical record to ensure they were available when decision-making was warranted. REFERENCE: WAC 388-97-0280(1)(2)(3)(a). <Resident 5> According to the 06/19/2023 Annual MDS, Resident 5 participated in their discharge planning in the MDS, and no guardian or legally authorized representative participated in the assessment. Review of Resident 5's 02/11/2022 Advanced Directives Acknowledgment form showed a copy of their AD was provided to the facility and their representative was verbally notified. In an interview on 09/25/2023 at 11:47, Staff C stated they never obtained a copy of Resident 5's AD. Staff C stated they should have followed through with Resident 5's representative and obtained a copy but did not. Based on interview and record review, the facility failed to ensure residents had the appropriate Advance Directive (AD) in place for 4 of 20 (Residents 65, 5, 373, & 24) reviewed for ADs. The facility failed to help residents (Resident 65) formulate an AD and document in the medical records that assistance was offered. The facility failed to obtain a copy from residents (Resident 5, 373, & 24) with an existing AD and make the documentation readily available in the medical records and accessible to facility staff. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> The 2023 Residents' Rights Regarding Treatment and ADs showed the facility would determine if the resident had executed an AD upon admission, and if not, determine whether the resident would like to formulate an AD. The policy outlined if the resident had and AD, copies would be made and placed on the medical record and communicated to the staff. <Resident 65> According to the 07/23/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 65 had clear speech and was able to understand and be understood by others during communication. The assessment showed Resident 65 had multiple complex medical diagnoses including kidney failure with dependence on dialysis (a treatment that cleaned the blood), high blood pressure, elevated blood sugar levels, and weakness to one side of the body from their stroke. In an interview on 09/19/2023 at 2:37 PM, Resident 65 stated they did not have an AD. When asked if the facility offered them assistance to formulate an AD, Resident 65 stated they could not recall precisely if they were offered assistance or not. Review of Resident 65's medical records showed there was no AD Acknowledgement form (a facility document) on file. In an interview on 09/25/2023 at 12:56 PM, Staff C (Director of Social Services) stated ADs determine residents' wishes that was important in the event of a significant change in condition, .they [ADs] tell us exactly who will make the decisions and what to do . Staff C stated they need to have due diligence in explaining the importance of ADs to residents. Staff C stated there was no AD Acknowledgement form found in Resident 65's medical records and was unsure of how it was missed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to log/report an allegation of neglect for 1 (Resident 32) of 20 sample residents reviewed. This failure placed residents at risk for unidentified neglect, avoidable pain, and other negative health outcomes. Findings included . <Resident 32> According to the 08/06/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 32 had no cognitive impairment, and no depression. The MDS showed Resident 32 exhibited no behavior and did not experience hallucinations or delusions. The MDS showed Resident 32 had occasional pain and required as-needed pain medications. Review of a 08/24/2023 grievance form initiated by Resident 32 showed the resident stated they pressed their call light to request care. Resident 32 stated Staff L (Certified Nursing Assistant) responded by asking them why they called for care before turning off Resident 32's call light and leaving without providing care. The grievance form indicated Resident 32 then waited over an hour before receiving their pain medication. The form was signed by Staff A (Administrator) on 09/16/2023. Resident 32's August 2023 Medication Administration Record (MAR) showed the resident was administered their as-needed pain medication three times on 08/24/2023: at 8:47 AM for a pain of 6/10, at 12:54 PM for a pain of 6, and at 6:44 PM for a pain of 8. Review of the facility's August 2023 Incident Reporting Log showed nothing was logged for Resident 32 for the 08/24/2023 grievance form. In an interview on 09/26/2023 at 12:58 PM Staff A stated they were not sure how the facility ruled out Resident 32 was neglected on 08/24/2023 after they alleged facility staff failed to provide them pain medication for over an hour. Staff A stated the incident should have been but was not added to the August 2023 Incident Reporting Log. Staff A stated Resident 32 received poor customer service. REFERENCE: WAC 388-97-0640(5)(a). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> Resident 17 was transferred to an acute care hospital on [DATE] Return Anticipated and readmitted on [DATE]....

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> Resident 17 was transferred to an acute care hospital on [DATE] Return Anticipated and readmitted on [DATE]. Record review showed no documentation or indication the facility provided Resident 17 written information regarding the facility's bed-hold policy as required. An interview on 09/26/2023 at 10:18 AM Staff C stated they should review their bed-hold policy with residents at time of discharge. Staff C stated if floor staff were unable to review the bed-hold policy at time of transfer out due to specific circumstances with the resident, it would then be the responsibility of social services to notify the resident or resident representative right away. Staff C stated there was no documentation that they went over the bed-hold policy with Resident 17 but they should have. REFERENCE: WAC 388-97-0120(4). Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 4 (Residents 9, 55, 66, & 17) of 8 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Resident 9> Resident 9 admitted to the facility on [DATE]. Record review showed Resident 9 was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 08/02/2023 Discharge MDS, Resident 9 again discharged to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation or indication the facility provided Resident 9 or their representative written information regarding the facility's bed-hold policy as required. During an interview on 09/25/2023 at 11:27 AM, Staff B (Director of Nursing) acknowledged there was no documentation to support Resident 9 or their representative was provided a written notice of the facility's bed-hold policy as required. <Resident 55> Resident 55 admitted to the facility on [DATE]. Record review showed Resident 55 was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 08/31/2023 Discharge MDS, the resident again discharged to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation or indication the facility provided Resident 55 or their representative written information regarding the facility's bed-hold policy as required. During an interview on 09/25/2023 at 11:27 AM, Staff B acknowledged there was no documentation to support Resident 55 or their representative was provided a written notice of the facility's bed-hold policy as required. <Resident 66> Resident 66 admitted to the facility on [DATE]. According to a 09/11/2023 Discharge MDS, Resident 55 was discharged to an acute care hospital on [DATE], Return anticipated. Record review showed no documentation or indication the facility provided Resident 66 or their representative written information regarding the facility's bed-hold policy as required. During an interview on 09/25/2023 at 11:27 AM, Staff B acknowledged there was no documentation to support Resident 66 or their representative was provided a written notice of the facility's bed-hold policy as required.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 admitted to the facility on [DATE] and was assessed as ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 admitted to the facility on [DATE] and was assessed as cognitively intact. In an interview on 09/19/2023 at 11:23 AM, Resident 9 stated they did not receive a copy of their CP since admission. A review of Resident 9's record showed baseline CPs were initiated on 01/31/2023 but there was no documentation showing facility staff provided Resident 9 with a copy. In an interview on 09/25/2023 at 11:27 AM, Staff B reviewed Resident 9's record and provided a copy of the baseline CPs. Staff B was unable to provide documentation showing Resident 9 was provided a copy of their baseline CP. Staff B stated the facility should have provided a copy of the CP to the resident and document but they did not. <Resident 66> Review of Resident 66's nursing progress notes showed Resident 66 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE] for condition change. According to the 09/20/2023 Medicare - 5 day MDS, Resident 66 readmitted on [DATE] and was assessed as cognitively intact. In an interview on 09/20/2023 at 9:43 AM, Resident 66 stated they came to the facility and then went back to the hospital and came back last week. Resident 66 stated they did not remember having a CP meeting or receiving a copy of their CP since admission and readmission. Review of Resident 66's record showed no documentation indicating the facility had a CP meeting with Resident 66 or provided a copy of the CP since admission and readmission. In an interview on 09/25/2023 at 11:32 AM, Staff B Reviewed Resident 66's record and was unable to provide documentation to show Resident 66 had a CP meeting and was provided a copy of their baseline CP. Staff B stated the facility should provide a copy of the CP to the resident and document but they did not. REFERENCE: WAC 388-97-1020 (3). Based on interview and record review the facility failed for 3 (Residents 68, 9, & 66) of 8 newly admitted and readmitted residents reviewed, to provide residents and/or their representative with a summary of their baseline Care Plan (CP). This failure resulted in residents and/or families not being informed of their initial plan for delivery of care and services, and placed residents at risk for unmet needs, and possible complications. Findings included . <Facility Policy> According to a 2022 facility Baseline Care Plan policy, the facility would develop and implement a baseline CP for each resident within 48 hours of a resident's admission. This policy showed a written summary of the baseline CP would be provided to the resident and representative by completion of the comprehensive CP. Staff would obtain a signature from the resident/representative to verify the summary was provided and make a copy of the summary for the resident's records. <Resident 68> According to a 07/19/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 68 was admitted to the facility on [DATE] and was assessed with clear speech, no memory impairment, and was able to understand and be understood by others. In an interview on 09/19/2023 at 12:33 PM, Resident 68 stated they were not given a copy of their CP since admission. Record review showed Resident 68's CPs were initiated on 07/13/2023, but there was no documentation showing the facility staff provided the resident with a copy. In an interview on 09/27/2023 at 2:04 PM, Staff B (Director of Nursing) stated their expectation was for facility staff to provide residents with a written summary of their baseline CP within 48 hours after admission. Staff B stated there was no documentation by staff in Resident 68's records to show a copy of the baseline CP was provided to Resident 68 as required.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 58> According to the 09/07/2023 Quarterly MDS showed Resident 58 did not have the capacity to make their own de...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 58> According to the 09/07/2023 Quarterly MDS showed Resident 58 did not have the capacity to make their own decisions. Resident 58 required extensive assistance from staff to meet their daily needs. Resident 58 had complex medical diagnosis to include dementia (a progressive neurologic disease), Diabetes (difficulty controlling blood sugar), hypothyroid (low production of thyroid hormone), and heart failure. Review of the 06/22/2023 activities assessment showed Resident 58 was unable to participate in independent activities due to their cognition. The assessment showed Resident 58 enjoyed reading, gardening, television, bingo, and morning exercise. Review of the 06/19/2023 CP showed Resident 58's CP did not include an activities section. Review of the undated Individual Service Plan (ISP - a document providing direction for care) showed the ISP included none of the identified activities from the assessment staff could use to assist Resident 58. Review of the facility activity binder showed no activity documentation by staff occurring from 09/08/2023 through 09/18/2023 for Resident 58, resulting in 10 days without offered activities. The facility could provide no activity documentation prior to 07/31/2023. Observation on 09/19/2023 at 12:54 PM showed Resident 58 in the hallway sitting in their wheelchair with a bedside table in front of them. The bedside table was empty. Resident 58 appeared to be in distress stating but what are we going to do. Staff Z (Certified Nursing Assistant) observed Resident 58 and offered to lay them down in their bed. Resident 58 stated I just got out of bed, isn't there something we should be doing. Staff Z assisted Resident 58 to lay down. In an interview on 09/25/2023 at 12:31 PM Staff I stated they were responsible for completing the activity assessment and implementing the activity program. Staff I stated the MDS department was responsible for care planning activities. In an interview on 09/25/2023 at 1:35 PM Staff D (MDS Coordinator) stated they did not update activities CPs, that was the responsibility of the activities director. Interviewed on 09/27/2023 at 9:27 AM Staff B stated they expected activities to be identified and implemented to provide life enrichment and behavior modification. <Resident 62> According to a 06/01/2023 admission MDS, Resident 62 admitted to the facility on [DATE], had no memory impairment, clear speech, was able to understand and be understood by others. This MDS showed Resident 62 required extensive physical assistance from staff for transfers and locomotion, had no rejection of care, and it was very important to the resident to do their favorite activities. In an interview on 09/19/2023 at 3:05 PM, Resident 62 stated had not participated in any activities since admission and would consider going to bingo if the staff assisted to get them there. Observations at this time showed no activity calendar in Resident 62's room. Record review showed no activity assessment or evaluation was completed by staff and no activity Care Plan (CP) was developed on admission. Review of a 05/31/2023 Care Conference evaluation showed staff left the activities section blank. Review of the facility activity binder showed no activity documentation by staff occurred for Resident 62 from admission until 07/31/2023, over two months later, at which time staff documented a room round occurred. In the comments section of the form, staff documented No participation of group activities. Staff OO was unable to indicate why that was written on the form. For August 2023, staff documented room rounds occurred 15 times and only once for giving Resident 62 a Daily Chronicle paper. As of September 25th, 2023, staff documented room rounds occurred 11 times and only once for providing the resident with the Daily Chronicle in September. In an interview on 09/27/2023 at 2:04 PM, Staff B (Director of Nursing) stated their expectation was for staff to evaluate and CP activity preferences for residents upon admission, and review periodically for changes. Staff B stated staff should be offering, providing assistance, and documenting activities provided, including 1:1 with staff, in the resident's records. <The Daily Chronicle> Observation on 09/21/2023 at 9:34 AM, showed Staff OO in hallway delivering a Daily Chronicle paper to residents. Staff OO was observed changing the typed date at the top of the paper to [DATE]. Staff OO stated they no longer had a subscription to obtain the daily chronicle paper and was recycling what I have. Staff OO stated they did not have any current ones. In an interview on 09/21/2023 at 9:34 AM, Staff OO stated they stopped activities during the facility outbreak and now just go room to room in the morning to deliver the Daily Chronicle paper. In an interview on 09/26/2023 at 3:28 PM, Staff I (Activity Director) stated they were new to the position and the assistant was off for the day. Staff I stated the daily chronicle was not passed out for the day and indicated the assistant only passes the paper out when they are working. Observations on 09/26/2023 at 4:05 PM showed Staff I distributing the Daily Chronicle paper to residents sitting in the dining room. In an interview at this time, Resident 75, after receiving the paper, stated I absolutely love these things. Resident 75 stated the papers have been duplicates lately. In an interview on 09/27/2023 at 10:12 AM, Staff OO stated they hand out the Daily Chronicle to give residents something to do. Staff OO stated they have been using duplicates of the chronicle since the previous activity director left at the beginning of August. The Daily Chronicle provided to residents on 09/19/2023 showed on that date [NAME] took their midnight ride in Massachusetts and a noted physician was born. A web search showed these events occurred on April 18th. The Daily Chronicle provided on 09/21/2023 showed on that date a famous singer was born. A web search showed the singer was born on April 20th. The Daily Chronicle provided on 09/26/2023 showed on that date a famous fashion designer was born. A web search showed the fashion designer was born on June 27th. The Daily Chronicle provided on 09/27/2023 showed on that date a famous actor was born. A web search showed the actor was born on June 28th. In an interview on 09/27/2023 at 2:04 PM, Staff B stated their expectation was for staff to provide residents with current news for activities and stated, oh my when reviewed the Daily Chronicle papers being used for residents were duplicates from April and June. REFERENCE: WAC 388-97-0940(1)(2). Based on observation, interview, and record review the facility failed to develop and implement individualized activity plans and ensure activity programs met the needs of each resident for 2 of 3 residents (Residents 38 & 58) reviewed for activities, and 1 supplemental resident (Resident 62). Failure to consistently implement meaningful individual activity plans left residents at risk for boredom, frustration, isolation, and a diminished quality of life. Findings included . <Resident 38> According to a 07/14/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 38 had no memory impairment, clear speech, and was able to understand and be understood by others. This MDS showed Resident 38 had no rejection of care and it was very important to the resident to be involved in their favorite activities. Review of a 03/03/2023 Activities evaluation showed staff documented Resident 38 was very active and participated in most activities, wished to participate in activities while in the facility, and required assistance from staff to get to activities. No further activity evaluations or assessments were found in Resident 38's records. Review of a 01/27/2023 leisure activities Care Plan (CP) showed a goal that Resident 38 would maintain involvement in cognitive stimulation and social activities as desired. Interventions gave directions to staff to invite the resident to scheduled activities and identified Resident 38's preferred activities were socials, music, and bingo. In an interview on 09/19/2023 at 9:13 AM, Resident 38 stated they used to participate in activities until a facility respiratory infection outbreak occurred. Resident 38 stated they were participating in a lot of stuff and now we have nothing. Resident 38 indicated they liked playing bingo and stated, they took it away. When asked how long ago the activities were stopped, Resident 38 stated, too long. In an interview on 09/21/2023 at 9:34 AM, Staff OO (Activities Assistant) stated they stopped activities during the facility outbreak and now just go room to room in the morning to deliver a Daily Chronicle (a daily newssheet commonly found in nursing homes that includes items of interest such as famous birthdays, trivia, and an on this date section), do bingo spin on Mondays and Wednesdays, and visit with residents in the afternoon, and stated, we do not do a lot of people for that. Observations on 09/21/2023 at 9:51 AM, showed a large activity board in the hallway still showing the following activities were scheduled for the day: 9:00 AM- Chronicle Delivery; 10:30 AM- Morning Stretch and Exercise; 11:00 AM - Coffee and Trivia; and 1:30 PM - Resident Council. There were no updates to the board to notify residents the current group activities were on hold. In an interview on 09/26/2023 at 12:57 PM, Resident 38 stated they did not receive the Chronicle paper yet today. In an interview on 09/26/2023 at 3:28 PM, Staff I (Activity Director) stated they were new to the position and the assistant was off for the day. Staff I stated the Daily Chronicle was not distributed for the day and indicated the assistant passes the paper out when they worked. Staff I stated due to the facility outbreak status, the assistant went to resident rooms doing bingo, coloring, and offering puzzles. Staff I stated the assistant used a binder to document the residents' activities. In an interview on 09/27/2023 at 10:12 AM, Staff OO stated staff did not chart activities in the resident's electronic records, but instead used a binder with individual pages. Staff OO indicated any documentation would be in the binder from February 2023 forward. Staff OO stated they kept the pages in the binder for six months and then shredded them. Review of the facility activity binder showed no activity documentation by staff occurred for Resident 38 from 04/12/2023 to 07/16/2023. For the remainder of July 2023 staff documented Resident 38 attended exercise and bingo four times and received the Daily Chronicle six times only.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were assessed and received necessary treatment and assistive devices to maintain vision abilities for 2 of 4 (Residents 65 & 62) residents reviewed for vision. Failure to identify vision deficits and to ensure residents received assistance with the use of corrective lenses left residents at risk for unmet needs and a diminished quality of life. Findings included . <Facility Policy> According to a 2023 Hearing and Vision Services policy, the facility would utilize a comprehensive assessment process for identifying and assessing a resident's vision abilities to provide person-centered care. The policy showed the facility would ensure all residents had access to hearing and vision services and receive adaptive equipment as indicated. The policy showed staff would refer any identified need for vision services/appliances to the social worker/designee who would be responsible for assisting residents to make appointments and arrange transportation. Staff would assist the resident with the use of any devices or adaptive equipment needed to maintain vision like glasses, contact lenses or any other device used by the resident. <Resident 65> According to the 07/23/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 65 admitted to the facility on [DATE] and was assessed to have clear speech. The MDS showed Resident 65 was able to understand and be understood by others during communication. The MDS showed Resident 65 had multiple diagnoses including a stroke (brain injury). The MDS showed Resident 65's vision was adequate and they did not use any assistive device to see or read printed materials. Review of a 08/25/2023 Physician Order (PO) showed Resident 65 had orders for Ophthalmology [the branch of medicine concerned with the diagnosis and treatment of eye disorders] evaluation and treatment as indicated. On 09/19/2023 at 12:09 PM, Resident 65 stated their vision was poor and would like to see an eye doctor. Observation on 09/25/2023 at 12:16 with Staff H (Resident Care Manager) after wound care treatment showed Resident 65 reached out their arms and started to feel for the water pitcher on top of their overbed table for a drink. When Staff H asked Resident 65 if they could not see well, Resident 65 responded, Yes. In an observation and interview on 09/26/2023 at 10:42 AM, a vision test was conducted for Resident 65 with Staff N (Licensed Practical Nurse) and showed Resident 65's eyes were not able to focus on the printed material. Resident 65 stated they used to be able to read but their eyesight diminished overtime and worsened after their stroke. Review of Resident 65's progress notes from 07/17/2023 until 09/26/2023 showed no documentation to demonstrate Resident 65 was referred to the eye doctor for their vision deficits. In an interview on 09/26/2023 at 10:50 AM, Staff N stated it was important to assess Resident 65's vision for safety, communication purposes, and to ensure the resident was comfortable navigating their environment. In an interview on 09/26/2023 at 10:58 AM, Staff Y (Social Service Assistant) stated they were not able to refer Resident 65 to the eye doctor because their vision deficits were not assessed appropriately during admission on [DATE]. <Resident 62> According to an 06/01/2023 admission MDS, Resident 62 had multiple complex diagnoses including diabetes and was assessed with no memory impairment, clear speech, and was able to understand and be understood by others. This MDS assessed Resident 62 with adequate vision with no corrective lenses. In an interview on 09/20/2023 at 9:41 AM, Resident 62 stated they had really poor vision and had an old prescription for glasses and contact lenses from about five years ago. Resident 62 stated they had not seen an eye doctor since admission. On 09/22/2023 at 1:33 PM, Resident 62 stated staff did not offer any vision or eye doctor appointments. According to a 05/26/2023 PO, Resident 62 may have a medical consult and treatment for their eyes as indicated. Review of a 06/26/2023 provider progress note showed documentation Resident 62 had an alteration in vision and gave recommendations for the resident to have a eye exam. Similar recommendations were again made on 07/03/2023, 07/10/2023, and on 07/12/2023. In an interview on 09/25/2023 at 11:10 AM, Staff C (Director of Social Services) stated the eye doctor comes to the facility quarterly to see everyone. Staff C stated their last visit was in June 2023. Staff C stated there was a binder at the nurses station where they add any residents with concerns, stated they also add new admissions, and have the ability to send residents out for referrals as needed. Review of the facility appointment binder on 09/25/2023 at the nurse's station showed no entries by staff to request an eye doctor appointment for Resident 62. In an interview on 09/26/2023 at 11:05 AM, Resident 62 indicated the contacts they had were the wrong prescription since they were from so long ago and stated they did not wear them since admission due to being afraid to put them in as they did not have any more pairs left. Review of Resident 62's Care Plan showed staff did not address the resident's alteration in vision or the use or lack of use of their contact lenses. In an interview on 09/27/2023 at 12:50 PM, Staff AA (Transportation Director) stated they had no previous or pending appointments for Resident 62 for an eye doctor. In an interview on 09/27/2023 at 2:04 AM, Staff B (Director of Nursing) stated Resident 62's eye doctor referral should be followed up with by staff. Staff B stated staff should have, but did not put Resident 62 on the list to be seen by in-house eye doctor. REFERENCE: WAC 388-97-1060 (3)(a). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 58> According to the 09/07/2023 Quarterly MDS Resident 58 admitted to the facility on [DATE] and assessed to hav...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 58> According to the 09/07/2023 Quarterly MDS Resident 58 admitted to the facility on [DATE] and assessed to have impaired memory. Resident 58 required extensive assistance of one staff member for locomotion, toilet use, and personal hygiene. Resident 58 had medically complex diagnosis including repeated falls identified. Review of the 06/19/2023 care plan (CP) showed Resident 58 required extensive assistance by staff and the use of a front wheeled walker (FWW) for transfers and ambulation and ensure Resident 58 has an unobstructed path to the bathroom. Observation on 09/19/2023 at 9:07 AM showed a matt on the ground to the left side of the bed. Resident 58's FWW was next to the bed towards the foot end and out of reach to Resident 58 because the matt impeded the FWW from being closer. Additional observations of the matt being next to the bed were made on 09/22/2023 at 3:12 PM Review of Resident 58's record did not provide instructions to staff for the mat on the floor including when it should be used, when it should be removed, and what additional assistance may be required due to the mat on the floor. An interview on 09/21/2023 at 12:10 PM Staff H (Resident Care Manager-RCM) stated a fall matt would provide an uneven surface for ambulation that could result in an obstructed pathway to the bathroom causing an increased risk for falling. Observation and Interview on 09/25/2023 at 05:56 AM showed Staff K (Registered Nurse) were standing outside Resident 58's room. Staff K stated they were waiting for another staff member to come and assist Resident 58 as they were attempting to stand from the edge of bed. At the same date and time a fall mat was observed on the floor under Resident 58's feet. An interview on 09/27/2023 at 9:27 AM Staff B stated they expected to obtain consent for the use of fall mats, and develop a care plan that directed staff when to use the mat. <Resident 5 > According to the 06/19/2023 Quarterly MDS Resident 5 had moderate memory/thought impairment. This assessment showed Resident 5's balance was not steady and they were only able to stand with staff assistance and had a history of falling and impulsiveness. Observation on 09/19/2023 at 2:42 PM showed a fall mat leaning up against the closet, not in place, and Resident 5's bed not in the lowest position. Observation on 09/20/2023 at 9:22 AM showed the fall mat was leaning on the closet and not in place. Observation on 09/21/2023 at 8:20 AM showed the fall mat leaning on the wall and not in place. Observation on 09/22/2023 at 9:11 AM showed no fall mat in the room and the bed was not in the lowest position. Observation on 09/25/2023 at 5:47 AM showed no fall mat in place and the bed not in the lowest position. Observation on 09/26/2023 at 2:09 PM showed the fall mat leaning on the wall and the bed was not in lowest position. Observation on 09/27/2023 at 8:54 AM showed the fall mat leaning on the closet, not in place, with Resident 5 sleeping in their bed which was lowered to ground with head of bed elevated 90 degrees, and the left side of bed against the wall with the fall mat not in place. In an interview on 09/19/2023 at 2:35 PM Resident 5 stated they fell all the time. On 09/24/2023 review of Resident 5's POs showed a PO for the bed to be in the lowest position when the resident was in bed to prevent injury if a fall occurred, a perimeter mattress to help the resident identify the edge of the bed, and a tiltable wheelchair (WC) to decrease fall risk. There were no orders for fall mats or for the bed to be against the wall. Review of the 07/17/2023 CP showed Resident 5 was at high risk for falls and staff were to keep the bed in the lowest position when the resident was in bed. This CP showed fall interventions were for fall mats on floor to the right and left side of bed to help decrease chance of severe injury, for the left side of the bed against wall for optimal room space, and to allow Resident 5 to watch TV comfortably while in bed, and acces to a tiltable WC to help with body positioning when out of bed. This CP did not include an intervention to use a perimeter mattress. In an interview on 09/25/2023 at 6:12 AM Staff B stated the last evaluation of Resident 5's need for fall mats, for the left side of bed to be placed against the wall, and for the bed to be in the low position was on 12/21/2022. Staff B stated they expected the need for devices to be assessed quarterly but they were not for Resident 5. Staff B stated Resident 5's CP for fall interventions was not up to date with current the POs for the left side of the bed to be against the wall, the fall mat to be on the floor on the right side of bed only since the left side of bed is against the wall, and for the perimeter mattress. In an interview and observation on 09/26/2023 at 2:04 PM Staff H stated Resident 5's fall mat was leaning up against the wall and needed to be on the floor on the right side of the bed. In an interview on 09/27/2023 at 8:57 AM Staff H stated the mat was propped up against the closet and not in place but should be. Staff H stated, I just put that back in place yesterday and they propped it again. REFERENCE: WAC 388-97-1060(3)(g) <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 admitted to the facility on [DATE], and was assessed as cognitively intact. Resident 9 had diagnoses of bipolar disorder (brain disorder that caused changes in a person's mood and ability to function) and anxiety disorder. Resident 9 demonstrated behaviors including hallucinations, delusions, and refusal of care. Resident 9 received an antipsychotic medication on seven of seven days during the assessment period. Observations on 09/19/2023 at 8:57 AM and 12:04 PM, and on 09/20/2023 at 8:02 AM Resident 9 was lying in bed. On 09/20/2023 at 10:49 AM, Resident 9 was observed transferring to the hospital for increased confusion. Review of the 07/22/2023 progress notes documented at 6:45 PM, 6:46 PM, and 6:48 PM showed Resident 9 refused their medications and stated they just wanted to die. There was no documentation showing the provider was notified about medication refusals and Resident 9's statements of wanting to die. Review of the social services documentation showed no follow up related to Resident 9's statement of wanting to die. Review of the 2023 accidents and investigation logs provided by the facility showed no record of an investigation initiated related to Resident 9's statement of wanting to die. In an interview on 09/25/2023 at 11:36 AM, Staff B stated they were not aware of Resident 9's statement of wanting to die. Staff B reviewed Resident 9's record and was unable to provide documentation showing follow up by social services. Staff B stated the facility should have initiated an investigation and followed up with Resident 9 if they had a suicidal plan, but they did not. In an interview on 09/26/2023 at 11:12 AM, Staff C stated they were not aware of Resident 9's statement. Staff C stated the nursing staff should have notified their supervisor of Resident 9's statement of wanting to die to ensure Resident 9 was safe, and did not have any plan to harm themselves, but the staff did not. In an interview on 09/26/2023 at 12:51 PM, Staff A (Administrator) stated they were not aware of Resident 9's statement of wanting to die. Staff A reviewed Resident 9's record and was unable to find a follow up note related to the resident's statement. Staff A stated the nursing staff did not notify their supervisor and the facility failed to investigate to ensure Resident 9 was safe. Based on observation, interview, and record review the facility failed to: Ensure 2 of 2 (Residents 30 & 9) residents with Suicidal Ideation (SI) were investigated for root cause, or provided an environment free from items they were not assessed to be safe with; ensure fall mats were used appropriately for 2 of 4 (Residents 58 & 5) reviewed for falls. These failures left residents at risk for falls, injury, self-harm, and other negative health outcomes. Findings included . <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including brain dysfunction, anxiety, depression, and dementia. The MDS showed Resident 30 had hallucinations and delusions, verbal behaviors that interfered with daily activities, and behaviors that disrupted care and/or the living environment. According to a nursing progress note on 04/27/2023 Social Services notified nursing that Resident 30 was having active suicidal thoughts, and had a plan. There was no corresponding note from Social Services. There was no explanation of how this knowledge was acquired or by whom. Resident 30's potential for self-injury . Care Plan (CP) showed Resident 30 was at risk for self-harm and identified cutting as a potential means to accomplish this. The CP included an intervention to use paper/plastic plates, glasses or silverware as needed. Observation on 09/22/2023 at 12:41 PM showed a pair of nail clippers located on Resident 30's bed. Resident 30 was observed in the hallway outside their room and was in a pleasant mood. In an interview at 09/22/2023 at 12:53 PM Staff H (Resident Care Manager - RCM) stated they believed Resident 30 was safe with the nail clippers. Staff H stated it was not difficult to determine if the resident was upset. Staff H stated they would find out more. In an interview on 09/22/2023 at 12:56 PM Staff B (Director of Nursing) stated they believed that Resident 30 was no longer at risk for self-harm, and the CP was likely in need of revision. Staff B stated they were unsure if Resident 30 was reassessed for risk of self-harm and stated they would ask Social Services. In an interview at 09/22/2023 at 12:59 PM Staff B asked Staff Y (Social Services Assistant) if Resident 30 was reassessed for self-harm. Staff Y stated they didn't think so and the nail clippers should be removed. Neither staff knew how Resident 30 obtained the clippers. Facility staff went to Resident 30's room and removed the nail clippers without incident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents admitted with Foley Catheters (F/C - a flexible tube inserted into the bladder) were assessed for the continued need for a F/C, attempted to remove the F/C as soon as possible, F/C tubing was secured with a leg strap to prevent accidental tugging and pulling, and a privacy bag (to cover the F/C bag) in place for 1 (Resident 66) of 3 residents reviewed for the F/C. These failures placed residents at risk for urinary tract infections, decreased bladder tone (muscle strength), urethral erosion (gradual destruction of the tissues), and dignity issues. Findings included . <Resident 66> Review of Resident 66's nursing progress notes showed Resident 66 admitted to the facility on [DATE] and was transferred to the hospital on [DATE] for a change in respiratory condition. According to the 09/20/2023 Medicare 5-day MDS, Resident 66 readmitted on [DATE] and was assessed as cognitively intact and had the F/C during the assessment period. In an interview on 09/19/2023 at 10:37 AM, Resident 66 stated they went to the hospital last week for respiratory issues. Resident 66 had difficulty with urinating while in the hospital so staff inserted a F/C temporarily. Hospital staff attempted a trial to remove the F/C and found Resident 66 was able to urinate independently. Hospital staff told the resident that facility staff will remove the F/C. Resident 66 stated they were in this facility for a week and staff did not talk to them about the F/C. Observations on 09/19/2023 at 10:31 AM and 3:23 PM, 09/20/2023 at 8:49 AM and 2:45 PM showed Resident 66 lying in bed. The F/C bag was in a wash basin sitting under the bed on the floor. There was no leg strap observed to secure the tubing to the Resident 66's leg. Observation on 09/22/2023 at 8:10 AM showed Resident 66 was up in their wheelchair in their room. The F/C was full of urine resting on the floor under their w/c. Staff II (Certified Nursing Assistant) emptied the F/C into a urinal and hung the bag under the w/c. There was no privacy bag on Resident 66's bed or w/c. Review of 09/15/2023 hospital discharge summary showed Resident 66 had F/C due to urinary retention. Resident 66 passed a voiding trial in the hospital and recommended F/C to be removed in the nursing facility. Review of the 09/19/2023 Physician Orders showed Resident 66 had a F/C, and staff were to drain the F/C bag every shift. Review of the 09/15/2023 F/C Care Plan showed interventions instructing staff to check for a leg strap securing the F/C tubing and provide the F/C care every shift. In an observation and interview on 09/25/2023 at 11:22 AM, Resident 66 was lying in bed. The leg strap on Resident 66's left calf area was loose and did not secure the F/C tubing. Staff S (Licensed Practical Nurse) was not sure why Resident 66 had a F/C in place and stated the leg strap should be on Resident 66's thigh, securing the tubing, but it was not. In an interview on 09/26/2023 at 11:49 AM, Staff B (Director of Nursing) reviewed Resident 66's record and was unable to find an assessment and an applicable diagnoses for the F/C. Staff B stated the facility should have assessed the resident for the F/C, attempted a trial to remove the F/C. Staff B stated the facility should have provided the privacy bag for dignity and the F/C should not be on the floor. Staff B was unable to provide any documentation if the faility provided any education to nursing staff for F/C care. REFERENCE: WAC 388-97-1060 (2)(a)(iii). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to implement ongoing communication and collaboration with the dialysis facility regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 1 of 2 (Resident 69) residents reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes. Findings included . <Facility Policy> The facility's undated Hemodialysis [a process of purifying the blood of a person whose kidneys were not working normally] policy showed the facility should ensure each resident had ongoing assessment of their condition and was monitored for complications before and after dialysis treatments received at a certified dialysis facility. The policy outlined the need for ongoing communication and collaboration with the dialysis facility to ensure the development and implementation of the dialysis Care Plan (CP) by the nursing home and dialysis center staff. The policy instructed the licensed nurse to communicate information to the dialysis facility by phone or in writing including: (1) nutritional/fluid management including documentation of weights, (2) dialysis treatment provided and the resident's response, and (3) dialysis adverse reactions/complications and/or recommendations for follow-up observation and monitoring. <Resident 69> According to the 07/21/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 69 had clear speech and was able to understand and be understood by others during communication. The MDS showed Resident 69 had multiple medical diagnoses including a brain injury with resulting weakness to one side of the body, kidney failure, dependence on dialysis, and diabetes (unstable blood sugar level). The MDS showed Resident 69 received a high-risk, injectable medication to manage their blood sugar levels for all seven days of the assessment period. The 07/15/2023 dialysis CP outlined Resident 69 needed hemodialysis due to kidney failure. The CP listed the frequency of Resident 69's dialysis treatment during the week and the name, address, and contact information of the dialysis center. The facility was not able to provide any documentation that showed a coordinated CP for Resident 69's dialysis treatment was developed. On 09/19/2023 at 11:53 AM, Resident 69 stated they went to dialysis every Monday, Wednesday, and Friday. At the same date and time, Resident 69's dialysis access cite to their right upper chest was observed covered with a clean dressing. Resident 69 stated the dialysis center was responsible of the dressing change and was done after their dialysis treatment. Review of the facility's contract with the dialysis center where Resident 69 went to for their dialysis treatment showed incomplete information. The dialysis contract: (1) did not identify the specific name of the dialysis facility, (2) was completed by a staff who identified themselves as the Facility Administrator but was not Staff A (Administrator at the time), (3) did not show the signature of the dialysis facility's provider and/or representative and their title/credential to acknowledge agreement with the dialysis contract. On 09/20/2023 at 9:33 AM, Resident 69 was observed going back to their room from the facility lobby entrance. Staff N (Licensed Practical Nurse) was surprised and told the resident they were supposed to get picked up at 8:30 AM for their scheduled dialysis. Resident 69 told Staff N they were told by a lady downstairs the appointment was at 10:00 AM. Staff N looked at the Transportation Wednesday 09/20/2023 schedule posted on the bulletin board by the nurse's station which showed Resident 69 should be ready by 7:30 AM, pick-up time was between 8:01 AM to 8:31 AM, and return time was between 2:20 PM to 2:50 PM. Review of the facility's Dialysis Schedule showed Resident 69 was scheduled to arrive the dialysis facility by 9:00 AM. Review of the September 2023 Medication Administration Record listed a 07/31/2023 physician order that showed Resident 69's dialysis schedule was 5:00 PM to 9:00 PM. At the same date and time, Resident 69 stated, this was not the first time a dialysis scheduling conflict occurred and they missed dialysis treatments in the past. Review of the Resident 69's Dialysis Transfer forms dated 07/17/2023, 08/14/2023, 08/18/2023, 08/28/2023, 08/31/2023, 09/01/2023, 09/04/2023, 09/06/2023, 09/11/2023, and 09/20/2023 showed seven out of the nine forms were incomplete. The forms were missing the following: name, address, and contact number of the dialysis center; pertinent resident information including medication changes and laboratory results since the last dialysis appointment; changes in Resident 69's medical and/or mental status. The forms did not have any dialysis report information such as the pre- and post-dialysis weights. The forms did not have any post-dialysis nursing evaluation such as the dialysis access site's condition for patency (the condition of being open and unobstructed) or any signs and symptoms of infection. In an interview on 09/26/2023 at 9:53 AM, Staff U (Resident Care Manager) stated care collaboration with the dialysis center was important because it ensured residents get dialyzed appropriately. Staff U stated when residents missed their appointments or when laboratory results were not sent over, neither the facility or the dialysis center would be able to effectively determine the resident's condition before, during, and after dialysis treatment. Staff U stated Resident 69 did not have a coordinated CP for their dialysis and there were no nursing progress notes from 07/20/2023 until 09/26/2023 that documented Resident 69's status after coming back to the facility from their dialysis treatments. Staff U stated there was no ongoing communication and collaboration with the dialysis center in Resident 69's medical records. Staff U stated the Dialysis Transfer forms were incomplete and not acceptable because the lack of information could compromise Resident 69's health and safety. REFERENCE: WAC 388-97-1900 (1), (6)(a-c). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

<2 South Hall Med Cart> Observation on 09/22/2023 at 8:51 AM of the 2 South Hall Medication Cart showed eight unused blood sugar medication administration needles in a storage drawer. These need...

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<2 South Hall Med Cart> Observation on 09/22/2023 at 8:51 AM of the 2 South Hall Medication Cart showed eight unused blood sugar medication administration needles in a storage drawer. These needles were not contained in any packaging. No expiration date was observed on the needles. In an interview at that time, Staff O (LPN) stated the needles came in a big box and staff would take what they needed. Staff O confirmed the needles should be stored so the expiration date could be observed. Observation on 09/22/2023 at 8:59 AM showed a medicated nasal spray laying in a compartment next to an inhaler. These two medications were not contained in separate bags and were touching each other. The medications belonged to two different residents. In an interview at that time, Staff O confirmed the medications should be contained and stored separately since they belonged to two different residents and were administered via different routes. REFERENCE: WAC 388-97-1300(2). <Resident 66> Review of a 09/20/2023 Medicare - 5 day Minimum Data Set (MDS- an assessment tool), Resident 66 was assessed cognitively intact and was able to understand and be understood in conversation. Observation on 09/19/2023 at 11:23 AM, and 09/20/2023 at 9:50 AM showed two inhalers (medication that is administered orally and requires the resident to put their mouth on the device) on Resident 66's nightstand. Resident 66 stated they brought the inhalers with them from the hospital at admission time on 09/15/2023. In an interview on 09/20/2023 at 9:55 AM, Staff S (Registered Nurse - RN) stated they did not notice inhalers on Resident 66's nightstand. Staff S stated the inhalers came with the resident from hospital and should not be left in Resident 66's room, they should be in medication cart. In an interview on 09/25/2023 at 11:22 AM, Staff B stated there should not be any medications in resident's room unless they were assessed for self-medication program. Staff B stated Resident 66 was not on self-medication program and there should be no medication left in their room but they did. <Resident 27> Review of a 05/09/2023 Quarterly MDS showed Resident 27 had no memory impairment, was able to understand and be understood in conversation, and had a diagnosis of a reflux disease. Observation on 09/19/2023 at 9:25 AM showed two large antacid tablets on Resident 27's over the bed table. Resident 27 stated they kept a bottle in their room so they could take them when they need them. Observations on 09/20/2023 at 9:53 AM showed Staff CC (Certified Nursing Assistant) assisting Resident 27 in their room. Two large antacid tablets were observed on the over-the-bed table at that time. In an interview on 09/20/2023 at 10:02 AM, Staff CC stated they did see the antacid tablets on the over-the-bed table. Staff CC stated they did not report the medication in Resident 27's room to the nurse because they did not know if the resident was allowed to have them or not. Staff CC stated sometimes the nurses left the tablets in Resident 27's room for the resident to have later. Review of Resident 27's care plan and physician's orders showed no directions indicating Resident 27 could store medications at their bedside. There were no assessments in place showing Resident 27 was capable or incapable of self-administering the antacid medications. <Resident 25> Review of a 05/29/2023 Annual MDS, Resident 25 was cognitively intact and could understand and be understood in conversation. Observation on 09/27/2023 at 9:50 AM showed Resident 25 sitting in bed with three medication cups in front of them on the over-the-bed table. One cup contained apple sauce, one cup was empty, and one cup contained an oblong white pill. At that time, Staff DD (RN) entered the room and asked Resident 25 if they were finished with their medications. Resident 25 stated they did not want the oblong white pill and Staff DD removed the three medication cups from the room. In an interview on 09/27/2023 at 9:52 AM, Staff DD stated they left the medications with Resident 25 unsupervised because Resident 25 stated they needed a few minutes and preferred to take their medications themselves. In an interview on 09/27/2023 at 10:57 AM, Staff B stated residents should not have medications at their bedside unless they were assessed for a self-administration program. Staff B stated nursing staff were expected to stay with the resident while the resident took their medications and could not leave a resident unattended with medications. Staff B stated they expected nurses to re-approach a resident if the resident was not ready to take the medications. Staff B stated it was not a safe practice to leave medications at the bedside. <Medicare 2 Med Cart> Observation on 09/22/2023 at 8:38 AM showed two narcotic liquid medication for a resident who was discharged home a month ago. In an interview on 09/22/2023 at 8:48 AM, Staff Q (RN) stated they should have destroyed these narcotic medications when the resident was discharged home a month ago but they did not. In an interview on 09/25/2023 at 11:24 AM, Staff B stated they expected staff should have destroyed the medications when resident was discharged home but they did not. Based on observations, interview, and record review, the facility failed to ensure drugs and biologicals were secured for 5 (Resident 54, 62, 66, 27, & 25) of 24 residents observed with medication in their rooms. The facility failed to ensure proper storage of drugs and biologicals on 2 (Medicare 2 and 2 South Hall Cart) of 4 medication carts. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed, self-administration of medications by residents. Findings included . <Facility Policy> Review of a facility undated 2023 Medication Storage policy showed all medications would be stored in locked compartments such as medication carts or medication rooms. This policy showed medications administered by mouth would be stored separately from medications administered through other routes. <Medications at Bedside> <Resident 54> Observations on 09/19/2023 at 10:00 AM and on 09/20/2023 at 9:53 AM showed three bottles of pills at Resident 54's bedside and visible from the hallway. In an interview and observation on 09/20/2023 at 9:57 AM with Staff FF (Licensed Practical Nurse - LPN) showed the three bottles of medications remained at bedside and Staff FF verified the bottles were different types of vitamin supplements. One bottle was labeled that it originally contained 120 tablets and was almost empty upon observation. Resident 54 stated they try to take the pills everyday and stated, I take enough that I'm healthy, I'm not sick. On 09/20/2023 at 9:57 AM, Staff FF reviewed Resident 54's records and was unable to find orders for Resident 54 to have medications at bedside. Staff FF stated the medications should not be left at the resident's bedside without orders. Staff FF stated Resident 54 was not assessed for self medication program. <Resident 62> Observations on 09/20/2023 at 9:31 AM showed Resident 62 had a medicine cup that contained 2 pills on their bedside table. In an interview at this time, Resident 62 stated there were three pills left in the cup from the day before and they were not sure if they should take them all in the morning. Resident 62 stated they decided to take the blood thinning medication only, but stated they dropped that pill on the floor while trying to take it. In an interview and observation on 09/20/2023 at 9:35 AM, Staff FF confirmed Resident 62's medications were left at their bedside and found the third pill on the floor under the resident's bed. Staff FF verified the medications left at Resident 62's bedside included a blood thinning medication, a pain medication, and an antacid medication, all of which were documented as administered in the evening on 09/19/2023. Staff FF stated Resident 62 most likely did not receive their evening medications from the night before, stated staff should not document medications were administered until they are, and confirmed medications should not be left at bedside. In an interview on 09/27/2023 at 2:04 PM, Staff B (Director of Nursing) stated their expectation was for orders to be in place if medications were okay to be left at a resident's bedside. Staff B stated staff should not document medications were administered and be left at a resident's bedside. Staff B stated staff should not have left the medications for Resident 54 and Resident 62 at the bedside.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure laboratory (lab-blood test) tests were completed as ordered for 2 of 5 (Residents 49 & 5) sample residents whose drug regimens were reviewed, and 3 (Residents 58, 62, & 68) supplemental residents. This failure placed residents at risk of medical complications from lack of monitoring of chronic medical conditions, and other negative health outcomes. Findings included . <Resident 58> According to the 09/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 58 had multiple medical conditions including diabetes (difficulty controlling blood sugar). Review of the 09/16/2023 Physicians orders (POs) showed Resident 58 had a lab test ordered to measure average blood sugar levels. The September 2023 Medication Administration Record (MAR) showed the lab was complete. No lab results could be found in the resident's record. Review of the 09/21/2023 PO showed Resident 58 had the same lab test ordered and included two additional tests to be collected. No results could be found in the resident's record. <Resident 49> According to the 07/13/2023 Quarterly MDS Resident 49 had multiple medical conditions including heart failure, diabetes, respiratory failure, and chronic wounds on their legs. Review of the 06/12/2023 PO showed Resident 49 had three labs ordered. The June 2023 MAR showed the labs were completed on 06/13/2023 at 9:31 PM. No results for the labs could be found in the resident's record. Review of the 06/16/2023 PO showed the same labs were ordered for Resident 49. The June 2023 MAR showed the labs were scheduled to be collected 06/20/2023 - 06/21/2023. No documentation to indicate Resident 49's labs were collected was found in the resident's record. Review of the 09/08/2023 PO showed the same labs were ordered for Resident 49. The September 2023 MAR showed the labs were scheduled to be collected 09/11-12/2023. Resident 49's MAR showed the labs were not collected. Review of the 09/21/2023 lab results for the 09/08/2023 labs showed the labs were not collected. In an interview on 09/27/2023 at 9:27 AM, Staff B (Director of Nursing) stated they were aware of the failed practice regarding labs. Staff B stated the nurse who processed the order to collect the labs did not complete the form for the lab to be collected. Staff B stated the issue was not fixed and lab collection was still an issue. Staff B stated they expected the nurse who processed the PO to complete the lab form and place it in the lab binder for the lab technician to collect the samples at the time the PO was processed. <Resident 5> According to the 06/19/2023 Annual MDS showed Resident 5 was assessed with moderate impairment with memory and thought processes. This assessment showed Resident 5's balance was not steady and they required staff assistance with standing, had a history of falling, and impulsiveness, and dizziness. This MDS showed Resident 5 had diagnoses including adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairment), malnutrition, and long-term use of blood thinner medications. Review of Resident 5's August 2023 MAR showed a lab ordered for 08/21/2023 was signed off as complete. Review of Resident 5's medical record on 09/25/2023 showed no results for the 08/21/2023 lab. In an interview on 09/25/2023 at 9:31 AM Staff H (Resident Care Manager) stated the floor nurse signed the MAR showing they obtained the lab, but they did not. Staff H stated there were no lab results, no nursing notes showing why the lab was not completed, and no doctor notification of the lab not being completed as ordered in Resident 5's medical record, but there should be. <Resident 62> According to a 06/01/2023 admission MDS, Resident 62 had multiple medically complex diagnoses and had an indwelling catheter in use during the assessment period. Review of Resident 62's POs showed an 08/07/2023 order to collect a urine sample related to increased sediment in their urine (matter that settles to the bottom of the liquid), painful urination, and nausea. Review of an 08/08/2023 provider progress note showed documentation Resident 62 had complained of increased sediment in their catheter, and nausea. The provider gave directions to staff to collect a urine sample due to ongoing use of the catheter and based on increased risk for a urinary tract infection. Record review showed no urine test results were found in the Resident 62's records and no follow up or further documentation by staff was available regarding obtaining or sending the urine sample to the lab. <Resident 68> According to a 07/19/2023 admission MDS, Resident 68 had multiple medically complex diagnoses including heart failure and required the use of an anticoagulant (blood thinner) medication during the assessment period. Review of Resident 68's POs showed the following lab tests: a 07/14/2023 order to obtain a CBC (Complete Blood Count - a comprehensive blood test) and a BMP (Basic Metabolic Panel - a blood test that measures chemical balance in your blood) on 07/18/2023 related to new admission status; a second order on 07/24/2023 for the CBC and BMP to be completed on 07/25/2023; a third order on 07/26/2023 again requesting the CBC and BMP to be obtained, 12 days after originally ordered by the provider. Review of the POs showed a 07/17/2023 order to obtain a urine drug test. Review of Resident 68's July 2023 MAR showed documentation staff signed the 07/14/2023 and the 07/26/2023 lab orders as completed and left the 07/24/2023 lab order blank with no documentation whether staff completed the test as ordered. Resident 68's record also showed staff signed the 07/17/2023 drug screen as completed when there was no documentation of the lab results in the record. Record review showed no test results for the labs ordered by the provider on 07/14/2023, 07/24/2023, and 07/26/2023 in Resident 68's records. In an interview on 09/27/2023 at 2:04 PM, Staff B stated lab orders should be completed as ordered by the physician with the results located in the resident's records. Staff B stated the lab orders for Resident 62 and Resident 68 were not completed by staff as ordered. REFERENCE: WAC 388-97-1620 (2)(b)(i). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident records were complete, accurate, and readily accessible for 4 (Resident 49, 38, 68, & 9) of 20 sample residents whose records were reviewed. The facility failed to ensure Medication Administration Records (MAR), Treatment Administration Records (TAR), weight records, and meal consumption documentation was complete and accurately reflected the care provided. These failures placed residents at risk for unidentified and/or unmet care needs. Findings included . <Facility Policy> Review of the October 2022 facility Documentation in Medical Record policy showed the facility would include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. <Resident 49> According to the 07/13/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 49 admitted to the facility on [DATE]. Resident 49 had the capacity to make their own decision. Resident 49 had multiple complex conditions including heart failure, chronic wounds to both feet, depression, and diabetes (difficulty controlling blood sugar). Review of Resident 49's August 2023 TAR included a Physicians Order (PO) for staff to check for burns on Resident 49's clothes, chair cushions, and lap blankets every shift. Record review showed from 08/01/2023 through 08/31/2023, Staff did not document the check was completed on 21 of the 93 opportunities. Review of Resident 49's August 2023 MAR included a PO for staff to monitor for adverse reactions of an antianxiety medication. Record review showed from 08/01/2023 through 08/31/2023, staff did not document Resident 49 was assessed on 10 of 93 opportunities. An interview on 09/27/2023 at 9:27 AM Staff B (Director of Nursing) stated they expected PO's to be followed and signed off as complete in the MAR and TAR. Staff B stated not signing POs was an indication the task was not completed. <Resident 9> Resident 9's September 2023 MAR included a PO for staff to obtain daily weights for heart failure monitoring. There were no instructions for the staff for when to notify the provider and what they needed to monitor for heart failure. Review of the MAR showed from 09/01/2023 through 09/14/2023, staff documented X on seven of the 14 opportunities. Review of Resident 9's record showed no documentation of the weights on 09/01/2023, 09/02/2023, 09/03/2023, 09/04/2023, 09/05/2023, 09/07/2023, and 09/14/2023. Additional review of the September 2023 MAR showed staff were to provide a diabetic snack at bed time and document the amount consumed by Resident 9. Review of the MAR showed on 14 opportunities from 09/01/2023 through 09/14/2023, staff documented a check mark, rather than amount consumed as directed. Review of the September 2023 TAR included a PO for staff to monitor a bruised area of Resident 9's left inner elbow area daily. Review of the TAR from 09/01/2023 through 09/19/2023 showed blank documentation on 09/12/2023, 09/13/2023, and 09/17/2023. In an interview on 09/25/2023 at 12:28 PM, Staff B stated nurses were expected to follow the POs and completed the MAR and TAR as directed. Staff B stated the nurses should have clarified the orders with the provider if they were not complete but they did not REFERENCE: WAC 388-97-1720(1)(a)(i-iv)(b). <Resident 38> Review of Resident 38's July 2023 nutritional intake documentation showed staff failed to document the resident's meal intake for nine of the 85 meals provided. August 2023 records showed staff failed to document the resident's intake for 11 of the 93 meals provided. September 2023 records showed staff failed to document the resident's intake for five of the 69 meals provided. <Resident 68> Review of Resident 68's July 2023 nutritional intake documentation showed staff failed to document the resident's meal intake for 10 of the 55 meals provided. August 2023 records showed staff failed to document the resident's intake for eight of the 93 meals provided. September 2023 records showed staff failed to document the resident's intake for three of the 54 meals provided. In an interview on 09/27/2023 at 2:04 PM, Staff B stated it was important to have complete documentation to evaluate a resident's nutritional status and indicated their expectation was for staff to document each resident's meal intake daily in the resident records.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a pneumococcal (pneumonia) vaccination within the recommended timeframe for 2 (Residents 5 and 49) of 5 residents reviewed for vaccinations. This failure placed residents at risk for contracting pneumonia, with its associated complications. Findings included . <Policy> The facility's undated Pneumococcal Vaccine (Series) policy showed each resident would be assessed for pneumococcal immunization upon admission. This policy showed pneumococcal vaccines would be offered in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. The policy showed for adults 65 years or older who only received a PPSV23 (pneumococcal polysaccharide vaccine), the facility would give one dose of PCV15 (pneumococcal conjugate vaccine) or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. <Resident 5> Review of Resident 5's immunization record showed a dose of PPSV23 was administered on 11/30/2015. Review of the medical record did not show Resident 5 received a PCV15 or PCV20 dose. In an interview on 09/22/2023 at 10:19 AM Staff M (Infention Preventionist) stated they follow the CDC pneumonia vaccine guidelines and recommendations. Staff M stated Resident 5 should have received a PCV15 or PCV20 but they did not. <Resident 49> Review of Resident 49's record showed they admitted to the facility on [DATE]. Review of Resident 49's immunization records showed they did not receive the pneumococcal vaccine. Review of the undated Pneumococcal Vaccine Informed Consent form showed Resident 49 consented to receiving the pneumococcal vaccine and had received education regarding the risks and benefits of receiving the vaccine. Further review of Resident 49's record showed the vaccine was not administered. In an interview on 09/27/2023 at 9:27 AM Staff B (Director of Nursing) stated they expected vaccines to be administered once consent was received. REFERENCE: WAC 388-97-1340(2). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure any of the 97 staff were offered Covid-19 (a highly transmissible infectious virus that causes respiratory illness, in severe cases can cause difficulty breathing and could result in impairment or death) education on the benefits and potential risk associated with the Covid-19 vaccine. This failure placed staff at risk for not being able to make an informed decision about immunizations. Findings included . Review of an undated facility Covid-19 Vaccination policy showed it is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from Covid-19 by educating and offering their staff the Covid-19 vaccination. This policy showed the facility will educate and offer the Covid-19 vaccine to residents, resident representatives and staff and maintain documentation of such. Review of the facility's staff Covid-19 vaccination status record showed no staff education was provided on Covid-19 vaccine risks and benefits for any of the staff currently working at the facility. In an interview on 09/22/2023 at 10:19 AM Staff B (Director of Nursing) stated they did not have documentation for any staff members receiving Covid-19 vaccine education. REFERENCE: WAC: 388-97-1680(2)(c). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

<Resident 38> According to a Quarterly MDS, Resident 38 had multiple complex diagnoses including cancer, heart failure, and arthritis and utilized a wheelchair for mobility. This MDS showed Resi...

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<Resident 38> According to a Quarterly MDS, Resident 38 had multiple complex diagnoses including cancer, heart failure, and arthritis and utilized a wheelchair for mobility. This MDS showed Resident 38 had no memory impairment, clear speech, was able to understand, and be understood by others. In an interview on 09/19/2023 at 9:33 AM, Resident 38 stated their WC wobbled and was hard for them to get it to move. Observations on 09/20/2023 at 2:58 PM showed staff bringing Resident 38 into the hall using their WC. At this time, the WC had an anti-tipper device on the back with a missing wheel on the right side. Resident 38 stated their seat cushion was also broken and they had to use stacked blankets in the seat instead. Resident 38 was observed reaching back behind them while trying to reach the wheels to propel the WC. Resident 38 stated it was hard to get the WC to move. Review of a facility maintenance log binder on 09/25/2023 at the nurse's station showed no entries by staff to request repair for Resident 38's WC. In an interview on 09/26/2023 at 3:21 PM, Staff H (RCM) confirmed the wheelchair Resident 38 was using had a missing anti-tipper wheel on the right side. Staff H stated residents should not be using WCs that are broken. <Facility Equipment> Observations on 09/22/2023 at 1:44 PM showed a mechanical lift used to transfer residents in the hallway outside of the social workers office. This mechanical lift was labeled as number 4 and was observed with broken, cracked uncleanable plastic areas on the base of the lift. In an interview on 09/27/2023 at 2:04 PM, Staff B stated their expectation was for resident and facility equipment to be repaired promptly to prevent accidents and injuries. REFERENCE: WAC 388-97-2100. Based on observation, interview and record review, the facility failed to ensure resident Wheelchairs (WCs) were maintain in good, safe, working order for 3 (Residents 30, 579 & 38) of 20 sampled residents reviewed. Failure to ensure WCs were in maintained in safe working condition left residents at risk for accidents, frustration, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 2023 Preventative Maintenance for Wheelchairs policy, the facility would develop and implement as part of their preventative maintenance program, a system for WC safety and maintenance. The policy showed all staff were responsible for ensuring WCs requiring maintenance are not used by residents and were reported to maintenance for repairs. The policy showed wheels, arm rests and brakes should be checked weekly or as indicated. The policy showed facility staff should ensure brakes are in good repair and able to hold the chair still during transfers. <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including neuropathy (nerve damage), difficulty walking and muscle wasting. The MDS showed Resident 30 used a WC for mobility. Observation on 09/21/2023 at 9:15 AM showed the left arm rest on Resident 30's WC was loose and tilted to the outside. In an interview on 09/25/2023 at 12:11 PM Resident 30 stated their chair needed repair and demonstrated the ring attached to the left wheel of the WC that allowed the resident to propel the WC with their hands was broken, and could easily ensnare a finger, or tear skin. Resident 30 stated the brakes are shot too and the arm rest is loose. Resident 30 stated they previously informed facility staff of the condition of their WC but did not recall when. In an interview on 09/25/23 at 1:11 PM Staff B (Director of Nursing) stated if nursing staff identified a WC was in need of repair or maintenance, they should make a note in the maintenance book to notify the maintenance department. Staff B stated if a resident reported a concern to staff, the same process of adding that information to the maintenance book should be followed. In an interview on 09/26/2023 at 10:13 AM Staff U (Resident Care Manager - RCM) stated they expected floor staff to observe and report to maintenance when WCs required repair. Staff U observed the condition of Resident 30's WC and stated oh my goodness. Staff U stated the WC needed replacement. <Resident 579> According to the 09/12/2023 Admit/Readmit Assessment, Resident 579 used a WC for mobility. The assessment showed Resident 579 used a Foley Catheter (FC - tubing to assist draining urine from the bladder). In an interview on 09/25/2023 at 10:03 AM Resident 579 stated they were frustrated because they were scheduled to go to an appointment with a urologist a couple of days ago where Resident 579 understood their FC would be removed. Resident 579 stated the battery to their electric WC was not charged prior to the appointment and the WC stopped working in the lobby and they were unable to make their appointment which was now rescheduled for 10/12/2023. Review of the appointment book located at the facility's reception desk showed Resident 579 was scheduled to see their urologist on 09/21/2023. In an interview with Staff AA (Transport Director) stated they recalled Resident 579 was unable to attend the appointment due to the battery dying. Staff AA stated it happened right here indicating the facility's lobby by the reception desk. In an interview on 09/26/2023 at 1:33 PM Staff A (Administrator) stated all staff were responsible for ensuring WCs were charged and functioning prior to appointments. Staff A stated the facility did not have a schedule or system for ensuring WC batteries were charged. Staff A stated their expectation was the resident would be adequately prepared for the day.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to consider and act promptly to address concerns raised by residents at the Resident Council (RC). Facility failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken left residents at risk for unresolved concerns, frustration, and a less-than-homelike environment. Findings included . Review of the facility's RC meeting minutes from February through July 2023 showed the facility held meetings on 02/17/2023, 04/21/2023, 05/19/2023, 06/16/2023, and 07/17/2023. The facility did not provide minutes for the 06/16/2023 but did furnish an attendance record. The facility did not have a meeting in August 2023. Review of the RC meeting minutes showed: - During the 02/17/2023 meeting, residents requested information about when the facility's bus would be available for outings as it was not in use at that time. Staff informed residents the bus would be available in 60 days. The 04/21/2023 meeting minutes showed the facility informed residents the bus issue was resolved and the bus would be available in 10 days. Residents again inquired about the status of the bus during the 05/19/2023 meeting and were informed the bus would be available once the Administrator resolved an issue with the title. In the 07/17/2023 meeting Residents were again told the bus was not ready, three months after residents were assured it would be available. -Resident expressed concerns with the reliability of an outside transportation provider used by the facility on 02/21/2023 and requested an alternative. During the 05/19/2023 meeting, residents requested a change in transportation service and were told by staff a new contract with a different provider would be acquired by the facility. The concern with the transportation provider were raised again on 07/17/2023, and again residents were informed the facility would acquire a new contract with another provider. (Review of appointment documentation for residents showed residents were still using the same transportation service until at least 09/21/2023). - Residents had unresolved concerns regarding resident call light wait times during the 02/17/2023 meeting. There was no meeting in March 2023. Unresolved concerns with call wait times were again brought up in the 04/21/2023 meeting. - During the 02/17/2023 meeting residents expressed they wanted the facility to start providing the Daily Chronicle (a daily newssheet common in nursing homes) again. In the 04/21/2023 meeting facility staff informed residents they would begin distributing the Daily Chronicle soon. During the 07/19/2023 Residents were again informed staff would begin distributing The Daily Chronicle daily. - Residents had concerns with cold foods during the 02/17/2023 and 04/21/2023 meetings, and with cold soup in particular on 07/17/2023. - Residents had concerns with the lack of vegetarian meal options during the 02/17/2023 and 04/21/2023 meetings. The 07/17/2023 minutes showed Staff J (Dietary Supervisor) was hired in May 2023 and had already started working on vegetarian diets five months after the concern was brought up in February. -None of the meeting minutes showed facility staff used the meeting as an opportunity to discuss with and educate residents on their rights while in the facility. Observation of the 09/22/2023 RC Meeting at 01:34 PM showed six residents were present, including Resident 29, the RC president, and Resident 25. During the meeting, Staff I (Activities Director) stated outings would resume once the bus was up and running. Resident 29 replied the bus that hasn't worked in two and a half years? It's never worked. During the meeting residents expressed frustrations with dietary services including the temperature and texture of the food, including overcooked meat. During the meeting multiple residents expressed frustration with call light wait times. In an interview on 09/26/2023 at 3:01 PM Resident 29 stated residents didn't have a clear sense of the follow up to the concerns raised at RC meetings. Resident 29 stated they suggested maintaining a notebook to track follow up. Resident 29 stated sometimes staff forgot to address prior RC concerns. Resident 29 stated they were told the facility informed them they needed to wait for a title for the bus from California, and added, how long can that take? Resident 29 also identified ongoing, repetitive food concerns as a theme at RC meetings. Resident 29 stated they did not recall the facility addressing resident rights except for one occasion when a meeting was called to specifically address smokers' concerns and smoking rules. In an interview on 09/27/2023 at 9:44 AM Staff A (Administrator) stated the facility was working on the bus. Staff A stated they thought the facility provided residents the best estimates they could regarding the status of the bus. Staff A stated repeated concerns in RC did not necessarily indicate a lack of responsiveness from the facility if different residents were sharing the concerns on different months. Staff A stated the minutes did not indicate which concerns were raised by which residents. Staff A stated the reason for the repeated call light wait time concerns could be changes in staff, as the facility experienced some staff turnover. Staff A stated they expected grievances generated from the RC meeting to be referred to Social Services. When asked if resident concerns and grievances were addressed timely, and if a rationale was provided when they could not be, Staff A stated the facility had some work to do regarding the RC process. In an interview on 09/27/2023 at 10:34 AM Staff C (Director of Social Service) stated they were the facility's Grievance Officer, and responsible for the resolution of grievances. Staff C stated that except for the most recent meeting on 09/22/2023, they were not referred grievances from the RC. Staff C stated receiving feedback about resident concerns from RC meetings would allow them to fulfill their role as Grievance Officer more effectively. Observation on 09/27/2023 at 10:44 AM showed the registration stickers (car tabs) on the rear license plate of the facility bus expired in 11/2020, indicating for nearly three years the bus could not be driven legally. REFERENCE: WAC 388-97-0920 (1-6) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to maintain a safe, clean, and comfortable environment, free of unpleasant noises, left residents at risk for a less than a homelike environment. Findings included . <Floor Trim> Observation on 09/25/2023 at 6:18 AM showed the thresholds for rooms 227, 228, 229, 230, 232, 235, 240, 243, 244, 247, 246 & 249 were missing black rubber trim between the hallway tiling and the tiling in the rooms. In an observation and interview on 09/27/2023 at 2:02 PM Staff A (Administrator) stated the trim was missing and should be replaced for the rooms identified <Elevators> Observation of the facility's two elevators on 09/21/2023 at 9:15 AM showed the paint on the handrail in the right elevator was worn off and looked unattractive. Both elevator cars had considerable scuff marks along the interior walls. Both elevator cars had unidentified garbage/debris visible through the opaque ceiling light fixtures. In an observation and interview on 09/27/2023 at 2:02 PM Staff A acknowledged the condition of the elevators and stated they were not in a very homelike condition. <Dining Room> Observation of the facility dining room on 09/22/2023 at 11:46 AM showed facility staff used the dining room to store eight boxes of Personal Protective Equipment (medical supplies such as masks, gloves, or gowns worn to prevent the spread of infectious diseases) and COVID tests. Some other empty boxes were also left in the dining room. A folding table and an empty picture frame were left behind a row of chairs against the wall near the door to the Admissions Office. Some bagged clean tablecloths were left on top of some of the boxes. Observation showed the above listed items remained in the dining room, and now three boxes of incontinent pads (disposable pads used to absorb urine used for some residents at risk of incontinence while in bed) were also left in the dining room, near the staircase to the resident units. In an observation and interview on 09/27/2023 at 2:02 PM Staff A stated the storage of the boxes and bags of tablecloths did not contribute to a homelike appearance and should be moved. <Dirty Wheelchair> Observation on 09/27/2023 at 8:45 AM showed Resident 29's wheelchair placed outside their room. The seat and ankle supports of the wheelchair were stained and dirty. In an observation and interview on 09/27/2023 at 2:02 PM Staff A observed the still dirty wheelchair and stated it needed to be cleaned. <Dumpster> Observation on 09/21/2023 at 8:04 AM showed the facility kept a large green dumpster at the back end of the covered parking, underneath resident bedrooms 227 to 233. The lid to the dumpster was wide open and would not provide a barrier to pests such as rodents and insects. The dumpster was observed to be open on 09/27/2023 at 4:15 PM and on 09/28/2023 at 9:00 AM. The dumpster now had bags of garbage stacked above the level of the lid. In an interview on 09/27/2023 at 2:02 PM Staff A declined to observe the dumpster. Staff A stated the facility needed to contract with a pest control company related to a concern with flies and maggots from a previous citation. Staff A stated it was important to avoid attracting insects and other pests and closing the dumpster lid contributed to this. Staff A stated the lid should be closed for customer service. <Stained Ceiling Tiles> Observation on 09/21/2023 12:47 PM showed stains on the ceiling tiles outside of the facility's central supply room. Observation on 09/26/2023 at 11:17 AM showed stains on the ceiling tiles outside the supply closet near the north Nurse's Station. In an interview on 09/27/2023 at 2:02 PM Staff A stated they did not know what caused the stained ceiling tiles. Staff A stated the stains did not look homelike. <Incomplete Blinds> Observation on 09/27/2023 at 2:02 PM showed the blinds to the window in room [ROOM NUMBER] was missing slats and did not offer the resident adequate privacy. In an interview at that time Resident 39 stated they were not satisfied with the state of the blinds in the room. In an interview on 09/27/2023 at 2:02 PM Staff A stated blinds in resident rooms should be maintained in good condition and provide full privacy for the resident. <Noise> On 09/22/2023 at 12:08 PM the residents who occupied room [ROOM NUMBER] were overheard loudly arguing, cussing at one another, and telling one another to shut up! The argument could be heard unpleasantly loud in the hallway. In an interview at this time, a resident in room [ROOM NUMBER] stated to the co-occupants of room [ROOM NUMBER] argued day and night. In an interview on 09/27/2023 at 2:02 PM Staff A stated the noise from room [ROOM NUMBER] impeded on the right to a homelike environment but the residents occupying the room had the right to express themselves. Staff A stated they were not sure if the facility had considered a room move or other strategies to manage the noise from room [ROOM NUMBER]. Staff A stated they would not want a loved one of theirs to have to listen to such arguing/noise. REFERENCE: WAC 388-97-0880. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Facility Policy> Review of the facility's 10/2022 Fall Prevention Program policy showed a fall risk indicator would be pl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Facility Policy> Review of the facility's 10/2022 Fall Prevention Program policy showed a fall risk indicator would be placed on the name plate to the resident's room. The policy indicated the facility would provide interventions that addressed unique risk factors measured by the fall assessment tool. <Resident 58> According to the 09/07/2023 Quarterly MDS Resident 58 was admitted to the facility on [DATE] and was assessed to have impaired memory. Resident 58 required extensive assistance of one staff member for locomotion, toilet use, and personal hygiene. Resident 58 had medically complex diagnosis including identified repeated falls. Review of the 06/19/2023 CP showed Resident 58 required one-person extensive assistance for toilet use, transfers, and locomotion. Observation on 09/25/2023 at 12:25 PM showed Resident 58 was independently taking themselves to the bathroom with the use of a front wheeled walker. Observation and interview on 09/26/2023 at 1:14 PM showed Resident 58 was standing at the side of their bed and sat down with the use of the front wheeled walker. Resident 58 stated they just came out of the bathroom and was about to take a nap. Observation on 09/19/2023 at 09:07 AM showed a padded mat was on the floor by the left side of Resident 58's bed. The same observation was noted on 09/25/2023 at 05:56 AM. Review of a 07/07/2023 Fall Assessment showed Resident 58 had a history of falls, had more than one diagnosis that were contributory to their falls, and did not use a front wheeled walker. The assessment showed Resident 58 had an impaired gait and could overestimate or forget their mobility limits. Observation and interview on 09/25/2023 at 05:56 AM showed Staff K (RN) were standing outside of Resident 58's room. Staff K stated they were waiting for another staff member to come and assist Resident 58 as they were attempting to stand from the edge of bed. At the same date and time, a fall mat was observed on the floor and was under Resident 58's feet. Review of a 07/07/2023 Incident report showed Resident 58 had a fall in the bathroom. Resident 58's fall resulted in an emergency room visit after injuring their right leg. The report did not identify the root cause of the fall. Review of the 06/19/2023 Fall CP showed there were no interventions in place to prevent the reoccurrence of Resident 58's falls. Observation on 09/19/2023 at 09:07 AM of Resident 58's door showed there was no signage to inform staff that Resident 58 was a fall risk. Similar observations were made on 09/20/2023 at 11:36 AM, 09/21/2023 at 12:12 PM, 09/22/2023 at 10:53 AM, 09/25/2023 at 5:56 AM, 09/26/2023 at 12:07 PM. In an interview on 09/21/2023 at 12:10 PM, Staff H stated the mat on the floor would cause an uneven walking surface and could make walking difficult for Resident 58. Staff H stated the fall mat could place Resident 58 at an increased risk of falls. In an interview on 09/27/2023 at 9:27 AM, Staff B stated they expected residents to have protocols in place that reflected the fall assessment. Staff B stated they expected incident reports to be thoroughly investigated and the interventions identified were captured in Resident 58's CP to prevent the reoccurrence of their falls. Refer to F565- Resident/Family Group and Response. Refer to F689- Free of Accident Hazards/Supervision/Devices. Refer to F686- Treatment/Services to Prevent/Heal Pressure Ulcers. REFERENCE: WAC 388-97-0640 (6)(a)(b). <Resident 65> According to the 07/23/2023 admission MDS, Resident 65 admitted to the facility on [DATE] and was assessed to have clear speech and with some degree of memory impairment due to a stroke (brain injury). The MDS showed Resident 65 had multiple diagnoses including a medical condition characterized by elevated levels of blood sugar in the body and weakness to one side of their body from their stroke. The MDS showed Resident was at risk for skin breakdown. Review of the 07/17/2023 admission Nursing Evaluation form showed Resident 65 was identified to have two skin issues: A right ankle scar, and a right heel Pressure Ulcer (PU). The 07/17/2023 nursing admission progress note showed Resident 65 had a dry/flaking scar tissue observed to their sacral (the triangular area located below the waist and above the tailbone) area. The progress note did not identify any open areas on Resident 65's tailbone and/or upper buttocks. In an observation and interview on 09/19/2023 at 12:10 PM, Resident 65 was noted wearing a foam boot to their right lower leg/foot. When asked if they have other skin issues, Resident 65 stated they have a sore on their bottom. Observation on 09/25/2023 at 11:18 AM of Resident 65's Stage 3 PU with Staff H (Resident Care Manager - RCM) and Staff N (Licensed Practical Nurse) during wound care treatment showed exposed fatty tissue layer and macerated (softened skin from being soaked) wound edges. Record review on 09/27/2023 at 9:00 AM showed a 07/19/2023 facility incident report completed by Staff B where Resident 65's Stage 3 (full-thickness loss of the skin that extended to the fatty tissue) PU was identified, two days after Resident 65's facility admission on [DATE]. The incident report did not rule out any potential abuse and/or neglect and lacked the necessary information including factors that contributed to Resident 65's skin breakdown. The report did not establish the root cause analysis of the incident, and showed No Records Found on multiple sections of the investigation. The incident report showed there was no notification provided to the physician or to Resident 65's representative regarding the Stage 3 PU identified. In an interview on 09/27/2023 at 11:18 AM, Staff B stated Resident 65's Stage 3 PU was identified during the facility's skin sweep. Staff B stated the investigation packet provided was all they have and encompassed the entirety of the investigation. Staff B stated the incident report should include pertinent information including wound care provider notes, current treatment orders, dietary consultations, and a summary of the root cause analysis of all contributory factors that led to Resident 65's skin breakdown but did not. Staff B stated they were unsure if the physician and Resident 65's representative were notified of the incident because there was no documentation found in Resident 65's medical records. <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease (disorder of central nervous system that affects movements including tremors), stroke, and bipolar disorder (brain disorder that causes changes in person's mood and ability to function). The assessment showed Resident 9 was cognitively intact and demonstrated behaviors of hallucinations, delusions, and rejection of care during the seven-day observation period. The assessment showed Resident 9 required supervision during transfers and dressing. Review of a 07/14/2023 nursing progress note showed Resident 9 complained of back pain. Resident 9 called 911 and asked the paramedics to take them to the hospital. Review of Resident 9's clinical record showed no documentation about Resident 9 going to the hospital, family notification, provider notification, returning from the hospital, or new orders from the hospital. Review of the 07/14/2023 hospital records showed Resident 9 came because of back pain and X-rays showed closed, acute, and non-displaced right 8th rib fracture. Review of the 07/16/2023 Staff A's progress note showed they talked to the resident about their visit to hospital on [DATE] and Resident 9 told Staff A about their rib fracture. The progress note showed Resident 9 was unable to say when or how the injury happened exactly and suggested it was probably during self-transfers. Review of the 07/17/2023 Alteration in Status Care Plan (CP) showed Resident 9 had displaced 8th posterior rib fracture and the interventions instructed staff to follow the provider's orders for weight bearing status and notify the provider for uncontrolled pain. Interventions included for staff to re-educate and re-approach Resident 9 for safety. In an interview on 09/19/2023 at 11:21 AM, Resident 9 stated they thought they had a fall but did not remember for sure. On 09/20/2023, Resident 9 was not available for interview. Resident 9's record showed the resident was sent to the hospital for increased confusion. In an interview on 09/25/2023 at 10:42 AM, Staff B stated they were not aware of Resident 9's fracture. Staff B stated the injury with unknown causes should be investigated thoroughly, and Resident 9 should be placed on alert charting and monitored for pain. In an interview on 09/26/2023 at 9:00 AM, Staff R (Registered Nurse - RN) stated they remembered Resident 9 told them about back pain, called 911, and went to the hospital. When Staff R was asked about the facility process for transferring a resident to the hospital, Staff R stated, the facility process was to assess the resident, notify the provider and the resident's family, fill out the paperwork, and document in the resident's record. Staff R was asked regarding Resident 9's hospital transfer documentation. Staff R was unable to provide any documentation and stated they missed it. Staff R stated they knew Resident 9 had a rib fracture related to self-transferring. Staff R was unable to provide any documentation that interventions were put in place to prevent reoccurrences. In an interview on 09/26/2023 at 9:59 AM, Staff A stated they completed the investigation about Resident 9's rib fracture and no abuse or neglect was noted. Staff A stated Resident 9 told them they got the rib fracture during self-transferring. Staff A provided the investigation and showed they reported the incident to the State on 07/16/2023. When asked Staff A about the interventions to prevent the reoccurrence, Staff A stated they talked to staff about encouraging the resident to use the call light for help with transfers. Staff A was unable to provide any documentation to show they updated the CP or provided any education to the staff or the resident. Staff A stated they used agency staff at times and they did not document Resident 9's hospital transfer. When asked how they educated agency staff (outside contracted staff), Staff A was unable to provide any information. In an interview on 09/27/2023 at 10:43 AM, Staff B stated they should have updated the CPs with interventions to prevent further injuries related to resident self-transfers but did not. Staff A and Staff B were unable to provide any documentation to support education was provided to CNAs and LNs about Resident 9's care plan changes, and documentation of their process regarding residents' hospital transfers and alert charting. Based on observations, interviews, and record review the facility failed to initiate and thoroughly investigate the occurrences of events for 5 of 20 (Residents 32, 30, 9, 65, & 58) sampled residents whose facility incident reports were reviewed. The facility failed to investigate and correct reported resident grievances and mental health status, identify the cause of an injury, the development of a new wound, and implement protocols and interventions to prevent reoccurrence of events. The failure to initiate, conduct a thorough investigation, and correct alleged violations left residents at risk for unidentified abuse and/or neglect and a decreased quality of life. Findings included . <Resident 32> According to the 08/06/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 32 had no cognitive impairment or depression diagnosis. The MDS showed Resident 32 exhibited no behavior during the assessment period. The MDS showed Resident 32 had occasional pain and was provided as-needed pain medications. Review of a 08/24/2023 grievance form initiated by Resident 32 showed the resident stated Staff L (Certified Nursing Assistant - CNA) answered their call by stating why are you calling me for this? before turning off Resident 32's call light. The grievance form indicated Resident 32 then waited over an hour before receiving their pain medication. The grievance did not show when Resident 32 requested assistance using their call light, what their pain level was, or when the resident received the as-needed pain medication. The grievance form showed staff were educated about pain medications being given on time and customer service. The back page of the grievance form included sections where staff could include information about the resolution of the grievance including findings, actions/recommendations, whether the grievance was conformed or not and what the resolution was, the date and time the resident was notified of the resolution of the grievance, and name and signature of the person completing the form, all of which were blank. The form was signed by Staff A (Administrator) on 09/16/2023. The August 2023 Medication Administration Record (MAR) showed Resident 32 was administered their as-needed pain medication three times: On 08/24/2023 at 8:47 AM for pain of 6/10; at 12:54 PM for a pain of 6/10; and at 6:44 PM for a pain of 8/10. It was unclear from the grievance form which of these three occasions, if any, was the occasion when Resident 32 alleged they were denied pain medication for more than an hour. In an interview on 09/26/2023 at 12:58 PM, Staff A stated they were not sure how the facility ruled out Resident 32 was neglected on 08/24/2023 after they alleged facility staff failed to provide them pain medication for over an hour. Staff A stated the grievance form did not note any psychosocial harm. Staff A stated Resident 32 received poor customer service. Staff A stated the grievance should have but was not investigated to rule out neglect. <Resident 30> According to the 06/18/2023 Quarterly MDS, Resident 30 had diagnoses including non-traumatic brain dysfunction, anxiety, and depression. The MDS showed Resident 30 had moderate cognitive impairment (difficulty with problem solving and forming new memories), experienced hallucinations and delusions, exhibited verbal behavior toward others, and had behaviors that interfered with their daily activities and disrupted their care and the living environment. Review of a 04/27/2023 progress notes, staff became aware Resident 30 had suicidal thoughts, and a plan. The note showed the facility notified the resident's physician, mental health provider, and responsible party. Review of the facility's investigation into Resident 30's Suicidal Ideation (SI) showed the investigation did not identify any predisposing physiological factors. The investigation included the witness statement of the nurse who was informed by Social Services (SS) of the concerns for Resident 32's SI but did not include a statement from the SS staff who told the nurse, nor identified who in the SS department first gained knowledge. The investigation included notes from the psychiatrist who noted worsening depression, and Resident 32's statement that they were depressed because they missed their family. The note did not identify if Resident 30's desire to see more of their family was the root cause of their SI. In an interview on 09/26/2023 at 12:50 PM Staff B (Director of Nursing) stated it was important to identify the root cause of SI and to thoroughly investigate the concerns that came with them. <Resident Council (RC) Minutes> Review of the facility's RC Minutes showed the following: The 02/17/2023 Minutes' Old Matters - Nursing section showed Unresolved: staff is sometimes rough with residents; the 04/21/2023 Minutes' Old Matters - Nursing section showed Unresolved: staff is sometimes rough with the residents - staff have been informed to be more gentle. The notes indicated Staff A attended the 04/21/2023 meeting. Neither set of RC Minutes indicated which residents shared the concern for rough care. In an interview on 09/27/2023 at 9:44 AM, Staff A stated the allegations of rough care should have but were not investigated to rule out potential abuse. Staff A stated it was not clear from the meeting minutes which residents had the concern, or which staff were potentially involved. Staff A stated the allegations should be reported immediately and investigated within five days as required.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> Resident 17 was transferred to an acute care hospital on [DATE] Return Anticipated and readmitted on [DATE]....

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> Resident 17 was transferred to an acute care hospital on [DATE] Return Anticipated and readmitted on [DATE]. Review of the residents transferred out log that social services updated, showed no documentation the LTCO was notified of the discharge. During an interview on 09/25/2023 at 1:00 PM, Staff C (Social Services Director) explained the facilities process for LTCO notification. Per Staff C the facility faxed a monthly Ombudsman Notice of Discharge list, of resident discharges for the month, to the LTCO by the tenth of each month per an agreement with the LTCO. Staff C was unable to provide any documentation showed LTCO was notified. In an interview on 09/27/2023 at 12:12 PM Staff Y (Social Services Assistant) stated they did not notify the LTCO for any residents transferred out of the facility. In an interview on 09/27/2023 at 12:45 PM Staff C stated they did not notifying the LTCO of residents transferring out of facility. Staff C stated they did not notified the LTCO of resident transfers to the hospital, but they should have. REFERENCE: WAC 388-97-0120(2)(a-d), -0140(1)(a)(b)(c)(i-iii). <Resident 27> Review of a 04/02/2023 Nursing Home Discharge MDS, Resident 27 discharged to the hospital on [DATE] and was assessed as return anticipated upon discharge from the hospital. Review of a 02/06/2023 nursing progress note showed Resident 27 returned to the facility on [DATE] after being treated at the hospital. Record reviewed showed no documentation the LTCO was notified of Resident 27's transfer to the hospital. The facility was unable to provide documentation showing the LTCO was notified of Resident 27's transfer to the hospital. <Resident 53> Review of an 08/26/2023 Nursing Home Discharge MDS, Resident 53 discharged to the hospital on [DATE] and was assessed as return anticipated upon discharge from the hospital. A 09/08/2023 nursing progress note showed Resident 53 readmitted to the facility on [DATE] after being treated at the hospital. Record review showed no documentation the LTCO was notified of Resident 53's transfer to the hospital. The facility was unable to provide documentation showing the LTCO was notified of Resident 53's transfer to the hospital. Based on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 6 (Residents 9, 55, 66, 27, 53 & 17) of 8 residents reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Resident 9> Resident 9 admitted to the facility on [DATE]. Record review showed Resident 9 was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 08/02/2023 Discharge Minimum Data Set (MDS - an assessment tool), the resident discharged again to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required for either the 02/15/2023 or 08/02/2023 transfers. The facility was unable to provide documentation showing the LTCO was notified of Resident 9's transfers. <Resident 55> Resident 55 admitted to the facility on [DATE]. Record review showed Resident 55 was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 08/31/2023 Discharge MDS, the resident discharged again to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required for either the 04/24/2023 or 08/31/2023 transfers. The facility was unable to provide documentation showing the LTCO was notified of Resident 55's transfers. <Resident 66> Resident 66 admitted to the facility on [DATE]. According to a 09/11/2023 Discharge MDS, Resident 55 was discharged to an acute care hospital on [DATE], Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required. The facility was unable to provide documentation showing the LTCO was notified of Resident 66's transfers.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the comprehensive assessments within the regulatory timeframes for 12 of 12 (Residents 68, 24, 65, 27, 37, 373, 4, 5, 579, 9, 66, & 69) sampled residents, 2 of 2 (Residents 54 & 379) supplemental residents, and 1 of 3 (Resident 372) closed records reviewed for resident assessments and timing. The failure to ensure comprehensive admission and Annual Minimum Data Set (MDS - an assessment tool) assessments were completed timely hindered the care planning process necessary to provide the appropriate resident care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life. Findings included . <Facility Policy> The 2022 MDS 3.0 Completion facility policy showed an admission MDS was completed within 14 days of admission, counting the day of admission as day 1. <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2019 RAI Manual outlined an admission MDS was a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. The manual outlined an Annual MDS was a comprehensive assessment for a resident that must be completed on an annual basis and the completion date must be no later than 14 days after the Assessment Reference Date (ARD). <Resident 68> According to the 07/19/2023 admission MDS, Resident 68 admitted to the facility on [DATE]. Review of the date of MDS completion by the Registered Nurse (RN) Coordinator showed 08/24/2023, 29 days past the regulatory timeframe as required. <Resident 24> Review of Resident 24's MDS schedule on 09/28/2023 showed the 08/13/2023 Annual comprehensive assessment was not completed. The MDS status remained In Progress and was more than 14 days from the ARD. <Resident 65> According to the 07/23/2023 admission MDS, Resident 65 admitted to the facility on [DATE]. Review of the date of MDS completion by the RN Coordinator showed 08/24/2023, 25 days past the regulatory timeframe as required. <Resident 27> Review of Resident 27's MDS schedule on 09/28/2023 showed the 08/08/2023 Annual comprehensive assessment was not completed. The MDS status remained In Progress and was more than 14 days from the ARD. <Resident 37> According to the 07/26/2023 admission MDS, Resident 37 admitted to the facility on [DATE]. Review of the date of MDS completion by the RN Coordinator showed 08/24/2023, 22 days past the regulatory timeframe as required. <Resident 373> Review of Resident 373's MDS schedule on 09/28/2023 showed the 09/18/2023 admission MDS was not completed. The MDS status remained In Progress and was more than 14 days from Resident 373's date of admission on [DATE]. <Resident 4> According to the 08/29/2023 admission MDS, Resident 4 admitted to the facility on [DATE]. Review of the date of MDS completion by the RN Coordinator showed 09/11/2023, six days past the regulatory timeframe as required. <Resident 5> Review of Resident 5's 06/19/2023 Annual comprehensive assessment showed the MDS was completed by the RN Coordinator on 07/10/2023, seven days past the regulatory timeframe as required. <Resident 579> Review of Resident 579's MDS schedule on 09/28/2023 showed the 09/18/2023 admission MDS was not completed. The MDS status remained In Progress and was more than 14 days from Resident 579's date of admission on [DATE]. <Resident 69> According to the 07/21/2023 admission MDS, Resident 69 admitted to the facility on [DATE]. Review of the date of MDS completion by the RN Coordinator showed 08/24/2023, 27 days past the regulatory timeframe as required. <Resident 54> Review of Resident 54's MDS schedule on 09/28/2023 showed the 08/10/2023 Annual comprehensive assessment was not completed. The MDS status remained In Progress and was more than 14 days from the ARD. <Resident 379> According to the 07/16/2023 admission MDS, Resident 379 admitted to the facility on [DATE]. Review of the date of MDS completion by the RN Coordinator showed 08/24/2023, 32 days past the regulatory timeframe as required. <Resident 372> According to the 08/15/2023 admission MDS, Resident 372 admitted to the facility on [DATE]. Review of the date of MDS completion by the RN Coordinator showed 09/11/2023, 20 days past the regulatory timeframe as required. <Resident 9> A review of the 08/18/2023 Quarterly MDS showed Resident 9 was readmitted on [DATE]. The required 14-day completion due date was 09/01/2023. This MDS showed complete date was 09/05/2023, 4 days late. <Resident 66> A review of the 08/29/2023 admission MDS showed Resident 66 was admitted on [DATE]. The required 14-day completion due date was 09/05/2023. This MDS showed the completed date was 09/11/2023, 6 days late and was completed 21 days after admission In an interview on 09/25/2023 at 9:32 AM, Staff B (Director of Nursing) stated it was important for comprehensive assessments to be completed timely due to the risk of not being able to capture the resident's care needs at that particular time. Staff B stated if the MDS was not accurate and timely, then the resident's care plan will be the same. Staff B stated they were aware the facility was behind with the completion of their residents' MDS assessments since the prior MDS nurse left the faciity on [DATE]. In an interview on 09/26/2023 at 2:13 PM, Staff EE (MDS Nurse) stated it was important to ensure timely completion of MDS assessments primarily for resident care and for the purposes of facility reimbursement. Staff EE stated they only work as on-call and completed MDS assessments once a week. Staff EE stated the facility was currently in a crisis because of the lack of knowledgeable MDS staff. Refer to F638- Quarterly Assessments At Least Every 3 Months. Refer to F641- Accuracy of Assessments. Refer to F642- Coordination/Certification of Assessment. REFERENCE: WAC 388-97-1000(b)(c)(ii), (3)(a). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframes for 7 of 10 (Residents 9, 32, 53, 58, 62, 25, & 17) sampled residents and 1 of 3 (Resident 4) closed records reviewed for resident assessments and timing. The failure to ensure resident assessments were completed timely placed the residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life. Findings included . <Facility Policy> The 2022 MDS 3.0 Completion facility policy showed a Quarterly MDS used an Assessment Reference Date (ARD) which was no later than 92 days from the ARD of the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2019 RAI Manual showed a Quarterly MDS was a non-comprehensive assessment used to track the resident's status between comprehensive assessments that ensured residents were monitored for critical indicators of a gradual onset of significant change(s) in their status. The RAI outlined a Quarterly MDS must be completed no later than 14 days after the established ARD of the assessment. Findings included . <Resident 9> Review of Resident 9's 08/18/2023 Quarterly MDS showed the Registered Nurse (RN) Coordinator completed and locked the assessment on 09/05/2023, four days past the regulatory timeframe as required. <Resident 32> Review of Resident 32's 08/06/2023 Quarterly MDS showed the RN Coordinator completed and locked the assessment on 09/05/2023, 16 days past the regulatory timeframe as required. <Resident 53> Review of Resident 53's 09/11/2023 Quarterly MDS showed the RN Coordinator completed and locked the assessment on 09/27/2023, two days past the regulatory timeframe as required. <Resident 58> Review of Resident 53's 09/07/2023 Quarterly MDS showed the RN Coordinator completed and locked the assessment on 09/27/2023, six days past the regulatory timeframe as required. <Resident 62> Review of Resident 62's MDS schedule on 09/28/2023 showed the 08/30/2023 Quarterly MDS was incomplete and was past the due date of 09/13/2023 as required. The assessment status remained In Progress and was more than 14 days from the ARD. <Resident 25> Review of Resident 25's MDS schedule on 09/28/2023 showed the 08/27/2023 Quarterly MDS was incomplete and was past the due date of 09/10/2023 as required. The assessment status remained In Progress and was more than 14 days from the ARD. <Resident 17> Review of Resident 17's MDS schedule on 09/28/2023 showed the 09/10/2023 Quarterly MDS was incomplete and was past the due date of 09/24/2023 as required. The assessment status remained In Progress and was more than 14 days from the ARD. <Resident 4> Review of Resident 4's MDS schedule on 09/28/2023 showed the 08/29/2023 Quarterly MDS was incomplete and was past the due date of 09/12/2023 as required. The assessment status remained In Progress and was more than 14 days from the ARD. In an interview on 09/25/2023 at 9:32 AM, Staff B (Director of Nursing) stated they were aware the facility was behind with the completion of their residents' MDS assessments. Staff B stated it was important to complete resident assessments accurately and timely for resident-centered care planning. In an interview on 09/26/2023 at 2:13 PM, Staff EE (MDS Nurse) stated it was important to ensure timely completion of MDS assessments primarily for resident care and for the purposes of facility reimbursement. Staff EE stated they only work as on-call and completed MDS assessments once a week. Staff EE stated the facility was currently in a crisis because of the lack of knowledgeable MDS staff. Refer to F636- Comprehensive Assessments and Timing. Refer to F641- Accuracy of Assessments. Refer to F642- Coordination/Certification of Assessment. REFERENCE: WAC 388-97-1000 (4)(a). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> Review of a 05/09/2023 Quarterly MDS showed Resident 27 had a diagnosis of advanced kidney disease and had a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> Review of a 05/09/2023 Quarterly MDS showed Resident 27 had a diagnosis of advanced kidney disease and had a nephrostomy (a tube put into the kidney to drain urine directly from the kidney to outside the body). This MDS showed Resident 27 was continent of urine despite having a nephrostomy tube. Observation on 09/19/2023 at 9:35 AM showed Resident 27 had a nephrostomy tube in place to their right lower back. In an interview on 09/26/2023 at 2:15 PM, Staff EE (MDS Nurse) stated the MDS was coded inaccurately, and Resident 27 should not be coded as continent of urine. <Resident 37> The October 2019 Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual outlined Enteral (a way of delivering nutrition directly to the stomach) feeding formulas should only be coded as Therapeutic Diet when the enteral formula was altered to manage problematic health conditions such as enteral formulas specific to diabetes (a medical condition characterized by elevated levels of blood sugar in the body). According to the 07/26/2023 admission MDS, Resident 37 had multiple medical conditions including difficulty swallowing and diabetes. The MDS showed Resident 37 was provided nutrition via a feeding tube inserted through their stomach and did not receive any skilled rehabilitation therapy from a Speech and Language Pathologist (SLP) during the assessment period. The MDS showed Resident 37 was on a therapeutic diet during the assessment period. Observation on 09/19/2023 at 10:09 AM showed Resident 37 was administered a Tube Feeding (TF) while in bed. The 07/20/2023 Hospital Discharge Summary outlined an instruction to the receiving facility that Resident 37 was to be on TF and NPO (nothing by mouth) except for limited intake per speech therapy. Review of Resident 37's progress notes during the MDS assessment period from 07/20/2023 until 07/26/2023 did not show any documentation Resident 37 consumed a meal by mouth. Review of the Physician Orders (POs) showed Resident 37's TF formula was changed to a therapeutic type on 09/11/2023, after the MDS assessment period. In an interview on 09/26/2023 at 2:28 PM, Staff EE stated Resident 37 was on NPO and did not receive a therapeutic diet during the assessment period. Staff EE stated the 07/26/2023 admission MDS was inaccurate. <Resident 65> According to the 07/23/2023 admission MDS, Resident 65 had multiple medical diagnoses including weakness to one side of the body sustained from a stroke (brain injury). The MDS showed Resident 65 had no functional limitation in their Range of Motion (ROM). Observation and interview on 09/19/23 at 2:24 PM showed Resident 65's right hand was contracted (deformed due to hardening of the muscles/tendons) and a soft splint was applied to the hand. In an interview at this time, Resident 65 stated they could not lift up their right leg. Review of the 07/17/2023 admission progress note showed Resident 65 had right side paralysis (the loss of mobility and function) to their arm and leg from their stroke. In an interview on 09/26/2023 at 2:32 PM, Staff EE stated Resident 65's limited ROM should have but was not captured in the MDS. Staff EE stated the 07/23/2023 admission MDS was inaccurate. <Resident 69> The 07/21/2023 admission MDS showed Resident 69 did not have any oral/dental issues. Observation on 09/19/23 at 10:35 AM showed Resident 69 was missing a lot of their teeth and the two upper native teeth remaining were jagged and broken. Review of the 07/15/2023 Nursing admission Evaluation form in Resident 69's medical records showed their oral status was assessed and broken teeth were identified. In an interview on 09/26/2023 at 2:26 PM, Staff EE stated an oral health assessment should be conducted by the nurse completing the MDS for accuracy. Staff EE stated Resident 69's broken teeth should have been but were not captured in the MDS. Staff EE stated the 07/21/2023 admission MDS was inaccurate. Based on observation, interview, and record review the facility failed to accurately assess 7 of 20 (Residents 9, 66, 37, 65, 69, 27, & 372) residents reviewed for accurate Minimum Data Set (MDS - an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 readmitted to the facility on [DATE] and received no narcotic medication during the assessment period. Review of the August 2023 Medication Administration Record (MAR) showed that during the assessment period (08/12/2023 - 08/18/2023), Resident 9 received narcotic (pain relieving medicine) medications on 08/01/2023 and 08/17/2023. In an interview on 09/26/2023 at 2:12 PM, Staff B (Director Of Nursing) stated Resident 9's MDS was inaccurate and should reflect the administration of narcotic medications twice during the assessment period. <Resident 66> According to the 08/29/2023 Admission/5 Day MDS, Resident 66 was admitted to the facility on [DATE], had diagnoses of multiple fractures, and was assessed with adequate hearing and clear speech. Resident 66 did not demonstrate any behavior or refusal of care during the assessment period. There were multiple areas marked as not assessed including activity preferences and pain assessment and were dashed. In an interview on 09/26/2023 at 2:15 PM, Staff B stated staff did not complete these assessments on or before the last day of the observation period and marked the dashes on MDS. Staff B stated staff should have assessed the resident and completed the MDS accurately to reflect Resident 66's medical status, but they did not. <Resident 372> Review of Resident 372's 08/15/2023 admission MDS showed no information was included in the section of the assessment where the resident's choices for daily and activity preferences should be captured. Instead of showing how interested Resident 372 was in each given activity (such as participation in group activities or spending time outside when the weather was nice), each question contained a dash. In an interview on 09/26/2023 at 2:15 PM - Staff EE stated the section was dashed because it was not completed before the assessment period ended. REFERENCE: WAC 388-97-1000(1)(b). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0642 (Tag F0642)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure: (1) all individuals who completed a portion of the assessment signed and certified to the accuracy of the portion they completed, and (2) the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of Care Area Assessments (CAA's) was knowledgeable of the Minimum Data Set (MDS - an assessment tool) process for 3 of 10 (Residents 65, 37, & 69) residents whose comprehensive MDS assessments were reviewed. These failures placed residents at risk for inappropriate care planning and unmet care needs. Findings included . <Facility Policy> The 2022 MDS 3.0 Completion facility policy showed the CAA process was designed to assist the assessor in systematically interpreting the information recorded on the MDS that facilitated decision-making regarding residents' plan of care. The policy showed CAA's were completed no later than 14 days after a resident's admission. The policy outlined Interdisciplinary Team (IDT) members completing a portion of the assessment must attest to the accuracy of the section they completed by their signature and indication of the relevant section(s) assessed. The policy instructed the RN overseeing the coordination and collaboration to sign, date, and attest to the timely completion of the CAA process in the Summary section. <Resident 65> According to the 07/23/2023 admission MDS, Resident 65 admitted to the facility on [DATE]. The MDS showed the individual CAA sections had a completion date of 07/30/2023 but the date the CAA process was signed off by the RN Coordinator showed 08/24/2023, 25 days past the completion date as required. Review of the MDS's Assessment Administration section showed Section V (the CAA section) was not captured under the column of sections completed, and the IDT member responsible did not attest the completion by signing and the section assessed to reflect the accuracy of their assessment. In an interview on 09/25/2023 at 9:32 AM, Staff B (Director of Nursing) stated the Section V of Resident 65's assessment was not captured and signed for in the MDS. <Resident 37> According to the 07/26/2023 admission MDS, Resident 37 admitted to the facility on [DATE]. The MDS showed the individual CAA sections had a completion date of 08/02/2023 but the date the CAA process was signed off by the RN Coordinator showed 08/24/2023, 22 days past the completion date as required. Review of the MDS's Assessment Administration section showed Section V was not captured under the column of sections completed, and the IDT member responsible did not attest the completion by signing and the section assessed to reflect the accuracy of their assessment. In an interview on 09/25/2023 at 9:32 AM, Staff B stated the Section V of Resident 37's assessment was not captured and signed for in the MDS. <Resident 69> According to the 07/21/2023 admission MDS, Resident 69 admitted to the facility on [DATE]. The MDS showed the individual CAA sections had completion dates of 07/31/2023 and 08/02/2023 but the date the CAA process was signed off by the RN Coordinator showed 08/24/2023, 27 days past the completion date as required. Review of the MDS's Assessment Administration section showed Section V was not captured under the column of sections completed, and the IDT member responsible did not attest the completion by signing and the section assessed to reflect the accuracy of their assessment. In an interview on 09/25/2023 at 9:32 AM, Staff B stated the Section V of Resident 69's assessment was not captured and signed for in the MDS. Staff B stated they were the RN Coordinator assigned to oversee the coordination and collaboration of the MDS process. Staff B stated the IDT member who used to complete the CAA's was a Licensed Practical Nurse and left the faciity on [DATE]. Staff B stated they have very limited knowledge of the MDS process and was not aware of their role in the CAA process, I need MDS training myself at this point because I have no clue . Staff B stated they were just locking all the MDS assessments because they did not have an RN MDS staff to do this task as required. Staff B stated there was a systemic failure in their MDS process due to staff turnover in this department and they were working on it. Refer to F636- Comprehensive Assessments and Timing. Refer to F638- Quarterly Assessments At Least Every 3 Months. Refer to F641- Accuracy of Assessments. REFERENCE: WAC 388-97-1000 (5)(a). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> According to the 06/12/2023 Quarterly MDS Resident 17 had diagnoses including anxiety and schizophrenia. Thi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> According to the 06/12/2023 Quarterly MDS Resident 17 had diagnoses including anxiety and schizophrenia. This assessment showed Resident 17 required AD medications daily. Review of the 02/10/2022 PASRR level I, Resident 17 required a level II evaluation referral for SMI related to diagnoses of schizophrenia, depressive mood disorder, and anxiety. An interview on 09/25/2023 at 7:31 AM Staff C stated the level II referral had not been sent, no invalidation was completed by the state representative, and the level II had not been done. Staff C stated they should have sent the referral for the level II, but they did not. Staff C stated they're supposed to send the referral in within 30 days. REFERENCE: WAC 388-97-1980(1). <Resident 9> Resident 9 admitted to the facility on [DATE]. According to the 08/18/2023 Quarterly MDS, Resident 9 was cognitively intact, had diagnoses of bipolar disorder and anxiety disorder, demonstrated behaviors including hallucination, delusions, and refusal of care. Resident 9 received AP medication on seven of seven days during the assessment period. During an interview on 09/19/2023 at 11:23 AM, Resident 9 stated, I had surgery done on my shoulder yesterday and surgeon told me that I am pregnant for 3 months. I cannot take any medications . According to a 07/28/2023 psychiatry note, Resident 9 had bipolar mix disorder severe with psychosis and anxiety disorder. Review of the 01/13/2023 level I PASRR showed Resident 9 was assessed to have Mood disorder and anxiety disorder. Review of the 05/19/2023 NOD completed by PASRR evaluator showed Resident 9 had bipolar disorder, anxiety disorder, received APs and increased the dosage related to Resident 9's yelling behaviors, aggressive towards staff, striking out, and refusal of care. The NOD recommended the facility for level II PASRR evaluation to follow. Review of Resident 9's medical record showed no documentation the facility followed up with the PASRR evaluator related to the level II PASRR. In an interview on 09/25/2023 at 1:06 PM, Staff C stated they received NOD on 05/19/2023 and should follow up with the PASRR evaluator within 30 days to receive the level II PASRR recommendations and they did not. In an interview on 09/26/2023 at 11:23 AM, Staff B Director of Nursing (DON) stated the facility should follow up with PASRR evaluator to receive the level II PASRR recommendations and updated the Care Plan (CP), but they did not. <Resident 55> According to the 07/07/2023 Quarterly MDS Resident 55 admitted to the facility on [DATE] and had diagnoses of Depression. Resident 55 received AD medication on seven of seven days during the assessment period. According to a 12/16/2022 psychiatry note showed Resident 55 had Psych, depression, and anxiety disorder and recommended Resident 55 to continue AD medications as prescribed. Review of the 12/08/2022 level I PASRR showed, Resident 55 was assessed without any SMI, including depression. In an interview on 09/25/2023 at 1:10 PM, Staff C reviewed Resident 55's PASRR and stated it did not reflect Resident 55's status. Staff C stated the facility should have updated the level I PASRR and sent to the evaluator, but they did not. In an interview on 09/26/2023 at 11:25 AM, Staff B stated the PASRR was inaccurate, and it should have been updated but it was not.<Resident 68> According to a 07/19/2023 admission MDS, Resident 68 had multiple medically complex diagnoses including an anxiety disorder, Post-Traumatic Stress Disorder (PTSD), and depression and required the use of AP medications. This MDS showed Resident 68 experienced verbal behavioral symptoms towards others daily and these symptoms interfered with Resident 68's care, participation in activities/social interactions, and significantly disrupted the living environment. Review of a September 2023 MAR showed Resident 68 was receiving an AP medication for a diagnosis of bipolar disorder (a mental illness characterized by extreme mood swings). Review of a 07/15/2023 level I PASRR showed staff identified Resident 68's only Serious Mental Illness (SMI) indicator was anxiety and PTSD. Staff did not identify Resident 68 had a bipolar disorder and required the use of medications. This level I PASRR showed staff documented Resident 68 required a level II evaluation referral for their SMI indicators. No level II evaluation was located in Resident 68's records. In an interview on 09/27/2023 at 10:54 AM, Staff C stated level I PASRR evaluations should be accurate and updated as required. Staff C stated level II PASRR evaluations should be completed and readily available in the resident's records within 30 days. Staff C was unable to locate a level II evaluation was completed for Resident 68. <Resident 76> According to a 08/30/2023 admission MDS, Resident 76 had multiple medically complex diagnoses including schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). Review of Resident 76's records showed no PASRR level I was available in the resident's records. An 08/24/2023 Notice of Determination (NOD) completed by a PASRR evaluator showed Resident 76 does require specialized behavioral health services and a level II report would follow. No documentation was located to show the facility followed up with obtaining the level II recommendations report. In an interview on 09/27/2023 at 10:54 AM, Staff C stated they had no documentation to show staff followed up to obtain the level II recommendations and stated it was their expectation level I PASRRs were readily available in the resident's records.Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed for 6 (Residents 30, 68, 76, 9, 55 & 17) of 9 residents reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> According to the facility's 2022 Resident Assessment - Coordination with PASARR Program policy, all residents must have a PASRR screening prior to admission, and the facility would keep a copy of the screening in the resident's record. The policy showed the facility's Social Services department was responsible for ongoing maintenance of accurate PASRR screenings and PASRR screening should be updated as needed to reflect changes both positive and negative to a resident's mental health status. This policy showed if a PASRR level I was positive, a PASRR level II referral would be made, and it would need to be completed prior to admission. <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including anxiety, depression, and non-Alzheimer's dementia. The assessment showed Resident 30 experienced hallucinations and delusions and exhibited behavioral symptoms that interfered with Resident 30's participation in activities/social interactions and significantly disrupted the living environment. The MDS showed Resident 30's behavior had neither improved nor worsened since the previous assessment. Review of the September 2023 Medication Administration Record (MAR) showed Resident 30 received an antidepressant (AD) medication to treat their depression, and an antipsychotic (AP) medication for unspecified dementia, severe, with psychotic disturbances. The MAR showed Resident 30 had a trial antianxiety (AA) medication as needed (PRN) from 09/05/2023 through 09/19/2023, and received a dose increase for their AA medication starting 09/20/2023. Record review showed the most recent PASRR screening in Resident 30's record was completed on 03/10/2023. This PASRR screening did not reflect Resident 30's anxiety or depression diagnoses and did not show Resident 30 had a dementia diagnosis. In an interview on 09/22/2023 at 12:59 PM Staff C (Director of Social Services) reviewed Resident 30's PASRR. Staff C stated it did not reflect Resident 30's current status and should be updated.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 65> According to the 07/23/2023 admission MDS, Resident 65 was assessed to have clear speech, ability to underst...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 65> According to the 07/23/2023 admission MDS, Resident 65 was assessed to have clear speech, ability to understand, and be understood by others during communication. The MDS showed Resident 65 had multiple complex diagnoses including weakness to one side of the body from their stroke (brain injury). In an observation and interview on 09/19/2023 at 12:22 PM, Resident 65 was seen eating their lunch in bed, their right upper extremity (RUE) was limp and remained in their side while they used their left hand to scoop up the food. When asked if they could move their RUE, Resident 65 stated, Not really, barely . In an observation and interview on 09/19/2023 at 2:24 PM, Resident 65 was wearing a right hand splint that supported their palm and contracted fingers. When asked if they were provided any exercises to promote movement of their weak RUE, Resident 65 stated they were unsure. Review of Resident 65's medical records showed a 09/06/2023 Restorative Referral/Hand-off Form from the rehabilitation department. The form outlined Restorative Nursing Program (RNP) exercises recommended for Resident 65 including: (1) left upper and lower extremity active Range of Motion (ROM), (2) right upper and lower extremity passive ROM, and (3) application of a RUE resting hand/wrist splint three to four hours a day. Review of the September 2023 Restorative Documentation form showed the implementation of Resident 65's RNPs was initiated on 09/08/2023 and was ongoing. Review of Resident 65's CP showed there was no CP developed regarding Resident 65's assessed mobility needs, and the RNPs currently being implemented. There were no set goals or any parameters indicated in the CP to evaluate if the RNPs established for Resident 65 were working effectively or not. In an interview on 09/22/2023 at 8:41 AM, Staff F (Restorative Aid) stated they provide Resident 65's RNPs at least three to five times a week. Staff F stated they do not report to or work under the guidance and/or supervision of a nurse. Staff F stated they were trained by the therapist on how to perform the RNP exercises. Staff F stated they would only involve a nurse when Resident 65 needed pain medications or when the resident declined to participate. In an interview on 09/25/2023 at 1:17 PM, Staff B (Director of Nursing) stated it was important to CP RNPs to ensure Resident 65's functional mobility was maintained and to prevent further RUE decline. Staff B stated they took the responsibility of the facility's RNPs and did not know who was in the position prior to their hire. Staff B stated Resident 65's CP should include their ongoing RNPs but did not. <Resident 9> According to the 08/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 9 admitted to the facility on [DATE] and had diagnoses of cancer pain, heart failure, and stroke. This assessment showed Resident 9 received pain medications to manage the pain. Review of September 2023 Medication Administration Record (MAR) showed Resident 9 received routine pain medications every day as ordered and narcotic medication eight times in the last 14 days as ordered to relieve their pain. Review of Resident 9's CPs showed no documentation about Resident 9's pain and pain medications. In an interview on 09/25/2023 at 11:33 AM, Staff B reviewed Resident 9's record and was unable to find any pain related CP. Staff B stated the facility should have initiated a pain CP and update as needed but they did not.<Resident 62> According to an 06/01/2023 admission MDS, Resident 62 had multiple complex diagnoses including diabetes and an immobility syndrome. This MDS assessed Resident 62 with adequate vision with no corrective lenses and normally used a wheelchair for mobility. <Vision> In an interview on 09/20/2023 at 9:41 AM, Resident 62 stated they had really poor vision, had prescription contacts, and needed to see an eye doctor to get new ones. Review of a 06/26/2023 provider progress note showed documentation Resident 62 had an alteration in vision with recommendations to follow up for a eye examination. Review of Resident 62's comprehensive CP showed no CP was established to address the resident's alteration in vision. <Mobility> In an interview on 09/19/2023 at 9:47 AM, Resident 62 stated they were considered to be in a paraplegic [loss of muscle function in the lower legs] state. Resident 62 stated they were no longer working with therapy but was working with restorative staff during the week. Review of Resident 62's comprehensive CP showed no CP was established to address the resident's alteration in mobility or the restorative program they were currently doing. In an interview on 09/27/2023 at 2:04 PM, Staff B stated staff should have, but did not establish a CP to address Resident 62's vision and mobility status. REFERENCE: WAC 388-97-1020(1),(2)(a)(b). Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were comprehensively developed and implemented for 4 (Residents 30, 9, 65, & 62) of 20 sample residents. Failure to develop and implement comprehensive CPs left residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including dementia, difficulty walking, and muscle wasting. The MDS showed Resident 30 used a wheelchair. The MDS showed Resident 30 required extensive assistance with most Activities of Daily Living (ADLs) including bed mobility, transfers, locomotion (moving around) on and off the unit, toilet use, and personal hygiene. Review of the comprehensive CP showed the facility developed no CP addressing Resident 30's need for assistance with ADLs. Nowhere in the comprehensive CP were Resident 30's ADL needs explained to staff. In an interview on 09/27/2023 at 12:20 PM Staff B (Director of Nursing) acknowledged the facility failed to develop an ADL CP for Resident 30, and stated they were not sure how that happened. Staff B stated the facility needed to work on CPs.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 58> According to the 09/07/2023 Quarterly MDS Resident 58 did not have capacity to make their own decisions. Res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 58> According to the 09/07/2023 Quarterly MDS Resident 58 did not have capacity to make their own decisions. Resident 58 required extensive assistance with the help of staff to meet their daily needs. Resident 58 had complex medical diagnosis to include dementia (a progressive neurologic disease), Diabetes (difficulty controlling blood sugar), hypothyroid (low thyroid hormone output), and heart failure. Review of the 09/02/2023 PO showed Resident 58 received wound care to their left great toe. Review of the 07/01/2023 skin impairment CP did not show the resident's left great toe was addressed. This CP did not address Resident 58's need for treatment to their left great toe wound. In an interview on 09/27/2023 at 9:27 AM Staff B stated Resident 58's CP should reflect the wound to the left great toe to ensure it heals without difficulty. Staff B stated Resident 58's CP should be revised to address Resident 58's wound care needs. <Resident 5> According to the 06/19/2023 Quarterly MDS Resident 5 had moderate memory impairment. This assessment showed Resident 5's balance was not steady and they were only able to stabilize with staff assistance and had a history of falling and impulsiveness with dizziness. In an interview on 09/19/2023 at 2:35 PM Resident 5 stated they fell all the time. On 09/24/2023 review of Resident 5's PO showed an order for the resident's bed in the lowest position when the resident was in bed to prevent injury if a fall occurred, for a perimeter mattress to assist the resident identify the edge of the mattress, a tiltable Wheelchair (WC) to decrease fall risk. There was no POs for fall mats or for the bed to placed against the wall. Review of Resident 5's 07/17/2023 CP completed showed the resident was at high risk for falls and staff should keep the bed in the lowest position when Resident 5 was in bed. This CP included fall interventions of fall mats on floor to right and left side of bed to help decrease chance of severe injury, for the left side of the bed to be placed against the wall for optimal room space and to allow Resident 5 to watch TV comfortably while in bed per Resident 5's preference, and a tiltable WC to help with body positioning in chair. This CP did not include use of a perimeter mattress. In an interview on 09/25/2023 at 6:12 AM Staff B stated the last evaluation of Resident 5's need for fall mats, placement of the bed against the wall, and putting the bed in the lowest position was on 12/21/2022. Staff B stated they expect the need for devices to be assessed quarterly but they were not for Resident 5. Staff B stated Resident 5's CP for fall interventions was not up to date with current POs for the left side of the bed placement against the wall, for the fall mat to placed on the floor on the right side of the bed, and for the perimeter mattress use. In an interview and observation on 09/26/2023 at 2:04 PM Staff H Licensed Practical (Resident Care manager) stated Resident 5's fall mat was leaning up against the wall and needed to be on the floor on the right side of the bed. In an interview on 09/27/2023 at 8:57 AM Staff H stated the mat was propped up against the closet and not in place but should be. Staff H stated, I just put that back in place yesterday and they propped it again. Review of Resident 5's medical record on 09/25/2023 showed the last documented care conference for Resident 5 was on 11/18/2021. In an interview on 09/19/2023 at 8:50 AM Resident 5 stated I haven't attended any care meetings. Nobody talks to me about my goals. I want to go home to South Dakota. In an interview on 09/25/2023 at 11:47 AM Staff C stated Resident 5's last care conference was 11/18/2021. Staff C stated they were expected to conduct care conferences quarterly, with any significant change in the resident, and as requested by the resident or resident representative. Staff C stated they should have care conferences with Resident 5 and their representative at least quarterly, but they did not. <Resident 17> Review of Resident 17's medical records on 09/24/2023 showed the last documented care conference was on 03/07/2022. In an interview on 09/19/23 at 12:00 PM Resident 17 stated they did not remember ever having a care conference since admission to the facility. In an interview on 09/25/2023 at 11:47 AM Staff C stated Resident 17 did not have a care conference since 03/07/2023 but they should have had them quarterly and as needed, per Resident 17's request. <Resident 27> <Care Conferences> Review of the 05/09/2023 Quarterly MDS showed Resident 27 had no memory impairment, was able to understand and be understood in conversation. This assessment showed Resident 27 did not reject care. This assessment showed had a diagnosis of advanced kidney disease and had a nephrostomy (a tube placed in the kidney to drain urine directly from the kidney to outside of the body). In an interview on 09/25/2023 at 8:05 AM, Resident 27 stated they could not recall when their last care conference was. Record review showed staff last held a care conference with Resident 27 in November 2022. In an interview on 09/25/2023 at 11:31 AM, Staff C stated care conferences were held upon admission, quarterly, and as needed for resident concerns. Staff C confirmed staff did not provide a care conference for Resident 27 since November 2022, nearly 11 months ago. Staff C stated care conferences were important for addressing and resolving resident concerns and issues. <Care plan Revision> Observation on 09/19/2023 at 9:25 AM, Resident 27 had a nephrostomy bag lying next to them on the bed. In an interview on 09/25/2023 at 8:05 AM, Resident 27 stated staff emptied the nephrostomy bag about twice per day. Resident 27 stated the bag was changed every other day. Review of Resident 27's order summary showed a 02/06/2023 PO for a right nephrostomy. The PO directed staff to document the urine output each shift. Review of a 09/20/2023 Individual Service Plan (ISP - directions to care staff) directed staff to assist Resident 27 with using the bathroom after meals. The ISP did not identify Resident 27 had a nephrostomy or that Resident 27 required staff assistance to empty the nephrostomy. Review of a revised 08/02/2023 impaired immunity CP showed Resident 27 was at risk for infection due to their nephrostomy. Review of a revised 02/06/2023 potential skin impairment CP showed Resident 27's nephrostomy increased their risk for skin impairment. These two CPs did not address specific care the nephrostomy required or the indication for the nephrostomy. These CPs did not identify any potential complications of the nephrostomy or if Resident 27 was under any specialty/outpatient care related to the nephrostomy. In an interview on 09/27/2023 at 10:55 AM, Staff B stated Resident 27 should have a focused CP related to the use of their nephrostomy. Staff B stated the CP should be more specific as to the type of care Resident 27 requires for the nephrostomy. <Resident 53> According to a 06/13/2023 admission MDS, Resident 53 was assessed to have no memory impairment and multiple medically complex conditions. This assessment showed Resident 53 had a foley catheter (indwelling tube that drained urine from the bladder), used supplemental oxygen, and did not have weight loss. <Foley Catheter> In an observation and interview on 09/20/2023 at 9:41 AM showed Resident 53 did not have a foley catheter in place. In an interview at that time, Staff JJ (Certified Nurse's Assistant - CNA) stated the foley catheter was removed about three weeks ago. Review of Resident 53's order summary showed a 09/08/2023 Physician Order (PO) for an indwelling catheter. This order directed staff to change the foley catheter and drainage bag as needed. Review of the September 2023 treatment administration record showed a 09/11/2023 PO for staff to provide a bladder retraining program due to the discontinuation of the foley catheter. Review of a 09/08/2023 Potential for infection related indwelling catheter CP showed Resident 53 had a foley catheter and directed staff to provide care each shift. <Weight Loss> In an interview on 09/25/2023 at 11:56 AM, Resident 53 stated they had lost 60 pounds while at the facility due to being sick and because of the food. Review of a 09/13/2023 Nutritional Assessment showed Resident 53 had a 34.6-pound (12 percent of their total body weight) weight loss in three months. This assessment showed interventions to be put into place to prevent further weight loss. Review of a revised 09/13/2023 nutrition CP showed Resident 53 was at nutritional risk and had a goal to have no unplanned, significant weight loss. This CP did not identify Resident 53 had significant weight loss or identify resident-specific information including Resident 53's dietary preferences or identify Resident 53 often ordered food outside the facility that did not follow their physician ordered diet. <Oxygen> Observation on 09/22/2023 at 1:23 PM showed Resident 53 in bed eating lunch. Resident 53 did not have oxygen on and did not have oxygen equipment in their room. Review of Resident 53's 09/21/2023 order summary, showed there were no POs directing staff to provide oxygen to Resident 53. Review of a revised 09/15/2023 CP showed Resident 53 had supplemental oxygen. This CP directed staff to monitor Resident 53's oxygen levels. In an interview on 09/27/2023 at 10:17 AM, Staff B stated it was their expectation Resident 53's CP was person-centered and identified their significant weight loss. Staff B stated Resident 53's CP should be updated to reflect Resident 53 no longer utilized a foley catheter or oxygen. Staff B stated it was important to keep CPs updated because CPs guided the staff on the accurate care of the resident. <Resident 37> According to the 07/26/2023 admission MDS, Resident 37 admitted to the facility on [DATE] and had multiple medical conditions including diabetes (a condition characterized by elevated levels of blood sugar) and difficulty swallowing. The MDS showed Resident 37 was provided nutrition via a tube inserted through their stomach. Review of Resident 37's record showed a 09/02/2023 nutrition/dietary progress note recommending a change of Tube Feeding (TF) formula from Fibersource to Diabeticsource due to Resident 37's diabetes. Review of the 2023 September MAR showed Resident 37's TF formula was changed from Fibersource to Diabeticsource on 09/11/2023. Review of Resident 37's 08/08/2023 nutrition CP showed Fibersource was the TF formula used for Resident 37. In an interview on 09/25/2023 at 9:32 AM, Staff B stated the CP was important in providing the appropriate resident care. Staff B stated Resident 37's CP should be updated to reflect the correct TF formula used but was not. <Resident 69> According to the 07/21/2023 admission MDS, Resident 69 had multiple medical diagnoses including kidney failure. The MDS showed Resident 69 had dependence on dialysis (a procedure that removed waste products and excess fluid from the blood when the kidneys stop working properly) treatment. On 09/21/2023 at 12:42 PM, Resident 69 was observed with a two-way external catheter (a flexible tubing inserted through a narrow opening into a body cavity and served as the entrance and exit points for blood during dialysis treatment) dialysis site to their right upper chest that was covered by a clean dressing. The 08/02/2023 dialysis CP listed a nursing intervention not to draw blood or take Resident 69's blood pressure in their arm with graft. The CP intervention was not applicable to Resident 69's care since their dialysis access site was observed on their right upper chest. In an interview on 09/25/2023 at 9:32 AM, Staff B stated the CP was important in providing the appropriate resident care. Staff B stated Resident 69's dialysis CP needed revision because it was not resident-specific. In an interview on 09/26/2023 at 9:53 AM, Staff U (Resident Care Manager) stated it was important for the nursing staff to know where Resident 69's dialysis access site was in order to monitor for signs and symptoms of infection. <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 admitted to the facility on [DATE] and was assessed cognitively intact, was understood and able to understand conversation. In an interview on 09/19/2023 at 11:23 AM, Resident 9 stated they did not remember having a care conference meeting for a long time since admission. Review of Resident 9's record showed no indication Resident 9 had a care conference in the last nine months. Review of Resident 9's record showed Resident 9 was hospitalized on [DATE], 08/02/2023, and 09/20/2023 due to a change in condition and no CP was initiated to instruct staff on how to prevent hospitalization. In an interview on 09/22/2023 at 11:51 AM, Staff C (Social Services Director - SSD) stated the facility offered and scheduled care conferences upon admission, quarterly, annually, at discharge, and as needed for any change in condition. Staff C reviewed Resident 9's record and stated Resident 9 did not have any quarterly care conference for nine months including when they readmitted . Staff C stated they should have offered and scheduled at least quarterly care conference, but the facility did not. In an interview on 09/25/2023 at 10:27 AM, Staff B reviewed Resident 9's record and was unable to locate any care conference notes. Staff B stated they should have scheduled quarterly care conference with the resident, but they did not. <Resident 55> According to the 07/07/2023 Quarterly MDS Resident 55 admitted to the facility on [DATE] and had diagnoses including depression. The MDS showed Resident 55 received antidepressant (AD) medication on seven of seven days during the assessment period and was assessed with no behavior or rejection of care during the assessment period. Review of Resident 55's nursing progress notes showed Resident 55 admitted to the facility on [DATE], was transferred to the hospital on [DATE] for change in condition and readmitted on [DATE]. Resident 55 was transferred to the hospital again on 08/31/2023 for a change in condition and readmitted on [DATE]. Review of the 01/13/2023 AD medication CP showed Resident 55 received two different kinds of AD medications. Review of Resident 55's September 2023 MAR showed Resident received only one kind of AD medication daily. In an interview on 09/25/2023 at 12:06 PM, Staff B stated they knew the facility had a CP issue and they should have updated the CPs upon Resident 55's readmission, but they did not. <Resident 62> According to a 06/01/2023 admission MDS, Resident 62 had no memory impairment, clear speech, was able to understand and be understood by others. In an interview on 09/20/2023 at 9:25 AM, Resident 62 stated they did not have any recent care conferences with staff to discuss their CP and goals. Resident 62 stated, they did one a long time ago. Record review showed a 05/31/2023 admission Care Conference evaluation that was signed as completed on 06/21/2023. No other care conference documentation was found in the resident's records. In an interview on 09/27/2023 at 10:54 AM, Staff C stated it was their expectation residents have a care conference within 72 hours of admission and then quarterly thereafter. Staff C stated, I've been behind with lots of new admits. Staff C stated Resident 62 should have but did not have a follow up quarterly care conference. Reference: WAC 388-97-1020(2)(c)(d). Based on observation, interview, and record review, the facility failed to ensure care plans (CPs) were maintained, revised and updated as required for 10 (Residents 30, 58, 9, 55, 37, 69, 27, 53, 5, & 17) of 20 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . <Facility Policy> Review of an undated 2023 facility Care Plan Revisions Upon Status Change policy, a resident's comprehensive CP would be reviewed and revised as necessary, when a resident experienced a status change. This policy showed that upon identifying a change in status, the nurse would notify the Minimum Data Set (MDS - an assessment tool) nurse and the MDS nurse and interdisciplinary team would discuss the resident's condition. The CP would be updated with new or modified interventions and these interventions would be communicated to all staff involved in the resident's care. <Resident 30> According to the 06/18/2023 Quarterly MDS, Resident 30 had diagnoses including insomnia. The MDS showed Resident 30 used antidepressant (AD) medications. Review of the Physician's Orders (POs) showed Resident 30 received an AD daily at bedtime. The PO showed the AD was ordered to treat Resident 30's insomnia Review of Resident 30's comprehensive CP showed the facility developed a CP addressing Resident 30's insomnia. This CP did not address Resident 30's use of the AD medication as a treatment for their insomnia. Resident 30's use of the AD medication was instead mentioned in Resident 30's behavior problem CP. In an interview on 09/27/2023 at 12:24 PM Staff B (Director of Nursing) stated Resident 30's CP needed revision to properly address the resident's AD medication usage. Staff B stated if the PO showed the medication was ordered to address insomnia it should be reflected on insomnia CP.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medications Given Outside of Parameters> <Resident 38> According to a 07/14/2023 Quarterly MDS, Resident 38 had mul...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medications Given Outside of Parameters> <Resident 38> According to a 07/14/2023 Quarterly MDS, Resident 38 had multiple medically complex diagnoses including high Blood Pressure (BP). Review of Resident 38's August 2023 MAR showed the resident was receiving two different medications for high BP with directions to staff to hold doses if SBP [Systolic BP - a measure of the pressure in your arteries when your heart beats] or HR [Heart Rate] < [less than] 60. This MAR showed staff gave one of the medications outside of these parameters on eight occasions, and the other medication outside of these parameters on 13 occasions. Review of Resident 38's September 2023 MAR showed the resident was receiving two different medications for high BP with directions to staff to hold doses if SBP [Systolic BP - a measure of the pressure in your arteries when your heart beats] or HR [Heart Rate] < [less than] 60. This MAR showed staff gave both medications outside of parameters on five occasions each. In an interview on 09/27/2023 at 2:04 PM, Staff B stated their expectation was for staff to follow POs and hold medications for those vital signs outside of the physician's prescribed parameters as required. <Resident 581> According to a 09/13/2023 admission MDS, Resident 581 had multiple medically complex diagnoses including kidney failure, malnutrition, and low calcium levels. During medication pass observations on 09/26/2023 at 2:00 PM, Staff N (LPN) prepared and administered the following medications for Resident 581: A multi-vitamin with minerals; a medication to treat an overactive bladder, calcium, and a vitamin supplement. Review of the September 2023 MAR showed the medications administered on 09/26/2023 at 2:00 PM to Resident 581 were scheduled to be given at 8:00 AM, six hours earlier. No documentation was found regarding why the medications were administered outside of the ordered time parameter. In an interview on 09/27/2023 at 2:04 PM, Staff B stated their expectation was for staff to administer medications within the ordered time frames by the physician and stated staff should have, but did not document the reason the medications were not administered as ordered. <Resident 53> Review of a 06/13/2023 admission MDS showed Resident 53 had no memory impairment and was able to understand others and be understood in conversation. This assessment showed Resident 53 had diagnoses related to their heart and a history of a stroke. Resident 53 had pain and received pain medications during the assessment period. Review of Resident 53's 09/21/2023 order summary showed a 09/08/2023 PO for a narcotic pain medication. This order showed staff were to administer one tablet of the narcotic every for a pain level of one to seven on a one to 10 pain scale. A second 09/08/2023 PO showed staff were to administer two tablets of the narcotic pain medication for a pain level of eight to 10 on a one to 10 pain scale. Review of Resident 53's September 2023 MAR showed on seven occasions, Resident 53 received two tablets of the narcotic pain medication for a documented pain level of less than eight. Review of Resident 53's August 2023 MAR showed a 07/27/2023 PO for staff to administer one tablet of a narcotic pain medication for a pain level of one to eight on a one to 10 pain scale. A second 07/27/2023 PO showed staff were to administer two tablets of the narcotic pain medication for a pain level of nine to 10 on a one to 10 pain scale. On two occasions, Resident 53 received only one tablet of the narcotic for a pain scale of nine out of ten. On seven occasions, Resident 53 received two tablets of the narcotic for a pain scale less than nine. In an interview on 09/27/2023 at 10:43 AM, Staff B stated it was their expectation nursing staff followed POs and gave medications within the directed parameters. <Signing for Tasks Not Completed) <Resident 62> According to a 05/26/2023 admission MDS, Resident 62 had multiple medically complex diagnoses including respiratory failure and required the use of oxygen during the assessment period. This MDS showed Resident 62 required physical assistance from staff for personal hygiene and had no rejection of care during the assessment period. In an interview on 09/19/2023 at 3:12 PM, Resident 62 indicated they no longer used oxygen and stated it was a couple months since they used it last. Observations at this time showed an upright oxygen tank with no tubing in the corner of the room. Review of Resident 62's September 2023 Treatment Administration Record (TAR) on 09/19/2023 showed staff were documenting twice daily during the month that Resident 62 was using oxygen to maintain their oxygen levels. Observations on 09/21/2023 at 2:56 PM showed the oxygen tank was no longer in Resident 62's room. In an interview at this time, Resident 62 indicated they requested staff to remove it and stated, I do not use it, or need it. Review of Resident 62's September 2023 TAR showed the resident had orders that directed staff to perform toenail care every week on Tuesday. This TAR showed nursing staff signed the nail care as completed on 09/05/2023, 09/12/2023, and 09/19/2023. Observations on 09/19/2023 at 9:47 AM showed Resident 62 with long jagged toenails. On 09/25/2023 at 12:55 PM Resident 62 was observed with the same untrimmed toenails. In an interview at this time, Resident 62 stated it was maybe a month or two since they had their toenails trimmed. In an observation and interview on 09/25/2023 at 12:57 PM with Staff RR (LPN) confirmed Resident 62's untrimmed toenails and stated, they do not appear they were trimmed. Observations on 09/20/2023 at 9:31 AM showed Resident 62 had a medicine cup that contained pills on their bedside table. In an interview at this time, Resident 62 stated the nurse left the pills from the previous day. In an interview on 09/20/2023 at 9:35 AM, Staff FF verified the medications left at Resident 62's bedside included a blood thinning medication, a pain medication, and an antacid medication, all of which were documented as administered in the evening on 09/19/2023. In an interview on 09/27/2023 at 2:04 PM, Staff B stated it was their expectation staff only sign for tasks they completed. REFERENCE: WAC 388-97-1620(1)(2)(b)(i)(ii). .Based on observation, interview, and record review the facility failed to: Ensure Physician's Orders (POs) were followed and clarified for 7 (Residents 32, 5, 42, 68, 9, 53, & 37) of 20 sample residents; ensure medications were given within ordered parameters for 3 (Resident 38, 581, &53) of 20 sample residents; and staff were signing for tasks not completed for 1 (Resident 62) of 20 sample residents. These failures left residents at risk for unmet care needs, inappropriate treatment, and other negative health outcomes. Findings included . <Facility Policy> According to a 2023 facility, Medication Administration policy, nursing staff would administer medications as ordered by the physician and administer the medications within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. This policy showed staff would: Obtain and record vital signs per POs and when applicable, hold the medication for those vital signs outside of the physician's prescribed parameters; observe resident's consumption of the medication; and sign the Medication Administration Record (MAR) after administration. <Following and/or Clarifying POs> <Resident 32> According to the 08/06/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 32 had diagnoses including Congestive Heart Failure (CHF), and edema (fluid retention). The MDS showed Resident 32 exhibited no rejection of care. Resident 32's POs included a 05/03/2023 PO to weigh the resident daily related to their CHF diagnosis. The PO directed staff to call the heart clinic for a weight gain of more than two pounds (lbs) in 24 hours. Record review showed Resident 32's weights were documented in the Medication Administration Record (MAR) and in the vitals documentation tab. Review of the MAR and the vitals documentation showed weights were not collected for Resident 32 on September 2023 from 09/03/2023 - 09/05/2023, and on 09/10/2023. In August 2023 weights were not collected on 08/02/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/09/2023, 08/11/2023, 08/15/2023, 08/16/2023, 08/17/2023, 08/19/2023, 08/20/2023, 08/22/2023, 08/23/2023, 08/4/2023, 08/26/2023, 08/28/2023, 08/29/2023, 08/30/2023, and 08/31/2023. In an interview on 09/27/2023 at 12:08 PM Staff B (Director of Nursing) confirmed Resident 32's PO for daily weights. Staff B stated the purpose of weighing Resident 32 daily was to monitor for fluid retention related to the resident's CHF diagnosis. Staff B stated not following the PO placed Resident 32 at risk for unidentified fluid overload. Staff B stated Resident 32's was not but should have been monitored daily, as ordered. <Resident 5> According to the 06/19/2023 Quarterly MDS, Resident 5 had moderate cognitive impairment. This assessment showed Resident 5 required maximum assistance with toileting, transfers, and hygiene, and Resident 5 was frequently incontinent of bowels. Review of Resident 5's bowel monitoring documentation on 09/24/2023 showed Resident 5 did not have a bowel movement (BM) on 09/02/2023, 09/03/2023, 09/04/2023, 09/05/2023, 09/06/2023, or 09/07/2023. Resident 5 did not have a BM for 6 days according to the documentation. Review of a 09/24/2023 PO showed orders for three laxatives to be administered as needed for constipation with a specified order to administer the first laxative if Resident 5 had no BM in three days. If no BM by the next shift after administration of the first laxative, staff were to administer the second specified laxative. If Resident 5 continued without a BM by the next shift, staff were to administer the third laxative, and if no results from the third laxative, staff were to notify Resident 5's physician. Review of Resident 5's September 2023 MAR showed no laxatives were administered September 2023. In an interview on 09/25/2023 at 9:31 AM Staff H (Resident Care Manager) stated the bowel protocol should be initiated if Resident 5 did not have a BM in three days by administering the first laxative, if no BM by the next shift, staff were to administer the second laxative, and if no BM by the next shift, staff were to administer the third laxative, and if no results, staff were to notify the physician. Staff H confirmed Resident 5 did not have a BM from 09/02/2023 to 09/07/2023 and Resident 5 did not receive their bowel protocol laxatives as ordered but they should have. In an interview on 09/25/2023 at 6:12 AM Staff B stated they expected staff to administer the laxatives per the bowel protocol if Resident 5 did not have a BM for three days. Staff B confirmed Resident 5 did not have a BM from 09/02/2023 to 09/07/2023 and they did not receive their laxatives as ordered but they should have. <Resident 42> According to a 06/01/2023 admission MDS Resident 42 had multiple medically complex diagnoses including arthritis and pain in the right hip. Review of the September 2023 MAR showed an order for a pain patch to be applied to the affected area topically [to skin] one time a day for pain 1-2 patches. There were no directions to staff to identify where the affected areas were or how to determine if one or two patches should be used. In an interview on 09/27/2023 at 2:04 PM, Staff B stated Resident 42's pain medication order should have, but was not clarified by staff for specific directions on where and how many patches to apply. <Resident 68> According to a 07/19/2023 admission MDS Resident 68 had multiple medically complex diagnoses including pain in left lower leg and required the use of a narcotic pain medication during the assessment period. Review of a September 2023 MAR showed Resident 68 had the following orders: A 07/13/2023 non-narcotic pain medication with directions to staff to administer one tablet every four hours as needed for pain; a second 07/13/2023 order for the same non-narcotic pain medication with directions to administer two tablets every four hours as needed for general pain.; and a third 07/13/2023 order for a narcotic pain medication with directions to staff to administer every six hours as needed for pain. There were no directions to staff to indicate what parameters should be used to identify which pain medication should be administered by staff. In an interview on 09/27/2023 at 2:04 PM, Staff B stated there should not be duplicate orders due to the risk of medication errors and pain medication orders should include parameters. Staff B stated the orders for Resident 68 needed to be clarified. <Resident 9> According to the 08/18/2023 Quarterly MDS, Resident 9 admitted to the facility on [DATE] and had diagnoses of cancer, heart disease, and stroke. An 08/10/2023 PO showed an order for a narcotic reversal medication with instructions to inject one spray intramuscularly every 24 hours as needed for opioid overdose. An 08/10/2023 PO instructed staff to apply a topical pain patch to Resident 9's lower back every 24 hours for pain as needed. This PO did not include pain scale parameters for when the as needed patch should be applied. Review of the August 2023 and September 2023 MAR showed no clarifying information the nurses could use for administering the narcotic pain reversal medication. In an interview on 09/25/2023 at 11:33 AM, Staff B reviewed Resident 9's POs and stated the narcotic reversal PO was inaccurate and the topical pain patch order was incomplete. Staff B stated the facility should have clarified the order with the provider but they did not. <Resident 53> Review of Resident 53's 09/21/2023 order summary showed a 09/08/2023 PO for a sublingual (medication that worked by being dissolved under the tongue) tablet. This medication was used for treating chest pain. The directions on this PO instructed staff to administer the medication by spraying it under Resident 53's tongue and showed the indications were for narcotic reversal. The directions and indications did not match the medication listed. A second 09/08/2023 PO for the same sublingual medication was listed and instructed staff to administer the tablet sublingually every five minutes as needed for chest pain. This PO did not instruct staff how many times to repeat the administration of the medication before calling for emergency services. Review of Resident 53's 09/21/2023 order summary showed a 09/08/2023 PO for a topical pain relief patch. This order instructed staff to apply the patch to painful areas once daily and remove per the schedule. The directions did not instruct staff on where Resident 53's painful areas were and where specifically the patch should be applied. Review of Resident 53's 09/21/2023 order summary showed two 09/08/2023 POs for the same muscle relaxer. The first PO instructed staff to administer one tablet of the muscle relaxer every eight hours as needed for muscle spasms. The second PO instructed staff to administer two tablets of the muscle relaxer every eight hours as needed for muscle spasms. These POs did not give parameters for nursing staff to follow or document to determine if Resident 53 should receive one or two tablets of the muscle relaxer. Review of Resident 53's 09/21/2023 order summary showed a 09/08/2023 PO for a prescription mouthwash. The directions instructed staff to administer the mouthwash twice daily for a mouth infection. There were no orders to monitor Resident 53's condition related to the mouth infection. There was no stop date or documentation instruction staff to reassess Resident 53's condition to determine if the mouthwash was still needed. In an interview on 09/27/2023 at 10:41 AM, Staff B stated the order for the sublingual chest pain medication should be clarified with clear instructions for staff. Staff B confirmed a specific location should be indicated for the pain relief patch so staff know where to apply the patch. Staff confirmed the orders for the muscle relaxers should be clarified so staff had parameters to follow. Staff B stated the prescription mouthwash should be clarified to know if a stop date was needed and expected follow up on Resident 53's oral condition to determine if the mouthwash was still necessary. <Resident 37> According to the 07/26/2023 admission MDS, Resident 37 had multiple medical conditions including Pneumonia (a lung infection) and CHF. The MDS showed Resident 37 received Oxygen (O2) therapy during the assessment period. Review of Resident 37's September 2023 MAR showed a 07/21/2023 PO to administer O2 at two to three Liters Per Minute (LPM) for their shortness of breath via a nasal cannula (a medical device used to provide supplemental O2 therapy to a person with low O2 level in their body). Review of the 07/31/2023 O2 therapy CP showed the nursing staff should maintain Resident 37's O2 setting at two to three LPM and to monitor for any signs and symptoms of respiratory distress. On 09/19/2023 at 10:09 AM, Resident 37 was observed lying in bed, an O2 concentrator (a device used to increase the strength of O2) was next to their bed and was being administered at 3.5 LPM of O2 as shown in the device's setting. In an interview on 09/19/2023 at 3:12 PM, Staff FF (Licensed Practical Nurse - LPN) stated the O2 concentrator should be set at two to three LPM as ordered. Staff FF stated administering 3.5 LPM was more than what was prescribed for Resident 37. In an interview on 09/20/2023 at 11:37 AM, Staff B stated they expected the nursing staff to follow the POs as written for resident safety.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 24> According to the 05/15/2023 readmission MDS, Resident 24 made their own decisions and required extensive ass...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 24> According to the 05/15/2023 readmission MDS, Resident 24 made their own decisions and required extensive assistance of two people to meet their ADL needs. Resident 24 had a progressive neurological condition that resulted in the need for artificial nutrition through a surgically implanted tube going directly into the stomach. Review of the shower documentation in Resident 24's record showed no bathing was documented between 08/30/2023 to 09/13/2023. This documentation showed Resident 24 was not bathed for 14 days. Review of the 04/22/2021 ADL CP showed Resident 24 was dependent on staff to provide a bed bath twice per week. This CP showed Resident 24 preferred a bed bath twice weekly. Review of the undated facility shower/bath schedule provided by staff on 09/20/2023 at 9:53 AM, showed Resident 24 was scheduled to receive a bath on Wednesday. No additional days were scheduled. Interviewed on 09/21/2023 at 9:15 AM Staff H (Resident Care Manager- RCM) stated residents were scheduled for bathing once per week and placed on a weekly schedule. Staff H stated copies of the schedule were maintained on the RCM office door. Staff H stated they expected showers/bath to be provided per the schedule once weekly. Staff H stated not providing shower/bathing could result in dignity issues and potential skin problems. <Resident 58> According to the 09/07/2023 readmission MDS, Resident 58 did not have the capacity to make their own decisions. Resident 58 required extensive assistance with the help of staff to meet their ADL needs. Resident 58 had complex medical diagnosis including dementia (a progressive neurological disease), Diabetes (difficulty controlling blood sugar), hypothyroidism, and heart failure. Review of the shower documentation in Resident 58's record showed no bathing was documented between 08/22/2023 to 09/13/2023. This documentation showed Resident 24 was not bathed for 16 days. Review of the 06/19/2023 ADL CP showed Resident 58 was dependent on staff to provide a bath/shower. This CP did not identify Resident 58's preferences regarding bathing. Review of the undated facility shower/bath schedule provided by staff on 09/20/2023 at 9:53 AM, showed Resident 58 was scheduled to receive a shower on Fridays. No additional days were scheduled. In an interview on 09/27/2023 at 9:27 AM Staff B stated they expected residents to receive showers according to the shower schedule. Staff B stated shower/baths should be provided based on resident preference. Staff B stated shower aids and CNAs were required to provide the shower/bath. <Bathing Assistance> <Resident 27> Review of a 05/09/2023 Quarterly MDS showed Resident 27 was able understand others and be understood in conversation. This assessment showed Resident 27 did not have memory impairment. This assessment showed Resident 27 required physical assistance from one staff member to bathe. This MDS showed Resident 27 did not refuse care. Review of a revised 02/06/2023 ADL CP showed Resident 27 required assistance from staff to bathe. This CP showed Resident 27 preferred two showers per week. Review of Resident 27's Individual Service Plan (ISP - document that identified the type of care a resident required from staff) on 09/20/2023 showed Resident 27 preferred showers and for staff to bathe Resident 27 as needed. Review of Resident 27's June 2023 shower documentation showed Resident 27 received a shower on two of four opportunities. This documentation showed Resident 27 only received two showers for the month of June. Review of Resident 27's July 2023 shower documentation showed Resident 27 received a shower on two of four opportunities. This documentation showed Resident 27 only received two showers for the month of July. Review of Resident 27's August 2023 shower documentation showed Resident 27 received showers on two of five opportunities. This documentation showed Resident 27 only received two showers for the month of August. Review of Resident 27's September 2023 shower documentation showed Resident 27 received showers on two of three opportunities for the month. In an interview on 09/19/2023 at 9:26 AM, Resident 27 stated they were supposed to get a shower today. Resident 27 stated they were supposed to receive two showers per week on Tuesdays and Fridays. In an interview that same day at 2:41 PM, Resident 27 stated they were still waiting for a shower. Review of the undated facility shower/bath schedule provided by staff on 09/20/2023 at 9:53 AM showed Resident 27 was only scheduled for one shower per week on Tuesdays. Resident 27 was not listed to receive showers on Fridays. In an interview on 09/21/2023 at 9:00 AM, Resident 27 stated they finally got their shower on 09/20/2023, a day late. Resident 27 stated they were supposed to have showers on Tuesdays and Fridays but said the staff never came on Fridays. In an interview on 09/22/2023 at 8:38 AM, Staff NN (Certified Nurse's Assistant) stated they were one of the staff who provided showers to the residents. Staff NN stated showers were only provided Monday through Friday. In an interview on 09/27/2023 at 10:50 AM, Staff B stated Resident 27 should be showered per their preference. Staff B sated if staff missed a shower for a resident, staff should re-approach or offer to shower the resident on a different day to make up for the missed shower. <Oral Care> <Resident 37> According to the 07/26/2023 admission MDS, Resident 37 admitted to the facility on [DATE] and had multiple medical conditions including severe memory impairment, heart failure, and difficulty swallowing. The MDS showed Resident 37 was provided nutrition daily via Tube Feeding (TF - a tube inserted through their stomach). The MDS showed Resident 37 was dependent on staff in performing their personal hygiene. The 07/20/2023 TF CP showed Resident 37 was not to receive anything by mouth because of their swallowing difficulty. The CP instructed the nursing staff to provide good oral care and maintain Resident 37's oral health. On 09/19/2023 at 10:09 AM, Resident 37 was observed asleep, lying flat on the bed while their tube feeding was on-going, their mouth was open and noted multiple and diffused whitish spots over their tongue. In an interview on 09/19/2023 at 10:16 AM, Staff U (RCM) stated they expected the nursing staff to provide Resident 37 with oral care and to follow the CP as instructed.Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 6 (Residents 9, 27, 24, 58, 37, & 62) of 20 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 9), bathing (Residents 27, 24, & 58) oral care (Resident 37), and nail care (Resident 62), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life. Findings included . <Facility Policy> Review of the facility's undated 2022 Activities of Daily Living policy showed the facility would provide ADLs in accordance with residents comprehensive assessment, Care Plan CP, and resident preferences to ensure a resident's ADL abilities do not deteriorate unless deterioration was unavoidable. <Shaving> <Resident 9> According to the 08/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 9 admitted to the facility on [DATE], was assessed as cognitively intact, and required one person assistance with personal hygiene. Observations on 09/19/2023 at 8:57 AM and 11:54 AM, and on 09/20/2023 at 8:55 AM showed Resident 9 was in bed and had long facial hair. In an interview on 09/19/2023 at 11:53 AM, Resident 9 stated they needed staff assistance with shaving because they could not shave themselves due to shoulder pain. Resident 9 stated they received a shower the day prior, and staff did not have time to shave them. According to the 02/24/2023 ADL self-care performance deficit CP, Resident 9 preferred grooming care daily. In an interview on 09/25/2023 at 10:31 AM, Staff B (Director of Nursing) stated they expected staff to check the resident's preferences related to ADLs and provide the supply and assistance as needed. If the resident refused, staff should document the refusals. Staff B reviewed Resident 9's record and stated the facility should have documented Resident 9's preferences and provided assistance with shaving their facial hair but they did not. <Nail care> <Resident 62> According to a 06/01/2023 admission MDS Resident 62 had no memory impairment, clear speech, and was able to understand and be understood by others. This MDS showed Resident 62 required extensive physical assistance from staff for bed mobility, transfers, personal hygiene, and bathing and had no rejection of care during the assessment period. Review of a 06/08/2023 ADL Care Area Assessment showed staff documented Resident 62 required extensive assistance of two staff for their ADLs, was at risk for decline in ADLs, and would assist resident with all their ADLs as needed. Review of Resident 62's September 2023 Treatment Administration Record (TAR showed the resident had orders that directed staff to perform toenail care every week on Tuesday. This TAR showed nursing staff signed the nail care as completed on 09/05/2023, 09/12/2023, and 09/19/2023. Observations on 09/19/2023 at 9:47 AM showed Resident 62 with long jagged toenails to both feet. In an interview on 09/25/2023 at 12:18 PM, Resident 62 stated they were worried about their toenails getting caught on the blankets and stated it was maybe a month or two since they had their toenails trimmed. In an observation and interview on 09/25/2023 at 12:57 PM, Staff RR (Licensed Practical Nurse) confirmed Resident 62's untrimmed toenails and stated, they do not appear they were trimmed. In an interview on 09/27/2023 at 2:04 PM, Staff B stated their expectation was for staff to perform nail care weekly as ordered. REFERENCE: WAC 388-97-1060(2)(c). .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility: Failed to ensure residents' skin was assessed, monitored, and treated as required for 3 (Residents 373, 68, & 579) of 6 residents reviewed for non-pressure skin and 2 supplemental residents (Residents 30 & 58); failed to ensure fluid monitoring was in place for a for 1 (Resident 372) of 3 discharged residents whose records were reviewed; failed to ensure Blood Glucose (BG) was monitored for 1 supplemental resident (Resident 380); failed to ensure residents with constipation/diarrhea were provided bowel care for 1 (Resident 17) of 4 residents reviewed for constipation/diarrhea. These failures placed residents at risk for new or worsening skin impairment, fluid overload, uncontrolled BG, skin irritation, discomfort, embarrassment, and other negative health outcomes Findings included . <Skin Impairment> <Resident 373> According to the 09/13/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 373 had the capacity to make their own decisions. Resident 373 was assessed to require substantial assistance with lower body dressing and putting on/taking off footwear. Resident 373 had medically complex conditions including a multidrug resistant organism to the right foot, diabetes type 2 (a condition that makes regulating BG difficult), anxiety, and depression. Review of the 09/13/2023 (Care Plan) CP showed Resident 73 had a diabetic ulcer to the bottom part of the right foot. An intervention on the CP showed to avoid mechanical trauma including cutting and trimming calluses, and to inspect feet daily for open areas. Observation and interview on 09/19/2023 at 9:58 AM showed Resident 373 walking in their room towards their bed. A tube was hanging visibly from the bottom of Resident 373's trousers. Resident 373 stated it was the tube to their wound vac (a suction device that assisted in wound closure/healing). Resident 373 stated they believed no one at the facility knew how to take care of their wound vac and it wasn't attended to in several days. Resident 373 was concerned at that time for the excess drainage on the wound and feared a worsening condition. Review of the undated Physician Order (PO) showed the order for the wound vac was discontinued on 09/18/2023. No additional treatment was listed for the wound. An every-other-day wound treatment to trim the callus and cover with a bordered dressing was placed on 09/19/2023 and initialed as completed by staff. In an observation and interview on 09/20/2023 at 9:24 AM Resident 373 stated they still had the wound vac on and stated no staff provided any attention to the wound in days. Resident 373 stated they were concerned about a worsening condition. The wound vac dressing was still attached with the tubing wrapped around Resident 373's ankle and tucked inside their sock. Observation and interview on 09/20/2023 at 3:47 PM showed Resident 373 removed the wound vac dressing and placed it in the garbage. Staff H (Resident Care Manager) confirmed the wound vac dressing was in the trash. Resident 373 told Staff H they removed the dressing themselves. Resident 373 was observed to have a quarter-sized wound on the underside of their right foot. In an interview on 09/22/2023 at 8:13 AM Staff Q (Registered Nurse - RN) stated they provided wound care on Tuesday. Staff Q stated they secured the existing non-functional wound vac dressing but did not place the ordered treatment. In an interview on 09/27/2023 at 9:27 AM Staff B stated they expected staff to follow POs as written to prevent worsening of the wound. Staff B stated orders should be clarified for accuracy when wounds required different treatments then prescribed. <Bowel Treatment> <Resident 17> According to the 06/12/2023 Annual MDS Resident 17 was able to make self-understood, understands others, and showed no confusion or memory impairment. This MDS showed Resident 17 did not exhibit rejection of care or behavioral issues. This MDS showed Resident 17 required one-person physical assistance with toilet use, personal hygiene, and was always continent of bowels. This MDS showed Resident 17 had medically complex conditions including a diagnosis of a chronic inflammatory bowel disease (a disease that caused inflammation of the digestive tract resulting in diarrhea). Review of the 07/10/2023 CP Resident 17 had a nutritional problem related to the inflammatory bowel disease and gastroesophageal reflux disease (GERD - stomach acid repeatedly flowing back into the throat) related to inflammatory bowel disease with an intervention to give medications as ordered and monitor for their effectiveness. In an interview on 09/19/2023 Resident 17 stated they had chronic diarrhea, and the facility did not attempt to find a treatment. In an interview on 09/25/2023 at 6:12 AM Staff B stated they expected staff to notify the doctor of Resident 17's episodes of diarrhea, initiate treatment as ordered by the doctor, and update Resident 17's CP. In an interview on 09/25/2023 at 9:31 AM Staff H stated Resident 17 had episodes of diarrhea on 09/03/2023, 09/20/2023, and 09/21/2023 without notification of the doctor and there was no documentation showing they did anything to help Resident 17 with their diarrhea. Staff H stated Resident 17 did not have any POs in place to treat their inflammatory bowel disease/diarrhea. Staff H stated Resident 17 should have some sort of treatment for when they have episodes of diarrhea, and the doctor should have been notified but were not. In an interview on 09/25/2023 at 11:47 AM Staff C Director of Social Services (SS) stated Resident 17 wanted to discharge to independent living but was unable to because they had an inflammatory bowel disease, and episodes of diarrhea for which they needed cleanup assistance. REFERENCE: WAC 388-97-1060 (1)(3)(k)(m). <Resident 68> According to a 07/19/2023 admission MDS Resident 68 had no memory impairment, clear speech, and was able to understand and be understood by others. This MDS showed Resident 68 was at risk of developing pressure ulcers/injuries and had no identified ulcers, wounds, or skin problems. In an interview on 09/19/2023 at 12:33 PM, Resident 68 stated they had boils (painful, pus-filled bumps under the skin caused by infected, inflamed hair follicles) to both armpits and were using warm washcloths to help decrease their pain. Review of a 07/26/2023 Pressure Ulcer Care Area Assessment (CAA) showed staff documented Resident 68 was at risk for impaired skin integrity and skin would be monitored every week. According to a 07/14/2023 skin impairment CP staff identified a goal for Resident 68 was to have no complications with skin impairment. This CP directed staff to complete weekly treatment documentation to include measurements of each area of skin breakdown including width, length, depth, type of tissue, drainage, and any other notable changes or observations. Review of a 08/07/2023 progress note showed the provider identified Resident 68 had a boil to their right armpit and was started on a medication to treat infections. An 08/07/2023 Skin and Wound Assessment completed by staff showed a New Wounds section that was left blank. No measurements of the boil to the right armpit were documented by staff. On 08/08/2023 a daily skilled evaluation was completed by staff that indicated Resident 68 had no skin conditions present. Similar findings were found on 08/09/2023, 08/10/2023, 08/11/2023, 08/12/2023, and 08/13/2023. Review of a 09/07/2023 progress note showed the provider identified Resident 68 was reporting a boil under both armpits and was started on a medication to treat infections. No Skin and Wound Assessments were completed by staff to identify, measure or describe the new wounds. Review of the September 2023 Treatment Administration Record (TAR) showed the PO to complete a weekly skin audit on 09/07/2023 for Resident 68 was left blank by staff. In an interview on 09/27/2023 at 2:04 PM, Staff B (Director of Nursing) stated their expectation was for staff to complete skin assessments every week as ordered and complete a Skin and Wound assessment if any skin impairments were found. Staff B stated if any wounds were present, staff were expected to document measurements and a description of each area and continue monitoring weekly until resolved. Staff B stated staff should have documented measurements of Resident 68's wounds but did not.<Resident 579> According to the 09/12/2023 Admit/Readmit assessment, Resident 579's skin was normal in color, warm, and dry. The assessment noted Resident 579 had a subcutaneous (under the skin) port (dialysis access site) on their left upper arm, used a foley catheter (tubing to assist with bladder drainage), had a scar on their right heel, and a below-knee amputation on their left leg. The assessment showed no other skin integrity concerns. Record review showed Resident 579 had diagnoses including kidney failure and diabetes. According to a 09/17/2023 progress note at 10:30 AM Resident 579 informed facility staff of pain to their left pinky finger. The note indicated Resident 579 stated they had a wound on that area for about 6 months. Resident 579 stated the wound opened and drained that morning and they had pain of 7/10. The note showed the tip of Resident 579's finger was black with scant amount of [ .] drainage noted. According to the September 2023 TAR, Resident 579's weekly skin audit on 09/19/2023 was coded with a minus sign. The TAR showed staff should code a minus when there were no new skin integrity issues. In an interview on 09/25/2023 at 11:16 AM Resident 579 stated their finger was painful. Resident 579 stated they were unsure if their fingertip required a dressing. Observation of the left pinky fingertip at that time showed a black scab on the tip of the finger. In an interview on 09/25/2023 at 11:23 AM Staff U (RCM) stated Resident 579's pinky finger skin impairment was not documented by facility staff when they conducted the Admit/Readmit assessment. Staff U stated staff should have identified the skin impairment. Staff U stated the wound could have possibly been caused by Resident 579's diabetes or kidney failure and referred to Resident 579's left foot amputation. Staff U stated the facility should have identified the impairment and sought orders for treatment. <Resident 30> According to the 06/18/2023 Quarterly MDS, Resident 30 exhibited behaviors that interfered with the activities and disrupted care/the living environment. This MDS showed Resident 30 had diagnoses including anxiety and depression. The MDS showed Resident 30 had no skin impairments. Observation on 09/21/2023 at 9:38 AM showed Resident 30 had a skin impairment by their hairline on the right side of their forehead. The impairment measured over an inch in length. A 09/17/2023 progress note showed the resident was agitated this evening and had begun to pick at scab on their right forehead. The note showed the nurse observed the scab bleeding, cleansed the wound, and dressed the scab. Record review showed no other progress notes explaining what skin impairment the scab covered, or the origin, size, or type of skin impairment. The most recent skin and wound assessment in Resident 30's record was completed on 04/19/2023 and showed no skin impairment. Review of Resident 30's September 2023 TAR showed no skin impairments identified during weekly skin checks, including for a skin check on 09/19/2023. The July and August 2023 TARs also showed no new skin impairments during weekly skin checks. In an interview on 09/27/2023 at 12:24 PM, Staff B stated they did not see an order for the dressing applied on 09/17/2023, or any other follow up. Staff B stated nursing staff should have but did not assess the skin impairment. <Resident 58> According to the 09/07/2023 Quarterly/Medicare 5-Day MDS Resident 58 did not have the capacity to make their own decisions. Resident 58 required extensive assistance from staff to meet their daily needs. Resident 58 had complex medical diagnoses to include dementia (a progressive neurologic disease), diabetes (difficulty controlling blood sugar), hypothyroidism (low output from the thyroid gland), and heart failure. A 09/02/2023 progress note showed Resident 58 readmitted to the facility after an acute stay at the hospital. Staff identified a wound to the left great toe. Review of a 09/02/2023 PO showed staff were to clean the left great toe and apply medicine to the wound daily. An observation and interview on 09/21/2023 at 12:10 PM showed Resident 58 had a wound to their left great toe and a wound to their right forearm. Staff H confirmed the location of both wounds. Staff H stated they would follow up with wounds identified. Review of the 06/19/2023 CP showed the wound to the left great toe and the right forearm were not part of the CP. The CP instructed staff to check the whole body for breaks in skin and treat promptly as ordered by the doctor, and to provide weekly wound documentation including measurements of each area of skin breakdown. Record review showed Resident 58's left great toe was assessed on 09/24/2023. An assessment of the wound on the right forearm were not provided by the facility. Review of the weekly skin assessment documentation in the September 2023 Treatment Administration Record (TAR) showed no entries for 09/01/2023 and 09/08/2023. In an interview on 09/27/2023 at 9:27 AM, Staff B stated they expected staff to assess Resident 58's skin weekly and findings should be communicated to the provider timely to ensure treatment was provided. Staff B stated all identified wounds should be added to the CP to provide direction to the staff on how to treat the specified wounds. <Monitoring for Fluid Overload> <Resident 372> According to the 08/15/2023 admission MDS Resident 372 had complex medical conditions including heart failure. The MDS showed Resident 372 admitted from an acute care hospital on [DATE]. Review of the 08/09/2023 hospital referral documentation showed Resident 372 had edema (fluid overload that causes swelling) to their legs. The documentation showed Resident 372 had fluid overload at admission to the hospital related to their heart failure, and recommended monitoring of their fluid intake/output, and daily weights. Review of the POs showed an 08/10/2023 to collect weights for 3 days then weekly weights on Wednesdays. Facility staff documented Resident 372 was weighed twice on admit on 08/10/2023 at 164 pounds (lbs) and on 08/11/2023 at 164 lbs. Resident 372 was next weighed on 08/16/2023 at 164.4 lbs. There was no order for daily weights. Record Review showed no monitoring of Resident 372's fluid intake and output. According to an 08/14/2023 progress note, Resident 372 tested positive for COVID (a respiratory virus) while in the facility a few days ago. An 08/17/2023 progress note showed Resident 372 experienced gastrointestinal symptoms related to their COVID diagnosis. An 08/19/2023 progress note showed Resident 372 was no longer at the facility. The note showed Resident 372 left emergently to the hospital that day at the insistence of their collateral contact. The note did not describe the condition of the resident at the time of discharge or the reason for the emergent discharge. In an interview on 09/20/2023 at 10:21 AM, Resident 372's collateral contact stated Resident 372 needed to be weighed daily to monitor fluid retention related to the resident's heart failure diagnosis. The collateral contact stated Resident 372 complained they could not breathe on 09/17/2023 when 911 was called. The collateral contact was concerned Resident 372's shortness of breath was related to the combination of edema due to heart failure and COVID diagnoses. In an interview on 09/27/2023 Staff B stated the purpose of monitoring fluid intake and output is to watch for fluid overload. Staff B stated there was no documentation the facility monitored Resident 372's intake or output, or collected daily weights as recommended by the hospital. Staff B stated Resident 372 became COVID positive while in the facility and it was possible the COVID infection could exacerbate heart failure symptoms. <Monitoring BG> <Resident 380> According to the 09/28/2023 MDS Resident 380 admitted to the facility from an acute hospital on [DATE]. The MDS showed Resident 380 had diabetes. In an interview on 09/27/2023 Resident 380's RR stated the resident had low blood sugar three or four days ago. The RR stated Resident 380 was lethargic at the time. Record review showed since admission on [DATE] the facility did not measure Resident 380's blood sugar to ensure they were within an acceptable range/establish the resident's baseline. In an on 09/27/2023 at 10:36 AM Staff B stated they expected, for a newly admitting resident with diabetes, the facility should ensure the resident's blood sugar was read to ensure it was stable, even if the resident was not dependent on insulin (a treatment that helps regulate BG).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 6 (Residents 24, 27, 53, 38, 68, & 62) of 10 residents reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure accurate intakes were documented, identify and act on significant weight changes placed residents at risk for delayed identification of interventions for continued weight loss. Findings included . <Facility Policy> According to the facility October 2022 Weights Monitoringpolicy, the facility would ensure all residents maintained acceptable parameters of nutritional status including usual or desirable body weight range. The facility would use a systemic approach to optimize resident nutritional status. The process would include monitoring the effectiveness of interventions and revising them as necessary. Information gathered from the nutritional assessment would be used to develop an individualized Care Plan (CP) which addressed resident specific nutritional concerns and preferences. Interventions would be identified, implemented, monitored, and modified as needed. This policy showed newly admitted residents would be weighed weekly for four weeks, residents with weight loss would be monitored weekly, and all other residents would be weighed monthly. The policy showed meal consumption information would be recorded. <Resident 24> According to the 05/15/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 24 made their own decisions and required extensive assistance of two people to meet their daily needs. Resident 24 had a progressive neurological condition and required artificial nutrition through a surgically implanted tube going directly into the stomach. Review of the 10/27/2021 nutrition CP showed the facility was to provide and serve the diet as ordered. Staff were to monitor intake, record every meal, provide, and maintain good oral hygiene. Review of the 07/26/2023 physician's diet order showed Resident 24 was to receive recreational feeding in small portions and staff were to administer a nutritional supplement via the Tube Feeding (TF) pump at 90 Milliliters Per Hour (ML/HR). Observation on 09/19/2023 at 9:05 AM showed Resident 24 lying in bed resting comfortably attached to a tube feeding pump running at 85 ML/HR. Similar observations were made on 09/20/2023 at 9:32 AM, 09/21/2023 at 11:42 AM, and 09/22/2023 at 8:00 AM. Review of the weights tab in the facility electronic medical record showed Resident 24 weighed 172 Pounds (LBS) on 03/17/2023 and 158 LBS on 09/13/2023 for a 8.14 Percent (%) weight loss in six months. On 08/09/2023 Resident 24 weighed 170 LBS for a 7.06 % weight loss in one month. Review of the 08/30/2023 Registered Dietician (RD) note showed Resident 24's weights were trending down. The RD note showed maintaining a stable weight was desired and recommended to increase the tube feeding pump rate by 5 ML/HR for a total of 90 ML/HR. Review of the 09/08/2023 RD note showed the recommendation on 08/30/2023 was not carried out and a recommendation again to increase the tube feed pump by 5 ML/HR for a total of 90 ML, over one month later. An observation on 09/22/2023 at 12:34 PM during tray line preparation in the kitchen showed Staff V (Kitchen Cook) starting to prepare Resident 24's meal tray when Staff J (Dietary Supervisor) stopped the meal preparation, stating Resident 24 was on tube feeding and didn't require a tray to be made. Interviewed on 09/27/2023 at 9:27 AM Staff B (Director of Nursing) stated they expected the RD's recommendations to be implemented within 24 hours. Staff B stated the nurse managers were responsible for ensuring the recommendations from the RD were followed. Interviewed on 09/27/2023 at 1:58 PM Staff W (RD) stated they expected their recommendations to be followed up on timely. Staff W stated they had weekly meetings where weight loss and interventions were discussed and recommended with the interdisciplinary team (IDT). Staff W stated they compiled the recommendations generated from the meeting and put them into a document that was emailed to the IDT. Staff W did not know who was responsible for completing the recommendations. <Resident 27> According to a 05/09/2023 Quarterly MDS, Resident 27 had no memory impairment and did not refuse care. Resident 27 was able to feed themselves independently and required set up assistance of their meal from the staff. This assessment showed Resident 27 did not have any weight loss. In an interview on 09/19/2023 at 9:43 AM, Resident 27 stated they believed they had lost weight. Resident 27 stated they did not want to lose weight but they did not have much of an appetite and the food at the facility was not good. Review of a 09/06/2023 Nutrition At Risk evaluation from the RD showed Resident 27 had a significant weight loss of 5 % in one month. This evaluation showed the RD recommended Resident 27 receive double desserts on their lunch and dinner tray to prevent further weight loss. This recommendation showed the IDT would monitor and follow up per protocol and as needed. Review of Resident 27's order summary showed a 09/06/2023 diet order for a regular diet, regular texture, thin liquids, and double desserts for lunch and dinner for weight loss. Observation on 09/21/2023 at 12:21 PM showed Resident 27 received only one serving of dessert. Resident 27's diet slip showed Resident 27 was on a regular diet, regular texture with thin liquids, extra sauce and gravy on the side. The diet slip did not show Resident 27 was to receive double desserts with lunch and dinner. Observation on 09/22/2023 at 12:46 PM showed Resident 27 eating dessert. Only one dessert was provided to the resident on their lunch tray. Observation and interview on 09/26/2023 at 12:07 PM showed Resident 27 eating their lunch. Only one dessert was observed on their tray. In an interview at that time, Resident 27 stated they only received one dessert with their lunches and dinners. In an interview on 09/27/2023 at 10:06 AM, Staff B stated the RD came to the facility every other Wednesday. Staff B stated her expectation was the RD's recommendations were implemented the next day after the RD emailed her final recommendations. In an interview on 09/27/2023 at 1:29 PM, Staff W stated their recommendations were implemented by the nursing team. Staff W stated their process for follow up was to do weekly weight reviews to see if a resident had weight changes. Staff W confirmed their recommendations for Resident 27 were not implemented and this placed Resident 27 at risk for further weight loss. <Resident 53> According to a 06/13/2023 admission MDS, Resident 53 had clear speech, was able to understand others and be understood. Resident 53 had no memory impairment. Resident 53 required staff set up for their meals and supervision. In an observation and interview on 09/21/2023 at 12:20 PM, Resident 53 was loudly stating they were unsatisfied with the provided lunch. Observation at that time showed a portion of ground meat, mashed potatoes, and a serving of soft, unidentified green vegetables. At that time, Resident 53 stated It looks like puke, they are starving me. In an interview on 09/22/2023 at 12:48 PM, Resident 53 stated their lunch was not good and they were ordering food from outside the facility. In an observation on 09/22/2023 at 1:23 PM, Resident 53 was eating pizza from a fast-food restaurant. Resident 53 was also eating from a large bag of potato chips. In an interview on 09/25/2023 at 11:56 AM, Resident 53 stated they were spending money like crazy on ordering food outside of the facility. Resident 53 stated they had lost a lot of weight because they did not like the food. Review of Resident 53's order summary showed a 09/08/2023 diet order for a mechanical soft level 6 (soft, bite-sized food that is soft, tender, and moist, and required less chewing) diet. Review of Resident 53's July 2023 nutritional documentation report showed either blank documentation or the resident refused the meal 21 times. August 2023 nutritional documentation report showed either blank documentation or Resident 53 refused the meal 27 times. September 2023 nutritional documentation report showed blank documentation or Resident 53 refused the meal 33 times. Review of Resident 53's July 2023 Treatment Administration Record (TAR) showed Resident 53 was documented as weighing 284 LBS on 07/08/2023, 07/15/2023, and 07/29/2023. Resident 53's TAR showed they refused to have their weight measured on 07/22/2023. Review of the August 2023 TAR showed Resident 53 weighed 284 LBS on 08/05/2023 and 08/19/2023. This TAR showed Resident 53 refused to be weighed on 08/12/2023 but documented Resident 53 weighed 284 LBS even though they refused to be weighed. On 08/26/2023, staff documented the resident was out of the facility and was unable to be weighed. Review of Resident 53's weight summary report showed Resident 53 weighed 259 LBS on 08/23/2023, four days after Resident 53 was documented to weigh 284 pounds. This showed Resident 53 lost 26 LBS or 7.5% of their body weight. There was no re-weight documented by staff to confirm the weight change. On 09/08/2023, Resident 53's weight was documented in the report as 250.4 pounds after readmitting to the facility from the hospital. Review of a revised 09/13/2023 CP showed Resident 53 was at nutritional risk and prescribed a mechanically alerted diet. This CP did not identify Resident 53 lost a significant amount of weight. The CP did not identify food preferences or that Resident 53 often ate food from outside that did not comply with the prescribed diet. A 09/20/2023 Nutrition/Dietary progress note showed the RD implemented two different supplements to help meet Resident 53's nutritional needs. The RD did not identify that Resident 53 did not like the texture of their food. The RD did not identify Resident 53 ordered most meals from outside restaurants because they did not like the food. The RD did not identify a risk and benefits consent should be established related to Resident 53 eating outside foods that did not comply with the recommended diet. In an interview on 09/27/2023 at 10:06 AM, Staff B stated it was their expectation a re-weight was obtained for a 3-to-5-LBS weight gain or loss. Staff B stated it was important to obtain a re-weight because this allowed staff to properly monitor physical condition and a resident's appetite. Staff B stated staff should have completed a risk and benefit consent for Resident 53 related to not following the prescribed diet, but they did not. In an interview on 09/27/2023 at 2:15 PM, Staff W stated they came to the facility every other week and worked remotely on the weeks they were not in the building. Staff W stated there should be a risk and benefit consent on file for residents who do not follow the prescribed diet. <Resident 38> According to a 07/14/2023 Quarterly MDS Resident 38 had multiple medically complex diagnoses including cancer, anemia, and diabetes (a disease that results in too much sugar in the blood) and was on a therapeutic diet. This MDS showed Resident 38 weighed 207 LBS and required supervision with eating. In an interview on 09/19/2023 at 9:26 AM, Resident 38 stated they were losing lots of weight and indicated they were not happy with the food. Review of a 04/24/2023 Care Area Assessment showed staff documented Resident 38 was at risk for low and high blood sugar levels, malnutrition, and weight loss and would proceed with CP to monitor weight weekly and as needed. Review of Resident 38's Physicians order (PO) showed weekly weights were ordered since 02/22/2023. According to Resident 38's records, on 03/02/2023 staff documented the resident's weight was 217.1 LBS and on 03/23/2023 was 207 LBS, a loss of 10.1 LBS. Staff failed to obtain a follow up weight until 04/06/2023, 14 days later. Review of Resident 38's weight records showed staff failed to obtain weekly weights on: three out of five weeks in March 2023; three out of four weeks in April 2023; five out of five weeks in May 2023; two out of three weeks in June 2023; and two out of four weeks in July 2023. A 07/11/2023 Nutritional Assessment showed the RD identified Resident 38 at nutritional risk and gave recommendations to obtain an updated weight. According to a revised 07/11/2023 nutrition CP staff identified Resident 38 had a potential nutritional problem with a history of weight loss. The goal established was for Resident 38 to maintain adequate nutritional status as evidenced by maintaining weight within three % of 220 LBS and consume at least 75% of at least two meals. Review of Resident 38's July 2023 nutritional intake documentation showed staff failed to document the resident's meal intake for nine of the 85 meals provided. August 2023 records showed staff failed to document the resident's intake for 11 of the 93 meals provided. September 2023 records showed staff failed to document the resident's intake for five of the 69 meals provided. In an interview on 09/27/2023 at 2:04 PM, Staff B stated their expectation was for staff to follow PO for weights, document meal intake for each meal daily, and re-weigh the resident on the same day if there was a weight loss or gain of three to five LBS. <Resident 68> According to a 07/19/2023 admission MDS, Resident 68 was on a therapeutic diet, weighed 273 LBS and required supervision with eating. Review of a 07/19/2023 nutrition CP showed the goal for Resident 68 was to consume at least 50-100% of most meals and included directions to staff to monitor intake and record every meal. Review of Resident 68's July 2023 nutritional intake documentation showed staff failed to document the resident's meal intake for 10 of the 55 meals provided. August 2023 records showed staff failed to document the resident's intake for eight of the 93 meals provided. September 2023 records showed staff failed to document the resident's intake for three of the 54 meals provided. In an interview on 09/27/2023 at 2:04 PM, Staff B stated it was important to have complete documentation to evaluate a resident's nutritional status and indicated their expectation was for staff to document each resident's meal intake daily. <Resident 62> According to an 06/01/2023 admission MDS Resident 62 had multiple medically complex diagnoses including heart failure and diabetes and was on a therapeutic diet. In an interview on 09/19/2023 at 3:15 PM, Resident 62 stated they were not eating much and were losing weight. Record review showed Resident 62 was admitted to the facility on [DATE] and according to the resident's weight records, was not weighed until 06/05/2023, 10 days after admission. Resident 62's weight on 06/05/2023 was documented as 376.5 LBS. According to a 05/30/2023 PO, Resident 62 had orders for daily weights related to heart failure. Review of Resident 62's weight records showed staff failed to obtain daily weights on: two out of two days in May 2023; 10 out of 30 days in June 2023; eight out of 31 days in July 2023; and 10 out of 23 days in August 2023. Review of a 06/06/2023 nutrition CP showed the goal for Resident 62 was to consume at least 50% of each meal and included directions to staff to monitor meals and offer a substitute or supplement if the resident's intake was 50% or less. Review of Resident 62's nutritional intake documentation showed either blank documentation or the resident consumed 50% or less: for May 2023 on five of the 16 meals provided; June 2023 on 42 of the 90 meals provided; July 2023 on 57 of the 93 meals provided; August 2023 on 60 of the 93 meals provided; September 2023 on 43 of the 72 meals provided. No documentation was found showing Resident 62 was offered or accepted a substitute or supplement. In an interview on 09/26/2023 at 11:05 AM, Resident 62 indicated they do not usually like the food provided and stated the staff rarely offer a supplement or replacement if they do not eat much. Resident 62 stated they order food from outside sources at times. In an interview on 09/27/2023 at 2:04 PM, Staff B stated it was important to have complete documentation to evaluate a resident's nutritional status and indicated their expectation was for staff to obtain weights as ordered, document meal intake daily, provide and document supplements offered/consumed, and follow up with the RD and provider as necessary. Refer to F657 Care Plan Timing and Revision. REFERENCE: WAC 388-97-1060(3)(h). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> According to the 07/13/2023 Quarterly MDS Resident 49 had the capacity to make their own decisions. Resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> According to the 07/13/2023 Quarterly MDS Resident 49 had the capacity to make their own decisions. Resident 49 had multiple complex conditions including heart failure, chronic wounds to both feet, depression, and diabetes (difficulty controlling blood sugar). An interview on 09/19/2023 at 9:30 AM Resident 49 stated they took medications to help with their mood. Resident 49 stated they didn't believe the dosages of their medications were adjusted. Review of September 2023 MAR showed Resident 49 took an AD and an Antianxiety (AA) medication daily. Review of the 04/07/2023 CP didn't show Resident 49 was utilizing an AD medication or AA medication. Review of the 04/12/2023 PHQ-9 (an assessment for depression) showed Resident 49 was feeling down/hopeless, had trouble falling/staying asleep, and had little energy. Review of the 04/10/2023 physicians progress note showed Resident 49 should be, but was not, monitored for worsening depression including anxiety, agitation, social withdrawal, poor appetite, and sleep pattern. Resident 49 should be but was not referred to the psychiatry specialty team. In an interview on 09/26/2023 at 10:14 AM Staff C stated when residents use AD and AA medications behaviors should be monitored daily to ensure the medications were working correctly. In an interview on 09/26/2023 at 1:28 PM Staff B stated they expected behaviors to be monitored to ensure correct dosage of medication are being utilized. Staff B stated not doing so could result in a dose or medication the resident may not need or may require more. <Resident 5> According to the 06/19/2023 Annual MDS Resident 5 had a brief interview for mental status score of 8/15 showing moderate cognitive impairment. This assessment showed Resident 5's balance is not steady and they were only able to balance with staff assistance, they had a history of falling, impulsiveness, and dizziness. This assessment showed Resident 5 received an AD and AP medication daily. Review of medical records for Resident 5, showed there was no documentation of the required gradual dose reduction for their AD medication or orthostatic blood pressure (BP- blood pressure monitoring lying, sitting, and standing to monitor for significant drops in their blood pressure with changes in position) monitoring related to the increased risk of orthostatic hypotension while taking psychotropic medications. An interview on 09/25/2023 at 6:12 AM Staff B stated they expect orthostatic BP monitoring per pharmacy recommendations when a resident is on AP medications. Staff B stated orthostatic BP monitoring is important because these medications can drop a person's BP causing them to be a greater fall risk and you want to ensure their BP is regulated for their safety. Staff B stated Resident 5 did not have their orthostatic BP monitored but it should be monitored monthly. Staff B stated Resident 5's AD medication had not had an attempt at a gradual dose reduction per requirements but should. REFERENCE: WAC 388-97-1060(3)(k)(i). <Adverse Side Effect Monitoring (ASE)> <Resident 53> According to a 06/13/2023 admission MDS, Resident 53 had no memory impairment. Resident 53 had diagnoses of anxiety, severe mood swings, and mental illness that affected their behaviors. This MDS showed Resident 53 received seven days of Antipsychotic (AP) medications during the assessment period. Review of Resident 53's order summary showed a 09/08/2023 PO for an AP medication to be taken twice daily. This summary showed a 09/08/2023 PO listing multiple ASEs the staff were to monitor for including orthostatic hypotension (a type of low blood pressure that happens when standing up from the sitting position or lying down). This order directed staff to document a Yes or No if Resident 53 displayed any of the listed ASE symptoms. The summary did not include an order for staff to obtain and document Resident 53's orthostatic blood pressure. In an interview on 09/27/2023 at 10:41 AM, Staff B stated there should be an order for nursing staff to obtain Resident 53's orthostatic blood pressure once per month, but there was not. <Resident 55> According to the 07/07/2023 Quarterly MDS Resident 55 admitted to the facility on [DATE] and had a diagnosis of Depression. Resident 55 received AD medication on seven of seven days during the assessment period and was assessed with no behavior or rejection of care during the assessment period. Review of Resident 55's September 2023 order summary showed a 09/13/2023 PO for an AD medication to be taken daily for depression. Review of the 01/16/2023 depression CP included the instructions for staff to monitor, document and report to provider symptoms of depression and anxiety. In an interview on 09/26/2023 at 10:14 AM Staff C (Social Services Director - SSD) stated when residents use AD medications, behaviors should be monitored daily to ensure the medications were effective. In an interview on 09/25/2023 at 12:09 PM, Staff B stated if the facility would not monitor and document resident's behaviors, the provider would not be able to know if the medication was effective or not. Staff B stated there should be an order for nursing staff to monitor Resident 55's behaviors every shift and document in their record but there was not.Based on interview and record review the facility failed to ensure 5 (Residents 30, 55, 49, 53 & 5) of 5 residents whose medication regimens were reviewed, were free of unnecessary psychotropic medications. This failure left residents at risk for unnecessary medications, adverse side effects and other negative health outcomes. Findings included . <Resident 30> According to the 06/18/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 30 had diagnoses including anxiety, depression, and insomnia (difficulty sleeping). The MDS showed Resident 30 took Antidepressant (AD) medications. The MDS showed Resident 30 had 2 non-injury falls in the facility since the prior assessment. Review of Resident 30's Physician's Orders (PO) showed a 03/14/2023 PO to monitor the resident's hours of sleep every shift, related to insomnia. Review of the September 2023 Medication Administration Record (MAR) showed Resident 30 had a 07/28/2023 PO for an AD medication 50 Milligrams (MG), give half a tablet at 8 PM for insomnia. The PO showed the medication was used to treat Resident 30's insomnia. On 09/25/2023 the PO was superseded by a new order for the same AD medication 50 MG for insomnia, give one tablet by mouth at 7 PM, doubling the dose. Review of the July 2023 MAR showed Resident 30 slept an average of the 5.67 hours on night shift when staff documented their sleep that month. The August 2023 MAR showed Resident 30 slept an average of 5.08 hours on night shift when staff documented their sleep. The September 2023 MAR showed Resident 30's nightly sleep increased to an average of 6.58 hours. ' Review of the 01/16/2023 Care Plan (CP) showed Resident 30's insomnia CP did not address how the AD medication was used to assist Resident 30 with their insomnia. Instead, a resident uses antianxiety medications CP showed Resident 30 used the AD medication for anxiety. According to a 09/15/2023 psychiatric progress note, the psychiatric provider noted they would recommend to [discontinue the AD medication] at this time to minimize sedation and reduce falls risk. According to a 09/25/2023 nursing progress note, Resident 30 Slept well from last night. In an interview on 09/26/2023 at 9:59 AM Resident 30 stated they sometimes struggled to sleep, especially if they had a stressful day. Resident 30 stated that lately the quality of their sleep neither improved nor worsened. In an interview on 09/26/2023 at 10:13 AM, Staff H (Resident Care Manager - RCM) stated the dose increase could be for behavior as Resident 30's behavior worsened recently. Staff H stated the PO showed the AD medication was for insomnia rather than behavior. Staff H reviewed Resident 30's sleep documentation and acknowledged the data showed Resident 30's sleep at night was documented to show improvement in the resident's sleep. Staff H stated, maybe the doctor [had] a rationale but stated the documentation was vague. In an interview on 09/27/2023 at 12:24 PM Staff B (Director of Nursing) stated the CP showed contradictory purposes for the AD medication and the facility needed to follow up with the provider to clarify. Staff B stated they were unsure why the AD medication dose was increased on 09/25/2023, as the provider added the order into the resident's record and did not notify the facility. Record review showed the September MAR showed nurses administered the increased dose of the AD medication on 09/25/2023, 09/26/2023, 09/27/3023. and on 09/28/2023.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 4 of 26 medications for 3 of 8 residents (Resident 66, 42, & 581) observed during medication pass resulted in a medication error rate of 15.38%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> According to a 2023 facility Medication Administration policy, staff would review the Medication Administration Record (MAR) to identify medication to be administered and would also compare the medication source with the MAR to verify resident name, medication name, form, dose, route, and time. <Resident 66> Observation of medication pass on 09/20/2023 at 8:42 AM, showed Staff S (Registered Nurse) enter Resident 66's room and hand the resident an anti-inflammatory inhaler medication to administer. At this time, Resident 66 looked at the inhaler and stated, this is not mine. Staff S took back the inhaler, apologized and went back to the medication cart to retrieve the correct inhaler for Resident 66. In an interview on 09/20/2023 at 9:30 AM, Staff S stated they made a mistake and should have, but did not check the label for the right resident name prior to handing it to Resident 66 to administer. <Resident 42> Observation of medication pass on 09/22/2023 at 8:58 AM showed Staff HH (Licensed Practical Nurse - LPN) prepare and administer multiple medications by mouth to Resident 42, including a multivitamin with iron, and a medication used to treat acid reflux. Resident 42 was eating breakfast prior to the medication administration. Review of September 2023 MAR revealed directions to staff to administer a multivitamin with minerals, rather than the multivitamin with iron that was administered. The order for the medication used to treat acid reflux gave directions to staff to administer 30 minutes before meals, rather than during the meal as administered. In an interview on 09/22/2023 at 12:35 PM, Staff HH verified the orders, located the different bottles of vitamins on the medication cart, and stated Resident 42 should have but did not receive the medication doses as ordered. <Resident 581> Observation of medication pass on 09/26/2023 at 1:52 PM showed Staff N (LPN) prepare and administer multiple medications by mouth to Resident 581 including Calcium 600 milligrams (mg) with Vitamin D 5 micrograms (mcg). Review of September 2023 MAR revealed directions to staff to administer Calcium 500 mg with Vitamin D 5 mcg, rather than the Calcium 600 mg that was administered. In an interview on 09/27/2023 at 2:04 PM, Staff B (Director of Nursing) stated physician orders should be followed and administered as prescribed. Staff B stated nursing staff should be following the five rights of medication administration which included the right medication, right resident, right dose, right route, and right time. REFERENCE: WAC 388-97-1060(3)(k)(ii). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

<Resident 27> Review of a 05/09/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 27 was understood and able to understand conversation. This MDS showed Resident 27 did ...

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<Resident 27> Review of a 05/09/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 27 was understood and able to understand conversation. This MDS showed Resident 27 did not have any memory impairment. In an observation and interview on 09/19/2023 at 9:25 AM, Resident 27 stated the facility food was often cold. Resident 27 stated it was cold due to food being served in Styrofoam trays because of a recent infectious outbreak. Several boxes of snacks brought in from outside of the facility were observed on Resident 27's side table. Observation on 09/21/2023 at 12:21 PM showed Resident 27 sitting on their bed with their lunch. The lunch tray consisted of chicken noodle soup, a toasted grilled cheese sandwich and drinks. In an interview at this time, Resident 27 stated the soup and sandwich were barely warm. Observation and interview on 09/21/2023 at 12:21 PM of Resident 27's meal slip showed the following: Diet; regular, regular thin liquids, notes; extra sauce, gravy on the side. No dislikes were listed on the diet slip. Observation and interview on 09/22/2023 at 7:58 AM showed resident 27 eating breakfast. Their breakfast consisted of scrambled eggs, sausage, two slices of toast, hot cereal, and an orange slice. Resident 27 stated they did not eat the toast because butter or jam was not provided. Observation and interview on 09/22/2023 at 12:46 PM showed Resident 27 ate their dessert and pushed away the rest of the meal. At that time, Resident 27 stated lunch was no good. Observation on 09/25/2023 at 12:56 PM showed Resident 27 eating their lunch. No plate warmer was observed under the plate. At that time, Resident 27 stated their lunch was luke warm. <Resident 40> In an interview on 09/19/2023 at 2:11 PM, Resident 40 stated the food at the facility was terrible. Resident 40 stated the eggs were cold and watery and the meat was terrible. Resident 40 stated They put gravy on the meat to camouflage the flavor. <Resident 53> Review of a 06/13/2023 admission MDS showed Resident 53 had no memory impairment. Resident 53 was able to understand others and be understood in conversation. In an observation and interview on 09/21/2023 at 12:20 PM, Resident 53 was heard shouting profanity related to their lunch tray that was delivered. In an interview at that time, Resident 53 stated the meat looks like puke, they are starving me. Observation showed a pile of dark, ground meat with gravy, mashed potatoes, and an unidentified green vegetable. In an observation and interview on 09/22/2023 at 12:48 PM, Resident 53 stated their lunch was not good, they were going to order food from outside the facility. Observation at 1:23 PM showed Resident 53 eating pizza from a fast-food restaurant. In an interview on 09/27/2023 at 12:39 PM, Resident 53 stated their lunch was .mush and I won't eat that. <Resident 25> According to a 05/29/2023 Annual MDS Resident 25 had intact cognition. This assessment showed Resident 25 was able to understand others and be understood in conversation. In an interview on 09/19/2023 at 9:51 AM, Resident 25 stated the facility food was terrible. Resident 25 stated the food was cold, the texture was terrible, and the food was all dried out. Resident 25 stated their coffee was always cold. In an observation and interview on 09/21/2023 at 12:29 PM, Resident 25 stated their mashed potatoes were very dry. No gravy was observed on the tray. During this time, Resident 25's roommate stated the potatoes were very dry and they did not get gravy either. Resident 25's roommate stated they requested gravy but it never came. Resident 25 stated their green beans were good, but the meat was also dry. In an interview on 09/22/2023 at 11:18 AM, Resident 25 stated they could not eat their breakfast because it was too cold. In an observation and interview on 09/25/2023 at 9:40 AM, Resident 25 was eating breakfast. They had an egg over easy, an orange slice, and a slice of bacon. There was no plate warmer observed under their tray. Resident 25 stated the bacon was ok, but the eggs were too dry and the meal was cold. <Test Tray Data> Observation on 09/22/2023 at 1:09 PM showed kitchen staff plating meals for residents. Observation showed there was no more rice or steamed vegetables for a remaining 11 residents who needed lunch. Observation at that time showed kitchen staff prepare mashed potatoes in place of rice and prepare more steamed vegetables. Staff took frozen, mixed vegetables, added warm water from a coffee carafe, placed the pan on the range to cook, then placed the vegetables on the steam table. The vegetables were observed to be swimming in water. On 09/22/2023 at 1:35 PM food temperatures and palatability were obtained from a test tray containing roasted pork loin, mashed potatoes, seasoned vegetables, a dinner roll, and carrot cake. Observation of a facility test tray provided to surveyors on 09/22/2023 at 1:35 PM showed the temperature of the meal items to be pork loin-118 degrees Fahrenheit (F), mashed potatoes-119 F, and mixed veggies-121 F. The pork loin serving was small, the length of a pointer finger and width of two pointer fingers. The pork was covered in gravy, tender, and luke warm. The mashed potatoes had the texture of a thick, dry paste. There was no gravy or butter. The potatoes were luke warm with no flavor. The seasoned vegetables were over-cooked, soggy, and mushy. <Resident Council Minutes (RCM)> Review of RCMs showed residents had concerns for cold foods during the 02/17/2023 and 04/21/2023 meetings. Residents had specific concerns with cold soup on the 07/17/2023 RCMs. In an interview on 09/26/2023 at 3:01 PM, the resident council president stated cold food was an ongoing, repetitive concern at resident council. In an interview on 09/27/2023 at 2:15 PM, Staff W (Registered Dietician) stated it was their expectation meals were served warm. Staff W stated it was important for the food to be warm because it allowed for palatability and enjoyment by the resident. Staff W was unaware of the food warmers not being used under plates during meal service. REFERENCE: WAC 388-97-1100(1)(2). Based on observation, interview, and record review the facility failed to serve foods that were appetizing in appearance, palatable, and served at the proper temperature. Observation of meal preparation and interviews with 5 (Residents 27, 53, 25, 68, & 38) sample residents and 1 supplemental (Resident 40) resident identified concerns about the taste, temperature, and overall palatability of food served by the facility. Failure by the facility to ensure meals were at the proper temperature and palatable when served, placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals. Findings included . <Resident 68> In an interview on 09/19/2023 at 12:28 PM, Resident 68 stated the food was edible and stated it was usually not warm enough. Resident 68 stated they were not sure where the food started from but indicated by the time it came to their hallway it was luke warm. <Resident 38> In an interview on 09/19/2023 at 9:27 AM, Resident 38 stated the food was cold almost all of the time.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. Multiple staff members were observed to fail to do one or more of the following: consistently perform Hand Hygiene (HH) before and after resident care/contact; apply/remove Personal Protective Equipment (PPE) in accordance with the Transmission Based Precaution (TBP- implement precautions based on the means of transmission in order to prevent or control infection) signs posted outside of resident rooms; and maintain infection control during passing ice in resident's rooms. Additionally, staff failed to ensure resident equipment was maintained in good condition with cleanable surfaces (Resident in room [ROOM NUMBER] bed 2). These failures placed all residents and staff at risk for contracting communicable diseases, including COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death), during a COVID-19 outbreak in the facility. Finding included . <Facility Policies> According to the facility's undated Isolation - Notices of Transmission-Based Precautions [TBP] policy, when TBPs were implemented, the Infection Preventionist (IP) determined the appropriate notification to be placed on the room entrance door sign identifying the type of isolation required (e.g. Airborne, Droplet, or Contact) to ensure personnel and visitors were aware of the type of precautions required. Each notification gave specific directions as to what PPE was required for all staff to use. The policy showed the facility followed Aerosol Contact Precautions [ACP] during a COVID-19 infection outbreak. The ACP showed all staff must wear an N-95 (a non-oil based type of respirator with 95 percent efficiency) mask, eye protection, gown and gloves before entering the isolation room, use disposable equipment or disinfect shared equipment, and to keep the room's door closed to prevent spreading the infection. According to the facility's undated Hand Hygiene [HH] policy, the nursing staff should perform HH between resident contact. <Hand Hygiene - Meal Service> Observations on 09/22/2023 at 8:03 AM showed Staff Z (Certified Nursing Assistant - CNA) passing Breakfast (BF) trays without performing HH. Staff Z collected a BF tray from the meal cart and brought it to room [ROOM NUMBER]-1, assisted the resident to sit up in bed, setup the tray, went back to meal cart without performing HH, and proceeded to collect the next tray. Staff Z collected the BF tray for room [ROOM NUMBER]-1 from the meal cart, entered the room and assisted the resident by setting up meal tray, and returned to the meal cart without performing HH. Staff Z collected room [ROOM NUMBER]-1 BF tray, entered room [ROOM NUMBER], assisted in tray setup, and the exited room, returning to meal cart without performing HH. An interview on 09/22/2023 at 8:57 AM Staff Z stated they should have and were expected to wash their hands between each meal tray, but they did not. An interview on 09/27/2023 at 2:06 PM Staff M (IP) stated they expected staff to perform HH between each meal tray and entry of a resident's room. <Hand Hygiene - Personal/Incontient Care> Observations on 09/21/2023 at 1:25 PM showed Staff LL (CNA) performing incontinence care for Resident 38. Staff LL was wearing gloves and used personal wipes during the care provided. After completing incontinence care, Staff LL touched the call light and then Resident 38's legs while still wearing the contaminated gloves. Observations on 09/22/2023 at 12:57 PM showed Staff II (CNA) enter room [ROOM NUMBER], put gloves on, and provided positioning assistance to a resident in the first bed. Staff II removed their gloves, and without performing hand hygiene, went into the hall, removed a lunch tray from the meal cart, and delivered it to the resident in the second bed in room [ROOM NUMBER]. Staff II then touched the second resident's wheelchair to move it, moved the bedside table closer, and put on gloves prior to assisting the resident with cutting up food. In an interview on 09/26/2023 at 1:25 PM, Staff M stated their expectation was for staff to perform hand hygiene before and after incontinence care and with each glove change. <PPE Use> In an interview on 09/19/2023 at 8:15 AM, Staff B (Director of Nursing) stated the facility had COVID-19 infection outbreak. Staff had to wear N-95 mask and eye shields at all times while in the facility. Observation on 09/19/2023 at 8:33 AM showed room [ROOM NUMBER] had an ACP sign outside the room, and an isolation cart with PPE included gown, face masks, eye protector shields, gloves, and disinfectant wipes. Observations on 09/19/2023 at 8:49 AM, 9:32 AM, 10:30 AM, and 11:43 AM showed room [ROOM NUMBER]'s door was left open. Observation on 09/19/2023 at 12:13 PM showed Staff PP (Physical Therapy Assistant) went to room [ROOM NUMBER] and had PPE on. Staff PP was observed removing their gloves and gown and came out of the room. Staff PP did not change their mask or disinfect their eye shields, went to another room. room [ROOM NUMBER]'s door was left wide open. Staff PP did not follow the sign posted on the door to keep the door closed to prevent spreading the infection. Observation on 09/20/2023 at 8:40 AM showed Staff T (CNA) went to room [ROOM NUMBER] with only a surgical mask on, no eye shield on, no gown, or gloves on. Staff T fixed the meal tray for bed 2 and came out of the room, sanitized their hands, did not change the mask, and went to room [ROOM NUMBER]. room [ROOM NUMBER]'s door was left open. In an interview on 09/20/2023 at 8:52 AM, Staff T stated they would wear PPEs only if they touched the resident with infection. When asked about ACP sign outside the room [ROOM NUMBER], Staff T stated they did not read the sign. Observation on 09/20/2023 at 9:18 AM showed Staff QQ (CNA) went to room [ROOM NUMBER] with mask on and no other PPEs. Staff QQ provided coffee to the resident, cleaned their table, door was open, talked to the resident for three minutes and came out of the room, sanitized their hands and did not change their mask. Observation on 09/20/2023 at 9:54 AM showed Staff NN (Shower aide) went to room [ROOM NUMBER], had mask and goggles on and no gloves or gown on. Staff NN started providing care to the resident in bed one to prepare for shower. In an interview on 09/20/2023 at 10:12 AM, Staff M stated they expected staff to wear N 95 mask and eye shield on at all the times, and for the residents with infections, staff must follow the isolation precautions signs posted outside the room. Staff M stated they expected staff to read the sign on room [ROOM NUMBER]'s door and keep the door closed, wear PPE before entering the room, remove the PPE before leaving the room, wash their hands, change their mask, and disinfect their eye shield. In an interview on 09/20/2023 at 10:37 AM, Staff B stated they expected staff to read and follow the sign on resident's doors for isolation precautions. Staff B stated room [ROOM NUMBER] was on Aerosol Contact Precautions and staff should have worn PPE including gown, gloves, N 95 mask, eye shield before they go inside the room but they did not. <PPE Use> Observation on 09/25/2023 at 5:38 AM showed a contact precautions sign posted outside room [ROOM NUMBER]. The sign instructed all staff to don a gown and gloves prior to entry to the room. At this time Staff B was observed to enter the room without donning a gown or gloves. Staff B washed their (still ungloved) hands. Staff B then left room [ROOM NUMBER]. <PPE - Mask Use> In an interview on 09/19/2023 at 8:15 AM, Staff B stated the facility was on a Covid-19 infection outbreak. Observation on 09/25/2023 at 5:38 AM showed the call light in room [ROOM NUMBER] was on. Staff GG (CNA) was observed wearing a surgical mask, went inside the room, and provided assistance to the resident. On 09/25/203 at 6:11 AM, Staff DD (Registered Nurse) was observed coming out from the elevator to start their shift, placed their belongings at the nurse's station, and was wearing a surgical mask. Staff B saw Staff DD wearing a surgical mask and told them to change their mask to an N-95 mask. In an interview on 09/25/2023 at 6:13 AM, Staff GG stated they knew the facility was in a Covid-19 outbreak. When asked what the staff expectation was as to the type of mask to wear while they were in the facility during a Covid-19 outbreak, Staff GG stated they were expected to wear an N-95 mask but they did not. In an interview on 09/26/2023 at 1:25 PM, Staff M stated they expected the staff to continue wearing an N-95 mask for infection control and safety until the facility was cleared by the Department of Health. <Ice Cart Service> Observations on 09/20/2023 at 3:42 PM showed Staff FF (Licensed Practical Nurse) obtain a resident's water pitcher from room [ROOM NUMBER]. Staff FF set the water pitcher down on the ice cart, used a scoop to get ice out of the bin, and then touched the scoop on the inside of the resident's water pitcher while filling it with ice. Staff FF then delivered that water pitcher to room [ROOM NUMBER] and went into room [ROOM NUMBER] to pick up another resident's water pitcher. Staff FF placed the next water pitcher down on the ice cart, picked up the contaminated scoop, put it into the main bin to get more ice, and again touched the scoop inside of the resident's water pitcher. Observations on 09/25/2023 at 12:14 PM showed the ice cart in the hallway with no ice scoop in the clear container in the front. On 09/25/2023 at 12:33 PM, staff approached the ice cart with a water pitcher, opened the lid, took the ice scoop out of the bin, and filled the water pitcher. Observations with Staff M on 09/26/2023 at 1:29 PM showed a brownish-black substance in the bottom of the clear container where the ice scoop is stored in-between use on the ice cart. This brownish-black substance was easily wiped off with a white tissue by Staff M. In an interview at this time, Staff M stated their expectation was for staff not to touch the resident's water pitchers with the scoop and indicated in doing so, contaminates the scoop and becomes an infection control concern. Staff M stated ice scoops should not be stored inside of the ice bin and staff should have placed the scoop inside the plastic protective container. Staff M confirmed the plastic ice scoop container was dirty and needed to be cleaned. In an interview on 09/20/2023 at 3:25 PM Staff J (Dietary Supervisor) stated kitchen staff were responsible for ensuring the cleanliness and sanitization of the ice cart. Staff J could not provide a cleaning schedule for the ice cart or a system of when the ice cart was last cleaned/sanitized. <Wheelchair Equipment> Observations on 09/25/2023 at 5:49 AM showed staff providing assistance to a resident in room [ROOM NUMBER]-2 and then bring the resident into the hallway using a wheelchair. The left arm rest of the wheelchair was cracked and peeling with the foam underneath the surface exposed. In an interview on 09/26/2023 at 3:21 PM, Staff H (Resident Care Manager) stated cracked and peeling arm rests was an infection control concern as the surfaces become uncleanable. REFERENCE: WAC 388-97-1320(1)(c)(2)(b). .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review the facility failed to: (1) follow measurement tools and conversion tables when preparing modified consistency diets, (2) routinely monitor food temperature on the steam table during meal service, (3) ensure dietary staff were knowledgeable of food safety practices including the appropriate temperatures of Potentially Hazardous Foods (PHF). These failures placed residents at risk for aspiration (inhaling food contents into lungs), development of lung infections, acquiring food-borne illnesses, and a decreased quality of life. Findings included . <Preparation of Modified Consistency Diet> On 09/22/2023 at 9:47 AM during lunch service preparation, Staff BB (Kitchen Cook) was observed preparing puree (a smooth and creamy liquidized substance) texture food for residents with altered swallowing ability. Staff BB gathered the ingredients and mixed cut-up vegetables, chicken broth, and two slices of bread in a blender and stated the mixture was the pureed vegetable component of the meal. Staff BB checked the consistency and noted it was still thin and runny. Staff BB then proceeded to add two more slices of bread. When asked about the measurement of mixed vegetables and chicken broth used, Staff BB stated they were unsure of the exact amount they mixed together and only approximated each food item. On 09/22/2023 at 11:17 AM, Staff BB gathered ingredients and mixed eight scoops of a 4-ounce (oz.) ladle of rice pilaf, 1oz. scoop of chicken base, and two cups of warm water in a blender. Staff BB stated the mixture was the pureed starch component of the meal. During both observations on 09/22/2023 at 9:47 AM and 11:17 AM, Staff BB did not refer to a measurement guide during food preparation. Staff BB stated they follow the instructional material from the third-party dietary consultant services utilized by the facility. When asked for a copy of the instructional material being referred to, Staff BB stated they did not have a copy in their possession and/or in the kitchen at the time and was going by memory during food preparation. Staff BB stated they would ask for a copy from the administration staff. On 09/26/2023 at 9:17 AM, Staff AA (Transportation Director) provided a Dysphagia [difficulty swallowing] Blenderized/Puree Diet facility document that showed the use, principles, and information about modified consistency diets but did not show the required measurements kitchen staff should follow in preparing puree texture food for safety. No other documentation was provided by the facility. <Food Temperature Monitoring> On 09/22/2023 at 12:02 PM, observed all food prepared were set at the steam tables for hot holding and lunch meal service was started by Staff BB and Staff V (Kitchen Cook). The lip of the metal pan containing the pork roast was noted with a significant gap from the steam table, was not flush to create a complete seal, and remained open to air during meal service. Staff BB and Staff V did not routinely monitor the food temperatures on the steam table. At 12:53 PM, Staff BB was asked to check the temperature of the pork roast and showed 135.3 degrees Fahrenheit (F), 9.7F below the pork's safe internal temperature. Staff J (Dietary Supervisor) raised the metal pan from the steam table and noted the pan was not touching the hot water and stated, the pan did not properly fit the steam tables' opening. In an interview on 09/22/2023 at 12:59 PM, Staff BB stated food temperatures should be re-checked in between meal service to ensure residents consumed foods that were maintained in appropriate cooking temperatures. In an interview on 09/27/2023 at 2:15 PM, Staff W (Registered Dietician) stated they expected the kitchen staff to serve warm foods because of concerns with appropriate and safe food temperatures. Staff W stated bacteria could grow in PHFs when the internal temperature drop. <Knowledge of PHF> <Department of Health (DOH) Guidelines> According to DOH's Food and Safety Program when preparing food, the temperature danger zone was between 41F and 135F. The guidelines showed the safe internal temperature for cooking meats were the following: - Whole or ground chicken, turkey, or other poultry: 165F - Ground beef, pork, hamburger, or egg dishes: 160F - Whole cuts (such as roasts, steaks, chops) of beef, pork, veal, and lamb: 145F Observation on 09/22/2023 at 12:53 PM showed the temperature reading of the pork roast being served during lunch service was 135.3F. Staff BB was asked what the safe internal temperature for cooking pork roast was, Staff BB unable to answer. Staff V stated, 155F. Staff J came out of their office that was adjacent to the meal service area and stated, No, pork's temperature should be at 145F, the same as poultry including bone-in chicken . In an interview on 09/27/2023 at 2:15 PM, Staff W stated kitchen staff were expected to be knowledgeable of PHF's proper cooking temperatures to prevent food-born illnesses and ensure resident safety. Refer to F801- Qualified Dietary Staff. REFERENCE: WAC 388-97-1100 (1). .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure that, unless the facility employed a full-time Registered Dietitian (RD), the Director of Food and Nutrition services (Staff J) met Washington State requirements including the completion of an academic program in nutrition or dietetics (the practical application of the science of diet and nutrition in relation to health and/or diseases) approved by the American Dietetic Association/Dietary Manager Association. This failure compromised residents nutritional status and placed residents at risk for receiving unsafe dietary services from a staff without the required competencies and skills to carry out food and nutrition services management. Findings included . <Staff J> On 09/21/2023 at 9:08 AM, Staff E (Business Office Manager/Human Resources - HR) provided Staff J's (Dietary Supervisor) personnel file for review. The Application for Employment form showed Staff J applied for the position on 05/25/2023. The facility provided a staff list with the hire dates showed that Staff J was hired for the position of Dietary Supervisor the following day on 05/26/2023. Review of Staff J's resume on file showed they graduated from high school and no other education related to food and nutrition was obtained. The resume listed four prior work experiences related to food preparation and service. Staff J's personnel file did not contain any reference checks or documentation to support a dietetic technician or dietetic assistant training program was completed prior to their hire as required by the State. In an interview on 09/21/2023 at 10:48 AM, Staff E stated they were responsible for safekeeping all staff records and everything they have on file were current. Staff E confirmed the facility's Registered Dietician (RD) was part-time and worked once a week (on Wednesdays) per the schedule. When asked if there were any documentation on file to support Staff J's role as Dietary Supervisor while working with a part-time RD, Staff E stated there was a current state issued Food Handler's Permit and nothing else. On 09/21/2023 at 2:39 PM, Staff A (Administrator) stated they did not confirm the validity of Staff J's work history prior to their employment with the facility. At the same date and time, Staff A stated they attempted to contact Staff J's first two employers to validate their work history but were unsuccessful. No further documentation was provided by the facility to support Staff J met the qualifications as required. Refer to F800- Provided Diet Meets Needs of Each Resident. Refer to F803- Menus Meet Resident Needs/Prep in Advance/Followed. Refer to F812- Food Procurement, Store/Prepare/Serve - Sanitary. REFERENCE: WAC 388-97-1160 (3)(b)(i). .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure: Cycle/planned and breakout menus were followed during meal service to residents; residents with specialized diets (Resident 429) were provided with meal options that met their needs; risks and benefits were discussed for residents (Resident 579) who elected to consume meals purchased outside of the facility. These failures placed residents at risk for less than adequate nutritional intake, consuming meal portion sizes and calories other than as planned by a Registered Dietician (RD), dissatisfaction with meals, and unmet nutritional needs. Findings include . <Unplanned Menus> Review of the Week 3- The Week At A Glance cycle menu provided by the facility showed the 09/21/2023- Thursday lunch menu was planned as: Meatballs with gravy, boiled red potatoes with parsley, dinner roll, and pound cake. Observation on 09/21/2023 at 11:21 AM showed the posted lunch menu outside of the main kitchen listed: Pot roast, buttermilk mashed potatoes, green beans, dinner roll, and chocolate pudding. Observation on 09/21/2023 at 12:22 PM showed Resident 69 was served with rice, peas and carrots, sliced meat with sauce on top, a dinner roll, and a brownie slice. The observed meal served to Resident 69 did not match either the planned Week 3 cycle menu or the lunch menu posted. In an interview on 09/21/2023 2:17 PM, Staff J (Dietary Supervisor) stated they switched the lunch menu to pot roast because the meatballs were not delivered. When asked who decided the food item switch, Staff J stated, Me. When asked if they receive any direction from any facility staff such as a Registered Dietician regarding food substitutes, Staff J stated, None. When asked how they determined what food item to substitute with and serve to residents, Staff J stated they look at what is closest to what should be served. Staff J stated they have not received the Fall Cycle Menu from the third-party consultant the facility utilized for their dietary services and had been improvising using the old cycle menus. Staff J stated there was no current process for residents to receive a copy of the weekly menu. Review of the Week 3- The Week At A Glance cycle menu provided by the facility showed the 09/22/2023- Friday lunch menu was planned as: Roasted pork loin with pear cider sauce, cornbread stuffing, seasoned Brussel sprouts, dinner roll, and ice cream. The alternate menu listed was roast beef. The dinner menu was planned as: Pot roast, egg noodles, herbed green beans, dinner roll, and frosted chocolate cake. Observation on 09/22/2023 at 9:35 AM showed the posted lunch and dinner menus outside of the main kitchen did not match the Week 3 cycle menu as planned. The lunch menu listed: Pot roast, buttermilk mashed potatoes, green beans, dinner roll, and chocolate pudding. The dinner menu listed: Baked Ziti, side salad, dinner roll, fruit cocktail, and cookies. Observation on 09/22/2023 at 9:35 AM of the lunch menu in the kitchen during lunch service preparation showed: Roasted pork loin, rice pilaf, seasoned vegetables, dinner roll, and carrot cake, and the alternated menu listed was barbeque riblet. The food items prepared did not match the planned Week 3 cycle menu or the lunch menu posted. Review of the breakout menu used for the 09/22/2023 lunch service according to and provided by Staff J showed a different set of menu compared to the planned Week 3 cycle menu, the lunch menu posted, as well as from the observed food items prepared by the kitchen staff for lunch service. The breakout menu listed: Honey thyme pork roast, parsley garnish, baked sweet potatoes, spinach, roll with margarine, and orange glazed pound cake. Observation on 09/22/2023 at 11:48 AM showed Staff J mixed the pork roast dripping from the metal pan with water. Staff J proceeded to pour cornstarch from a box with no measurement. Staff J did not use any measuring device during the preparation. Observation of the lunch tray service on 09/22/2023 from 12:02 PM until 1:44 PM showed Staff V (Kitchen Cook), responsible for dishing out the lunch plates, did not use nor refer to a breakout menu. At 12:30 PM, observed room [ROOM NUMBER]-2's meal ticket showed ALT x2 hand-written on it. Staff V stated the notation meant the resident wanted double of the alternate menu and Staff V proceeded to put two slabs of barbeque riblets on the plate. When asked how they determined how much portion size to give the resident, Staff V stated they either went by the number of meat slices or would approximate the amount based on small or large portion as indicated in the meal ticket. Observation on 09/22/2023 at 1:09 PM showed the rice pilaf ran out. Staff V counted the remaining meal tickets and stated there were 11 residents left that needed to be served lunch. Staff J took a box of dried mashed potato, poured the contents into a large metal bowl, added water and started whipping the mixture without measuring or checking the food temperature to ensure palatability (the quality of being acceptable to the taste). Observation on 09/22/2023 at 1:24 PM showed room [ROOM NUMBER]-2's diet order in the meal ticket was blank. Staff V dished out pork loin, a scoop of mashed potato, and mixed vegetables. When the kitchen aid was about to put the plate inside the meal cart, Staff BB (Kitchen Cook) stopped the kitchen aid and handed them a different plate to be served. Staff BB stated Staff J personally cooked fried rice for the resident. In an interview on 09/27/2023 at 2:15 PM, Staff W (RD) stated they were not employed by the facility, worked once a week on Wednesdays, and rotated working remotely and in-person. When asked how far out they prepared the menus, Staff W stated, I don't do that. Staff W stated they did not manage the kitchen workflow including the facility's breakout menus because their role in the facility was more resident-care driven such as the nutrition assessments and reviews. Staff W stated the breakout menu was important because it categorized the different types of diets and portion sizes prescribed for residents to meet their nutritional needs. Staff W stated measuring food items being prepared/mixed together was important, especially for the safety of residents with altered-texture diets when swallowing their food. Staff W stated it was not acceptable for a kitchen staff to cook a meal for a specific resident without following dietary instructions from an RD, .they [kitchen staff] follow a cycle menu for a reason and we do not deter from that .if they [residents] have therapeutic diets, the 'personally prepared food' may not be nutritionally appropriate . Staff W stated they expected all kitchen staff to follow both the cycle and breakout menus during meal service as required. <Vegetarian Diet - Resident 429> Review of the Resident Council minutes documented during the 02/17/2023 and 04/21/2023 meetings showed residents had concerns with the lack of vegetarian meal options. Review of a 08/07/2023 PO showed Resident 429 was on a vegetarian diet. In an interview on 09/19/2023 at 9:07 AM, Resident 429 indicated the food was terrible and stated, I am a vegetarian, it seems to be too much for them [kitchen staff] to understand. Resident 429 stated the food was not nutritionally balanced. Observations on 09/19/2023 at 12:48 PM showed Resident 429 was delivered their lunch tray which included a scoop of plain mashed potatoes, cooked spinach, yogurt, a health shake, and a dinner roll. In an interview at this time, Resident 429 looked at their tray and stated, there is no nutritional value in this. Resident 429 only ate a couple of bites and stated they had to ask friends to bring them fruits for them to eat. Observations on 09/21/2023 at 12:36 PM showed Resident 429's lunch tray included a scoop of plain mashed potatoes, green beans, cottage cheese, yogurt, and a health shake; similar to the food items served for lunch two days ago. Review of the 09/22/2023 lunch breakout menu showed the Vegetarian Option included cooked beans, baked sweet potato, spinach, and a dinner roll with margarine. At 12:50 PM, observed Resident 429's lunch tray with a scoop of plain rice, cooked vegetables, and a health shake; and was different from breakout menu as planned. In an interview at this time, Resident 429 stated they were unhappy with their meal and turned it away after a couple of bites. In an interview on 09/27/2023 at 2:15 PM, Staff W stated the breakout menus instructed the kitchen staff on how to prepare meals to meet the residents' nutritional needs according to their prescribed diet. Staff W stated they expected the kitchen staff to follow and serve the food items listed in the breakout menus for residents with specialized diets, including vegetarian, as written.<Controlled Carbohydrate (CCHO) diet - Resident 579> Review of a 09/12/2023 Physician's Order (PO) showed Resident 579 was on a CCHO diet. Resident 579's Nutrition CP included an intervention to provide Resident 579 their diet as ordered by the physician. The 09/12/2023 Diebetes CP included an intervention to monitor/document/report Resident 579's compliance with their diet, and document any issues. In an interview on 09/19/2023 at 11:55 AM Resident 579 stated they could not eat the facility's food, complaining that it was cold and bland. Resident 579 stated they used a restaurant delivery service at least once a day. Observation on 09/21/2023 at 2:21 PM showed Resident eating Chinese food in packaging showing it came from a restaurant In an interview on 09/25/2023 at 10:03 AM Resident 579 stated the facility did not provide a menu to allow the resident to make a choice between meal possibilities. Resident 579 stated a family member brought them some chicken, mashed potato, and rice. In an interview on 09/27/2023 at 2:15 PM Staff W stated their expectation was when a resident with orders for a therapeutic diet such as a CCHO diet and regularly ordered food from outside the facility, the facility should at a minimum, discuss with the resident and document the risks and benefits of nonadherence to their ordered diet on a Risks vs. Benefit form. Staff W stated no Risks vs. Benefits documentation was available in Resident 579's record. Record review showed no Risks vs. Benefit documentation was located in Resident 579's chart. Refer to F800- Provided Diet Meets Needs of Each Resident. Refer to F801- Qualified Dietary Staff. Refer to F804- Nutritive Value/Appearance, Palatable/Prefer Temp. Refer to F812- Food Procurement, Store/Prepare/Serve - Sanitary. REFERENCE: WAC 388-97-1160 (1)(a)(b). .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food was procured, stored, prepared and served in accordance with professional standards of safety. Facility failed to ensure: (1) food safety was maintained and temperatures monitored in the resident refrigerator, (2) open foods were dated, (3) kitchen equipment (oven) was in good, working condition, (4) menu ingredients were ordered timely, and (5) ready-to-eat foods were covered during transport as required placed residents at risk for unsafe cooking temperatures, ingesting expired and/or contaminated food, and the development of food-borne illness. Findings included <Facility Policy> The facility's 2021 Food Receiving and Storage showed all foods stored in the refrigerator or freezer would be covered, labeled, and dated with the use by date. The policy instructed staff to maintain individual resident food items and snacks kept on the nursing unit refrigerator as followed: - All Potentially Hazardous Food items were kept below 41 degrees Fahrenheit in the resident refrigerator. - All foods belonging to residents must be labeled with the resident's name, the item, and the use by date. - Refrigerators had a working thermometer and temperatures were monitored accordingly. <Resident Refrigerator - North Unit) On 09/21/2023 at 10:59 AM, observation showed a resident refrigerator located inside the supplies and storage room. There was no temperature log observed anywhere inside the room to validate the refrigerator temperature was monitored as indicated in the facility policy. At the same date and time, observation showed the resident refrigerator door panel was dirty and heavily stained with several orange-colored drips, both to the outside of the panel door and along the rubber lining that sealed the door when it was closed. There were multiple packages of opened foods that were not labeled and dated including a carton of ice cream, a bottle of orange juice, and a container of cocktail sauce. There were expired foods observed including a carton of whole yogurt milk that expired in 09/03/2023 and a sectional container of fresh cut fruits that expired in 09/15/2023. In an interview on 09/21/2023 at 11:11 AM, Staff B (Director of Nursing) stated they do not know if the resident refrigerator's temperature were monitored because there was no logs found. Staff B stated the dirty condition of the resident refrigerator was unacceptable because of potential infection control issues. Staff B saw the unlabeled, undated, and expired resident foods inside the refrigerator and stated they expected the nursing staff to label and date foods to ensure resident safety due to the risk of food-born illnesses from ingesting expired food. <Undated and Expired Food> Observation on 09/19/2023 at 9:23 AM showed open and undated food items in the kitchen freezer including two bags of cooked egg omelet and one bag of mixed vegetables. In an interview on 09/19/2023 at 9:27 AM, Staff BB (Kitchen Cook) stated all kitchen staff were expected to follow the facility's food labeling guidelines and to write the open and use by dates on the food's packaging for safety. Observation and interview on 09/21/2023 at 10:15 AM showed undated individually prepared mixed canned fruits in small, plastic containers sitting on a tray on top of a metal rack inside the kitchen refrigerator. Staff BB stated they were probably leftover desserts from yesterday's meal service. Staff BB stated the mixed fruits were undated and should be discarded for safety. <Broken Oven Door> Observation and interview on 09/22/2023 at 11:01 AM during lunch service preparation showed Staff BB opened the oven door, took a big metal pan out, could not close the oven door initially and had to slam the door shut. The oven door was observed detached from the lower left corner of the unit. Staff BB stated they were burned once by the broken oven door. Staff BB stated the maintenance department was notified a month and a half ago and was told a replacement door was ordered. On 9/26/2023 at 10:23 AM, Staff MM (Environmental Services Director) stated they were aware of the broken oven door and that they were in collaboration with Staff A (Administrator) regarding the purchase of a whole new oven unit. Staff MM stated there were no more parts available for purchase to fix the broken oven door because the company where the facility's oven was purchased was no longer making parts specific to that model. On 09/22/2023 at 11:28 AM, Staff J (Dietary Supervisor) stated the information shared by Staff BB regarding the broken oven door was accurate. On 09/26/2023 at 10:59 AM, Staff A was asked for any documentation regarding the status of the facility's kitchen oven and/or any communication with kitchen equipment vendors. No further documentation was provided by the facility. <Food Procurement> According to the Week 3 - At A Glance Cycle Menu, the 09/21/2023's main lunch entrée was meatballs with gravy. On 09/21/2023 at 12:22 PM, the sign posted outside the main kitchen door on the first floor door showed the main lunch entrée for the day was pot roast and not meatballs with gravy as planned. In an interview on 09/21/2023 at 2:09 PM, Staff J stated the facility's food service vendor delivered orders placed every Mondays and Thursdays. Staff J stated the meatballs were ordered and was supposed to be delivered today [Thursday] but the food service vendor did not come. At 3:09 PM, Staff J stated the food service vendor arrived for delivery. Staff A joined the conversation and asked Staff J when was the order placed for the meatballs. Staff J stated they placed the order for the meatballs two days ago. On 09/21/2023 at 4:30 PM, Staff A provided a copy of the food delivery invoice and did not list the meatballs as part of the facility's order. Staff A stated they do not have any documentation to support the meatballs were ordered timely in consideration of the 09/21/2023's lunch service as planned. <Uncovered Food> Observations of the South Hall on 09/21/2023 at 12:32 PM showed staff delivering lunch trays. The staff were carrying the trays with uncovered pudding through the hallways. Similar observations were made on 09/22/2023 at 12:50 PM, and 09/25/2023 at 12:33 PM, when staff were observed delivering lunch hall trays with all the desserts uncovered as they walked in the hallways. In an interview on 09/27/2023 at 2:04 PM, Staff B stated absolutely when asked if all food should be covered when being transported through halls in resident areas. Observations of the South Medicare Hall on 09/21/2023 at 12:48 PM showed staff delivering the lunch trays to the resident's rooms with uncovered pudding through the hallways. Observations of the North Hall on 09/22/2023 at 12:31 PM showed staff delivering lunch trays to the resident's rooms with uncovered desserts through the hallways. Similar observations were made on 09/22/2023 at 1:08 PM showed staff were delivering lunch trays to resident's rooms with the desserts uncovered through the hallways. Additional observations on 09/26/2023 at 12:57 PM showed the same issue, staff delivered the dessert to room [ROOM NUMBER]-1 uncovered. In an interview on 09/26/2023 at 1:43 PM, Staff B stated all food should be covered when transported from the kitchen to the hallways and to the resident's rooms. Refer to F803- Menus Meet Resident Needs/Prep in Advance/Followed. REFERENCE: WAC 388-97-1100 (3), -2980. .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish an infection prevention and control program that included developing an Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 5 (Resident 9, 27, 5, 64, and 56) of 5 residents reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of ABOs. Findings included . <Facility Policy> According to the revised December 2016 Facility ABO Stewardship- Orders for ABOs policy ABOs will be prescribed and administered to residents under the guidance of the facility's ABO Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. This policy also says appropriate indications for use of ABO's include meeting criteria for clinical definition of active infection. This policy stated when a culture and sensitivity was ordered, the results will be communicated to the prescriber as soon as available to determine if ABO therapy should be continued, modified, or discontinued. This policy did not indicate which criteria the facility utilized in determining appropriate ABO usage. In an interview on 09/22/2023 at 10:19 AM Staff M (Infection Preventionist) stated the facility used the McGeers criteria (a tool used for infection surveillance activities and management of ABO usage). Staff M stated when a resident admitted to the facility with an infection, they were expected to obtain, from the hospital, the appropriate diagnosis for the prescribed ABO, start and stop date of ABOs, lab results, and data to ensure resident meets McGeers criteria. Staff M stated when a resident acquired an infection in house, they were expected to ensure the resident's symptoms meet the McGeers criteria, the prescribed ABO was appropriate and needed, lab results were communicated to the prescriber to ensure the least invasive ABO was prescribed, and the order was complete with name, dose, length of course, and had an appropriate diagnosis. <Resident 9> Review of the 08/18/2023 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 9 was originally admitted [DATE] with a Brief Interview for Mental Status (BIMS) of 14 which indicated Resident 9 was cognitively intact, without confusion. According to the physician orders, Resident 9 was prescribed four separate ABO courses since admit. During the first course: Resident 9 did not receive the complete ABO course per physician orders; second course was prescribed for pneumonia without any diagnostics obtained to provide evidence of pneumonia; and the fourth course was prescribed for a tooth abscess on 08/01/2023. A Urinalysis (UA) was obtained on 07/28/2023 that showed Resident 9 had a Urinary Tract Infection (UTI). A culture and sensitivity (C&S - microbiology evaluation of urine showing which ABO's were resistant/susceptible for the treatment of the specific bacteria resident had in their urine) report showed the ABO prescribed for the tooth abscess had an uncertain therapeutic effect on the bacteria associated with the UTI. Review of Resident 9's medical records showed no documentation the urine test results were reviewed or addressed. Review of ABO line listing showed no review of Resident 9's ABOs to ensure they met the McGeer's criteria. Review of the ABO line listing showed only the fourth course of ABOs in it. <Resident 27> According to the July 2023 ABO line listing, Resident 27 received ABOs for a UTI. Resident 27's July 2023 Medication Administration Record (MAR) showed that Resident 27 received 2 ½ days of the 10-day course of ABO's prescribed for UTI. Review of Resident 27's medical records showed no documentation or results of a UA to assess for UTI or a C&S report to ensure appropriate ABO prescription, or if McGeers was met. In an interview on 09/22/2023 at 10:19 AM Staff M stated they did not obtain a UA to assess for a UTI and that Resident 27 did not meet the McGeers criteria to be treated with an ABO. Staff M stated they did not notify the prescriber that Resident 27 did not meet McGeers criteria because they reviewed July 2023 ABO line listing toward the end of August 2023 and the resident had already completed the ABO course, so it was too late. Staff M stated they should have reviewed the ABO order at the time of order to ensure Resident 27 met McGeers criteria, but they did not. <Resident 5> Review of Resident 5's 2023 ABO usage showed they received a course of ABOs for a UTI in February 2023 without assessing urine or obtaining a C&S report. In an interview on 09/22/2023 at 10:19 AM Staff M stated Resident 5's ABO was not reviewed because they only had ABO line listing for July and August of 2023, no previous ABO surveillance was completed. <Resident 64> Review of the August 2023 ABO line listing showed Resident 64 received an ABO on 08/02/2023 for a UTI. In an interview on 09/22/2023 at 10:19 AM Staff M stated they had not reviewed August 2023 ABO line listing yet and that it was too late because Resident 64 completed their ABOs on 08/14/2023. Staff M stated they understood it defeated the purpose of reviewing ABOs by reviewing them over a month after they were prescribed because they could have received an inappropriate ABO putting them at risk for building up a resistance to ABOs for future need. <Resident 56> Review of the August 2023 ABO line listing showed Resident 56 received ABOs on 08/11/2023 for a skin infection. August 2023 MAR showed an ABO was started on the evening of 08/11/2023 and was administered twice daily through 08/16/2023 AM. On 8/17/2023 the ABO was restarted for another 3 doses which went through 08/18/2023 AM. On the evening of 08/18/2023 the same ABO was restarted again and went through 08/25/2023 AM. These changes were not reflected on the August 2023 ABO line listing document. In an interview on 09/22/2023 at 10:19 AM Staff M stated they had only added Resident 56's ABO to the line listing but did not review the August 2023 ABO line listing yet and that it was too late now to make sure the resident had an appropriate diagnosis, and an appropriate ABO was prescribed since Resident 56 had completed the course already. In an interview on 09/22/2023 at 10:19 AM Staff M stated there was no record of ABO Surveillance prior to July 2023 and that they did not complete the September 2023 report. Staff M stated they started the ABO line listing in August 2023 by adding all the residents that received ABOs in July 2023 and forward. Staff M stated they would not review for appropriateness of prescribed ABOs until the following month after the resident received the ABO. Staff M stated they reviewed July in August and August in September. Staff M stated they realized this defeated the purpose of the ABO Stewardship program which was to ensure the appropriateness of the prescribed ABO and to make sure there were not ABOs being prescribed unnecessarily which could cause resistance to ABOs and superbugs (hard to treat bacteria with only limited ABOs that will treat the bacteria). REFERENCE: WAC 388-97-1060(3)(k)(i). .

Jul 2023 6 deficiencies 1 Harm

SERIOUS (H) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement physician orders (PO) timely, assess, measure, and document the wound characteristics consistently, implement preventative measures, and develop and implement a care plan (CP) that directed staff how to manage wounds for 4 (Resident 1, 2, 3 & 4) of 4 residents reviewed for wounds. These failures caused harm to Resident 1 who required a surgical toe amputation and three intravenous (IV) antibiotic treatments for the toe bone infection, caused harm to Resident 2 who developed maggots in their wound, and caused harm to Resident 3 and 4 who had delayed healing to wounds and placed all residents at risk for new wounds, deterioration of existing wounds, risk for decline in medical status, risk of infection, pain and diminished quality of life. Findings included . Review of the undated facility Skin Care policy, to ensure effective healing of resident wounds, licensed nurses would perform wound assessments according to the wound assessment schedule and an IDT (Intra Disciplinary Team) would meet regularly as a skin committee to review wound assessments and recommend changes to the resident's CP. Wounds included pressure ulcers (PU), lacerations, skin tears, abrasions, or other skin issues considered to be at risk for poor healing by the Director of Nursing (DNS) or the skin committee. Not all skin issues would be followed by the skin committee or be included on the wound assessment schedule if the DNS or skin committee determined the skin issues would likely heal without worsening. Skin ulcers caused by vascular disease such as venous, arterial, and stasis ulcers, were not included in the facility's skin care policy that was provided by facility staff. For resident's identified at risk for PU's, facility staff would use preventative measures and implement a two hour positioning schedule and complete an assessment for appropriate pressure reducing devices. When a PU developed, staff would complete an incident report, notify the provider and family, provide appropriate treatment, notify the Resident Care Manager (RCM) who would complete a PU assessment, update the resident's CP, and complete weekly PU assessments until the wound was resolved. If the PU/wound showed no improvement within 14 days, staff would contact the provider for a new treatment. <Resident 1> According to the 06/04/2023 Quarterly Minimum Data Set (MDS) an assessment tool) showed Resident 1 admitted to the facility on [DATE], had impaired decision making, and diagnoses including a brain bleed, chronic kidney disease, and diabetes with a history of toe amputations. The MDS showed Resident 1 was assessed to require extensive assistance of one staff member for bed mobility, dressing, eating, toilet use, and personal hygiene. Review of section M, skin conditions, showed Resident 1 had no PU's, and no other types of ulcers or wounds. The MDS showed Resident 1 was at risk for developing PU's, had a nutrition or hydration intervention to manage skin problems, received applications of dressings to their feet, and did not receive PU care. Review of an admission assessment, dated 02/28/2023, showed Resident 1's skin was assessed with no PU's. Review of Resident 1's diabetes CP, dated 02/28/2023, directed staff to check the resident's body for breaks in skin and treat promptly as ordered by the physician. Resident 1's clinical record showed no CP in place for the resident's skin integrity risk related to their diabetes diagnosis and history of toe amputations or directions to staff on how to manage and prevent Resident 1's risks of skin breakdown. Review of a Braden Scale (a tool used to assess risk for development of PU), dated 02/28/2023, showed Resident 1's Braden Score (determined by six subscales and added together to get a score between 9 and 23, less than 9 very high risk, 10-12 high risk, 13-14 moderate risk, and 15-18 at risk) was a 15, indicating Resident 1 was at risk for PU development. Review of a Nursing Progress Note (NPN), dated 04/27/2023, showed Resident 1 was working with physical therapy when a a blackened and bleeding area was observed to the tip of the big left toe. Review of a physician encounter note, dated 04/27/2023, showed Resident 1 was seen for a wound on the tip of the left toe, staff were instructed to use measures to prevent further skin breakdown by tenting bed garments (keeps the weight of bed garments off the toes), wound care to include damp debridement and cleaning of wound, followed by a non-stick dressing to be changed every other day until Resident 1 was seen by an outside wound provider. The provider referred the resident to an outside wound provider for the left foot wound. The physician directed staff to notify them immediately if redness, odor, pus drainage (indicative of an infection), or concerning appearance of the wound or abnormal vital signs in the resident. Review of physicians orders (PO) showed a 04/27/2023 PO that directed staff to cleanse the left toe wound and cover with a dressing. Review of a physician encounter note, dated 04/28/2023, showed Resident 1's wound was assessed with redness, pus drainage, and odors. The physician directed staff to obtain a specimen of the wound drainage, ordered a lab draw and started Resident 1 on an antibiotic to treat the wound infection to the left toe. A 04/28/2023 PO showed Resident 1 was started on an antibiotic three times a day for seven days for the wound. Review of a NPN, dated 04/29/2023, showed staff documented Resident 1's wound specimen was obtained and ready for the lab to pick up. Review of wound culture (determines which bacteria is present in wound) results, dated 05/17/2023, showed the lab specimen was collected on 05/11/2023, thirteen days after the physician ordered the wound drainage specimen to be sent for culture. The wound culture results showed three different types of bacteria, one being a multi-drug resistant organism (resistant to many antibiotics), and the results could not determine if the lab specimen was contaminated. In an interview on 07/07/2023 at 12:45 PM, Staff A (Administrator) was asked why the delay in collecting the wound drainage for culture and was not able to provide answers. The Director of Nursing (DNS) was not available for an interview and other facility staff were not able to provide answers on why there was a delay in collecting the wound drainage for culture. Review of a physician encounter note, dated 05/22/2023, showed Resident 1 was seen by the physician for follow up on wound culture results, five days after the facility received the results. The physician encounter note showed Resident 1 would be started on two antibiotics to treat the wound infection of the left toe. The note showed the physician continued to wait for the outside wound provider notes, would refer Resident 1 to a podiatrist for possible amputation of the left toe, and directed staff that any suspected treatment failure should prompt a review for the need for emergency evaluation, hospitalization, and continued urgency for a podiatry consultation. Review of Resident 1's clinical record showed no wound provider notes that documented Resident 1 was seen or assessed by the wound provider after the physician ordered on 04/27/2023. A 05/11/2023 PO showed the physician ordered Resident 1 to consult with the outside wound provider, fourteen days after the original PO was made. Review of Resident 1's clinical record showed no outside wound provider notes that documented Resident 1 was seen by an outside wound provider after the physician ordered on 05/11/2023. Review of a physician encounter note, dated 05/26/2023, showed Resident 1 was seen by the physician for a right heel PU of the deep tissue and directed staff to continue wound care with the outside wound provider and schedule a podiatry consult. Review of Resident 1's clinical record showed no PO for a treatment for the right heel PU on 05/26/2023 or thereafter. Review of a skin and wound evaluation, dated 06/01/2023, showed Resident 1 was assessed with a facility acquired, unstageable (unable to determine extent of wound) pressure ulcer to the right heel, unknown how long the wound was present, and the wound measured 3.6 cm (centimeters) by 2 cm. The assessment showed facility staff assessed the wound with no signs of infection, no pain, and no progress with the right heel wound. A skin and wound evaluation, dated 06/01/2023 showed facility staff documented measurements of 3.9 cm by 0.8 cm, all other areas of the assessment were left blank and did not indicate the type of wound, location, where acquired, how long it was present, description of wound characteristics, pain presence, treatments, or progress. Review of a NPN, dated 06/09/2023, showed staff documented the podiatry referral was made, eighteen days after the referral request was first made by the physician on 05/22/2023. Resident 1's podiatry appointment was made for 06/19/2023, twenty-eight days after the referral was first made by the physician. Review of a facility skin and wound evaluation, dated 06/15/2023, showed facility staff documented Resident 1 had a open lesion (ulcer or sore) located on the left foot, first digit that was acquired at the facility on 04/27/2023. The wound measured 2.7 cm by 2.1 cm, and facility staff documented the wound improved. The assessment showed facility staff left descriptions of wound characteristics, pain, treatments, and notifications blank. This was the first wound assessment found for Resident 1's wound to the left great toe, seven weeks after it was discovered by facility staff on 04/27/2023. Review of a NPN, dated 06/19/2023, showed Resident 1 was sent to the hospital per Collateral Contact's (CC) request and concern for the left toe wound. Review of a hospital encounter note, dated 06/19/2023, showed Resident 1 presented at the hospital with a open wound with bone exposed to the left great toe. Drainage and a foul odor were observed by the physician. The note showed Resident 1 was seen by a podiatrist that same day [06/19/2023] who recommended Resident 1 go to the hospital for osteomyelitis (bone infection) of the left great toe. Resident 1 was admitted to the hospital for osetomyelitis to the left great toe. During an interview on 07/05/2023 at 3:11 PM Resident 1's collateral contact (CC) stated the resident admitted to the facility with no wounds on the left foot big toe, previously had four toes on the left foot amputated, and the resident's podiatrist informed the CC Resident 1's feet should be assessed every other day and the podiatrist should be notified immediately for any new sores or open areas. The CC stated the podiatrist really wanted to save the big toe because it helped with Resident 1's balance. CC stated they received a call from facility staff that Resident 1 had a slight infection and needed to see a podiatrist. The CC went to the podiatrist appointment and when the bandage was removed from Resident 1's left foot big toe, three bones were observed protruding from the wound. The toe was swollen, red, and infected. The podiatrist immediately sent Resident 1 to the hospital to be evaluated. Resident 1 had the left big toe amputated, a central line (used for IV therapy) placed, and required antibiotic therapy for the next six to eight weeks for the left toe infection. CC stated when they asked to see the wound, facility staff would tell the CC the dressing was just changed, or the doctor just looked at the wound and therefore did not see the toe wound prior to the podiatrist appointment and stated if they would have known they could have taken Resident 1 to the podiatrist sooner. Observations of pictures of Resident 1's left big toe on 07/05/2023 at 4:08 PM showed pictures taken at the podiatrist appointment on 06/19/2023 and Resident 1's left big toe was observed red, swollen, and slightly falling over to the left with two large open areas and three separate bones protruding through the open areas. A second picture showed Resident 1's right heel with a large area covered in dry dark tissue. During an interview on 07/07/2023 at 12:36 PM Staff A stated that after reviewing Resident 1's CC concerns about Resident 1's wounds it was identified that we have a problem with wounds. Staff A stated Resident 1 had no wounds upon admission to the facility and the wound to the left big toe was identified by facility staff on 04/27/2023. When asked why it took twenty eight days for Resident 1 to be seen by a podiatrist, Staff A stated that the current medical director puts PO's in their progress notes and facility staff can't be expected to review every physician progress note for PO's. When asked when were the bones identified as being exposed through the skin, Staff A was not able to answer, Staff B (DNS) was not available for an interview, and other facility staff were not able to provide answers or did not recall Resident 1. <Resident 2> According to the 05/23/2023 admission MDS, Resident 2 admitted to the facility on [DATE], was able to make their own decisions and needs known, and had diagnoses including cardiogenic shock (heart is unable to pump as much blood as the body needs), heart failure, peripheral vascular disease (a circulatory condition with narrowed blood vessels and reduced blood flow to the limbs), and history of blood clots. The MDS assessed Resident 2's skin with no PU's, at risk for developing PU's, had no other ulcers, wounds or skin problems, but received applications of dressings to the feet. Review of a nursing admission assessment, dated 05/16/2023, showed facility staff assessed Resident 2 with dark hardened tissue to the left toes, scattered dark scabs to the right toes, and dry scabs to the left lower leg. The assessment did not document the measurements of the wounds. Review of a Braden scale, dated 05/16/2023, showed Resident 2's braden scale score was 18, indicating at risk for PU development. Review of a skin integrity CP, dated 05/17/2023, showed Resident 2 had the potential for impairment to their skin integrity due to ischemia (restriction of blood supply) to the lower extremities. Interventions directed facility staff to monitor and document the skin injury and include the size and treatment. The physician would be contacted if abnormalities, failure to heal, or any signs or symptoms of infection were observed in the wound. The CP did not show Resident 2 had actual impairments to their skin that required treatments. Review of a provider note, dated 05/24/2023 showed Resident 2 had a non-pressure, chronic ulcer of the right foot and recommended meticulous wound care. Review of a NPN, dated 06/09/2023, showed Resident 2 requested wound dressings be changed to both feet. Review of a NPN, dated 06/12/2023, showed facility staff documented when changing Resident 2's wound dressings to the left foot, maggots (fly larva) were observed coming out of the wound, indicating a source (fly) landed on the residents wound, laid eggs that developed into maggots Resident 2 was sent to the hospital for further evaluation, as maggots were not a current treatment for wound care and non-medical maggots carry multiple bacteria that can lead to infection. Review of a NPN, dated 06/20/2023, showed Resident 2 readmitted to the facility on [DATE] with a left foot wound infection that required three different antibiotics to treat the wound infection. Resident 2's right foot was noted with scattered scabbing and all left toes with wounds with eschar (dark, dry, dead skin). Review of a facility skin and wound evaluation, dated 06/22/2023, showed facility staff documented wound measurements of 8.1 cm by 4.1 cm, but did not indicate the type of wound, location of the wound, where acquired or how long it was present, wound characteristics, pain, treatments, progress of wound, or who was notified of the presence of the wound. Review of Resident 2's clinical record showed one facility skin and wound evaluation [completed on 06/22/2023] , thirty seven days after their admission on [DATE], indicating the facility did not monitor wounds or perform wound assessments which led to an infection and maggots in Resident 2's wound. In an interview on 06/23/2023 at 2:50 PM Staff B (DNS) stated it was a difficult question to answer when asked how maggots got into Resident 2's wound. Staff B stated they could not find a cause of the maggots and Resident 2 would refuse dressing changes at times and no flies were observed in the resident's room. Review of the May 2023 and June 2023 Treatment Administration Record (TAR) showed Resident 2 had not refused any treatments and facility staff documented treatments as completed. In an interview and observation on 06/23/2023 at 3:45 PM, Resident 2 stated that a couple flies landed on their left foot but there wasn't too many in their room. Resident 2 was observed sitting in bed and dressings were observed to both feet. In an interview on 07/07/2023 at 12:40 PM Staff A stated the facility had problems with wounds and Resident 2's toes were gangrenous (decaying due to lack of blood flow) and in bad shape. <Resident 3> According to the 04/13/2023 admission MDS Resident 3 admitted to the facility on [DATE], was able to make their own decisions and needs known, had diagnoses including heart failure, diabetes, and a chronic ulcer of the right foot, right ankle, and an open wound on the left foot. The MDS assessed Resident 3's skin with a PU, was at risk for developing PU's, had two unhealed and unstageable PU's that required PU care and application of dressings to the feet. Review of a nursing admission assessment, dated 04/07/2023, showed Resident 3's skin was assessed with wounds to both feet, on heel and sole. The assessment did not show what type of wound, site of each wound, and measurements of the wounds. Review of a Braden scale, dated 04/07/2023, showed Resident 3's braden scale score was an 18, indicating Resident 3 was at risk for PU's. Review of a 04/11/2023 PO directed staff to refer Resident 3 to an outside wound provider. Review of a skin integrity CP, revised 04/20/2023, showed Resident 3 had an actual impairment to their skin integrity that consisted of an unstageable PU to their left heel and an unstageable PU to their right inner ankle. Interventions directed staff to document weekly wound measurements of each area of skin breakdown with length, depth, type of tissue, drainage, and any other notable changes in the wound. Staff would identify causative factors, eliminate if possible, and would have Resident 3 followed by an outside wound provider. Review of an outside wound provider assessment, dated 04/18/2023, showed Resident 3 was assessed with a right inner ankle arterial ulcer that measured 1 cm x 1 cm x 0.3 cm and a unstageable left heel PU that measured 6.5 cm x 4.5 cm. The wound provider recommended treatments, pain medication prior to wound treatments and to offload pressure to prevent worsening of wounds. Review of an outside wound provider assessment, dated 05/03/2023, showed Resident 3 had their right inner ankle wound assessed but no measurements were documented. Resident 3's left heel PU measured 6 cm x 4 cm and the wound provider recommended treatments, pain medications to wound treatments and to offload pressure to prevent worsening of wounds. Review of an outside wound provider assessment, dated 05/17/2023, showed Resident 3 had their right inner ankle wound measured at 1 cm x 1 cm x 0.3 cm and their left heel PU measured 6 cm x 4 cm. The outside wound provider documented a surgical debridement procedure of the right inner ankle wound occurred. Review of an outside wound provider assessment, dated 05/31/2023, showed Resident 3 had their right inner ankle wound measured at 1.4 cm x 1 cm x 0.5 cm and their left heel wound measured 4.6 cm x 3.2 cm. The wound provider documented that the right inner ankle wound deteriorated with palpable (can feel) bony presence, osteomyelitis was suspected, and recommended Resident 3 obtain an urgent appointment with an infectious disease (ID) provider or a podiatrist, and nursing was to monitor the surrounding skin for any spreading redness to the right inner ankle wound. Review of Resident 3's clinical record showed no PO's from 05/31/2023 with the wound care provider's urgent recommendation to have Resident 3 assessed by a ID provider or a podiatrist. Review of NPN's from 04/24/2023- 06/23/203, showed no indication the facility staff made an appointment for Resident 3 to be seen by a ID provider or a podiatrist or documentation from an infectious disease or podiatry consult, which delayed care that Resident 3 was assessed to require by the outside wound provider. Review of a skin and wound evaluation, dated 06/14/2023, showed Resident 3 had a PU that was from a medical device, to the left heel that was unstageable. The evaluation showed the PU was present on admission, progress had deteriorated, and measured 5.1 cm by 3.3 cm, which indicated the PU became larger since it was last measured on 05/31/2023. The evaluation did not assess the wound characteristics, pain, treatments, and notifications, as they were left blank. A skin and wound evaluation, dated 06/14/2023, showed Resident 3 had a PU that was from a medical device to the right inner ankle that was unstageable. The evaluation showed the PU was present on admission, the PU was stable, and measured 1.4 cm x 1.2 cm. The evaluation did not assess the wound characteristics, pain, treatments, and notifications, as they were left blank. There was no documentation to show what medical device had caused the PU to the left heel and how to avoid worsening of the wound related to the use of a medical device. Review of Resident 3's clinical record showed no documentation that facility staff or the outside wound provider assessed Resident 3's wound during the week of 04/24/2023-04/28/2023, 05/08/2023-05/12/2023, 06/05/2023-06/06/2023, and 06/19/2023-06/23/2023, indicating the facility did not monitor wounds or perform wound assessments. In an observation and interview on 06/23/2023 at 5:10 PM Resident 3 was observed in bed, a dressing was observed to their left heel that was saturated in a green and brown substance and a dressing observed to the right ankle with no drainage. Resident 3 stated Look at my slippers, I just bought them and they are wet with that brown green drainage, it's everywhere, on the bed, it's even on my pillow. It has been draining this green stuff since I first got here. Some of the other residents complained that it smelled and didn't want to look at it when it didn't have a dressing on it. During an interview on 07/07/2023 at 12:45 PM Staff A stated the facility had a problem with wounds, there was a breakdown in communication between physicians and facility staff, and PO's were not carried out as expected. The Director of Nursing (DNS) was not available for an interview and other facility staff were not able to provide answers on why Resident 3 was not seen by an ID doctor or a podiatrist after the outside wound care provider recommended an urgent consult for the resident's wounds. <Resident 4> According to the 05/22/2023 Quarterly MDS, Resident 4 admitted to the facility on [DATE], was able to make their own decisions and needs known, and had diagnoses including a neurological condition, malnutrition, muscle wasting, and weakness. The MDS assessed Resident 4's skin with no PU's, at risk for PU's, no other ulcers, wounds or skin conditions, but did receive application of dressings to their feet. Review of a admission assessment, dated 11/14/2022, showed staff documented Resident 4 had no wounds. Review of a Braden assessment, dated 02/16/2023, showed Resident 4's braden scale score was a 16, indicating Resident 4 was at risk for PU's. Review of a skin CP, revised 03/17/2023, showed Resident 4 had an actual impairment to their skin integrity related to a chronic ulcer of the left foot second toe. Interventions directed staff to monitor and document the location, size, and treatment of skin injury weekly and when abnormalities were observed in the wounds facility staff would contact the provider. Review of an outside wound provider assessment, dated 04/26/2023, showed Resident 4 was seen for the chronic ulcer to the left foot second toe. The assessment showed the ulcer continued to drain pus but no infection was noted. The assessment referred Resident 4 to a podiatrist for a nail tear on the left foot second toe. The wound provider recommended treatments to the toe three times a week and as needed. A outside wound provider assessment, dated 05/03/2023, showed similar findings of continued pus drainage and referred Resident for to a podiatrist for the second toenail tear. Review of a wound provider assessment, dated 05/17/2023, showed Resident 4 was not able to be seen by a podiatrist due to insurance reasons, the facility would have the in-house podiatrist see Resident 4, and the resident would be seen monthly by the outside provider. The assessment showed Resident 4's chronic ulcer on the left foot second toe measured 0.5 cm by 0.5 cm and a depth of 0.2 cm. The assessment showed the ulcer was not expected to heal until the resident was seen by the podiatrist for the nail tear. The outside wound care provider placed orders for dressing changes to the chronic ulcer three times a week. Review of Resident 4's clinical record on 06/27/2023, showed after 05/17/2023 facility staff did not assess or document the resident's ulcer weekly to include the type, size, location, wound characteristics, and notifications of abnormal findings as the CP directed. Review of PO's showed on 04/26/2023 the wound provider treatment orders were carried out and did not change for two months on 06/23/2023. Due to the lack of facility wound documentation it is unclear if the ulcer improved or became worse after receiving the same treatment for an extended duration. Review of the June 2023 MAR showed staff did not document the left foot second toe wound and left the documentation blank on 06/12/2023, 06/19/2023, and 06/23/2023. In an interview and observation on 06/23/2023 at 4:15 PM Resident 4 stated that a podiatrist showed up today [06/23/2023] without notice and performed a procedure on their second toe. Resident 4's left foot second toe was observed wrapped in a bloodsoaked gauze and secured with tape. Review of Resident 4's clinical record showed no documentation that the resident was seen by the podiatrist or documentation about the toenail removal procedure and the outcome to Resident 4's second toe. In an interview on 07/07/2023 at 12:26 PM Staff A (Administrator) was not able to answer why it took nearly two months for Resident 4 to be seen by the in-house podiatrist and stated the previous medical director documented their orders in progress notes and did not communicate orders to the facility staff which ultimately delayed care and treatment to Residents 1, 2, 3 & 4. Staff A stated there was a breakdown in communication between providers and facility staff but would expect PO's to be carried out timely, wounds measured and documented weekly, and the provider to be notified of any abnormal findings with a wound. The Director of Nursing (DNS) was not available for an interview and other facility staff were not able to provide answers on why it took two months for Resident 4 to be seen by a podiatrist. REFERENCE: WAC 388-97-1060(3)(b) .

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility administration failed to manage the facility to ensure the facility was managed in a manner that effectively utilized resources so residents could attain or maintain their highest practicable physical, mental and/or psychological well-being and substantial compliance with federal regulatory requirements. The Administration failed to ensure there was an active, comprehensive, system to assess, treat, and monitor skin/wound issues. The facility failed to develop and implement a transfer agreement with a local hospital. The facility failed to develop and implement a Facility Assessment (FA) that met the needs of the facility's resident population. The facility failed to identify training requirements for facility staff based on the FA, failed to ensure facility staff received required mandatory training to meet resident specific care needs, and failed to ensure Nurses Aides (NA) received 12 hours of required continuing education including a system to track NA education participation. These failures caused residents to suffer delayed wound healing and more extensive wound treatments, placed all residents at risk for unmet care needs, delays in transfer to a hospital if an urgent situation arose, inadequate care from untrained staff, and diminished quality of life/quality of care. Findings included . During a review of the facility's historical surveys the 01/12/2022, 07/18/2022, and 03/21/2023 Statement of Deficiencies (SOD) showed the facility had repeat deficiencies in Quality of care related to wound care services. <Quality of Care (Refer to F684)> The administration failed to ensure the facility had a system by which residents with wounds received required quality care and services in accordance with standards of nursing practice. The facility failed to implement physician orders (PO) timely, assess, measure, and document wound characteristics consistently, implement preventative measures,or develop and implement a care plan (CP) that directed staff how to manage resident wounds. These failures placed all residents at risk for new wounds, deterioration of existing wounds, risk for decline in medical status, risk of infection, pain and diminished quality of life. <Transfer Agreement (Refer to F843)> The administration failed to ensure the facility had a written transfer agreement with at least one area hospital approved for participation with Medicare/Medicaid programs. This failure placed all residents at risk for delayed transfer and potential lack of access to the hospital in the event of an emergency requiring this action. <Facility Assessment (Refer to F838)> The administration failed to develop, evaluate, and implement a Facility Assessment (FA) to determine the resources required to meet resident needs. The failure to accurately/comprehensively assess resident needs identified by their biopsychosocial and cultural conditions, staffing levels required, the education/training and competencies required to ensure residents received required care and services, and the physical environment, placed residents at risk for unmet care needs. <Training Requirements (Refer to F940> The administration failed to ensure the facility developed, implemented, and maintained an effective training program for all new and existing staff and included the training program in the Facility Assessment (FA). The failure to ensure the FA included the training program and the failure to provide annual mandatory training on abuse/neglect, mandated reporting, resident rights, communication, dementia care, and behavioral health care, placed all residents at risk for unmet care needs, inadequate quality care and a diminished quality of life. <NA 12 hours Required Education (Refer to 947)> The administration failed to ensure that Nurses' Aides (NA) received the required yearly 12 hours of mandatory in-service training. This failure place residents at risk for inadequate care from staff, unmet care needs, potential abuse and neglect, and a diminished quality of life. During an interview on 07/27/2023 at 3:25 PM, Staff A (Administrator) stated they were employed by the facility in April 2023. Staff A stated they should have been aware of the current identified issues. Staff A stated they now see a problem with specific areas, like wound care, transfer agreement, FA, and required training and tracking of staff training within the facility. Staff A stated without a consistent Director of Nursing some systems were not being monitored and the Resident Care Managers had split roles as the facility Infection Preventionist and as the Staff Development Coordinator. REFERENCE: WAC 388-97-1620 .

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to develop, evaluate, and implement a Facility Assessment (FA) to determine the resources required to meet resident needs. The failure to accurately/comprehensively assess resident needs identified by their physical conditions, resident's cultural needs, staffing levels required, the education/training and competencies required by staff, and the physical environment placed residents at risk for unmet needs. Findings included . Review of the facility's 04/24/2023 FA included facility contact information included only Staff A (Administrator) but did not include the Director of Nursing, the Governing Body Representative(s), the Medical Director, or any other staff involved in the development of the Facility Assessment (FA). The FA included a Cultural Considerations section that included another facilities name in the header. This section showed a resident's average age, gender, religion, and ethnicity to include Caucasian, Hawaiian, and Hispanic residents, but did not include all ethnicities to represent the current population as observed at the facility, such as African American or Asian. In an interview on 07/27/2023 at 2:46 PM Staff A (Administrator) stated the FA provided was their facility assessment and not another facilities, the other facilities name was left on the assessment because the other facility built the assessment and the FA was completed by the home office. The FA did not include a Resident Profile section that showed the facility's average daily census, or average number of resident's admitted /discharged . The profile did not contain resident's acuity level (the level of care required based on the resident's medical/physical condition), diseases/conditions, physical disabilities or cognitive/thought/decision-making ability disabilities that the facility could successfully manage/treat. There was no list of common diseases that required complex medical care for which the facility was able to provide care and services. The FA showed a list of Disease types and the number of residents identified with these diseases. The last column showed what Special equipment if needed might be required for resident care. All of this information was left blank and unanswered. For example the facility documented a resident with diabetes did not require special equipment to manage the disease. A person with diabetes might need a machine used to measure blood sugar levels. A second section showed the development of the FA required, specific clinical needs, and was separated by the amount of staff assistance the resident required. There was no information in this section, all left blank. Additional columns showed environment modifications, actions and competencies needed, that were all left blank. In an interview on 07/27/2023 at 3:40 PM Staff C (Resident Care Manager/Staff Development Coordinator) stated a resident with diabetes would need special equipment like a glucometer (a machine used to measure blood sugar levels), lancet ( a needle), test strips (used to check a blood sugar level), alcohol swabs, and emergency medication to prevent blood sugar levels from dropping too low. The FA showed a Position/Workforce section that included positions, total numbers and desired number of staff for the positions. Review of the management section showed no documentation of a Staff Development Coordinator, Admissions Coordinator, Physicians, or Nurse Practitioners. The nursing section showed the facility did not identify the current number of staff in those positions to include; licensed nurses, nurses aides, physical therapist, occupation therapist, speech therapist, receptionist, activity aides, cooks, dietary aides, and housekeepers. This section did not include a staffing plan that identified the number of staff, the type of staff that was needed to meet all the residents needs based off the assessment, a individual staff assignment that showed how the facility determined and reviewed individual staff assignments. The FA showed a Workforce Profile that included a section for staffs professional requirements and listed administrative staff, direct care staff, and volunteers, and others. There was a column that showed Competencies (ability to perform resident care) related to resident care as needed. The competency columns were left blank for all professionals identified, including licensed nurses, nurses aides, and the social worker. Multiple pages in this section were left blank. This section did not identify the staff training or competency needs required to care for the facility's resident population In an interview on 07/27/2023 at 4:00 PM Staff A stated they would expect the FA to include any special equipment required to treat resident disease processes. Staff A stated they would expect the position/workforce profile to include current levels of staff positions, all positions have competencies listed to ensure staff are able to provide care, and training's and education requirements to meet the residents needs. The FA showed a section titled List Survey History and changes that have been made to systems, this page was left blank. The FA showed a Building and Physical Environment section that identified building elements. Under dining room notes, documentation showed plans submitted to state for renovation. In an interview on 07/27/2023 at 2:46 PM, Staff A stated there were no plans to renovate the dining room. Staff A was unable to provide any plan that was submitted to the state for approval of the dining renovation. Staff A stated the dining room renovation was left from previous editions of the FA and was not relevant to the current facility and administration. Staff A stated other information documented on the FA was relevant to the current facility. Staff A stated the FA was not thorough as many pages and sections were left unanswered. Staff A stated they would expect the FA assessment to be thorough to reflect the current resident population and required needs, such as equipment for diseases, required staff training, and needed positions and work forces to meet the identified resident needs through the FA. REFERENCE: WAC 388-97-1620 (1) .

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0843 (Tag F0843)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility failed to have a written transfer agreement with at least one area hospital approved for participation with Medicare/Medicaid programs. This failure placed all residents at risk for delayed transfer and potential lack of access to care, services, and the hospital in the event of an emergency. Findings included . On 07/27/2023 at 1:06 PM Staff A (Administrator) was asked to provide the facility transfer agreement. An undated document was provided that showed it was an example of what a transfer agreement should include but was not specific to the facility and did not include facility information or identify a local hospital with which the facility had an agreement for transferring residents if a facility emergency arose requiring that action. On 07/27/2023 at 3:45 PM Staff A stated they would expect the facility to have a transfer agreement with a local hospital but was not able to locate the facility transfer agreement. REFERENCE: WAC 388-97-1620(6)(a).

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff, and include the training program in the Facility Assessment (FA). The failure to ensure the FA included the training program and the failure to provide annual mandatory training on abuse/neglect, mandated reporting, resident rights, communication, dementia care, and behavioral health care, placed all residents at risk for unmet care needs, inadequate quality of care, and diminished quality of life. Findings included . Review of the undated facility Training Requirements policy, showed the facility would develop, implement, and maintain an effective training program for all new and existing staff. The amount and types of training required were based on the FA. All facility staff would be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and would be able to demonstrate competency (ability to perform required care and services correctly) in the topic areas of the training program. Review of the 04/24/2023 FA, showed no indication the facility incorporated required training into the FA as no training plan was identified to meet the resident population needs. On 07/27/2023 at 9:45 AM Staff C (Resident Care Manager/Staff Development Coordinator) was asked to provide a training schedule or documentation to include which annual mandatory training topics were provided to staff, on what date, and for how long. Staff C was unable to provide any documentation to support the facility had a training plan for any staff. During an interview on 07/27/2023 at 3:45 PM Staff A (Administrator) stated they would expect the training needs of the facility staff be identified and incorporated in the FA to ensure staff would meet resident's specific needs and be competent on the mandatory/required training topics. REFERENCE: WAC 388-97-1680 .

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility failed to ensure that Nurses' Aides (NA, Certified Nursing Assistants) received the required 12 hours of mandatory in-service training for 3 of 3 NA's (Staff D, E & F) reviewed for mandatory staff education. This failure place all residents at risk for receipt of inadequate care by staff, unmet care needs, potential abuse or neglect, and a diminished quality of life. According to the undated facility Training Requirements policy, training requirements should be met prior to facility staff independently providing services to residents, annually, and as necessary based on the facility assessment. The Staff Development Coordinator (SDC) would maintain a training schedule and a documentation system for completed training's for all staff. Documentation of required training would be forwarded to the human resource department and maintained in the staff member's personnel file. Findings Included . <Staff D> A review of the undated facility Hire and Annual Due Dates employee list showed Staff D, (Restorative Aide/Certified Nurses Aide), was hired on 02/01/2021. The facility was not able to provide documentation that showed Staff D received 12 hours of continuing education as required. <Staff E> A review of the undated facility Hire and Annual Due Dates employee list showed Staff E, (Certified Nurses Aide), was hired on 04/04/2022. The facility was not able to provide documentation that showed Staff E received 12 hours of continuing education as required. <Staff F> A review of the undated facility Hire and Annual Due Dates employee list showed Staff F, (Certified Nurses Aide), was hired on 03/04/2021. The facility was not able to provide documentation that showed Staff F received 12 hours of continuing education as required. In an interview on 07/27/2023 at 1:06 PM Staff A (Administrator) was asked to provide documentation for NA's that showed 12 hours of completed continued education. At 3:25 PM Staff A was asked again to provide documentation for NA's and stated we don't have it, there was no tracking system in place to ensure NA's received the required 12 hours of continuing education. Staff A stated they would expect the NA's to have 12 hours of continued education offered, completed, and documented as required and the SDC was expected to monitor, track, and document education hours for NA's to ensure the required 12 hours are met. REFERENCE: WAC 388-97-1680(2),(a-c) .

Jun 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to respond timely to a resident with a positive Tuberculosis (TB- a serious bacterial disease that mainly affects the lungs and can be spread to others by coughing or sneezing) test which delayed treatment for 1 of 3 residents (Resident 1), and failed to protect and monitor 2 potentially exposed residents (Resident 3 & 5), these failures placed all residents, staff, and visitors at risk for acquiring TB, a contagious communicable disease. Findings included . According to the 08/2022 Centers for Disease Control (CDC) Tuberculosis testing and diagnosis guidelines, people who work or live in a high-risk setting like a nursing home should be tested for TB infection. The TB skin test required a person to have a small amount of tuberculin fluid injected into the skin on the lower part of the arm and have the skin test results interpreted within 48-72 hours for a reaction to the TB skin test. The skin would be inspected for redness and an induration (hard raised formation of the skin) by using the fingertips to find margins of the induration and a ruler to measure the induration size. Measurements would be recorded in millimeters (mm) and the size of the induration would determine if the test result was positive. A second step TB skin test would be administered one to three weeks later. If a resident had a positive first step TB test, they would be considered to have a history of positive TB and should not receive TB skin testing. The CDC recommends positive TB test be reported immediately to the local health department. Review of a revised 05/28/2023 facility Administration and Interpretation of Tuberculin Skin Test policy showed the facility would administer and interpret TB skin test in accordance with current CDC guidelines and state and federal regulations. Review of a revised 05/28/2023 facility policy TB Infection Control Plan showed residents were tested for latent TB (infected with TB but no symptoms are present) and screened for TB disease if infected with TB. Residents with a positive TB test would be referred to the physician or medical director for evaluation. Review of a revised 05/28/2023 facility Tuberculosis Exposure policy showed the Infection Preventionist was responsible for notifying the local health department of a confirmed case of Covid-19. Review of a revised facility policy dated 05/28/2023 Responding to Positive TB Tests showed the goal of TB testing was to identify persons infected with TB and to expedite treatment of those at risk for developing TB disease. Procedures for a positive TB test directed staff to obtain the resident's medical history to include any history of positive TB tests, BCG (Bacillus Calmette-Guerin) vaccine (primarily used against tuberculosis in countries where TB is common) status, history of treatments for latent TB infection or TB disease, known exposure to a person infected with TB, risk factors for exposure, and any symptoms of TB. If the resident's skin TB test was positive, the medical director or another qualified practitioner would observe TB reactions and confirm the findings. The physician would be notified to perform a medical evaluation of the resident with the positive TB test. The policy showed staff would notify local health officials and follow any recommendations. The facility should educate employees, residents, and/or resident representatives about latent TB infection and risk factors for progression of TB disease. The resident would be exempt from further TB testing. Review of a revised 05/28/2023 facility Treatment of Non-Infectious Tuberculosis policy showed the facility would document a treatment plan for the tuberculosis and should include the reason for treatment, name and contact information of the TB expert in charge of the TB treatment regimen, description of the treatment regimen to include the name, dosage, frequency, and duration of treatment, monitor the resident for reactions to the medications, address adherence to the the treatment, and methods for evaluating the response to the treatment. The treatment plan would be included in the resident's care plan (CP). Resident 1 According to the 05/23/2023 Medicare 5-Day Minimum Data Set (MDS-an assessment tool) Resident 1 admitted to the facility on [DATE] and was re-admitted on [DATE] after a short hospital stay for chest pain, a potential symptom of TB. Resident 1 was assessed as able to make their own decisions and needs known. Review of a 05/16/2023 PO directed staff to administer a TB skin test to Resident 1 on 05/16/2023 and read the TB test results on 05/19/2023. A 05/23/2023 PO directed staff to administer a second step TB skin test on 05/23/2023 and read the TB test results on 05/26/2023. Review of a 05/19/2023 Nursing Progress Note (NPN) showed Resident 1 was observed with an induration (hardened, raised area that can be felt) of 1.9 cm (centimeters) by 1.9 cm at the TB injection site on the right forearm. A second NPN on 05/19/2023 showed Resident 1 was put on isolation related to a positive TB test result and a chest x-ray was obtained. Staff documented they would continue to monitor Resident 1. The NPN did not show what type of isolation was initiated, if the physician was notified, or what was done to protect the resident's roommate from the potential TB exposure. Review of Resident 1's clinical record showed no indication, on 05/19/2023, the facility obtained the resident's medical history pertaining to TB, the medical director or qualified practitioner observed the TB reaction or confirmed the findings. There was no documentation the resident's physician was notified for a medical evaluation, or the resident was provided education on TB and risk factors associated with TB. A 05/22/2023 physician note showed Staff D (Medical Director) documented the provider informed me this morning that Resident 1 had a positive TB test, had no symptoms, a chest x-ray was completed, and the chest x-ray results were negative for pulmonary TB. Review of a 05/23/2023 Physicians Order (PO) directed staff to obtain a Quantiferon TB Gold Test (a blood test that detects Mycobacterium tuberculosis, the bacteria that causes TB). According to the May 2023 Medication Administration Record (MAR) facility Staff E (Licensed Practical Nurse) administered a 2nd step TB test, on 05/23/2023 four days after the first TB test was positive, contrary to prescribed testing procedure. Staff E documented administering the TB test to the same right arm and test results returned positive. On 06/08/2023 at 8:47 PM, email communications with Staff B (Director of Nursing) showed Staff C (Infection Preventionist/LPN) spoke with Staff E and confirmed they did administer the 2nd TB step, despite the first TB test being positive, contrary to procedure. Review of the 05/25/2023 Quantiferon test results, for Resident 1, showed Resident 1 had a positive result. The facility received the results on 05/25/2023 at 5:26 AM, according to the lab test results. There was no documentation to show that staff received, acknowledged, or acted upon this information. A 05/26/2023 NPN showed Staff B documented Resident 1 had a positive Quantiferon test and airborne isolation (used to help prevent the spread of pathogens that can remain suspended in the air and required a negative pressure ventilation room) was initiated. Staff B documented a practitioner instructed facility staff to remove Resident 1's roommate (Resident 2) to a private room with airborne precautions. The NPN showed Resident 2 was not moved to a private room but to a room with another resident increasing potential exposure risks. The NPN then showed the same practitioner directed staff to treat Resident 1 as person with latent TB and return Resident 2 to the room. A 05/26/2023 NPN showed Staff B documented speaking with the local health department, eight days after Resident 1's initial positive TB skin test. Staff B documented no changes will be made at this time and Resident 1 remains on airborne isolation. Review of a 05/28/2023 NPN showed Staff B documented Resident 1's new status of a positive Quantiferon blood test, three days after notification. Staff B spoke with a practitioner who wanted the medical director to be involved with the decisions for treatment. According to the 05/28/2023 NPN, there was no response from the medical director. The practitioner instructed the facility to send Resident 1 to the local hospital for a negative pressure room (pulls air out of room) where airborne isolation precautions could be implemented as the facility does not have a negative pressure isolation room. This was nine days after Resident 1's initial positive skin test. Review of 05/28/2023 Hospital discharge instructions directed staff to have close follow-up with the primary care physician for continued treatment for suspected latent asymptomatic TB and a close follow up with a referred infectious disease provider. The follow up with the Infectious Disease provider had not occurred as of 06/12/2023. Review of a 05/28/2023 NPN showed Resident 1 would remain on airborne precautions in the facility. Resident 1 returned to the facility to the same room with PO's to start medication for TB treatment. Review of Resident 1's clinical record showed no PO for isolation and no CP in place to instruct staff in how to manage a resident with positive TB. Observations on 06/02/2023 at 2:40 PM showed Resident 1 in bed, an isolation cart was observed outside the door, no sign was observed on the door, and the door was open. The resident had no comments at this time. Staff F (Corporate Nurse Consultant) stated on 06/12/2023 at 8:00 AM, in an email, Resident 1 was screened by the nurse on 05/19/2023 at 2:51 PM and 8:21 PM per the respiratory screen in the PO's. Review of the May 2023 MAR showed on 05/19/2023 Resident 1 was screened for Covid-19 symptoms and not common symptoms of TB. Review of Resident 1's clinical record showed a 06/09/2023 NPN that Staff C documented attempts to make an appointment with Infectious Disease x 3 times with no response. This was 12 days after the referral was made. In an email communication at 06/12/2023 at 8:00 AM Staff F was asked if Resident 1 was seen by the Infectious Disease provider as referred by the hospital provider on 05/28/2023. Staff F stated staff processed the order and clarified processed meant the Resident Care Manager (RCM) called and requested the appointment for the Infectious Disease. As of 06/12/2023, fifteen days after the referral was made Resident 1 still was not seen by the Infectious disease provider, <Resident 2> According to the 04/30/2023 Quarterly MDS Resident 2 was able to make their own decisions, needs known, and shared a room with Resident 1. Review of a 05/19/2023 NPN showed Resident 2 was moved from their room to a different room due to a medical isolation requirement in which Resident 3 was already residing. Review of Resident 2's demographic information record (date, status, and current room in facility) showed on 05/23/2023 Resident 2 was moved back into the previous room with Resident 1. A 05/26/2023 Provider encounter note showed Resident 2 was seen for an acute visit for exposure to TB, one week after their roommate tested positive for TB. The Provider documented they would check Resident 2 for TB to ensure the resident was not infected and directed staff to monitor Resident 2 for TB symptoms of generalized weakness, weight loss, fever, and night sweats. Review of Resident 2's Quantiferon lab result showed the blood work was collected on 05/26/2023 and result positive for TB on 05/28/2023. A 05/28/2023 NPN showed Resident 2 was sent to a local hospital for the positive TB and returned the same evening with PO's to start medication for TB treatment. Review of Resident 2's record showed no PO for isolation and no CP in place for the how staff were to care for a resident with positive TB. Observations on 06/02/2023 at 2:40 PM showed Resident 2 in their wheelchair eating lunch, an isolation cart was observed outside the door, no sign was observed on the door, and the door was open. The resident had no comments. <Resident 3> According to the 04/16/2023 Quarterly MDS Resident 3 was not able to make decisions or their needs known due to their medical diagnoses. In an interview on 06/02/2023 at 11:45 AM Staff C stated Resident 2 was moved into the room with Resident 3 on 05/19/2023. When asked if Resident 3 was being monitored for TB symptoms, Staff C replied all residents are being monitored for TB symptoms. Review of Resident 4's record and progress notes showed no documentation that Resident 3 was potentially exposed by Resident 2, no documentation that Resident 3 was screened for TB symptoms, isolated, or followed up performed by a medical provider for this potential exposure. The only documentation the facility provided was related to Covid-19 symptom screening, not TB screening. Review of Resident 3's PO's showed a 06/06/2023 PO that directed staff to perform a respiratory screen, eighteen days after Resident 3 was potentially exposed. <Resident 4> According to the 05/29/2023 admission MDS Resident 4 admitted to the facility on [DATE] and was able to make their own decisions and needs known. A 05/26/2023 NPN showed Resident 4 had a positive TB test, but no symptoms. The NPN did not indicate the size of the induration from the TB test, if the Provider confirmed the findings, and what type of isolation was initiated. Review of the Resident 4's clinical record showed no PO for isolation. Review of Resident 4's immunization record and May 2023 MAR on 06/02/2023 showed no indication of TB test results in the record. A 05/27/2023 NPN showed staff would continue Droplet Precautions for Resident 4 and the Provider ordered a chest x-ray to rule out TB. A 05/28/2023 NPN showed Resident 4's chest x-ray returned negative and the Provider ordered the Quantiferon TB blood test. Review of a 05/29/2023 Provider encounter note showed Resident 4 had already been in the facility for sufficient amount of time to transmit TB and since Resident 4 was asymptomatic there was no need for transfer to the hospital. Observations on 06/02/2023 at 2:38 PM showed Resident 4 in their room eating lunch, no isolation cart or signs was observed on the door. The resident stated they had no concerns. Review of Quantiferon TB lab results showed the blood work was collected on 06/04/2023, one week after the resident was seen by the Provider and ordered the test on 05/29/2023. The lab result on 06/09/2023 as indeterminate. Review of Resident 4's PO's showed a 06/08/2023 PO that directed staff to do a respiratory screen and monitor the resident for symptoms of cough, chills, fatigue, headache, sore throat, shortness of breath, loss of taste or smell, chills, fever, vomiting, nausea, and diarrhea. Staff provided documentation that showed they were monitoring for Covid-19. In an email communication on 06/08/2023 at 8:47 PM Staff B and Staff F stated the measurements of the first TB test are unknown because they were not documented. The nurse who preformed the test reported to Staff B the induration was slightly larger than a pencil eraser, about 6 mm (millimeters). Staff B was asked if this was considered a positive test result, Staff F replied the nurse did measure it but did not document. Staff B and Staff F considered the test results to be positive. A 06/12/2023 Provider encounter note showed the Provider saw Resident 4, four days after the Quantiferon TB results returned. The provider documented initial Quantiferon results were indeterminate and repeat tests showed the same results. The Provider documented I will treat for acute or latent Tuberculosis and will consider other treatment if Resident 4 developed symptoms. A 06/12/2023 NPN showed Staff C documented the facility would monitor the residents closely for signs and symptoms of active TB. <Resident 5> According to the 05/24/2023 admission MDS Resident 5 admitted to the facility on [DATE] and was able to make their own decisions and needs known. Resident 4 moved into the room with Resident 5 on 05/23/2023. Review of a 05/27/2023 NPN showed after a four day delay Resident 5 was placed on alert for a potential exposure to TB because Resident 4 was positive for TB. Review of PO's showed no PO for staff to monitor Resident 5 for TB symptoms. A 05/30/2023 NPN showed Resident 5 or their family was not educated upon discharge about the potential TB exposure, what steps to take if symptomatic, and the risk of exposing others in the community. In a electronic communication on 06/12/2023 at 8:00 AM Staff F stated the facility did not obtain PO's for isolation or CP's for isolation. Staff F stated the current practice was to place signs on the door and appropriate Personal Protective Equipment (masks/gowns) outside the door for staff to use. REFERENCE: WAC 388-97-1360(1)(a)(b) .

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to thoroughly investigate allegations of abuse, resident to resident altercations, and trendable intrusive behaviors as potential abuse. Failure to thoroughly investigate detracted from the facility's ability to prevent further repeated and potential abuse for multiple residents including, but not limited to Residents 1, 2, 3, 4 & 5. Findings included . Resident 1 Review of the 12/20/2022 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 was severely cognitively impaired, exhibited no behaviors towards others, and did not wander. The resident was assessed with medically complex conditions, including Dementia. Review of Resident 1's record showed the last Elopement Screen was dated 12/16/2022 and indicated the resident exhibited no wandering behaviors. Review of the 08/01/2022 Care Plan (CP) showed Resident 1 was at risk for psychological or emotional harm related to a resident to resident altercation. Interventions included directives to staff to monitor for changes in behavior such as combative or resistive with care, social withdrawal. The 03/16/2022 Self-Care deficit CP was revised 03/21/2023 to add, If resident is going in to other residents rooms, offer 1:1 activities and remove from other residents room. During an interview on 03/21/2023 at 12:36 PM, Resident 2 stated that two days prior Resident 1 was trying to grab her boobs. Resident 2 stated, This morning he came to my door, just staring at me. Resident 2 stated they were on the phone with their son who said to scream for help. Resident 2 stated that two staff were there and intervened as Resident 1 was pushing to get in the room. Resident 2 stated that staff kept saying, He's okay, he's okay. We'll get him out of here. Resident 2 stated they did not want to go out in the hall as Resident 1 sat right outside the door. On 03/21/2023 at 12:45 PM, Resident 1 was observed seated outside their room, in the hallway across from Resident 2's room. Resident 1 waved hand gesters at a male resident who passed by. During an interview on 03/21/2023 at 1:08 PM, Staff C (Social Services Director) stated the other day Resident 1 was at Resident 2's door making inappropriate comments and gestures. That did not sit well with Resident 2 who wanted to discharge. Again this morning Resident 1 was at the door trying to push his way in. Resident 2 felt uncomfortable and wanted to leave. Staff C denied Resident 1 exhibited adverse behaviors, and noted that this was an isolated incident. Resident 1 sat out in common areas and didn't bother a lot of people. During an interview on 03/21/2023 at 2:28 PM, Staff B, (Director of Nursing), stated that Resident 1 was non-English speaking, not conversational, but understood basic questions. Staff B stated Resident 1 was super nice to female staff, mean to male staff and able to be redirected when they wandered off. Staff B stated they had no complaints from other residents, and stated, He doesn't really cause any trouble. Review of the facility 03/20/2023 Incident Investigation showed no statements from the nursing assistants who cared for Resident 1 or Resident 2. There were no interviews with other Residents to determine if the incident was isolated or if others had negative interactions with Resident 1. The action plan listed was monitoring for potential psychosocial harm, provide inservice education for resident redirection and provide redirection of Resident 1 back to their room. During an interview on 03/21/2023 at 2:28 PM, when asked if they interviewed any other residents, Staff B stated Resident 2's roommate was not in the room when the incident occurred. When asked if residents were interviewed to determine if Resident 1 exhibited similar behaviors with other residents, Staff B stated, No, I didn't. When discussing actions taken to protect the residents, Staff B stated that Resident 1's Power of Attorney was resistant to moving Resident 1. Staff B stated they did not put Resident 1 on one-to-one supervision, but noted that Resident 1 should be in line of sight of staff. During an interview on 03/21/2023 at 12:45 PM, Staff D (Registered Nurse) stated Resident 1 moves around the unit, knocks on doors, and goes into rooms. Staff D stated they watch Resident 1, tell them not to go into rooms, but they don't listen. When the staff redirect, Resident 1 shows their fist, throws whatever they have in their hands. During an interview on 03/21/2023 at 1:35 PM, Resident 3 stated that one day Resident 1 wheeled their wheelchair in front of Resident 3's doorway and they could not get out. Resident 3 stated his son moved Resident 1 away and Resident 1 yelled and swore. Resident 3 stated there were a lot of people around when it happened, but they did not intervene. Resident 3 stated that when they pass by Resident 1, He gives me a dirty look. Resident 3 stated that when Resident 1 goes into his room, Resident 1 talks and swears at him. Resident 3 clarified, I can't understand him, but it sounds like it. Review of Resident 3's record showed no altercations with, or incidents involving Resident 1. There was a 03/13/2023 progress note that Resident 3 left the facility with their son to go to an appointment. During an interview on 03/28/2023 at 12:42 PM, Resident 3's Representative recalled Resident 1 saw they were in a hurry to leave and Resident 1 stopped, blocked the doorway and wouldn't let us leave. Resident 3's Representative stated they were able to squeeze out and told an attendant that Resident 1 was blocking them. The attendant went and moved Resident 1 out of the area. Resident 3's Representative they had seen Resident 1 block areas of the hallways, and by the nurses station, which made it tough for residents in wheelchairs to pass by, either in front of or behind Resident 1. Resident 3's Representative stated Resident 1 was very nosey as they had seen Resident 1 go into the doorways of other resident's rooms. Staff sometimes sat and watched Resident 1, other times they went into the room and brought Resident 1 out to sit in the hallway. During an interview on 03/21/2023 at 12:53 PM, Resident 4 recalled they were out in front of the nursing station the other day, Resident 1 was pulling Resident 4 backwards. Resident 4 stated they got the staff's attention and they pulled Resident 1 away. Resident 1 was making hand gestures like they wanted to hold hands and came back at me. Resident 4 stated they kept their door closed, they did not want Resident 1 in the room. In the past Resident 1 had opened the door and staff caught them before they got in the room. During an interview on 03/21/2023 at 1:38 PM, when asked if they had problems with any other resident, Resident 5 described Resident 1 and stated they come by and push their room door open. Resident 5 stated no staff respond or redirect Resident 1. Resident 5 stated they yell at Resident 1 to Shut my Mother F***** door! During an interview on 03/21/2023 at 2:28 PM, when informed of the results of resident interviews, Staff B stated they were not previously aware of Resident 1 exhibiting those behavior. Reference WAC 388-97-0640 (6)(a)(b). .

Jan 2022 39 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

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Based on interview and record review the facility failed to recognize, assess, and treat pain for 1 (Resident 23) of 5 residents reviewed for pain management. Failure to consider administration of pain medication prior to care and services that were clearly and repeatedly identified by staff to cause pain, caused Resident 23 to experience untreated pain, and for a reasonable person would result in fear and emotional distress. Findings included . Resident 23 According to the 11/02/2021 admission Minimum Data Set (MDS- an assessment tool), Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, had no rejection of care, and had one sided paralysis. This MDS showed the resident required extensive two-person physical assistance for bed mobility and transfers, received a regularly scheduled pain regime, and as needed pain medication. According to the Bowel and Bladder Care Area Assessment associated with this MDS, pain was a modifiable factor contributing to urinary incontinence. According to a 10/26/2021 Pain assessment the resident reported having occasional pain or hurting in the past five days which limited day-to-day activities because of pain. In an interview on 01/04/2022 at 10:23 AM Resident 23 indicated they previously worked with therapies, but stopped participation related to issues with knee pain. Resident 23 stated they recently received injections in their knees due to excruciating pain because of bone-on-bone issues in their knees. They elaborated they had no pain when lying in bed without movement, but movement or standing caused unbearable pain and that staff disregarded the significance of the pain. Occupational Therapy (OT) notes dated 10/28/2021 showed the resident Reported pain in her butt 10/10 while lying in bed, R [right] shoulder pain 8/10 while lying in bed . patient did not tolerate ROM [range of motion] to left shoulder. Attempted sit > stand [an exercise going from a sitting to a standing position] several times . R[ight] knee brace not used as part was missing. Patient unable to come to full stand with maximum Assist Physical Therapy (PT) notes dated 10/29/2021 showed staff tried the [bike exercises] patient having too much pain in [their] legs . and patient sitting in wc [wheelchair] had c/o [complained of] pain in left thigh. Review of November 2021 MARs (Medication Administration Records) showed Resident had physician orders for Gabapentin three times a day for neuropathy (nerve dysfunction which can cause numbness, tingling, and pain in the affected area) and had as needed orders for Baclofen up to four times a day for muscle spasms, Ibuprofen every six hours for moderate pain, and Tylenol as twice a day for pain. According to these MARs, nursing staff documented three times a day for each day the resident experienced no pain. According to PT notes dated 11/04/2021 at 8:36 AM, attempt to stand multiple times patient having too much pain in right knee . Review of November 2021 MARs showed the resident was not offered pain medication prior to this therapy session. PT notes dated 11/05/2021 at 12:44 PM showed, patient is stating that [their] bottom hurts and did not want to get out of bed .with encouragement patient sat EOB [Edge of Bed]. Review of November 2021 MARs showed staff did not offer or provide as needed pain medication on this day. Physical Therapy notes dated 11/08/2021 showed, patient stated [they] had fallen a couple days ago, did not want to get out of bed .patient refused to do any therapy .and began to get verbally abusive . There was no indication facility staff assessed the reason behind the resident's refusal and did not rule out pain as a rationale for refusal. Review of November 2021 MARs showed staff did not offer or provide as needed pain medication on this day. November 2021 MARs showed on 11/09/2021 Resident 23 received Tylenol at 11:16 AM. Therapy notes dated 11/09/2021 at 6:26 PM showed patient received Tylenol for R[ight] knee pain, however, refuses to continue despite several attempts, talked with DON [Director of Nursing] about pain and [patient's] request for cortisone shot in knee. There was no documentation to show how soon after the Tylenol administration that therapy was provided, or that staff considered the resident's continued refusal to participate was related to the Tylenol being ineffective. There was no indication facility staff acted on the resident's request for cortisone treatments. PT notes dated 11/10/2021 showed attempted standing pt [patient] unable secondary to c/o R knee pain, Tylenol on board and R knee brace donned without effectiveness. OT notes dated 11/10/2021 showed pt limited by R knee pain . Review of November 2021 MARs showed staff did not offer or provide as needed pain medication on this day. Physical Therapy notes dated 11/11/2021 at 2:54 PM showed staff applied, SWD (Short Wave Diathermy- a therapeutic treatment most commonly prescribed for muscle and joint conditions. It uses a high-frequency electric current to stimulate heat generation within body tissues), to the lateral R knee secondary to pt c/o pain limiting effort and ability. While staff provided the billable service of SWD, staff failed to consider or offer pain medication. PT notes dated 11/12/2021 showed staff provided SWD to work on decreasing R knee inflammation prior to performing lower extremity activities including Range of Motion. No pain medication was offered or provided. Therapy notes dated 11/15/2021 showed diathermy was provided to the resident's right knee, to improve decreased pain in right knee. PT notes dated 11/16/2021 at 4:48 PM showed the SWD was provided and staff attempted to see pt, pt reply's with excuses not to get out of bed .Pt continues to come up with excuses not to get OOB, educated pt on importance of participation and OOB activity to continue to progress. Facility staff failed to rule out pain as a cause for refusals and did not offer or provide pain medication prior to therapy. Physical Therapy staff documented on 11/18/2021 that SWD was provided to assist with pain management allowing for improved effort and ability to perform therapy. Staff further documented with attempts to walk the resident again resistant to therapy. Record review showed no as needed pain medications were offered or provided despite documented need for pain management. PT notes on 11/19/2021 showed SWD services to decrease pain were provided in conjunction with working on foot placement related to transfers. Record review showed no as needed pain medication was offered or provided. PT notes dated 11/22/2021 showed, pt c/o pain with R knee with all standing. Similar PT notes dated 11/23/2021 showed staff had to provide, .multiple rest secondary to c/o R knee pain without resistance . and low standing time up to 25 [feet] at best secondary to c/o R knee pain despite bio-freeze (a topical menthol gel for sore muscles and joints). OT notes dated 11/23/2021 showed Pt demonstrated fear of pain/falling. While the November 2021 MAR showed the resident received Tylenol at 1:49 PM on 11/22/2021 and at 12:36 PM on 11/23/2021, there was no indication the pain medication was provided as a premedication for therapy or assessed for effectiveness. Further OT notes dated 11/24/2021 showed, .pt demo fear of falling with movement with R knee pain impacting performance . Review of 11/24/2021 MARs showed the resident received as needed Tylenol only at 3:07 AM, not in conjunction with or prior to any Therapy. PT staff documented on 11/30/2021, pt states 2/10 pain without movement, 9/10 with movement and Manual stretching to [Left Lower Extremity], limited Rand of Motion d/t [due to] tightness and c/o pain despite Tylenol on board. Pt resistive and non-compliant with therapy session. Contrary to the therapy note, review of November 2021 MARs showed Resident received as needed Tylenol once on 11/30/2021 at 1:20 AM, and received no other as needed pain medication this day. Physical Therapy notes dated 12/01/2021 showed, Pt .continuously refuses standing and stand pivot transfers and often is verbally abusive. Many attempts to decrease pain have been attempted such as SWD, bio-freeze and soft knee brace donned prior to movement to no avail. Record review showed no indication facility staff considered providing pain medication prior to therapy sessions based on the identified pain the resident experienced with movement and standing. According to a Risks/Benefits form dated 12/02/2021 staff advised the resident of the risks associated for Refusing to get out of bed and refusing therapy. Staff documented multiple risks of not getting out of bed including, may contribute to increased pain, especially in lower back and multiple benefits which included, May contribute to less general pain. Staff did not identify the reason for refusing to get out of bed or refusal of therapy or consider pain as the reasons for refusals. Therapy notes dated 12/03/2021 showed Pt refuses all therapy even pain relief but failed to identify what pain relief was offered. Provider notes by the Advanced Registered Nurse Practitioner [ARNP] dated 12/02/2021 showed, Seen at bedside, she feels sad, depressed and she hurts. Her knees hurt most. Is interested in starting lidocaine patches to bilateral knees . Physical therapy notes that she has some difficulty with knee pain and recommend a steroid injection. In an interview on 01/07/2022 at 12:17 PM, Staff B (Director of Nursing) acknowledged Resident 23 refused therapy related to complaints of pain stating the resident had bone on bone in the knees. Staff B stated the plan was for Resident 23 to get (Steroid) injections to both knees, then start therapy back up two weeks after the injections. Record review showed no plan to premedicate the resident for pain prior to therapy and no interventions regarding pain which would increase the resident's participation in therapy. According to Staff B, of the 23 days of therapy reviewed Resident 23 received no as needed pain medication on 18 days. In an interview on 01/10/2022 at 11:56 AM Staff B indicated the facility was aware that standing and movement caused the resident pain. After reviewing therapy notes and MARs, Staff B indicated therapy continued to have the resident perform movement, standing and stand to pivot exercises without benefit of pain medication. At this time, Staff B confirmed staff should have, but did not, objectively reassess the resident's pain after identifying on 11/04/2021 that the resident experienced pain during therapy until 12/02/2021 when the Risk versus Benefit of refusing therapy and transfers was completed. When asked why there was a three-week delay from the PT note on 11/09/2021 to when the Provider ordered steroid injection on 12/02/2021, Staff B replied, I thought I told the ARNP, but there is no note . In the interview on 01/10/2022 at 12:05 PM, Staff B stated the standard of practice for residents identified to experience pain with therapy was, .to do a pain assessment, and premedicate, reassess to see the effectiveness and refer to the doctor. Staff B elaborated the resident should be on alert charting regarding the pain. In an interview on 01/10/2022 at 10:50 AM, Staff AA (Therapy Director) stated if a resident experiences pain, therapy staff normally offer pain medication 30 minutes prior to therapy and schedule it with the nurses. At this time Staff AA confirmed staff should have, but did not provide pain mediation prior to therapy interventions which were known to cause pain, stating, I need to do an Inservice REFERENCE: WAC 388-97-1060(1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved for 2 (59 & 60) of 13 resident's reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform residents of the their findings and the actions taken, precluded the facility from identifying grievance trends and placed residents at risk of feelings of frustration, unimportance, decreased self worth and quality of life. Findings included . According to the April 2017 facility Grievance Policy, upon receipt of a grievance and/or complaint, the Grievance Officer/Designee will review and investigate the allegations and submit a written report of such findings to the Administrator within 5 working days of receiving the grievance and/or complaint. The resident would be informed (verbally and in writing) of the findings of the investigation and the actions that would be taken to correct the identified problems. Resident 59 According to the 12/14/2021 Quarterly Minimum Data Set (MDS an assessment tool) the resident was assessed as cognitively intact, able to understand and be understood in conversation. The assessment showed it was very important for the resident to take care of their personal belongings and somewhat important to have a place to lock up their personal belongings. In an interview on 01/03/2022 at 12:49 PM Resident 59 stated they were missing 3 cell phones and 3 tablets, and staff were notified of the missing items. The resident stated they did not have a phone available in the room and the facility had a portable phone that residents could use but they don't have one now. On 01/04/2021 at 8:53 AM Resident 59 stated the items were missing for awhile and Staff A (Administrator) told the resident, the items must be on the personal inventory list to be reimbursed. During this interview, a drawer with a keyhole was observed at the bottom of the resident's closet that was filled with wound care supplies. Resident 59 stated they don't have a key to the drawer in the closet. Review of the facility Grievance Book showed a 07/23/2021 grievance initiated by Staff A for Resident 59 missing 3 I-Pods. The resolution of the grievance on 08/02/2021, ten days after the grievance was made, showed the resident located the equipment and the solution was to keep items locked in a drawer. In an interview on 01/11/2022 at 3:36 PM Staff L (Social Services Director) stated the maintenance department was notified when a resident needed a key for a drawer to lock up personal items and Staff L did not know if Resident 59 had a key for their drawer. Review of the maintenance log on 1/11/2022 at 3:45 PM showed no indication a key request, for Resident 59, was on the maintenance log. A 07/30/2021 Grievance showed Resident 59 had some electronics go missing. The resolution documented on 08/03/2021 showed could not verify what they meant by electronics. During an interview on 01/06/2022 at 9:06 AM Staff L stated when they spoke with Resident 59 they had located the resident's electronics but then we kept hearing they were missing. We couldn't replace it because no one saw them using any electronics. In an interview on 01/07/2022 at 9:48 AM Staff FF (Activities Director) stated Resident 59 doesn't participate in activities but liked to use electronics in their room, like a tablet or their cell phone. Staff FF saw the resident using their electronics about a month ago. A 08/11/2021 Grievance showed Resident 59 had a grievance initiated by Staff L for 3 I-Pads that went missing. Review of the grievance form showed on 08/12/2021 Staff L documented the resident stated 2 of the 3 I-pads were not working and the resident would supply a receipt for repayment of the missing items. A fourth Grievance was filled on 08/30/2021 for Resident 59's missing 3 tablets. Review of the grievance form showed on 09/03/2021 Staff L documented that the resident had no verification of the missing items, and they continue to make allegations with no proof of purchase or receipt of the items. Staff L further stated they have asked the resident to list purchased items on the inventory list and the resident was aware that no items would be replaced. Review of the 08/17/2021 facility Personal Belonging Inventory showed the resident had 3 cell phones and 1 Kindle tablet. The form was signed by Staff GG (Medical Records). In an interview on 01/06/2022 at 11:57 AM Staff GG stated they were asked to update the resident's inventory list and visualized the 3 cell phones and 1 Kindle tablet. On 01/06/2022 at 9:06 AM Staff L verified the residents personal inventory list showed 3 cell phones and 1 Kindle tablet and they were not sure why the inventory was done on 08/17/2021. Staff L further stated, if it is on the list we need to replace the items or reimburse the resident. During an interview on 01/10/2022 at 9:32 AM Staff L stated they spoke with the resident and confirmed the cell phones are missing. During an interview on 01/12/2022 at 10:41 AM Staff HH (Certified Nursing Assistant-CNA) stated when a resident had a grievance they inform the nurse or nurse managers. In an interview on 01/11/2022 at 3:36 PM Staff L stated grievances should be resolved with 5 days and they expect staff to initiate the grievance form so they can follow up. Staff L stated Resident 59's grievances were resolved in a timely manner with the information they had at that time. Resident 60 According to the 12/14/2021 Quarterly MDS, the resident was assessed as cognitively intact, and able to be understood and understands verbal communication. The assessment showed it is very important for the resident to take care of their personal belongings and somewhat important to have a place to lock up their personal belongings to keep them safe. In an interview on 01/04/2022 at 11:59 AM Resident 60 stated they were missing a razor and 2 blankets that were brought to the resident from a family member. Resident 60 stated they told staff and they are aware. Review of the resident's 02/16/2021 personal inventory list showed 2 blankets. In an interview on 01/12/2022 at 10:41 AM Resident 60 stated they informed a CNA, a laundry staff member, and Staff A (Administrator). In an interview on 01/12/2022 at 10:48 AM Staff A stated the resident did not inform them of the missing blankets. During an interview on 01/10/2022 at 9:32 AM with Staff L (Social Services Director) stated they were not aware of Resident 60 missing blankets and would expect the staff to initiate a grievance form. REFERENCE: WAC 388-97-0460 (1)(2) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate and thoroughly investigate, and timely resolve allegations of misappropriation and resident to resident verbal abuse for 1 of 1 (Resident 16) and 1 supplemental resident (Resident 61) reviewed for abuse. The facility's failure to investigate allegations of verbal abuse and misappropriation detracted from staffs' ability to determine if abuse had occurred and precluded them from identifying and implementing interventions to prevent reoccurrence. These failures placed residents at risk for unidentified and/or continued abuse and misappropriation, as well as feelings of helplessness and diminished self worth, related to the facility's lack of response to their reported concerns. Findings included . Facility Policy According to the facility's undated Abuse Investigation and Reporting [AIR] Policy, all reports of resident abuse, neglect, exploitation, misappropriation of resident property and/or injuries of unknown source will be thoroughly investigated and reported as required to the appropriate local, state and federal agencies. The investigator at a minimum will: interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident; interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; interview the roommate; and interview other resident's. Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 12/12/2021 5 day Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of depression, and demonstrated to behaviors or refusals of care. In an interview on 01/03/22 at 01:47 PM, Resident 16 stated that their fluorescent orange purse, that hung from the side of the bed, was missing for over a month. According to the resident the purse contained a broken cell phone, and two new ones and explained when the old cell phone stopped working, their sister sent a $200 phone which they felt was too expensive, so they asked a facility aide to go buy a cheaper one, which the aide did, so they could return the more expensive one to their sister. Resident 16 indicated the missing purse and phones were reported to the social worker, nurse manager, laundry manager, and multiple aides (did not know staff members names, just title). The resident declined sharing the identity of the aide that they report purchased one of the phones on their behalf citing, I'm not sure if they can get in trouble for that, so I would rather not say. Per Resident 16 after reporting the missing property, no one followed up with them about the status of the missing property and stated, Not having a cell phone is infuriating. On 01/11/2022 at 12:21 PM, when asked if they were aware Resident 16 had a fluorescent orange purse and that it was missing, Staff S (Restorative Aide) stated, Yes, it was about two months ago (that it went missing), it happened once before but I went and found it in laundry. Review of the facility incident log showed no entry for Resident 16's missing purse or phones. Review of the facility Grievance log showed a 11/11/2021 grievance for Resident 16's missing items. According to the 11/11/2021 grievance form [Resident 16] explains two cell phones are missing. The sections on the document titled, Department manager investigative findings, Action Taken, grievance confirmed/not confirmed, Describe solution and Person notified of resolution, remained blank. Under Findings staff documented ongoing-waiting on sister to send cell phone or SS [Social Work] will order a new one. In an interview on 01/07/2021 at 1:28 PM, when informed the facility documented they would reimburse their sister for a new phone or SS would order one Resident 16 said Yeah, they just talked to me about that last night. In an interview on 01/10/2021 a 4:14 PM, Staff B (Director of Nursing) explained when there is an allegation of missing or stolen personal property, the facility should interview the alleged victim to get specifics of the complaint, then check the resident's room and laundry for the item, if not found, interview staff members, other residents (if applicable) to determine when the items were last seen (i.e. investigate). Staff B then acknowledged that there was no indication the facility identified the missing purse/cell phones as an allegation of misappropriation, or that the allegation was timely or thoroughly investigated. Additionally, on 01/03/2022 at 1:59 PM, Resident 16 indicated they had an incident with another resident and explained they often heard Resident 62 in the hallway asking for snacks form staff. Per Resident 16, Resident 62 sounded very outgoing so I sent a note and some cookies [to Resident 62's room] saying hey let's have a conversation sometime. The next when [Resident 62] was going by my room I said, How are you doing and [Resident 62] said 'I don't talk to b*tches.' I said I'm not a b*tch.[Resident 62] waved their hand and said 'Everybody here knows you're a b*tch.' That is one of the most hurtful things that has ever happened to me, that's why I wanted to talk to a manager. Per Resident 16 they reported the incident to Staff S and Staff TT (Evening Nurse Manager, Registered Nurse). During an interview on 01/11/2022 at 12:21 PM, Staff S said Resident 16 told me [Resident 62] said some rude things to them or was making fun of them, but then moved on, so I wasn't sure if it was a big deal. Staff S indicated they did not specifically remember Resident reporting that Resident 62 called them a B*tch, but stated, I can see [Resident 62] saying that .[Resident 62] cusses and is not very honest. Staff S then confirmed they did not inform any supervisors of the reported incident stating, [Resident 16] didn't seem that upset about it. In an interview on 01/12/2022 at 1:47 PM, Staff TT, denied Resident 16 informed them of the alleged resident to resident incident. Staff TT did acknowledge because the incident was reported to a staff member it should've been investigated, but was not, as an allegation of verbal abuse. Resident 61 According to the 11/17/2021 Quarterly MDS, Resident 61 had diagnoses including depression, and had no behaviors. The MDS assessed Resident 61 to be totally dependent on the assistance of two or more staff for transfers, and to require extensive, two-person assistance with toileting. Review of the facility Grievance Log revealed Resident 61 filed grievances with the facility on 10/28/2021 and 11/29/2021. Review of the 10/28/2021 Facility Grievance form revealed the form had a liquid spilled on the first page which made parts of Resident 61's handwriting unreadable. On the form, Resident 61 wrote they had to wait a prolonged time period for assistance with toileting that evening after a Zoom (video calling software) call, that CNAs (Certified Nursing Assistants) came to their room at different times individually, but never together, and that at shift change they were told by a nurse the CNAs stated they [Resident 61] refused to be assisted. Resident 61 wrote it felt like I was being called a liar. I am very upset. The Grievance form was signed by Staff L (Social Services Director - SSD) and Staff A (Executive Director - ED). The grievance form concluded that Resident 61 refused to be changed at designated times and staff made efforts to provide care at appropriate intervals. The form included a section to describe the solution, where Staff L wrote Resident agrees to abandon call when she needs to be changed to avoid skin/breakdown issues. The form did not identify which aides were involved. Review of the 11/29/2021 grievance revealed the form was initiated by an unidentified staff member and stated the resident did not remember when the incident took place. The grievance stated Resident 61's call light was on for over two hours while awaiting care, at which point, Resident 61 called the police, and that when police arrived, they were unable to locate staff, and that food temperatures have been cold. In the action taken section, Staff L wrote referred to nursing. In the Resolution section, Staff L stated they referred the food concern to the kitchen and in the Actions/Recommendations section, Staff L wrote Resident need [sic] to call aids [sic]/nursing and address. Under Solution, Staff L wrote that aides offered and Resident 61 refused toileting as they were on the phone. The form was signed by Staff L on 11/30/2021 and Staff A on 12/4/2021. The form did not identify which aides were involved. Review of the facility's Incident Log revealed these grievances were not logged or investigated as allegations of potential neglect. In an interview on 01/07/2022, Staff L (Social Services Director) stated they did not identify the grievances as allegations of neglect, and acknowledged the facility did not obtain witness statements from the aides, and did not know if the facility had a police report associated with the situation, and added nursing investigated it. In an interview on 01/11/2022 at 9:45 AM, Staff B stated that Resident 61 had a history of refusing assistance and manipulative behavior, and thus the facility did not investigate the incident as an allegation of neglect. In an interview on 01/11/22 at 01:31 PM, Staff A stated that the facility did not investigate the grievances, and as a result, did not have statements from the staff involved, or any record of the police visiting the facility. Staff A stated the resident's patterns of behavior may have contributed to the facility's failure to identify the grievances as allegations of neglect. Reference: WAC 388-97-0640 (6)(a)(b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13 A review Resident 13's 10/04/2021 Discharge MDS showed the completed date was 10/30/2021. The transmission date was 11/30/2021, 31 days after completion. In an interview on 01/11/2022 at 12:35 PM, Staff B confirmed the lateness of Resident 13's Discharge MDS and agreed it was not transmitted within the required 7-day period. Resident 43 Review of Resident 43's 06/13/2021 Discharge tracker MDS, showed it was not completed until 07/15/2021, 32 days after the ARD, not within 7 days of the event date as required. During an interview on 01/10/2021 at 3:07 PM, Staff B acknowledged Resident 43's Discharge tracker MDS was not completed within the required timeframe and stated it was, Late. Resident 19 Review of Resident 19's 08/30/2021 Discharge tracker MDS, showed it was not completed until 09/25/2021, 26 days after the ARD, not within 7 days of the event date as required. Review of Resident 19's 09/07/2021 Entry tracker MDS, showed it was not completed until 09/25/2021, 18 days after the ARD, not within 7 days of the event date as required. During an interview on 01/10/2021 at 3:07 PM, Staff B acknowledged Resident 19's 09/07/2021 Entry tracker and 08/30/2021 Discharge tracker, were not completed within 7 days of the event date as required. REFERENCE: WAC 388-97-1000(4)(b), (5)(a). Based on interview and record review, the facility failed complete and/or transmit the required Minimum Data Set (MDS - an assessment tool) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for 4 (Residents 118, 43, 19, & 13) of 7 sample residents with discharges reviewed for resident assessments. Findings included . Resident 118 Review of census documents showed Resident 118 admitted to the facility on [DATE]. According to progress notes dated 12/16/2021, the resident had a change in condition which required transfer to the hospital. Record review showed no MDS which reflected the resident was discharged with return either anticipated or not anticipated. According to an Entry Tracking MDS document, the resident readmitted to the facility on [DATE]. In an interview on 01/05/2022 at 2:11 PM, Staff B (Director of Nursing) reviewed the resident's record and confirmed there should be a Discharge MDS which correlated with the 12/16/2021 hospital discharge.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed for 2 (Residents 2 & 118) of 4 newly admitted residents reviewed, to provide residents and/or their representative with a summary of their baseline care plan (CP). This failure resulted in residents and/or families not being informed of their initial plan for delivery of care and services and placed residents at risk for unmet needs and possible complications. Findings included . Resident 2 According to the 12/20/2021 admission Minimum Data Set (MDS - an assessment tool), Resident 2 admitted to the facility on [DATE] and was assessed as cognitively intact. In an interview on 01/04/2022 at 9:14 AM, Resident 2 stated they were not given a copy of any CP since admission. Record review showed CPs were initiated on 12/14/2021 but no indication facility staff provided Resident 2 with a copy. Resident 118 Review of progress notes showed Resident 118 admitted to the facility on [DATE] and transferred to the hospital due to a change of condition on 12/16/2021. According to the 01/04/2021 admission MDS showed the resident readmitted to the facility on [DATE] and was assessed as cognitively impaired with diagnoses including dementia. In an interview on 01/03/2022 at 2:32 PM, Resident 118's family member indicated no care plan information was provided since the resident was admitted to the facility. In an interview on 01/11/2022 at 7:50 AM, Staff B was able to provide CP documents initiated on 12/29/2021 but was unable to provide documentation to support Resident 118's family was provided a copy of the baseline CP. Similar findings were identified for Resident 2. REFERENCE: WAC 388-97-1020 (3).

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 5 (Residents 13, 2, 14, 66 & 59) of 24 sample residents were provided treatment, care, and services in accordance with professional standards, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure residents received care for non-pressure related skin conditions, edema management, bowel management, alert monitoring and documentation for care and condition changes. These failures placed residents at a potential risk for decline in medical status and quality of life related to unmet care needs. Findings included . Resident 13 According to the 10/14/2021 Quarterly Medicare/5-day Minimum Data Set (MDS - an assessment tool) Resident 13 re-admitted to the facility on [DATE], and had a new primary diagnoses of acute pulmonary edema (fluid in the lungs) with acute respiratory (breathing) failure, and a long-standing diagnosis of end-stage kidney disease which required dialysis. The MDS assessed Resident 13 to be cognitively intact, and able to understand others and be understood. According to the facility policy for Alert Charting (undated), the nurse will make a progress note (PN) indicating alert status and include information why a resident is on alert and what symptoms staff should observe and report. Next, on the following shifts, nurses are to document a PN indicating alert charting and document observations during their shift regarding the alert condition. Notification of physician is documented in the PN. A PN dated 10/04/2021 at 7:35 PM showed Resident 13 did not attend the previous day's dialysis appointment on 10/03/2021 at 11:30 AM due to a transportation failure. There were no PNs that showed Resident 13 was placed on alert monitoring on 10/03/2021 for the risk of fluid overload or notification of the facility physician. There was no PN that demonstrated the facility staff discussed with the dialysis center a plan for care to Resident 13 while waiting for the next available appointment on 10/04/2021. There were no PNs informing the following shifts about the missed dialysis, or the alert charting and monitoring required. A PN on 10/04/2021 at 7:35 PM showed Resident 13 also missed the 10/04/2021 7:00 PM dialysis appointment due to another transportation failure. The PN showed Resident 13 started having labored breathing, shortness of breath, and edema all over (due to fluid overload), the blood pressure (BP) was 194/105 and pulse (P) was 94 beats per minute. Resident 13's vital signs log for 10/04/2021 showed at 1:49 AM, BP was 125/60 and P was 77, at 8:23 AM BP was 148/84 and P was 72, at 3:00 PM BP was 153/92 and P was 68. A PN at 7:35 PM showed 911 was called and Resident 13 was taken to the emergency room. A review of the 10/08/2021 hospital discharge summary (HDS) showed the resident was diagnosed with hyperkalemia (increased potassium in blood), metabolic acidosis (increased acid in blood), uremia (increased waste products in blood) and fluid overload (excess fluid in blood) secondary to the missed dialysis treatments. The HDS showed Resident 13 required emergent hemodialysis during hospitalization to stabilize breathing, blood volume, blood toxic contents, and circulation. In an interview 01/11/2022 at 12:28 PM Staff B (Director of Nursing) stated Resident 13 should have and was not placed on alert monitoring after missing dialysis on 10/03/2021. Staff B stated the nursing staff did not complete shift assessments for possible fluid overload, including lung sounds, vital signs, or edema monitoring and did not notify the physician, thus missing Resident 13's changing condition. Resident 2 According to the 12/20/2021 admission MDS, Resident 2 admitted to the facility on [DATE], was assessed as cognitively intact and required two-person assistance with bed mobility. This MDS showed the resident had multiple medically complex diagnoses including heart failure, high blood pressure, kidney failure and multiple wounds. According to a Baseline care plan (CP) dated 12/14/2021 staff identified the resident was skin at risk with an intervention of elevate bilateral heels with pillow or equivalent as tolerated. A 12/14/2021 CP identified the resident had pressure wounds to multiple locations, including the right heel. Observations on 01/03/2022 at 12:55 PM showed Resident 2 lying in bed, both lower extremities were noted to be swollen, the right greater than the left, with socks indented into the skin. In an interview at this time, the resident stated their legs were swollen, which was why they were recently re-hospitalized . In an interview on 01/04/2022 at 9:17 AM Resident 2 indicated the edema was a problem stating, They [staff] were suppose get me stockings, the doctor said they ordered [them] but they on back order . Similar observations of edematous (swollen with fluid) lower extremities were noted on 01/04/2022 at 8:10 AM, 9:22 AM and 1:20 PM. Observations on 01/05/2022 at 7:45 AM and 9:07 AM showed the resident lying in bed without benefit of lower leg elevation. Record review showed no indication facility staff assessed the resident's edema or provided interventions to reduce the edema. During observations on 01/05/2022 at 10:34 AM, Staff B assessed the resident with 4+ edema on right and 3+ on left, on the shins mid shin. At this time Staff B confirmed staff should, but did not, monitor the edema stating, It should be on the TAR. Staff B subsequently implemented interventions of elevating the resident's lower extremities on pillows and lower leg wraps to decrease edema. Resident 14 According to the 10/18/2021 admission MDS Resident 14 admitted to the facility on [DATE] resident was assessed with multiple medically complex diagnoses including heart disease, diabetes and an above the knee amputation. Observations on 01/03/2022 at 2:35 PM showed Resident 14 had a bandaid to the left forearm, a scab to the left anterior shin and a small scab to the right lateral arm. Similar observations were noted on 01/04/2022 at 8:28 AM. Record review showed no treatment order for a bandaid to the left forearm. According to January TARs, staff performed a weekly skin audit on 01/04/2022 and indicated there were no new skin issues. During a skin assessment on 01/05/2022 at 9:30 AM, Staff B confirmed the presence of the scab on anterior left shin, bandaid on left forearm, and the scab on right arm and identified a new skin issue on the tip of one of the resident's toes. In an interview at this time, Staff B indicated staff should have identified these skin issues during the skin assessment the previous day. Resident 66 According to the 11/16/2021 Quarterly MDS, Resident 66 had diagnoses including dementia, arthritis and muscle weakness, and did not have any instances of constipation during the assessment's lookback period. In an interview on 01/03/2022 at 03:14 PM, Resident 66 stated they experienced occasional constipation and that they took a laxative each morning. Review of Resident 66's MAR revealed the following orders: Docusate Sodium Capsule 100 MG Give 100 mg by mouth in the morning for constipation date 10/06/2021; Milk of Magnesia [MOM]Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth as needed for Constipation if resident does not have a bowel movement for three days, administer milk of magnesia per physician's order on day four dated 05/03/2018; Bisacodyl Suppository 10 MG Insert 10 mg rectally as needed for Constipation if milk of magnesia offers no results, administer a stimulant laxative suppository (Bisacodyl, etc.) per physician order on the next shift, during waking hours only dated 05/03/2018; Fleet Enema [ .] 7-19GM/118ML (Sodium Phosphates) Insert 1 applicator rectally as needed for constipation if resident continues to have no results from suppository, administer an enema on the next shift, during waking hours only . dated 05/03/2018. Resident 66's comprehensive CP included a 11/25/2021 resident has Potential for Constipation CP that directed to follow the bowel protocol for bowel management and to record Resident 66's bowel output. Review of Resident 66's bowel output monitor revealed no bowel movement was documented on 12/18/2021, 12/19/2021, 12/20/2021 and 12/21/2021. Resident 66's 12/2021 MAR revealed no documentation of the administration of MOM as ordered, after three days without a bowel movement on 12/21/2021. In an interview on 1/11/2022 at 09:45 AM, Staff B stated that Resident 66 did not, but should have received treatment for constipation after a three-day interval with no bowel movement. Resident 59 According to the 12/14/2021 Quarterly MDS, the resident was assessed as cognitively intact, able to understand and be understood in conversation, and had diagnoses including Diabetes, Congestive Heart Failure, and Venous insufficiency (Improper functioning of veins in lower legs). Resident 59 was assessed to require extensive assistance from staff for bed mobility, transfers, dressing and personal hygiene. The resident was dependent on staff for toileting. Observations made on 01/04/2022 at 9:25 AM showed Resident 59 had 2 open ulcers (wounds) to the outer right side of their right leg. Review of the resident's clinical record showed on 01/06/2022 a weekly skin check was completed, and no new wounds or skin issues were identified by staff. On 01/07/2022 at 11:24 AM observations were made of wound care for Resident 59. The resident turned on their right side and raised red marks were observed on the left outer hip measuring 10 cm (centimeters) by 2.5 cm. The resident denied scratching their hip and were not sure what caused the red marks. The resident's bottom was observed with redness that caused the resident pain when touched. In an interview on 01/07/2022 at 11:36 AM Staff Y (Wound Nurse) stated they would expect the nurse who completed the skin check to have identified the red marks to the resident's left hip and redness to the buttocks. Reference: WAC 388-97-1060 (1) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure on-going assessments, documentation, and prevention of pressure ulcers consistent with professional standards of practice for 2 (Resident 40 & 2) of 7 residents reviewed for pressure ulcers. Failure to assess and monitor pressure ulcers and implement preventative measures, such as positioning, placed residents at risk for deterioration in skin condition. Findings included . According to 2016 National Pressure Injury Advisory Panel (NPIAP) definitions of pressure injury staging, a Stage IV pressure injury was defined as full-thickness skin and tissue loss with exposed or directly palpable fascia (connective tissue), muscle, tendon , ligament, cartilage or bone in the ulcer. Resident 40 According to the 11/22/2021 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 40 was assessed with severe cognitive impairment, had diagnoses including multiple sclerosis with hemiplegia (paralyzed on one side of the body), and required extensive assistance of two staff members for bed mobility, dressing, and personal hygiene. Review of the MDS Skin conditions section, showed the resident was assessed at high risk for skin conditions, had a unhealed Stage IV pressure ulcer, and was not on a turning or repositioning schedule. Review of the 10/01/2019 Stage IV Sacral Pressure Ulcer (PU) care plan (CP) showed interventions that directed staff to float heels with pillows while in bed, turn/reposition at least every 2 to 3 hours for pressure off loading of the sacrum (base of the spine), and the bed should be as flat as possible to reduce shear. On 01/03/2022 at 1:20 PM Resident 40 was observed lying on their back in bed with their legs on a cushioned wedge, their heels were resting on the cushion. On 01/05/2021 at 8:22 AM Resident 40 was observed lying on their back in bed, the head of the bed (HOB) was slightly elevated. At 10:17 AM the resident remained lying on their back, the HOB was slightly elevated and their legs on a cushioned wedge. Their heels were observed resting on the cushion. Similar observations were made on 01/05/2022 at 12:18 PM and 2:15 PM. On 01/06/2022 at 8:17 AM Resident 40 was observed lying on their back in bed with their legs on a cushioned wedge, their heels were resting on the cushion. Similar observations were made on 01/06/2022 at 12:11 PM. In an interview on 01/06/2022 at 1:34 PM Staff HH (Certified Nursing Assistant) stated the cushioned wedge is used to elevate the resident's legs. During an interview on 01/07/2022 at 10:29 AM Staff Y (Wound Care Nurse/Licensed Practical Nurse) stated the resident should be repositioned every 2 hours and they never refuse to be repositioned. Staff Y stated they would expect the cushioned wedge to be used with the heels floating off the edge to avoid pressure on the heels. Resident 2 According to the 12/20/2021 admission MDS, Resident 2 admitted to the facility on [DATE], was assessed as cognitively intact and required two person assistance with bed mobility. This MDS showed the resident was at risk for pressure ulcers, and had multiple PUs. According to the PU Care Area Assessment (CAA) associated with the admission MDS, staff documented Resident 2, needs assistance with significant movements for adequate pressure relief. Staff assist and encourages frequent repositioning and offloading of heels as able. According to a Baseline CP dated 12/14/2021 staff identified the resident was skin at risk with an intervention of elevate bilateral hells with pillow or equivalent as tolerated. A 12/14/2021 CP identified the resident had pressure wounds to multiple locations, including the right heel. Observations on 01/03/2022 at 12:55 PM showed Resident 2 lying in bed, both heels were noted directly on the mattress with no pillows or devices to offload pressure from the heels A gauze dressing was noted to the right heel. Similar observations were noted on 01/04/2022 at 8:10 AM, 9:22 AM and 1:20 PM. Observations on 01/05/2022 at 7:45 AM and 9:07 AM showed the resident lying in bed without benefit of heel elevation. During an observation on 1/05/2022 at 10:01 AM, Staff B confirmed there were no pillows or positioning devices which would allow Resident 2's heels to be elevated. In an interview at this time, the resident reported staff did not assist with elevating their heels or providing frequent repositioning. REFERENCE: WAC 388-97-1060(3)(b). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to: ensure appropriate safety measures to prevent a fall were implemented for 1 (Resident 14) of 11 Residents reviewed for accidents, ensure hallways were free of accident hazards, and ensure hazardous materials stored in supply closets were secured. These failures left residents at risk for avoidable injury, and exposure to unsafe materials. Findings included . Resident 14 According to the 10/18/2021 admission MDS (Minimum Data Set, an assessment), Resident 14 was assessed with a history of falls and experienced a fall since admission to the facility. According to the falls risk Care Plan (CP) dated 10/12/2021, interventions for safety, related to falls included bilateral floor mats to decrease risk of potential injuries. Observations on 01/03/2022 at 2:35 PM showed Resident 14 lying in bed with one gray fall mat noted on the floor, on the right side of the bed. Observations on 01/04/2022 at 10:14 AM showed the resident lying in bed with a gray fall mat noted leaning up against the wall. A similar observation, of the resident lying in bed with one gray fall mat to the right of the bed only, was noted on 01/05/2022 at 9:05 AM. During observations on 01/05/2022 at 9:33 AM, Staff B (Director of Nursing) confirmed Resident 23 had only one fall mat in the room and that staff should implement the care-planned interventions to prevent injury related to falls. Supply Closets Unlocked On 01/03/2022 at 1:03 PM a door labeled Activity Supplies was observed with a keypad that was unlocked. Upon opening the door, small bins of nail clippers, razors, deodorant, shaving cream and other supplies were observed. Similar observations were made on 01/05/2022 at 8:46 AM. On 01/05/2022 at 9:19 AM a door labeled Housekeeping Supplies was observed unlocked. A bag of fish food and a container of fishpond water cleaner were sitting inside the closet. During an interview on 01/11/2022 at 1:21 PM Staff E (Maintenance Director) stated the doors are usually locked. Staff E looked at the fishpond water cleaner and it showed to keep out of reach of children. Staff E acknowledged the activities supply and housekeeping supply door were not but should be locked to keep residents safe. Hallway Hazards On 01/12/2022 at 7:26 AM, 2 long fluorescent light were observed to be leaning against the wall between the facility's elevators at an angle of 70 degrees. There was nothing securing the fluorescent tubes to the wall or on the ground. In the Fireplace Day Area less than 20 feet from the elevator, an unidentified resident was observed to be using a hand/foot exercise unsupervised at that time. In an interview on 01/12/2022 at 7:27 AM, Staff B stated the tubes were an accident hazard and immediately removed them. Reference: WAC 388-97-1060 (3)(g) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide medically related social services for 3 (Residents 23, 61 & 25) of 7 residents reviewed with behaviors. Failure to follow up after instances of refusals of care left residents at risk for unmet care needs and negative health outcomes. Findings included . Refer to CFR 483.25(k), F-697 Pain Management Resident 23 According to the 11/02/2021 admission Minimum Data Set (MDS- an assessment tool), Resident 23 had multiple complex diagnoses including depression, anxiety disorder, paralysis of the left upper and lower extremities, moderate cognitive impairment, and had no rejection of care but did demonstrate verbal behavioral symptoms towards others. In an interview on 01/04/2022 at 10:23 AM Resident 23 indicated they previously worked with therapies, but stopped participation related to issues with knee pain. The resident also indicated a fear of transfers because they were dependent on staff and, I am afraid I will fall. According to a Risks/Benefits form dated 12/02/2021 staff advised the resident of risk associated for, Refusing to get out of bed and refusing therapy. In an interview on 01/07/2021 at 12:17 P, Staff B (Director of Nursing) stated the resident refused therapy related to complaints of knee pain. Record review showed no indication facility staff attempted to identify the reason behind the resident's refusals or attempted to identifying or seek ways to support the residents' individual needs through the assessment and care planning process. Facility staff failed to identify or promote individualized, non-pharmacological approaches to care that meet Resident 23's needs. Resident 61 According to the 11/17/2021 quarterly MDS, Resident 61 had diagnoses including depression, and was assessed with obvious or likely cavity or broken teeth. On 01/02/2022 at 08:20 AM, Resident 61 was observed with missing teeth, and stated they had more than a few teeth missing. According to a Social Services (SS) progress note, Resident 61 declined treatment by the dental Hygienist on 10/12/2021, and follow up was recommended for two weeks later. SS will continue to support through discharge. Record review revealed no follow up, and no rescheduling, or later attendance of an appointment with the dental hygienist. In an interview on 01/11/2022 at 12:15 PM, Staff L (Social Services Director) stated when a resident rejects care, they look for the cause of the refusal and seek solutions and gave examples such as involving a resident's family or doing a Risk vs. Benefit with the resident. Staff L stated the Hygienist was due to return to the facility two weeks after the missed encounter, and had agreed they would see Resident 61 first, upon return. Staff L stated I sent them a list and haven't heard back from them. I sent a note to them and the dentist. Staff L stated they would look for and provide any documentation to support follow up for Resident 61 seeing the Hygienist. No further documentation was provided. Resident 25 Resident 25 was admitted to the facility on [DATE]. According to the 10/18/2021 Modification of Admission/ Medicare - 5 Day MDS, Resident 25 was cognitively intact with clear speech, able to be understood and understand conversation. This MDS assessed Resident 25 with Multiple Sclerosis (MS - a progressive neurological disease that affects the brain and spinal cord) and demonstrated no rejection of care. According to a Shower/Weight Refusal form, Resident 25 refused a shower/weight today and was signed by staff and dated 12/24/2021. This form directs staff to ask the resident their preference and reschedule, and if this is the resident's second refusal in a row, LN (Licensed Nurse) to investigate and establish why the resident is refusing and take the proper steps to ensure the residents preferences are being met. If LN is unsuccessful, LN is to notify RCM (Resident Care Manager). RCM to notify Social Services and provider if still refusing. In an interview on 01/12/2022 at 1:45 PM, Staff B stated Resident 25's CP and ISP should, but did not, reflect the resident's refusals. Staff B confirmed staff did not have documentation that staff attempted to determine the reason behind the resident's refusals or how staff might meet the resident's needs. Reference: WAC 388-97-0960 (1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and incorporated for 1 (Residents 13) of 5 sample residents and 1 (Resident 36) supplemental resident whose medication regimens were reviewed. This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects and at risk of receiving medications without required pharmacist oversight. Findings included . The facility policy Medication Regimen Reviews (MRR) (undated) showed the consultant pharmacist performs a MRR for every resident in the facility reviewing mediation and are done upon admission and at least monthly thereafter. The pharmacist provides a report to the attending physician within 24 hours and a copy to the Director of Nursing and the Medical Director. Copies of the MRR, including the physician responses, are maintained as part of the permanent medical record. Resident 36 According to the 11/22/2021 Quarterly Minimum Data Set (MDS- an assessment tool) showed Resident 36 was assessed as cognitively intact and had diagnoses of multiple medically complex conditions including end stage renal disease. Review of a 11/09/2021 MMR for Resident 36 showed recommendations to adjust the dosage or frequency for medications as appropriate for residents with a decreased Creatine Clearance (shows how the kidneys are working). The recommendations included a dose reduction for Tramadol (pain medication) to be given at 12 hour intervals and Gabapentin (nerve pain medication) dose to be adjusted based on the creatine clearance. The MRR was not signed by the Physician or in the resident's medical record. Record review on 01/12/2022 showed the Tramadol was changed on 12/28/2021, 49 days after the recommendation was made and the Gabapentin was changed on 12/06/2021. In an interview on 01/12/2022 at 8:30 AM Staff B (Director of Nursing- DNS) stated the Physician's response should be in the resident's record, and MRR's should be completed within 2 weeks or sooner for an urgent recommendation. Staff B confirmed the 11/09/2021 MMR recommendations for Resident 36 were not addressed timely by staff. Resident 13 The 10/14/2021 Quarterly Medicare/ 5-day MDS showed Resident 13 had a MRR and did not have any recommendations for follow up by the physician. A review of Resident 13's progress notes showed the pharmacist completed a MRR on 09/10/2021, 10/12/2021 and 11/09/2021. There were no recommendations in Resident 13's record for any of the MRRs completed in September, October, or November. In an interview on 01/11/2022 at 1:02 PM, Staff B looked in the master MRR book and stated there was one recommendation for 09/10/2021, one for 10/12/2021 and two for 11/09/2021. Copies of these recommendations were provided from the master book. Staff B acknowledged these MRRs were not in Resident 13's medical record. A review of the 09/10/2021 recommendation regarding Famotidine (medication for heartburn), showed it was not signed by the physician until 10/08/2021. The 10/12/2021 recommendation regarding Xarleto (medication for blood clot prevention), was not signed by the physician until 11/08/2021. The two 11/09/2021 recommendations for Gabapentin for pain and Hydroxyzine for anxiety/ itching were not signed by the physician until 12/06/2021. Hydroxyzine was not changed on the Medication Administration Record until 12/15/2021. In an interview on 01/11/2022 at 1:02 PM, Staff B acknowledged the delay in implementing the recommendations and stated there was not an efficient process in place to implement the pharmacist recommendations due to the nurse staffing shortage that was taking time away from the nurse managers. REFERENCE: WAC 388-97-1300(1)(c)(iii-iv)(4)(c), -1780(1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13 The 10/14/2021 Quarterly Medicare 5-day MDS showed Resident 13 was assessed to require assistance with toileting and hygiene, was incontinent of urine and bowels, and was not on a toileting program. A review of Resident 13's PO dated 10/08/2021 showed Docusate (a stool softener) one tablet two times daily for constipation, hold for loose stools. There were also POs for Milk of Magnesia (MOM) as needed (PRN) if no BM for three days, Dulcolax suppository PRN, and Fleets enema PRN. A review of Resident 13's 12/2021 and 01/2022 bowel movement (BM) logs showed resident did not have a BM on 12/12, 12/13, and 12/14/2021 (3 days), 12/17, 12/18, and 12/19/2021 (3 days), or 1/1, 1/2, 1/3, or 1/4/2022 (4 days). There were three episodes of no BM for 3 days, within 30 days. A review of the 12/2021 MAR showed Resident 13 did not receive any MOM, Dulcolax suppository, or a Fleets enema in December. In an interview on 01/06/2022 at 10:23 AM, Staff B stated the nurses are expected to administer the PRN bowel medications according to the POs. Staff B expects a PRN bowel medication to be given on day three with no BM and verified this was not done for Resident 13. Staff B also agreed that if there were three periods of no BM for three days over 30 days, the Docusate was not effective and should be re-evaluated. Resident 38 According to the 11/22/2021 Quarterly MDS Resident 38 was diagnosed with high blood pressure (BP) and dementia, with severe cognitive impairment. Review of Resident 38's 07/19/2021 physician order (PO) showed Lisinopril (BP med) to be held if the systolic blood pressure (SBP- top number) was less than or equal to 110 and call the physician. Review of the December 2021 MAR showed Resident 38 had a SBP of 110 on 12/14/2021 and a SBP of 107 on 12/24/2021. Staff administered the Lisinopril both times. Review of Resident 38's POs did not show the physician was notified for the SBP that was outside of parameters or that the physician provided authorization to give the medication outside of parameters. In an interview on 01/06/2022 at 10:23 AM, Staff B stated the nurses are expected to, but did not, follow the PO for Lisinopril. REFERENCE: WAC 388-97-1060(3)(k)(i). Based on observation, interview, and record review the facility failed to ensure 2 (Residents 14 & 13) of 5 sample residents and 1 (Resident 38) supplemental resident were free from unnecessary medications. Failure to ensure adequate monitoring and indications for use placed residents at risk for inadequate treatment of conditions and adverse side effects. Findings included . Resident 14 Resident 14 admitted to the facility on [DATE] and according to the 10/18/2021 admission Minimum Data Set (MDS- an assessment tool) was assessed with multiple medically complex diagnoses including diabetes. Review of the 11/2021 Medication Administration Records (MAR) showed physician orders (PO) to administer insulin each evening for treatment of diabetes. A second PO directed staff to check blood sugars three times a day and administer insulin as needed based on the results of the blood sugar checks (sliding scale). According to provider notes dated 11/23/2021, nursing staff were directed to discontinue the sliding scale coverage, but not the blood sugar monitoring. In an interview on 01/07/2022 at 11:20 AM, Staff B (Director of Nursing) confirmed nursing staff discontinued the blood sugar monitoring on 11/23/2021 when staff discontinued the sliding scale order. Staff B stated that while the orders were linked, nursing staff should have continued the blood sugar monitoring in order to monitor the effectiveness of the insulin. According to a 12/09/2021 nutrition and hydration review, Resident 14 was reviewed by the interdisciplinary team during a previous NAR (Nutrition at Risk) meeting related to significant weight loss. Review of the December 2021 MARs showed direction to staff, on 12/14/2021,to administer Mirtazapine daily for loss of appetite. Record review on 01/07/2022 showed facility staff failed to assess Resident 23's weight since 11/25/2021. In an interview on 01/07/2022 at 11:20 AM, Staff B confirmed staff should, but did not, monitor Resident 23's weight in order to determine the effectiveness of the Mirtazapine.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5 percent (%). One (Staff II) of 3 Licensed Nurses made 2 errors during 30 opportunities, for 1 (Residents 33) of 6 residents observed for medication pass. This resulted in an error rate of 6.6%. This failure placed residents at risk for not receiving the intended therapeutic effects of physician ordered medication. Findings included . According to the undated facility Installation of Eye Drops policy, when administering two or more different eye drops allow three to five minutes between each application. On 01/11/2021 at 9:29 AM Staff II (Registered Nurse) was observed administering Resident 33's eye drops. Staff II administered Brimonidine 2% (used to treat Glaucoma) one drop to the right eye, waited 90 seconds and administered Cosopt Solution (used to treat Glaucoma) one drop to both eyes. Failing to wait 3-5 minutes constituted as one medication error. After waiting 90 seconds, Staff II administered Rhopressa 0.02% (used to treat Glaucoma) to both eyes. Failing to wait 3-5 minutes constituted as one medication error. Review of Resident 33's Physicians Orders (PO) showed a 09/08/2021 PO for Brimonidine 2%, instill in right eye twice daily for Glaucoma. A 09/07/2021 PO showed Cosopt 22.3-8.6 milligrams (mg)/milliliter (ml), administer in both eyes twice daily for Glaucoma. A 09/08/2021 PO showed Rhopressa, instill 1 drop in both eyes in the morning for Glaucoma. Must wait 3-5 minutes for each different eye medication. In an interview on 01/12/2022 at 8:30 AM Staff B (Director of Nursing) stated they would expect the nurse to administer eye drops according to the PO and should have waited 3-5 minutes between administering different eye drops. WAC: REFERENCE 388-97-1060(3)(k)(ii) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medications at the Bedside Resident 60 On 01/03/2022 at 12:30 PM, three medicine cups containing a powdered substance were observed on the bedside table. Resident 60 stated the medicine was their dialysis medication, Tums (an antacid) and they were not sure of the other medication. On 01/06/2022 at 8:13 AM, two medicine cups containing a powered substance were observed sitting on the bedside table. Resident 60 was out of the facility at dialysis. In an interview on 01/06/2022 at 8:26 AM, Staff SS (LPN) stated the resident left for dialysis at 5:00 AM, and medications were not administered until Resident 60 returned from dialysis. Staff SS stated the two medicine cups look like crushed medication, they could not identify the medication and stated the medication should not be left at the bedside. Resident 36 On 01/05/2022 at 8:28 AM, a medicine cup containing pills was observed on the bedside table in front of Resident 36. During an interview on 01/05/2022 at 8:36 AM, Staff Y (LPN) stated Resident 36 was alert and oriented and wanted their medications delivered with their breakfast tray. Staff Y stated they tried to give the medications earlier, but the resident asked Staff Y to leave the medications on the table. Staff Y left the medications and explained they planned to go back later to ensure the resident took the medications. Resident 40 On 01/05/2022 at 12:18 PM, a small round white pill was observed on the floor behind the resident's door. The pill remained on the floor during observations on 01/06/2022 at 8:17 AM, 01/07/2022 at 9:28 AM, 01/10/2022 at 8:51 AM In an interview on 01/10/2022 at 12:53 PM, Staff Y confirmed it was a pill on the floor but could not identify the medication. Staff Y stated medication should not be on the floor. On 01/10/2022 at 3:21 PM, Staff Y stated the medication was Glipizide (a diabetes medication). During an interview on 01/06/2022 at 1:12 PM, Staff B (Director of Nursing) stated nurses were expected to watch and validate all medications were taken by the residents, and medications were not allowed to be left at the bedside Resident 59 On 01/05/2022 at 9:39 AM, a large jar without a lid, and a plastic spoon resting inside was observed on the resident's bedside table. In an interview on 01/07/2022 at 10:47 AM, Staff Y stated the jar was Zinc Oxide, it was used for more than one resident and should not be stored open at the bedside, especially if multiple residents use the cream. REFERENCE: WAC 388-97-1300(1)(b)(ii),(c)(ii-iv), (2), -2340. Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were secured, labeled with required resident identifying information, treatments stored in clean condition, and expired medications and biologicals were disposed of timely in accordance with professional standards, in 1 of 2 medication carts, 1 of 1 treatment carts and 1 of 1 medication rooms reviewed. Findings included . Medication Storage and Labeling North Hall Medication Cart Observation of the north hall medication cart on 01/03/2022 at 1:13 PM, with Staff Z (Licensed Practical Nurse- LPN), showed an open vial of insulin for Resident 50 which was not dated, a container of Phenazopyridine Hydrochloride (a medication used to treat urinary tract problems) 99.5 MG (milligram) tablets with no identifying resident name for whom it was intended, and antibiotic eye drops for Resident 38 dated for 10/21/2021. Record review showed the antibiotic eye drops for Resident 38 were discontinued on 10/25/2021. In an interview on 01/03/2022 at 1:13 PM, Staff Z stated insulin should be dated when opened, medications should be labeled with the resident's name for whom they were intended, and the antibiotic eye drops should be removed when discontinued. An observation on 01/05/2022 at 9:53 AM, showed the north hall medication cart was left unlocked when the nurse walked away from the cart to go to a resident room down the hall. In an interview on 01/05/2022 at 10:17 AM, Staff C (Corporate Nurse Consultant) was in the hall next to the medication cart. Staff C verified the cart was still unlocked, 24 minutes after the nurse walked away. Staff C stated the cart is expected to be locked when not being used. North Hall Treatment Cart An observation on 01/05/2022 at 2:28 PM, there was an unlocked treatment cart in the hallway next to room [ROOM NUMBER]. There was a container of Zinc Oxide (a cream for skin) on the top of the cart that was observed in the same location since 9:53 AM that morning. In an interview on 01/05/2022 at 2:28 PM, Staff V (Resident Care Manager) stated the cart is expected to be locked and the Zinc Oxide should not be on top of the cart unsecured. Staff Z arrived at the cart and was told it was unlocked. Staff Z demonstrated locking the cart and the drawers were still able to be opened. Staff V stated it was broken and would need to be fixed since it was not allowed to be unsecured in the hallway. On 01/05/2022 at 2:30 PM, in an observation and interview of the contents of the cart showed two opened tubes of Hydrocortisone (a cream for skin) without a name or date or an outer cover to keep clean. Staff V stated they were house supply; nurses use for multiple residents by dispensing into a cup. Staff V stated the tubes should have an outer cover to keep clean. On 01/05/2022 an observation at 2:30 PM, showed a tube of Skintegrity (a cream for skin) that had dried cream stuck to the outside of the tube. Staff Z stated it looked like someone was wearing gloves with cream on them and held the outside of the tube. Staff V confirmed the tube was house supply and was unclean and should not be in the treatment cart in that condition. In the same observation, on 01/05/2022 at 2:30 PM, a vial of Lidocaine (a numbing liquid to inject into the skin) was observed opened, used, undated and uncovered so staff were unable to keep the medication clean. The Lidocaine vial did not have a resident name or open date on the vial. Staff Z stated it was probably used on (unidentified resident) and should be labeled and covered. Staff Z stated the Lidocaine was also house supply but should be covered to stay clean. Medication Room Observation of the medication room on 01/03/2022 at 1:20 PM, showed two cartons (containing approximately 25 each) of house supply purple top vacutainers (tubes for retrieving blood samples) which expired 12/31/2021, approximately seven red top vacutainers which expired 05/31/2021. The medication room refrigerator contained Latanoprost eye drops for Resident 26 which was open but not dated. Central Supply Room On 01/03/2022 at 1:55 PM, a door labeled Central Supply was unlocked and no staff were observed in the office, over the counter medications in bottles, tubes of ointments, and nursing supplies were observed on shelves. On 01/05/2022 at 1:28 PM, the Central Supply office was observed unlocked with no staff present. Inside the door, there was packets of triple antibiotic ointment, needles, and syringes were observed easily accessible on the shelf. On 01/05/2022 at 2:09 PM, Staff I (Central Supply Clerk) stated a new lock was needed for the central supply office because the current lock does not have a key.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure prompt dental services were provided for 4 (55, 2, 14 & 18) of 13 state pay residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs, and a diminished quality of life. Findings included . Resident 55 Resident 55 admitted to the facility on [DATE]. According to the 11/28/2021 Significant Change Minimum Data Set (MDS- an assessment tool), the resident had severe cognitive impairment, required extensive assistance with oral care, had obvious or likely cavities or broken natural teeth, and had a mechanically altered diet, Record review showed Resident 55 was seen by the dentist on 03/02/2021 and 04/09/2021. Review of the 03/02/2021 dental consult showed the resident was assessed with red irritated gums, heavy wall to wall plaque and calculus, and broken teeth or root tips to the following lower teeth, numbers 20, 21, 24, 25, 26 &27. The dentist hand wrote on the form [Resident 55] would like ext. [extractions] and new dentures. Under Doctor Recommendations new dentures was checked, and upper/lower was circled. Review of the 04/09/2021 dental consult showed the dentist hand wrote Needs lower root tips and teeth extracted and new upper/lower dentures. Review of the resident's comprehensive Care Plan (CP) showed a Dental Care r/t [related to] full upper denture and multiple lower missing and broken teeth, multiple missing lower teeth, visible decay, visible roots CP, revised 01/03/2022, that directed staff to Coordinate arrangements for dental care, transportation as needed/as ordered and to monitor for signs and symptoms of oral/dental problems needing attention such as, missing, loose, broken, eroded, eroded, or decayed teeth. Which had already been identified in the dental consults and were identified under Problem of this CP. The CP made no mention of the dental recommendation for extraction of Resident 55's lower root tips and teeth, or that the resident was to have new upper and lower dentures made. In an interview on 01/11/2022 at 12:03 PM, Staff I (Certified Nursing Assistant, and staff formerly responsible for coordinating dental services at the facility) stated Resident 55 had declined to have their teeth extracted. Staff I later provided a copy of their 04/09/2021 2:44 PM progress note which stated,I asked resident if she wanted her bottom teeth extracted for dentures. Resident states, 'No, no. No dentist.' Will f/u [follow up] with resident. Staff I denied use of an interpreter for the conversation and reported the resident's daughter was the resident's responsible party (e.g. made medical decisions, signed consents to treat etc.) When asked if the daughter was present for the above documented conversation Staff I stated, No. Review of the 02/08/2021 and 05/11/2021 Quarterly MDSs showed, the resident was assesed to be severely cognitively impaired. Additionally, a Communication problems r/t primary language is Romanian but understands simple English CP, revised 01/03/2022, showed staff were directed to Use the communication binder located at bedside to facilitate communication. Record review showed the following progress notes about scheduling Resident 55 's extractions: 03/04/2021 4:30 PM Resident seen by [Smile Seattle]. Resident noted with multiple broken teeth and missing teeth. she told dentist she would like extractions and dentures; 05/07/2021 8:52 AM Advanced General Dentistry referral and admission record faxed to UW [University of [NAME]] School of Dentistry re: resident to acquire X-Rays, extractions, and dentures. UW accommodates residents in wheelchair and hoyers.; 05/10/2021 7:18 AM Resident's referral from [Smile Seattle] for dental work, denied by UW. They do not work with residents who need a hoyer.; and 05/10/2021 2:00 PM Request [Smile Seattle] office, Dentist, to send a referral to HMC [Harborview Medical Center] Dental, so I may fax to schedule resident. Record review showed no further entries in the record about the referral or indication that staff followed up with HMC to schedule the appointment. During an interview on 01/12/2022 at 11:52 AM, Staff B (Director of Nursing) acknowledged there was no indication or documentation that facility staff followed up with Smile Seattle to ensure the referral was sent to HMC dental as requested, or that they followed up with HMC dental to schedule the appointment. Resident 2 According to the 12/20/2021 admission MDS, staff assessed the resident was cognitively intact and had no broken dentures. Observations on 01/04/2022 at 9:16 AM showed Resident 2 had a broken tooth on the upper left portion of their denture. The resident stated the denture was broken for a while. In an interview on 01/11/2022 at 7:50 AM, Staff B stated staff should have referred Resident 2 for dental services related to the broken denture. Resident 14 According to the 10/18/2021 admission MDS Resident was identified as cognitively intact, able to understand and be understood in conversation, required an altered textured diet and was without natural teeth. According to the Care Area Assessment (CAA) associated with this MDS, the resident was at risk for alteration in dental function related to resident having full upper and full lower dentures which fit without difficulty at this time. She is provided with routine assistance in cleaning her dentures. Observations on 01/04/2022 at 8:16 AM showed Resident 14 had no natural teeth. At this time the resident stated they had dentures, When they first pulled my teeth 12 years ago but indicated she wished to have new dentures. The resident stated, I told them [staff] I was interested in getting dentures and that was the last I heard of it. Review of the a Smiles Seattle Denture consult dated 12/07/2021 showed the resident would like new dentures. In an interview on 01/10/2022 at 8:22 AM, Staff L (Social Services) was asked to provide information to support Resident 14 was referred for dentures. No information was provided. Resident 18 Resident 18 was admitted to the facility on [DATE] and according to the 10/28/2021 admission MDS was cognitively intact with clear speech, able to be understood and understand conversation. In an interview on 01/04/2022 at 11:03 AM, Resident 18 stated they had upper and lower dentures. Resident 18 indicated they do not wear the lower dentures because they do not fit right. Resident 18 reported they would like to go see a dentist and stated, It would be nice to have both sets back in. According to a Physician Order dated 10/22/2021, Resident may have medical consult and TX [treatment] as indicated. (Dental, Podiatry, Eye and Hearing). Review of the 10/22/2021 Admit/ Readmit Assessment showed staff assessed Resident 18 with having their own teeth and had broken or carious teeth. According to a 11/14/2021 CAA, staff documented, CAA triggered due to likely cavity per intake nurse assessment . and Will proceed with care planning. Review of CP on 01/10/2022 revealed no information addressing teeth or dentures. In an interview on 01/07/2022 at 11:07 AM, Staff B stated staff should have, but did not identify Resident 18 had dentures and needed assistance in obtaining a dental appointment for proper denture fitting. Refer to CFR 483.20(g), F-641, Accuracy of Assessments REFERENCE: WAC 388-97-1060(3)(j)(vii). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a system to ensure consistent communication and collaboration of care occurred between the facility and hospice staff for 1 (Resident 38) of 1 resident reviewed for hospice services. The facility did not develop or maintain a comprehensive hospice plan of care in collaboration with hospice, did not identify what services were to be provided by hospice, and did not obtain the hospice nurse visit notes and recommendations to implement into the resident's care. This failure placed Resident 38 at risk for not receiving necessary care and services. Findings included . Resident 38 The 06/02/2021 admission Minimum Data Set (MDS-an assessment tool) showed Resident 38 was admitted to the facility on [DATE] and had hospice services on admission. Resident 38's primary diagnosis was Alzheimer's disease with late onset. Review of the 06/28/2021 facility Care Plan (CP) showed Resident 38 had a terminal prognosis of dementia and failure to thrive. The interventions to support the hospice focus area included, adjust care as needed to compensate for the resident's inabilities, monitor for pain, encourage support of family, and work cooperatively with the hospice team to ensure needs are met. The 06/28/2021 facility CP did not provide instructions to staff on what to monitor and report to hospice (such as change of condition, change of treatment, clinical complications, need to transfer, or death of the resident), when to notify hospice, or what specified hospice services provided to Resident 38. The CP did not provide information to staff about hospice's responsibilities, such as, providing medical direction, nursing management and support, bath aide visits, social worker services, medication, medical supplies and equipment, and all other hospice services that were necessary for the care for Resident 38. In an interview on 01/06/2022 at 9:12 AM, Staff B was asked where to find the hospice provider CP and visit documentation in the medical record. Staff B looked in Resident 38's record and was unable to find the CP and hospice visit communication records. In an interview on 01/11/2022 at 12:05 PM, Staff B provided the hospice care plan, physician recertification, standing medication orders, and hospice visit notes. Staff B stated the information was not in the facility prior to 01/07/2022 and was loaded to Resident 38's record on 01/11/2021. Staff B confirmed Resident 38's facility CP was not in coordination with the hospice services and Resident 38's care plan did not identify which services hospice provided and under what conditions hospice was to be notified. A review of the 10/23/2021 hospice CP showed the nurse, and the hospice bath aide were each scheduled to have weekly visits for eight weeks. The CP showed a list of Resident 38's medications delineating which ones were covered by hospice. The CP showed a wheelchair was provided by hospice. A review of Resident 38's 06/28/2021 facility CP did not show coordination of the care required by the resident and provided by the hospice bath aide, the hospice nurse, hospice medications, or the hospice provided wheelchair. These services were provided by hospice and not communicated to staff thru the care plan. A 11/13/2021 6:10 PM hospice nurse visit note showed a discussion with the nurse on duty regarding Resident 38's edema (swelling). A 11/22/2021 11:00 AM hospice nurse visit note showed a discussion with the nurse on duty about poor appetite monitoring. An 11/29/2021 9:00 AM hospice nurse visit note showed a discussion with the nurse on duty regarding poor appetite, bowel frequency, and urinary infection symptoms. A 12/06/2021 11:30 AM hospice nurse visit note showed a discussion with nursing staff for a medication count and to implement elevating hands as much as possible to decrease swelling and limit salt intake. By not obtaining the hospice nurse visit notes, and not documenting Resident 38's care and service provision or identified needs the facility was not able to incorporate the identified resident issues/recommendations into Resident 38's CP or implement timely interventions. The facility did not implement edema monitoring, dietary review or change diet as identified, recommended and discussed with the hospice nurse in the hospice visit notes. Review of Resident 38's 06/28/2021 CP showed no revision to the interventions to elevate Resident 38's edematous arms per the 11/15/2021 discussion with the hospice nurse about the new edema findings. Review of Resident 38's current 05/27/2021 diet order showed no changes indicating a limited salt diet per the 12/06/2021 hospice nurse recommendation. In an interview on 01/11/2022 at 12:05 PM, Staff B stated the nurses were expected to document in the progress notes any communication with the hospice team. Staff B stated nurses were expected to act on the recommendations from the hospice nurse. In the 12:05 PM interview, Staff B stated hospice was not sending their progress notes and the facility did not have a system to obtain the notes. Staff B stated there was facility nurse staffing difficulties and no medical records staff which prevented the facility from coordinating and updating the care plans. Staff B stated the facility did not have an effective system to coordinate hospice care for Resident 38. REFERENCE: 388-97-1020(2)(d), (5)(a). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13 The 10/14/2021 Quarterly Medicare/5-day MDS showed Resident 13 was [AGE] years old and had a diagnosis of end-stage renal (kidney) failure which required dialysis. This MDS showed Resident 13 was not offered or provided the 2021 influenza vaccine. This MDS also showed Resident 13 was not up to date on their Pneumococcal vaccination with the provided reason that it was offered and declined. Review of a 04/17/2021 Pneumococcal Vaccine Informed Consent form signed by Resident 13 showed the resident consented to the PCV13 and the PPSV23. There was no consent/decline form in Resident 13's record that the 2021 influenza vaccine was offered. Record review showed no indication the 2021 influenza vaccine, PCV13 or the PPSV23 was administered by the facility. In an interview on 01/11/2022 at 1:20 PM, Staff J (Infection Control Nurse) was asked to provide documentation of both the influenza and Pneumococcal vaccination status, Staff J was not able to locate the information for the influenza. Staff J confirmed Resident 13 had requested but was not provided the Pneumococcal vaccines. REFERENCE: WAC 388-97-1340(1)(2)(3). Based on interview and record review, the facility failed to ensure 2 (Residents 14 & 13) of 5 residents reviewed for vaccinations, were offered the recommended vaccinations. This failure placed residents at risk for contracting pneumonia and/or influenza, with the associated complications of infection. Findings included . Review of the Centers for Disease Control (CDC) 2021 Recommended Adult Immunization Schedule showed a person age [AGE] or older should receive 1 dose of the Pneumococcal polysaccharide 23 (PPSV23). If the PPSV23 was administered prior to age [AGE] years, administer 1 dose PPSV23 at least five years after previous dose. A person age [AGE] or older should receive 1 dose of the Pneumococcal conjugate 13 (PCV13) based on shared clinical decision making and if previously not administered. If a resident requires both pneumo vaccines, PCV 13 should be administered first and the PPSV23 should be administered at least 1 year apart. The CDC 2021 Recommended Adult Immunization Schedule (Table 1) for persons who are immunocompromised showed a person without a previous PPSV23 or PCV 23 should receive the PCV13 if over age [AGE] and receive the PPSV23 eight weeks after the PCV13, and the first booster PPSV23 at least 5 years after the first dose of PPSV23. Resident 14 Resident 14 admitted to the facility on [DATE] and according to the 10/18/2021 admission Minimum Data Set (MDS - an assessment tool) staff identified the resident was [AGE] years old, and not up to date on Pneumococcal vaccinations and documented, not offered. Record review showed an undated Pneumonia Vaccine Consent form which indicated the resident had a PCV13 in 2019 but the section of the consent which addressed the PPSV23 was blank. In an interview on 01/07/2022 at 12:17 PM, Staff B (Director of Nursing) reviewed Resident 14's record and confirmed facility staff should, but did not, offer the PPSV23, according to CDC guidance.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 18 Resident 18 was admitted to the facility on [DATE]. According to the 10/28/2021 admission MDS Resident 18 was assessed as cognitively intact with clear speech, able to be understood and understand conversation. In an interview on 01/03/2022 at 1:11 PM, Resident 18 stated, I went nine days without a shower, my daughter finally called and then I got one. Resident 18 indicated they prefer showering once a day, like normal people. Resident 18 stated they were only getting showered once weekly on Wednesday's and stated, it really changes my whole attitude when I'm showered and feel clean. Review of Resident 18's ISP on 01/05/2022, directed staff that the resident, Prefers: shower daily in morning or evening. Record review showed the ISP for bathing task was revised to include Resident 18's preference on 11/22/2021. According to an undated facility shower schedule provided by staff, Resident 18 was scheduled for bathing twice weekly on Wednesday and Saturday evenings. Review of bathing records showed Resident 18 only received one shower per week for 3 out of 4 weeks in November 2021 and only one shower per week in December 2021. According to these records facility staff did not provide the resident showers twice weekly as scheduled or daily as preferred. In an interview on 01/07/2022 at 11:07 AM, Staff B stated staff should have, but did not provide showers at least twice weekly for Resident 18. Staff B stated it was their expectation that staff should be assisting residents with showers according to the resident's preference. Resident 25 Resident 25 was admitted to the facility on [DATE]. According to the 10/18/2021 Modification of Admission/ Medicare - 5 Day MDS, Resident 25 was cognitively intact with clear speech, able to be understood and understand conversation. This MDS assessed Resident 25 with Multiple Sclerosis (MS - a progressive neurological disease that affects the brain and spinal cord) and reported it was very important to choose between a tub bath, shower, bed bath or sponge bath. In an interview on 01/04/22 at 9:59 AM, Resident 25 stated, I get exhausted after a shower due to my MS, it's very taxing on me. Resident 25 indicated they were frustrated that staff continued to offer showers and stated they would prefer bed baths or washing self-everyday with wipes. Review of Resident 25's ISP on 01/05/2022, showed directions to staff indicated, Bathing (Prefers: SPECIFY) and did not direct staff regarding the frequency or preference of bathing. According to an undated facility shower schedule provided by staff, Resident 25 was scheduled for bathing twice weekly on Tuesday and Friday evenings. Review of bathing records showed Resident 25 did not have any documented bed baths until 01/11/2022 after preference was addressed with Staff B by surveyor. According to a Shower/Weight Refusal form, Resident 25 refused a shower/weight today and was signed by staff and dated 12/24/2021. This form directed staff to ask the resident their preference and reschedule the bath/shower, and if this is the resident's second refusal in a row, LN (Licensed Nurse) were to investigate and establish why the resident was refusing and take the proper steps to ensure the resident's preferences were being met. If LN was unsuccessful, the LN was to notify the RCM (Resident Care Manager). RCM was to notify Social Services and the provider if still refusing. In an interview on 01/12/2022 at 1:45 PM, Staff B stated Resident 25's CP and ISP should have, but did not reflect the resident's preference for bathing. Staff B confirmed staff did not have documentation that showed Resident 25's refusals were investigated to establish if refusals were related to their preference for bed bath instead of showers. Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 12/12/2021 5 day MDS, the resident was cognitively intact, could understand and be understood, and required extensive assistance with most activities of daily living including bathing. During an interview on 01/03/22 at 02:26 PM, Resident 16 stated, I asked for two bed baths [bb] a week, but that hasn't happened here for a while ., I get baths on Wednesday and Sunday [but] they don't do them on the weekends anymore. The resident denied feeling unclean but indicated they still preferred two bed baths a week. According to the December 2021 and January 2022 bathing record Resident 16 prefers two showers a week. Review of the document showed the resident went the following periods between being offered/provided bathing: 12/01/2021- bb; 12/05/2021- refused; 12/16/2021-bb (10 days); 12/22/2021- bb (6 days); 12/28/2021-refused (not the resident's scheduled bath day); 12/29/2021- bb (6 days); 01/05/2022- bb (6 days); and 01/12/2022- bb (6 days), confirming the resident's assertion that bathing was not offered and/or provided per their identified preference. During an interview on 01/12/2022 at 11:57 AM, Staff B indicated facility staff failed to provide bathing in accordance with their identified preferences. REFERENCE: WAC 388-97-0900(1)(3). Based on observation, interview and record review the facility failed to allow 7 (Residents 2, 14, 23, 118, 16, 18 & 25) of 8 residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/ or type of bathing. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life. Findings included . Resident 2 According to the 12/20/2021 admission Minimum Data Set (MDS - an assessment tool) Resident 2 admitted to the facility on [DATE], was cognitively intact and reported it was very important to choose between a tub bath, shower, bed bath or sponge bath. In an interview on 01/04/2022 at 9:23 AM, Resident 2 stated they did not receive bathing as frequently as they wanted and stated, I want at least two bed baths a week but that's not what I get. Review of the Individual Service Plan (ISP - directions to staff regarding resident care) staff were directed, Bathing (Prefers: SPECIFY) and did not direct staff regarding the frequency or type of bathing. Review of facility bathing records showed the resident received only one bed bath, on 12/22/2021, from admission on [DATE] through 01/05/2021. In an interview on 01/05/2022 at 9:33 AM, Staff B (Director of Nursing) stated residents should receive bathing at least twice a week and the ISP should specify the resident's preferences. Resident 14 According to the 10/18/2021 admission MDS Resident 14 admitted to the facility on [DATE] and was cognitively intact, able to be understood and understand conversation, and reported it was very important to choose between a tub bath, shower, bed bath or sponge bath. In an interview on 01/04/2022 at 8:11 AM, Resident 14 stated, When I first got here I didn't get a shower for a long time. Resident 14 stated they preferred, but did not receive, showers, at least twice a week. Review of the ISP dated 01/05/2022, staff were directed, Bathing (Prefers: Showers, depend on staff) and did not direct staff regarding the frequency of bathing. Review of resident bathing records showed from 12/20/2021 through 01/05/2022, the resident received a shower on 12/22/2021 and a bed/towel bath on 12/30/2021. In an interview on 01/05/2022 at 10:05 AM, Staff B reviewed the resident's record and confirmed the resident did not receive showers twice a week per their stated preference. Resident 23 According to the 11/02/2021 admission MDS, Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, had no rejection of care, reported it was very important to choose between a tub bath, shower, bed bath or sponge bath, and had no bathing during the assessment period. In an interview on 01/04/2022 at 10:18 AM, Resident 23 stated they would like a shower at least three times a week. According to the ISP as of 01/05/2022 staff were directed to Provide sponge bath when a full bath or shower cannot be tolerated. There were no directions to staff regarding resident's preference for frequency or type of bathing. According to bathing records, the resident received a shower on 12/13/2021 and 12/30. Staff documented the resident was provided a bed or towel bath on 12/14/2021, 12/17/2021, 12/21/2021, 12/24/2021 and 01/04/2022. The resident did not receive bathing according to preferred type (shower) or frequency (three times a week) or time (morning). In an interview on 01/05/2022 at 10:05 AM, Staff B reviewed the resident's record and confirmed neither the resident's Care Plan (CP) or ISP included specifics regarding resident preference of type (shower) and frequency (three times a week) of bathing. Staff B confirmed the resident received more bed baths than showers and staff did not document why the resident could or would not tolerate showers. Resident 118 According to the 01/04/2022 admission MDS, Resident 118 admitted to the facility on [DATE] and had severe cognitive impairment, but was able to state it was very important to choose between a shower, tub bath and bed bath. In an interview on 01/03/2022 at 2:08 PM, the resident stated they didn't get to make choices about bathing, stating at home, it was every two or three days, that showers were preferred, but none were provided since admission. Upon review of Resident 118's medical record on 01/05/2022 at 9:48 AM, Staff B stated Resident 118 did not receive any bathing since admission but based on the shower schedule, should have received bathing twice. Staff B indicated the resident's CP should, but did not, reflect the resident's preferences for bathing frequency and type.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 60 According to the 12/14/2021 Quarterly MDS, the resident admitted to the facility on [DATE] and was assessed as cognitively intact, able to understand and be understood in conversation. Review of the 02/16/2021 facility admission Agreement showed an Advanced Directive Acknowledgement form that was blank and without signatures. During an interview on 01/10/2022 at 9:32 AM Staff L stated Advanced Directives should be addressed upon admission, especially if it is part of the admission packet. Staff L acknowledged Resident 60 did not have the opportunity to formulate advanced directives. Resident 36 According to the 11/22/2021 Quarterly MDS, the resident admitted to the facility on [DATE] and was assessed as cognitively intact, able to understand and be understood in conversation. Review of the 08/18/2017 admission documents showed no indication the facility offered the resident the opportunity to formulate an advanced directive. On 01/04/2022 at 1:42 PM Staff GG was asked to provide Resident 36's admission agreement. No advanced directive information was provided. In an interview on 01/10/2022 at 9:32 AM Staff L stated the resident should, but did not, have the opportunity to formulate advanced directives. Resident 59 According to the 12/14/2021 Quarterly MDS, the resident admitted to the facility on [DATE] and was assessed as cognitively intact, able to understand and be understood in conversation. Review of the 10/25/2017 admission documents showed no indication the facility offered the resident the opportunity to formulate advanced directives. On 01/04/2022 at 1:42 PM Staff GG was asked to provide Resident 59's admission agreement. No advanced directive information was provided. In an interview on 01/10/2022 at 9:32 AM Staff L stated the resident should, but did not, have the opportunity to formulate advanced directives. Resident 40 According to the 11/22/2021 Quarterly MDS, the resident admitted to the facility on [DATE] and was assessed as not able to make their own decisions and sometimes could understand and be understood in conversation. Review of the 12/07/2018 admission Agreement showed on 11/19/2018 Resident 40's POA signed the AD form but did not mark the box indicating if the resident had an advanced directive, what type of advanced directive, or if they did not have an advanced directive. In an interview on 01/06/2021 at 9:27 AM Staff L stated they could not find any information about ADs for Resident 40 but if the resident had an advanced directive they would expect it to be in the residents record. REFERENCE: WAC 388-97-2080 (1)(d)(iii), (2), (3)(a) & -0240. Resident 18 Resident 18 was admitted to the facility on [DATE]. According to the 10/28/2021 admission MDS Resident 18 was assessed as cognitively intact with clear speech, understood and able to understand conversation. In an interview on 01/03/2022 at 1:05 PM, Resident 18 stated they had ADs. Resident 18 identified their daughter was the POA for healthcare decisions and stated she was looking out for me. According to the 10/27/2021 Baseline Care Plan Evaluation, Resident 18 was identified with having ADs. Review of records revealed no advance directives were found for Resident 18. In an interview on 01/07/2022 at 11:07 AM, Staff B stated AD/ POA paperwork should be obtained on admission and placed into the electronic records. Staff B indicated advance directives were important to have readily available in case of any change in resident conditions. Resident 54 According to the 12/7/2021 quarterly MDS, Resident 54 admitted to the facility on [DATE]. Review of the EHR revealed no evidence the facility had either collected, or offered to assist with formulation of, an AD for Resident 54, as required. In an interview on 01/10/2022 at 1:15 PM, Staff L (Social Services) confirmed that the facility did not collect, or offer to formulate an AD for Resident 54. Resident 61 Similar findings for Resident 61 who, according to the 11/17/2021 Quarterly MDS, admitted to the facility on [DATE]. Resident 61's EHR contained no evidence the facility collected, or offered to assist with formulation of, an AD for Resident 61, as required. Resident 66 Similar findings for Resident 66 who, according to the 11/16/2021 quarterly MDS, admitted to the facility on [DATE]. Resident 66's EHR contained no evidence the facility collected, or offered to assist with formulation of an AD for Resident 61, as required. During an interview on 01/06/2021 at 12:48 PM, Staff GG (Medical Records) was asked to provide a copy of the Advanced Directive Acknowledgment Form (a form that is completed by the resident or resident representative upon admission, that indicates if the resident has an AD or would like more information about ADs and their right to formulate one) for Resident's 19, 43, 55, 54, 61 and 66. On 01/07/2021 at 10:10 AM, Staff A (Administrator) stated the facility was unable to locate the Advanced Directive Acknowledgment Form(s) for the requested residents. Resident 19 Resident 19 admitted to the facility on [DATE]. According to the 10/22/2021 Quarterly MDS, the resident was cognitively intact, and was able to understand and be understood. During an interview on 01/04/2021 at 10:29 AM, Resident 19 indicated they were unsure what an AD was and did not recall receiving any information from the facility about ADs. Review of the EHR (Electronic Health Record)showed no indication the facility provided the resident with written information informing them about ADs and the right to formulate one. Resident 43 According to the 09/08/2021 admission MDS, Resident 43 admitted to the facility on [DATE]. Review of the EHR showed no AD was present in the resident's record, nor was there any indication the facility provided written information informing the resident of their right to formulate one. Resident 55 According to the 11/28/2021 Significant Change MDS, Resident 55 re-admitted to the facility on [DATE]. Review of the resident's EHR revealed no AD was present in the record, nor was there any indication the facility provided the resident with written information about ADs or their right to formulate one. Based on interview and record review, the facility failed to address required documentation for advanced directives, including incorporation into the care planning process, for 13 (Residents 14, 23, 19, 43, 55, 54, 61, 66, 18, 60, 36, 59, & 40) of 17 residents reviewed for Advanced Directives (ADs). These failures placed the residents at risk of losing their right to have their stated preferences/decisions regarding end-of-life care followed. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS - an assessment tool) Resident 14 admitted to the facility on [DATE] and was assessed as cognitively intact and was understood and able to understand conversation. In an interview on 01/04/2022 at 8:19 AM, Resident 14 stated they had a daughter but was not asked if they wanted to formulate an AD at the time of admission. Record review showed no indication Resident 14 was offered the opportunity to formulate an AD. According to admission paperwork dated 10/21/2021 a person other than Resident 14 signed all admission agreement documents and on some documents identified themselves as POA (Power of Attorney, a person designated to make decisions for a person). Record review showed no Power of Attorney paperwork. According to an interview on 01/07/2021 at 11:19 AM, Staff B (Director of Nursing) stated the person who signed the admission paperwork was Resident 14's previous roommate. Staff B was unable to explain why staff had had someone other than Resident 14, who was cognitively intact, complete the admission paperwork. In an interview on 01/10/22 08:46 AM Staff JJ (Administrative Staff) indicated the system for advanced directives was not intact. Resident 23 According to the 11/02/2021 admission MDS Resident 23 had moderate cognitive impairment, and was understood and able to understand conversation. In an interview on 01/04/2022 at 10:34 AM Resident 23 indicated they wanted their significant other to make their health care decisions in the event they could not. Record review showed no indication Resident 23 was offered the opportunity to formulate and AD. In an interview on 01/07/2012 at 11:19 AM, facility staff was asked to provide documentation to support Resident 23 was offered the opportunity to formulate an advanced directive. No information was provided.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to provide timely notice, in writing, of changes in payment status and potential charges for services not covered under Medicare/ Medicaid for 5 (Residents 19, 18, 23, 2 & 49) of 5 residents reviewed. Failure to have a system to provide Notices of Medicare Non-Coverage (NOMNC- a notification that Medicare benefits were ending), and Advanced Beneficiary Notices (ABN- a notification of costs when services provided may not be paid by Medicare) and assist residents or their representatives to understand these notices or assist with the appeal process placed residents at risk of insufficient information to make care and financial decisions. Findings included . Resident 18 Record review showed, Resident 18 signed a NOMNC form on 12/23/2021 which acknowledged Medicare Part A skilled services would have a last covered day (LCD) of 12/27/2021. The NOMNC form was incomplete and did not list the contact information for the Medicare Health Plan for Resident 18 to appeal the notice. Resident 18 signed the ABN on 12/23/2021 and checked the box for Option 2 which specified I want the skilled services listed . do not bill Medicare . I am responsible for payment. I cannot appeal if Medicare is not billed. In an interview on 01/12/2022 at 9:51 AM, Staff L (Social Services Director) stated Resident 18 was issued the NOMNC by their health plan because the facility did not send the medical record information needed to continue the skilled coverage. Staff L stated Resident 18 wanted to appeal on 12/23/2021 when they signed the NOMNC form. Staff L stated they helped Resident 18 check Option 2 on the ABN because they were trained that Option 2 helped the resident with an appeal. Staff L stated the facility did not help Resident 18 with the appeal process and Resident 18 did not continue with skilled services as requested. Resident 23 On record review, Resident 23 signed a NOMNC form on 12/08/2021 which acknowledged Medicare Part A skilled services LCD was 12/10/2021. The NOMNC did not contain the contact information needed to appeal the decision from their Medicare Health Plan. Resident 23 signed the ABN form and checked the box for Option 2 which specified they wanted the skilled services to continue and would be responsible for the payment of skilled services. In an interview on 01/12/2022 at 9:51 AM, Staff L stated they helped Resident 18 check Option 2 on the ABN but Resident 23 did not want to continue with skilled therapy and they did not want to initiate an appeal of the NOMNC. Staff L stated option 2 was checked in error. Resident 19 On record review, Resident 19 received Medicare Part A skilled services and chose to remain in the facility. The NOMNC showed the last covered day of Medicare coverage was on 09/27/2021, and was signed by the resident on 09/27/2021 the same day as coverage ended. The ABN was also signed 09/27/2021 with the box for Option 2 checked, which specified the resident wanted to continue the skilled services. In an interview on 01/12/2022 at 9:51 AM, Staff L stated Resident 19 did not ask for or file for an appeal to the NOMNC decision and was assisted by Staff L to check Option 2 on the ABN form in error. Staff L stated Resident 19 did not receive any skilled services after the last covered date of 09/27/2021, even though Option 2 was checked. Resident 2 On record review, Resident 2 signed a NOMNC form on 10/29/2021 which acknowledged Medicare Part A LCD of skilled services was 11/09/2021. The ABN was also signed 10/29/2021 with the box for Option 2 checked, which specified the resident wanted to continue skilled services but Resident 2 was discharged from the facility on 11/10/2021. In an interview on 01/12/2022 at 9:51 AM, Staff L stated Resident 2 went home after the NOMNC last covered day. Staff L stated Resident 2 did not need an ABN and the Option 2 was checked in error. Resident 49 On record review, Resident 49 signed a NOMNC form on 12/28/2021 which acknowledged Medicare Part A LCD of skilled services was 12/30/2021. Resident 49 chose to appeal the NOMNC notice and remain in the facility. There was no ABN form in Resident 49's record to show what the charges for care and services would be if the appeal was lost. Resident 49 won the appeal and continued skilled services. A second NOMNC signed by Resident 49 on 01/06/2022 showed a LCD of 01/08/2022. Resident 49 decided to remain in the facility and appeal a second time. There was no ABN form in the record to show Resident 49 was informed of the charges for care and services if the appeal was lost. Resident 49 lost the appeal and stayed in the facility without notification of the costs of care the facility would bill the resident. In an interview on 01/12/2022 at 9:51 AM, Staff L stated Resident 49 was not provided an ABN notice when they stayed at the facility past the last covered day. Staff L stated Resident 49 was not informed of the costs of care to stay in the facility. In an interview on 01/12/2022 at 1:11 PM, Staff A (Administrator) stated the NOMNC form is expected to be completed with health plan contact information for an appeal when a resident has Medicare Managed Plan, which was not done for Resident 18, 23 and 2. Staff A stated residents are required to be given 2-day notice for a NOMNC which was not done for Resident 19. Staff A stated the facility staff is expected to send requested information to Managed plans timely so continue coverage of Medicare skilled services is not impacted. Staff A stated the facility system for issuing the NOMNC and ABN notices was not intact. REFERENCE: WAC 388-97-0300(1)(e),(5),(6). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13 According to a 10/04/2021 Discharge MDS, Resident 13 was discharged to the hospital 10/04/2021 with a return anticipated. A 10/08/2021 admission MDS showed Resident 13 was re-admitted to the facility on [DATE]. Review of the facility October 2021 Ombudsman notification log, Resident 13 was not listed as discharged on 10/04/2021. In an interview on 01/10/2022 at 11:39 AM, Staff L stated the facility initiated the hospital transfer and Resident 13 should be on the facility October 2021 Ombudsman notification log. Staff L stated the medical record system used to have a monthly discharge report used to notify the Ombudsman, but when a resident discharges and returns to the facility they are not on that report. REFERENCE: WAC 388-97-0120(2)(a-d), -0140(1)(a)(b)(c)(i-iii). Resident 54 According to an 11/19/2021 progress note. Resident 54 was transferred emergently to hospital after being found unresponsive following seizure activity. In an interview on 1/10/2021 at 1:15 PM, Staff L stated that the LTC Ombuds was not, but should have been notified of Resident 54's unplanned hospitalization, and added, I need to figure out the plan for residents who discharge and return with [Staff B]. Based on interview and record review, the facility failed to notify the residents' representatives and ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 7 (Residents 19, 55, 16, 43, 118, 54 & 13) of 7 residents reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . According to the facility's undated Transfer or Discharge Notice policy, staff are to notify the resident and/or representative in writing of the reason for, date of, and destination of the transfer or discharge. This policy also directs staff that a copy of the notice will be sent to the Office of the State LTCO. Resident 19 Resident admitted to the facility on [DATE]. According to a 08/30/2021 Discharge Minimum Data Set (MDS, an assessment tool), the resident was discharged to an acute care hospital on [DATE], Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required. Resident 55 Resident 55 admitted to the facility on [DATE]. Record review showed the resident was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 11/16/2021 Discharge MDS, the resident again discharged to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required for either the 11//09/2021 or 11/16/2021 transfers. Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 11/22/2021 Discharge MDS, the resident discharged to an acute care hospital on [DATE], Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required. Resident 43 Resident 43 admitted to the facility on [DATE]. According to the 06/13/2021 Discharge MDS, the resident discharged to an acute care hospital on [DATE], Return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required. During an interview on 01/06/2022 at 1:34 PM, Staff L (Social Services) explained the facilities process for LTCO notification. Per Staff L the facility faxed a monthly Ombudsman Notice of Discharge [OND] list, of resident discharges for the month, to the LTCO by the tenth of each month per an agreement with the LTCO. Review of the November OND showed: Resident 55's 11/09/2021 and 11/16/2021 hospital transfers were not included on the list, nor was Resident 16's 11/22/2021 transfer. During an interview on 01/06/2022 at 1:34 PM, Staff L acknowledged the facility failed to notify the LTCO of Resident 55's and 16's transfers as required and explained that the facility's current system of printing discharges for the month at the end of the month, was ineffective, as residents who transferred to the hospital but had returned, failed to show up. Proof of LTCO notification was also requested for the transfers of Resident 43's on 06/13/2021 and Resident 19 on 08/30/2021. No further information was provided. Resident 118 Review of census documents showed Resident 118 admitted to the facility on [DATE]. According to the 12/16/2021 5 Day MDS, Resident 118 was assesed with severe cognitive impairment and diagnoses which included dementia. According to progress notes dated 12/16/2021 the resident experienced a change in condition which required a facility initiated transfer to the hospital. According to an Entry Tracking MDS document, the resident readmitted to the facility on [DATE]. In an interview on 01/03/2022 at 2:36 PM, Resident 118's family member stated the facility did not provide notification of the resident's hospital transfer. The family member stated, I only found out when the hospital discharge planner called to notify me [they] were discharging from hospital back to the facility. In an interview on 01/05/2022 at 2:11 PM, Staff B (Director of Nursing) reviewed the resident's record and confirmed there was no indication facility staff notified Resident 118's family of the hospital transfer stating, Yes they should document they notified the family. Review of the OND for December 2021 showed Resident 118 was not listed. In an interview on 01/11/2022 at 8:56 AM, Staff L stated they were not made aware of Resident 118's hospitalization so the resident was not included on the list.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 7 (Residents 19, 55, 16, 43, 118, 54 & 13) of 8 residents reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . Resident 19 Resident 19 admitted to the facility on [DATE]. According to a 08/30/2021 Discharge Minimum Data Set (MDS, an assessment tool), the resident was discharged to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation or indication the facility provided the resident or resident representative written information regarding the facility's bed-hold policy as required. During an interview on 01/06/2022 at 01:55 PM, Staff B (Director of Nursing) acknowledged there was no documentation to support the resident or resident's representative was provided a written notice of the facility's bed-hold policy as required. Resident 55 Resident 55 admitted to the facility on [DATE]. Record review showed the resident was discharged to an acute care hospital on [DATE] Return anticipated and re-admitted to the facility on [DATE]. According to the 11/16/2021 Discharge MDS, the resident again discharged to an acute care hospital on [DATE] Return anticipated. Record review showed no documentation or indication the facility provided the resident or resident's representative written information regarding the facility's bed-hold policy for the 11/09/2021 or 11/16/2021 discharges as required. During an interview on 01/06/2022 at 01:55 PM, Staff B acknowledged there was no documentation to support the resident or resident's representative was provided a written notice of the facility's bed-hold policy for the 11/09/2021 or 11/16/2021 discharge(s). Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 11/22/2021 Discharge MDS, the resident discharged to an acute care hospital on [DATE], Return anticipated. Record review showed no documentation or indication the facility provided the resident or resident's representative written information regarding the facility's bed-hold policy as required. During an interview on 01/06/2022 at 01:55 PM, Staff B acknowledged there was no documentation to support the resident or resident's representative was provided a written notice of the facility's bed-hold policy as required. Resident 43 Resident 43 admitted to the facility on [DATE]. According to the 06/13/2021 Discharge MDS, the resident discharged to an acute care hospital on [DATE], Return anticipated. Record review showed no documentation or indication the facility provided the resident or resident's representative written information regarding the facility's bed-hold policy as required. During an interview on 01/10/2022 at 03:12 PM, Staff B acknowledged there was no documentation to support the resident or resident's representative was provided a written notice of the facility's bed-hold policy as required. Resident 118 Review of census documents showed Resident 118 admitted to the facility on [DATE]. According to the 12/16/2021 5 Day MDS, Resident 118 was assessed with severe cognitive impairment and diagnoses which included dementia. According to progress notes dated 12/16/2021 the resident experienced a change in condition which required a facility-initiated transfer to the hospital. According to an Entry Tracking MDS document, the resident readmitted to the facility on [DATE]. In an interview on 01/03/2022 at 2:36 PM, Resident 118's family member stated the facility did not provide bed-hold information at the time of the resident's transfer to the hospital. Record review showed no documentation or indication the facility provided the resident or resident's representative written information regarding the facility's bed-hold policy as required. In an interview on 01/06/2022 at 10:42 AM Staff A (Administrator), after reviewing the record and interviewing staff, stated staff should have, but did not offer a bed hold for Resident 118. Resident 54 According to the 12/07/2021 Quarterly MDS, Resident 54 had diagnoses including a seizure disorder. According to progress notes, on 11/19/2021 Resident 54 experienced a seizure and was transferred to hospital emergently after they were found unresponsive. According to the 11/19/2021 Discharge MDS, Resident 61 was discharged Return anticipated. According to a 11/22/2021 progress note Resident 54 readmitted to the facility on [DATE]. In an interview on 01/10/2022 at 03:07 PM, Staff T, Business Office Manager, stated that Bed Holds were the responsibility of the Admissions Department, and that Resident 54 should have, but was not provided a Bed Hold. Resident 13 According to a 10/04/2021 Discharge MDS, Resident 13 went to the hospital and was anticipated to return to the facility. Record review showed no documentation the facility provided the resident or the resident representative with written information regarding the facility's bed-hold policy as required. During an interview on 01/11/2022 at 12:05 PM, Staff B stated Resident 13 did not have a bed hold notification provided at the time of discharge and the facility did not currently have a system in place for bed holds. REFERENCE: WAC 388-97-0120(4). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure comprehensive admission and annual assessments were completed within the required time frames for 14 (Residents 13, 2, 55, 32, 118, 19, 23, 14, 18, 268, 43, 35, 16, & 40) of 24 sample residents reviewed. These failures placed residents at risk for unidentified care needs, delayed services, and decreased quality of life. Findings included . According to the Resident Assessment Instrument (RAI - a manual that instructs staff on timing requirements for assessments), admission assessments are required to be completed by the 14th calendar day of the resident's admission, and annual assessments are required to be completed within 14 days of the Assessment Reference Date (ARD, +14 days). Resident 55 Record review showed Resident 55 had an Annual Minimum Data Set (MDS, an assessment tool) with an ARD of 08/11/2021, but it was not completed until 10/03/2021, 53 days late. Additionally, Resident 55 had a Significant Change MDS with an ARD of 11/28/2021. Record review showed it was not completed until 12/13/2021, 15 days late. Resident 16 Record review showed Resident 16 had an Annual MDS with an ARD of 10/16/2021, but it was not completed until 11/18/2021, 33 days late. Additionally, Resident 16 had a Quarterly MDS with an ARD of 07/16/2021. Record review showed it was not completed until 09/22/2021, 68 days late. Resident 19 Record review showed Resident 19 had a Quarterly MDS with an ARD of 07/21/2021, but it was not completed until 09/25/2021, 66 days late. Additionally, Resident 19 had a Quarterly MDS with an ARD of 10/22/2021. Record review showed it was not completed until 11/27/2021, 36 days late. Resident 43 Record review showed Resident 43 had a Quarterly MDS with an ARD of 05/24/2021, but it was not completed until 06/14/2021, 21 days late. During an interview on 01/10/2022 at 3:07 PM, Staff B (Director of Nursing- DNS) acknowledged the MDS for Residents 55, 16, 19 and 43 were not completed within 14 days of the ARD and were late. Resident 2 Resident 2 was admitted on [DATE]. According to the 12/20/2021 admission MDS, the assessment was not completed until 01/04/2022, 7 days late . The Medicare 5-day MDS dated [DATE], reviewed on 01/06/2022, was completed on 01/03/2012 and ready for export, but was not signed by a Registered Nurse and the nursing components were not completed, including sections B, G, GG, H, I, J, K, L, M, N, and O. In an interview on 01/06/2022 at 12:32 PM, Staff Y (Licensed Practical Nurse-LPN) stated the admission MDS was late, and the incomplete sections should have been done by 1/03/2022. Staff Y stated the 5-day MDS should have been submitted on 01/04/2022. Upon further review, after the interview with Staff Y, the 12/20/2021 Medicare 5-day MDS was completed and signed on 01/07/2021, 18 days late. Resident 14 Resident 14 was admitted to the facility on [DATE]. Review of the 10/18/2021 admission MDS showed a completion date of 11/18/2021, 17 days late. In an interview on 01/11/22 at 7:46 AM, Staff B confirmed this MDS was late. Resident 23 Resident 23 was admitted to the facility on [DATE]. Review of the 11/02/2021 admission MDS showed a completion date of 12/03/2021, 18 days late. In an interview on 01/11/2022 at 7:39 AM, Staff B confirmed the admission MDS was completed late. Resident 118 Resident 118 was admitted to the facility on [DATE]. The 01/04/2022 Admission/5 day MDS was not completed until 01/12/2022. In an interview on 01/06/2022 at 12:55 PM, Staff Y stated the MDS was due on 01/11/2021 and was late. Resident 32 Resident 32 was admitted to the facility on [DATE]. Review of the 10/31/2021 admission MDS showed that it was not completed until 12/10/2021, 26 days late. Resident 18 Resident 18 was admitted to the facility on [DATE]. Review of the 10/28/2021 admission MDS showed that it was not completed until 11/24/2021, 14 days late. Resident 268 Resident 268 was admitted to the facility on [DATE]. Review of the 12/22/2021 admission MDS showed that it was not completed until 01/04/2022, 5 days late. In an interview on 01/10/2022 at 10:53 AM, Staff B confirmed the MDS for Resident 32, 18, 268 were not completed in the required time frame and were late. Resident 40 Review of the 11/22/2021 Quarterly MDS showed a required completion due date was 12/06/2021. This MDS was completed on 12/11/2021, 5 days late. In an interview on 01/10/2022 at 12:44 PM Staff Y (MDS Nurse) stated the 11/22/2021 was completed 5 days late. Resident 13 A review of the 10/08/2021 Quarterly/5-day MDS showed Resident 13 was readmitted on [DATE]. The required 14-day completion due date was 10/22/2021. This MDSs showed the completed date was 11/18/2021, 42 days after the admission. Resident 35 A review of the 11/23/2021 admission MDS showed Resident 35 was admitted on [DATE]., The required 14-day completion due date was 12/02/2021. This MDS showed the completed date was 12/10/2021, 21 days after admission. In an interview on 01/11/2022 at 12:35 PM, Staff B acknowledged the MDSs for Residents 13 and 35 were late. Staff B stated the facility is trying to get the MDS assessments done on time and there is a new MDS LPN in training and a Registered Nurse (RN) or DNS must sign the MDSs. Staff B stated there is also an on-call, off-site RN but not all the MDSs are getting completed on time. REFERENCE: WAC 388-97-1000(b)(c)(ii). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 35 A 11/22/2021 Nurse Practitioner (NP) admission assessment showed Resident 35 was a cognitively intact, female resident. The NP assessment showed Resident 35 had diagnoses including a small bowel obstruction (blockage), constipation, anemia (low iron), hyperlipidemia (increased lipids), depression and pain. The NP assessment showed Resident 35 had a recent surgery to insert a gastric (stomach) feeding tube and there was a new surgical wound. The NP assessment showed Resident 35 had multiple sclerosis (nerve disease) and a right hand contracture. A review of the 11/2021 MAR for the seven day lookback period showed Resident 35 was administered Venlafaxine and Trazodone, both treatments for depression, Atorvastatin and Clopidogrel both treatments for hyperlipidemia, Senna for treatment of constipation, Nystatin for a fungal infection on feet, Hydrocodone a treatment for pain. A review of the 11/23/2021 admission MDS showed errors in data entry including Resident 35 was male, no impairment in range of motion of hand, no constipation, anemia, neurogenic bladder, hyperlipidemia, depression, or pain. This MDS showed no surgical wound or wound care. A review of the 11/2021 Medication Administration Record (MAR) for the seven day lookback period showed Resident 35 was administered Gabapentin (a nerve pain medication) for pain three times a day and Hydrocodone, (an opioid pain medication) was administered on 11/20/2021 and 11/21/2021. The 11/23/2021 admission MDS showed no opioids were administered in the seven day lookback, and no routine pain medication or as needed pain medication was administered. The 11/2021 Treatment Administration Record (TAR) showed a urinary catheter was in place with a diagnosis of neurogenic (nerve dysfunction) bladder. Review of the 11/23/2021 admission MDS showed no diagnosis of neurogenic bladder. In an interview on 01/11/22 at 1:04 PM, Staff B reviewed the NP assessment, the physician orders in comparison to the incorrect MDS entries, and stated the MDS did not represent Resident 35's medical status and the MDS was incorrect. Resident 38 A review of the 11/22/2021 Quarterly MDS showed Resident 38 was assessed to need two person supervision for eating. This MDS showed Resident 38 was on hospice services, but the prognosis (life expectancy) question was marked not assessed/no information. There were multiple areas marked as not assessed including pneumonia vaccination, hearing, speech, range of motion and dental was marked unable to examine. In an interview on 01/11/2022 at 12:05 PM Staff B stated an on-call Registered Nurse (RN) completed the 11/22/2021 MDS and does not come to the facility to complete the assessment. Staff B indicated the on-call RN gathers the information from the staff nurses and the resident record. Staff B stated the MDS assessments are expected to be completed and correctly represent the resident. Staff B reviewed the incorrect MDS entries and stated the MDS did not represent Resident 38's medical status and the MDS was incorrect. REFERENCE: WAC 388-97-1000(5)(a). Resident 36 According to the 02/25/2021 Quarterly MDS, the resident was assessed as cognitively intact, able to understand and be understood in conversation. The resident had diagnoses including End Stage Renal Disease and was dependent on Dialysis. Review of the 02/25/2021 Quarterly MDS, Section K Nutritional status showed the resident had no or unknown weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Review of Resident 36's weight record showed on 01/07/2021 the resident weighed 348 lbs. (pounds) and on 02/11/2021 weighed 327.8 lbs., a loss of 20.2 lbs or -5.8% in weight. In an interview on 01/12/2022 at 8:30 AM Staff B stated they would expect the weight loss of 5% or more to be captured on the MDS. Resident 268 According to the 12/22/2021 admission MDS, Resident 268 was cognitively intact and assessed with adequate vision with corrective lenses and without any open lesions other than surgical wounds. Observations on 01/03/2022 at 12:41 PM showed Resident 268 had multiple open and closed lesions scattered on arms. Resident stated, Wish they would get rid of the parasite wounds. Review of 12/21/2021 Alteration in Skin Integrity assessment showed Resident 268 had multiple abrasions that required a referral to the Wound Team for treatment. Observations on 01/11/22 8:27 AM, showed Resident 268 had a pair of sunglasses sitting on the overbed table. In an interview at this time, Resident 268 indicated they only had sunglasses and stated, I need prescription glasses, I can read but I have trouble seeing distance. In an interview on 01/12/2022 at 1:45 AM, Staff B confirmed staff should have, but did not accurately identify the vision and skin status for Resident 268 on the MDS. Resident 18 According to the 10/28/2021 admission MDS, Resident 18 was cognitively intact and assessed with obvious or likely cavity or broken natural teeth. In an interview on 01/04/2022 at 11:03 AM, Resident 18 stated they had full dentures and showed they were wearing the upper dentures. Resident 18 indicated they also had lower dentures as well and stated, I don't wear them because they don't fit right. Review of the 10/22/2021 Admit/ Readmit Assessment assessed Resident 18 to have their own teeth and indicated they had broken or carious teeth. In an interview on 01/07/2022 at 11:07 AM, Staff B confirmed the admission MDS and admission assessment for Resident 18 was inaccurate for dental. Resident 32 According to the 10/31/2021 admission MDS, Resident 32 was assessed with medically complex conditions, including an anxiety disorder and depression. This MDS indicated Resident 32 did not receive any antianxiety medications during the seven-day look-back period. Review of October 2021 Medication Administration Records showed Resident 32 received Buspirone (an anti-anxiety medication) on six days of the look-back period. In an interview on 01/12/2022 at 1:45 PM, Staff B stated the admission MDS was not accurate and should have included Resident 32 received an anti-anxiety medication during the assessment period. Resident 54 According to the 12/07/2021 Quarterly MDS, Resident 54 had diagnoses including Benign Prostate Hyperplasia (a condition where an enlarged prostrate can restrict urinary flow), and Obstructive Uropathy (a condition in which the flow of urine is blocked). This MDS assessed Resident 54 to have a urinary catheter, and indicated the resident had both an external catheter and an indwelling catheter. On 01/06/2022 at 8:37 AM, Resident 54 was observed to have an indwelling catheter. In an interview on 01/11/2022 at 9:45 AM, Staff B stated that Resident 54 required an indwelling catheter, not an external catheter. Staff B stated the 12/07/2021 MDS was not accurate. Based on observation, interview and record review the facility failed to accurately assess 15 of 24 residents (Residents 2, 14, 23, 43, 19, 55, 54, 268, 36, 214, 55, 18, 32, 38, & 35), reviewed for accurate Minimum Data Set (MDS- an assessment tool). Failure to ensure accurate assessments placed residents at risk for unidentified and/or unmet needs. Findings included . Resident 2 According to the 12/20/2021 admission MDS, staff assessed the resident was cognitively intact and had no broken dentures. Observations on 01/04/2022 at 9:16 AM showed Resident 2 had a broken tooth on the upper left portion of their denture. The resident stated the denture was broken for a while. In an interview on 01/06/2022 at 12:55 PM, Staff Y (Licensed Practical Nurse- LPN) confirmed the resident's upper denture had a broken tooth and stated the MDS was incorrect. Resident 14 According to the 10/18/2021 admission MDS, Resident 14 was cognitively intact and assessed with no vision problems, did not use corrective lenses and received non drug interventions for pain. The Care Area Assessment (CAA) associated with this MDS indicated the resident was, At risk for alteration in dental function related to resident having full upper and full lower dentures which fit without difficulty at this time . Observations on 01/04/2022 at 8:54 AM showed Resident 14 had glasses at the bedside and was noted with no natural teeth and no dentures. The resident stated they last had dentures approximately 12 years ago. In an interview on 01/11/2022 at 7:48 AM Staff B (Director of Nursing) confirmed the Dental CAA did not match the coding on the MDS and observations showed the resident didn't have dentures. Staff B indicated the MDS did not accurately reflect the Resident 14's use of corrective lenses. According to instructions in the Resident Assessment Instrument (RAI - a manual that instructs staff on appropriate coding of assessments), in order to code non-medication pain interventions, the implemented interventions must be included as part of a care plan (CP) that aims to prevent or relieve pain and includes monitoring for effectiveness and revision of care plan if stated goals are not met. There must be documentation that the intervention was received and its effectiveness was assessed. It does not have to have been successful to be counted. In an interview on 01/12/2022 at 11:02 AM Staff Y who completed the MDS, was asked what non-drug interventions for pain were captured on this MDS. No supporting information was provided. Resident 23 According to the 11/02/2021 admission MDS Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, had adequate vision without the need for corrective lenses, and experienced pain that did not interfere with day to day activities. Observations on 01/04/2022 at 10:33 AM showed Resident 23 had glasses at bedside next to a book. The resident stated at this time, they needed glasses and it made it easier to see. In an interview on 01/11/2022 at 7:40 AM, Staff B confirmed the presence of corrective lenses at the bedside and stated the MDS should, but did not, accurately reflect the resident's vision status. Resident 43 Resident 43 re-admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident received no injections during the assessment period. Review of the November and December 2021 Medication Administration Record (MAR), showed during the assessment period (11/25/2021- 12/01/2021) the resident received subcutaneous Lantus (a medication used to treat diabetes) injection twice daily. During an interview on 01/10/2022 at 3:12 PM, Staff B stated that the MDS was incorrect, and should reflect that the resident received injections on 7 of 7 days in the assessment period. Resident 19 Resident 19 admitted to the facility on [DATE]. According to the 10/22/2021 Quarterly MDS the resident was cognitively intact, and required only supervision for bed mobility, transfers, dressing, toileting, and personal hygiene, but was assessed to be dependent for bathing. During an interview on 01/10/2022 at 3:12 PM, Staff B stated that the MDS incorrectly coded Resident 19 as dependent for bathing. Additionally, according to the 10/22/2021 Quarterly MDS, the resident was assessed to be at risk for pressure injuries, but did not have pressure reducing devices to their wheel chair or bed. During an interview on 01/10/2022 at 3:12 PM, Staff B stated that all the facility mattresses were pressure rated and the MDS was inaccurately coded. Similar findings were noted on the 07/21/2021 Quarterly MDS, in which the resident was assessed to be at risk for pressure injuries, but did not have pressure reducing devices to their wheel chair or bed. During an interview on 01/10/2022 at 3:12 PM, Staff B stated the MDS was inaccurately coded. Resident 55 Record review showed Resident 55 discharged from the facility Return Anticipated on 11/16/2021 and re-admitted to the facility on [DATE]. According to the 11/28/2021 Significant Change (SC) MDS, the resident had severe cognitive impairment, with unclear speech, was sometimes understood and able to understand, vision was adequate without corrective lenses, was at risk for pressure injuries and was on a turning and repositioning program. Review of Resident 55's consults showed they were last seen by the facility's optometrist on 12/24/2019. Review of that Optometry Consultation [OC] showed Resident 55 Declined eye exam today and recommendations were made to Reschedule PRN [as needed]. No further OCs were found in the resident's record. According to the 08/31/2020 Annual MDS and 11/18/2020 Quarterly MDS, Resident 55 was assessed with impaired vision, without corrective lenses. On the 02/08/2021 Quarterly and 08/11/2021 Annual MDSs facility staff failed to assess Resident 55's vision. Review of the 05/11/2021 Quarterly MDS showed staff assessed the resident had adequate vision with the use of corrective lenses. On the 11/22/2021 SC MDS staff assessed, the resident's vision to be adequate, without corrective lenses. Record review showed the Resident 55's baseline CP had a 11/23/2021 goal of Resident will utilize devices to meet needs r/t vision/dental/hearing. According to the CP the goal was resolved on 12/02/2021. Review of the comprehensive CP showed no CP addressing vision was developed or initiated. During a interview on 1/12/2022 at 11:57 AM, after reviewing the discrepancies in Resident 55's MDS assessments (in which: the 08/31/2020 Annual and 11/18/2020 Quarterly MDSs assessed the resident had impaired vision without corrective lenses; the 05/11/2021 Quarterly MDS assessed the resident's vision was adequate with corrective lenses; and the 11/22/2022 SC MDS assessed the resident had adequate vision, without corrective lenses) Staff B stated the 11/16/2021 SC MDS was coded Inaccurately. According to the RAI a turning/ repositioning program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated based on an assessment of the resident's needs. During a interview on 1/12/2022 at 11:57 AM, Staff B indicated the MDS was incorrectly coded as the facility did not have the documentation to support the resident turning and repositioning was organized, planned, documented, monitored, and evaluated, as required to meet the definition of program.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained and/or treatment plans were incorporated into the resident's care plan (CP) and that resident's with newly evident or possible serious mental illness indicators, intellectual or a related conditions were referred for level II evaluations for 2 (Resident 19 & 23) of 3 residents reviewed who required level II PASRR evaluations. This failure placed residents at risk for not receiving necessary mental health care and services, unmet psychosocial needs and mental distress. Findings included . Resident 19 Resident 19 admitted to the facility on [DATE]. According to the 10/22/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had diagnoses of bipolar disorder and schizophrenia, demonstrated no verbal or physical behaviors towards others, and received antipsychotic and antidepressant medication on seven of seven days during the assessment period. During an interview 01/04/2021 at 10:33 AM, Resident 19 reported I asked for calls with my mental therapist, the care manager said they made an appointment, but I haven't seen one since I have been here, the last time was my last appointment [prior to hospitalization]. I am hearing voices, they talk to me .they're just criticizing me, saying stuff like you're an a**hole, stuff like that, but I am not seeing my mental therapist enough. According to the 03/25/2021 level I PASRR, Resident 19 had serious mental illness indicators (SMIIs) of Mood Disorders-Depressive or Bipolar disorders. The box for Schizophrenia was not checked. Record review showed the resident was followed by Mental Health Services. The resident was seen by psychiatry on 04/02/2021, 09/07/2021, and 11/12/2021. Each psychiatry note indicated the resident denied AVH (Audio Visual Hallucinations). However, Resident 19 is now reporting audio hallucinations of hearing voices. According to the psychiatrist notes the resident had diagnoses of chronic schizoaffective disorder, bipolar disorder, anxiety and poly substance abuse. According to to the level 1 PASRR A referral for a PASRR level II is required if .there is a credible suspicion that a SMI may exist and the qualification for exempted hospital discharge do not apply. During an interview on 01/12/2021 at 11:07 AM, Staff B (Director of Nursing) acknowledged the level 1 PASRR did not accurately reflect the resident's SMIIs and acknowledged the diagnoses of schizophrenia and the resident's reports of, and distress related to, the currently reported auditory hallucinations represented a change, and should have been identified by staff. Staff B stated that the level I PASRR should have been updated and the resident referred for a level II evaluation. Resident 23 Resident 23 was admitted to the facility on [DATE] and according to the 11/02/2021 admission MDS was assessed with an anxiety disorder and depression. According to Resident 23's 10/28/2021 Level 1 PASRR, the facility indicated the resident had serious mental illness indicators (SMI) of Depression and anxiety and required a Level II evaluation referral. Record review on 01/10/2022 revealed no evidence that Level II evaluation was completed. In an interview on 01/10/2022 at 10:42 AM, Staff L (Social Services) was asked to provide documentation that the facility obtained a Level II evaluation. Staff L provided a Notice of Determination dated 11/23/2021 from the PASRR evaluator that showed Resident 23 did meet requirements for specialized behavioral health services. Staff L indicated the evaluation for these services usually gets completed a few days after a Notice of Determination is obtained and stated, I have never had it take this long to get the documents. Staff L stated they have not received any Level II assessment evaluations since they started working at facility. On 1/10/22 at 11:37 AM Staff L provided the Level II Evaluation Summary and stated, They normally come to me. It went directly to medical records. In an interview on 01/10/2022 at 1:21 PM, Staff L stated Level II evaluation recommendations are important to, maximize treatment and to see if additional resources are needed for mental health while the resident is in the facility and when they leave. Staff L stated the Level II recommendations should have been implemented and indicated the system for PASRR's was not intact. REFERENCE: WAC 388-97-1915(4). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions and/or a PASRR was completed for each resident prior to admission, for 2 (Resident 19 & 62) of 6 and 1 (Resident 55) supplemental resident reviewed for unnecessary medications and/or level II PASRR. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . Facility Policy According to the facility's undated Admissions Criteria Policy, all new admissions and readmissions are screened for mental disorders (MD) and intellectual disabilities (ID) or related disorders (RD) per the . PASRR process The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD. Resident 19 Resident 19 admitted to the facility on [DATE]. According to the 10/22/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had diagnoses of Bipolar disorder and schizophrenia, demonstrated no verbal or physical behaviors towards others, and received antipsychotic and antidepressant medication on seven of seven days during the assessment period. During an interview 01/04/2021 at 10:33 AM, Resident 19 stated, I am hearing voices, they talk to me .they're just criticizing me, saying stuff like you're an a**hole, stuff like that, but I am not seeing my mental therapist enough. According to a 12/10/2021 psychiatry note, the resident had diagnoses of Chronic Schizoaffective Disorder, Bipolar Disorder, anxiety and a history of polysubstance abuse. Review of the 03/25/2021 level I PASRR showed, Resident 19 was assessed to have serious mental illness indicators (SMIIs) of Mood Disorders- Depressive or Bipolar The box for Schizophrenia was not checked. During an interview on 01/12/2022 at 11:07 AM, Staff B (Director of Nursing) acknowledged Resident 19's level I PASRR was not accurate and needed to be updated. Resident 55 Resident 55 re-admitted to the facility on [DATE]. According to the 11/28/2021 Significant Change MDS, the resident had severe cognitive impairment, diagnosis of depression and received antidepressant medication on seven of seven days during the assessment period. Record review showed Resident 55 had a 11/22/2021 order for Duloxetine (an antidepressant) daily for depressive disorder. Review of the 11/11/2021 level I PASRR, showed Resident 55 was assessed without any SMIIs, including depression. During an interview on 01/12/2022 at 11:07 AM, Staff B stated that the level I PASRR was inaccurate and needed to be updated. Resident 62 According to the 10/16/2021 Quarterly MDS, the resident admitted to the facility on [DATE], and had diagnoses including anxiety, depression, a history of substance abuse, alcoholism and cirrhosis. The MDS assessed Resident 62 to have mild depression. Record review revealed no Level I PASRR available in Resident 62's Electronic Health Record (EHR). In an interview on 01/07/22 at 10:25 AM, Staff L (Social Services Director) stated that Level I PASRR's should be collected prior to admission for all residents. Staff L stated that there was no Level I PASRR screening in Resident 62's record and there should be one present in the record. Staff L stated that Resident 62 had diagnoses that indicated they could benefit from Level II PASRR services. REFERENCE: WAC 388-97-1980(1) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans were maintained, revised and updated as required for 7 (Residents 14, 23, 54, 62, 18, 32, & 40) of 24 sampled residents. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS, an assessment) Resident 14 admitted to the facility on [DATE] and was cognitively intact, able to be understood and understand conversation and had multiple medically complex diagnoses. Resident 14's 10/12/2021 baseline care plan (CP) included goals of resident will [discharge] to a location that meets their needs (top 5 discharge goals) and Resident will have toileting needs met. In an interview on 01/11/2022 at 8:39 AM Staff B indicated this was not measurable as there were no discharge goals listed and no objective measurable context for toileting goals. According to a 11/06/2021 behavior CP, staff indicated interventions of Minimize potential for the resident's disruptive behaviors (SPECIFY) by offering tasks which divert attention such as (SPECIFY) and reward the resident tor appropriate behavior by (SPECIFY rewards), as indicated. In an interview on 01/11/2022 at 8:39 AM Staff B indicated the CP should identify what disruptive behaviors the resident demonstrated, what specific individualized tasks staff should attempt to divert attention and what rewards staff should provide the resident. Staff B was unable to identify what disruptive behaviors Resident 14 demonstrated. Review of December 2021 and January 2022 Medication Administration Records (MARs) showed the resident received Methadone (a synthetic opioid used to treat opioid addiction) daily. Review of CP documents showed no CP which addressed the resident's particular needs as it related to addictions or the Methadone use. In an interview on 01/11/2022 at 8:39 AM Staff B indicated there should be goals and interventions related to the Methadone use. Resident 23 According to the 11/02/2021 MDS Resident 23 had moderate cognitive impairment, was understood and able to understand conversation. This assessment indicated the resident had limited range of motion to both the upper and lower extremity on one side of the body and paralysis. Observations on 01/04/2022 at 10:18 AM showed Resident 23's left wrist was turned inward and the fingers of the left hand were tightened into a fist. The resident stated an inability to move their right hand or arm. According to a 10/27/2021 leisure activities CP, staff were instructed to introduce the resident to residents with similar background, interests and encourage / facilitate interactions. In an interview on 01/11/2022 at 8:39 AM Staff B was unable to identify how or if this intervention was implemented. According to an Activities of Daily Living (ADL) CP dated 10/25/2021, staff interventions included provide sponge bath when a full bed bath or shower cannot be tolerated. In an interview on 01/11/2022 at 8:39 AM Staff B indicated the CP should, but did not, include the resident's preferences for type and frequency of bathing. According to the 10/25/2021 ADL CP, staff should provide PT [Physical Therapy] / OT [ Occupational Therapy] evaluation and treatment per MD [Medical Doctor] orders. Record review showed therapy services were stopped at the beginning of December 2021. In an interview on 01/07/2022 at 8:37 AM, Staff B indicated there was a plan for Resident 23 to stop therapy at that time, then start therapy again two weeks after a pain treatment was provided. In an interview on 01/11/2022 at 8:39 AM Staff B indicated this plan was not, but should be, care planned. According to a 10/26/2021 baseline plan of care, resident goals included, resident will have toileting needs met and baseline plan of care will be identified. Interventions included wears brace on [their] left leg - notify LN for skin breakdown. In an interview on 01/11/2022 at 8:39 AM Staff B confirmed the goals were not individualized and the toileting needs were not objectively measurable. Staff B stated the intervention for the leg brace should be clarified as to who applies it, when and for how long. According to a behavior CP dated 11/08/2021, interventions included education resident/family on successful coping and interaction strategies such as (SPECIFY) and Minimize potential for the resident's disruptive behaviors (SPECIFY) by offering tasks which divert attention such as (SPECIFY). In an interview on 01/11/2022 at 8:39 AM Staff B confirmed there were multiple CPs with interventions included (SPECIFY) that should be but were never updated, or individualized. A 10/26/2021 heart disease CP had interventions which included encourage walking on a daily basis. In an interview on 01/11/2022 at 8:39 AM Staff B confirmed this was an unrealistic expectation as the resident was not able to walk. A 10/26/2021 incontinence CP included interventions of observe pattern of incontinence and initiate toileting schedule if indicated. In an interview on 01/11/2022 at 8:39 AM Staff B indicated this intervention was not applicable and should be discontinued as the resident was on a check and change program. According to a 10/26/2021 CP the resident used antianxiety medications. Interventions included, monitor / record occurrence of for target behavior symptoms: pacing, wandering, disrobing . In an interview on 01/11/2022 at 8:39 AM Staff B confirmed the resident was incapable of pacing or wandering and had no history of disrobing. According to a 10/26/2021 CP, Resident 23 had a stroke (bleeding in the brain) which affected the movement on the resident's left side. In an interview on 01/11/2022 at 8:39 AM Staff B indicated the CP should, but did not, include interventions for an identified contracture to the left hand. Resident 54 According to the 12/7/2021 quarterly MDS, Resident 54 readmitted to the facility on [DATE], and had diagnoses including muscle weakness, difficulty walking, Benign Prostate Hyperplasia (BPH - a condition where an enlarged prostate impedes urinary flow) and obstructive uropathy (a condition where urine does not drain freely from the bladder/kidneys.) The MDS assessed Resident 54 to require an indwelling catheter, and to require one-person assistance with bathing. Review of Resident 54's comprehensive CP revealed the following: Resident 54's 11/22/2021 resident is able to structure own leisure activities of choice CP stated the resident's preferred activities are (SPECIFY) and the resident likes the following independent activities: (SPECIFY); the 11/22/2021 resident has an ADL self-care performance deficit . CP stated the resident requires (SPECIFY what assistance) by (X) staff with (SPECIFY bathing/showering) (SPECIFY FREQ) and as necessary; the 11/22/2021 the resident at risk for falls . CP stated, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: (Specify); the 11/22/2021 resident has a Foley Catheter r/t obstructive uropathy . CP stated change catheter (as needed). (Specify Size 20FR)(SPECIFY Type of Catheter) and The resident has (SPECIFY Size)(SPECIFY Type of Catheter) ., and Check tubing for kinks [# TIMES] each shift. In an interview on 01/07/2022 at 12:30 PM, Staff B stated the instances on Resident 54's CP where it stated SPECIFY or # TIMES indicated that the CP was inaccurate and needed to be resident-specific. Resident 52's comprehensive CP also included a current 11/22/2021 Establish baseline plan of care CP with a Target date of 11/04/2021. The comprehensive CP included a 11/22/2021 resident is at for falls . CP that stated Pt [sic] evaluate and treat as ordered or PRN. In an interview on 01/10/22 at 10:42 AM, Staff AA (Director of Rehabilitation) stated Resident 54 was discharged from therapy on 11/09/2021 and had not been seen since by therapy for evaluation or treatment. In an interview with at 01/11/2022 at 09:45 AM, Staff B stated the intervention for PT to evaluate and treat was a generic intervention that needed to be revised. Resident 62 According to the 10/16/2021 Quarterly MDS, Resident 62 admitted to the facility on [DATE], and had diagnoses including GERD and constipation. According to the 06/10/2021 Quarterly MDS, Resident 62 stated that doing their favorite activities was important to them, Review of Resident 62's comprehensive CP revealed the following: the 06/10/2021 resident can structure own leisure activities . CP stated The resident likes the following independent activities (SPECIFY); the resident has GERD . CP stated monitor VITAL SIGNS (SPECIFY FREQ.); the resident has constipation . CP stated the resident will have a normal bowel movement every (SPECIFY) day through the review date, and the resident will pass soft, formed stool at the preferred frequency of (SPECIFY FREQ); the resident has potential impairment to skin integrity . CP stated the resident will be free from injury (SPECIFY) to (SPECIFY location) through the review date.; The comprehensive CP included a 06/10/2021 Baseline CP. In an interview on 01/07/2022 at 12:30 PM, Staff B stated the purpose of a baseline CP is to ensure essential care is provided while the facility assesses and care plans for a resident's more specific care needs and that they should be discontinued after a comprehensive care plan is implemented, and that Resident 62's Baseline CP should be discontinued. In an interview on 01/10/2022 at 08:45 AM, Staff B stated instances where Resident 62's CP stated SPECIFY were not resident-specific and needed to be fixed. Resident 18 According to the 10/28/2021 admission MDS, Resident 18 had multiple medically complex diagnoses including stroke and hemiplegia (paralysis of one side of the body). The MDS assessed Resident 18 to require extensive physical assistance for transfers and locomotion. According to the 10/22/2021 limited physical mobility CP, interventions included LOCOMOTION: The resident is able to: (SPECIFY) and LOCOMOTION: The resident requires (SPECIFY assistance) by (X) staff for locomotion using (SPECIFY). According to a 11/06/2021 behavior CP staff identified a goal of The resident will have fewer episodes of (SPECIFY: behavior) (SPECIFY: daily/weekly) by review date. According to a 12/09/2021 discharge CP, staff indicated the goal was, SPECIFY, with interventions left blank. In an interview on 01/07/2022 at 11:07 AM Staff B confirmed staff should have but did not, update and individualize Resident 18's CPs. Resident 32 According to the 10/31/2021 admission MDS, Resident 32 had medically complex conditions including fracture and required the use of routine pain medications. Review of January 2022 Medication Administration Records (MARs) showed Resident 32 had an order dated 11/23/2021 for Lidocaine Patch 4%, (a medication used to treat pain), to be applied daily to right lower front side of ribs. This MAR also revealed a 10/25/2021 order for Nitrofurantoin (an antibiotic used to treat and prevent urinary tract infections) to be given daily. Review of Resident 32's CP on 01/03/2022 revealed no CP addressing pain, and no CP that addressed urinary tract infections. In an interview on 01/12/2022 at 1:45 PM, Staff B confirmed the CP should have, but was not revised and updated to reflect Resident 32's current condition. Resident 40 According to the 11/22/2021 Quarterly MDS, Resident 40 was assessed with severe cognitive impairment, sometimes able to understand and be understood in conversation, and had diagnoses including multiple sclerosis (immune system disease that damages nerves) and hemiparesis (paralysis of one side of the body). Resident 40's Activities of Daily Living CP (revised 10/30/2019) showed an intervention revised on 08/12/2021 for an enabler bar (a side bar/rail) to the left side of the bed, for bed mobility. Observations made on 01/03/2022 at 1:20 PM, 01/04/2022 at 8:25 AM, 01/05/2022 at 10:17 AM, 01/06/2022 at 12:11 PM, and 01/07/2022 at 9:28 AM showed no enabler bar to the left side of the resident's bed. In an interview on 01/12/2022 at 8:30 AM Staff B stated the care plan needed to be updated because the resident no longer uses an enabler bar. Reference: WAC 388-97-1020(2)(c)(d). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13 The 10/14/2021 Quarterly Medicare 5-day Minimum Data Set (MDS- an assessment tool) showed Resident 13 was cognitively intact, speech was clear, and was able to make self understood and understood others. A review of the POs showed four separate orders all dated 10/09/2021. One order showed daily monitoring of a bruise on the inner right elbow. The second order showed bruise monitoring on the right shoulder. The third order showed bruise monitoring to the right thumb. The last order directed a warm compress be applied to the right calf every evening. A review of the November 2021, December 2021 and January 2022 MARs showed staff signed all four tasks completed. In an interview on 01/07/2022 at 11:15 AM, Resident 35 stated those bruises were from a hospital stay and healed a long time ago. Resident 35 stated the staff does not still look at the bruises because they are gone. Resident 35 stated the staff stopped the warm compress on the right calf a long time ago and it is healed too. In an interview on 01/08/2022 at 9:47 AM, Staff B stated nurses are expected to follow and sign orders when completed and discontinue orders when resolved. Staff B stated the nurses signed for monitoring bruises that no longer could be monitored and signed for a warm compress that was no longer provided and these tasks should have been discontinued when resolved. Resident 35 A review of the 11/23/2021 admission MDS showed Resident 35 received all nutrition and hydration thru a gastric tube placed in the stomach. Resident 35 was assessed as cognitively intact, had clear speech, was able to understand others and be understood. In an interview on 01/03/2022 at 12:50 PM, Resident 35 stated they did not eat or drink or take medications by mouth, everything was given through the gastric tube. Review of the 12/19/2021 physician order (PO) for Iron Sulfate showed give one tablet by mouth one time daily for anemia. The 12/10/2021 PO for Miralax (a laxative) showed give one packet by mouth, one time a day. In an interview on 01/05/2022 at 8:47 AM, Staff Z (LPN) stated Resident 35 did not take any medications by mouth and they were all crushed and administered by the gastric tube. Staff Z stated, they gave the iron crushed through the tube and mixed the Miralax in water and gave through the tube every morning. Staff Z reviewed the PO for Miralax and Iron Sulfate which both instructed to administer by mouth. Staff Z acknowledged the instructions needed to be clarified for route and the Miralax needed instructions to mix with a fluid. Staff Z stated the orders needed to be clarified. In an interview on 01/06/2022 at 10:37 AM, Staff B stated the medications for Resident 35 should all be given through the gastric tube and the orders should have been clarified for Iron and Miralax. Staff B reviewed Resident 35's physician orders and stated the 11/19/2021 Tylenol by mouth order and the 11/23/2021 Trazodone by mouth order should also be clarified to gastric tube. Review of Resident 35's 11/20/2021 admission orders showed staff was instructed to monitor bruises on the abdomen, left thigh, right thigh, and left arm. A 11/28/2021 order instructed monitoring of a bruise on the right collarbone. A 12/16/2021 order instructed staff to monitor a bruise on the left hand. Review of a 11/19/2021 order for Nystop (a fungal powder) instructed staff to apply powder to both feet two times daily for a rash, until resolved. A review of the December 2021 and January 2021 MARs showed staff signed for ongoing monitoring of the six bruises and twice daily application of Nystop powder. In an observation on 01/04/2022 at 9:16 AM, Staff was repositioning resident and a skin check with Staff Z confirmed Resident 35 did not have any bruising to the arms, legs back or abdomen and there was no redness on the feet. In an interview on 01/06/2022 at 10:37 AM, Staff B stated staff should discontinue monitoring and treatments when issues are resolved. Resident 38 Review of Resident 38's physician orders showed a 12/22/2021 order to monitor for adverse side effects of an anti-anxiety medication. Further review of the orders showed Resident 38 was not presently on an anti-anxiety medication, one was discontinued on 11/17/2021. In an interview on 01/06/2022 at 10:23 AM, Staff B stated staff did not discontinue the side effects monitoring order when the medication was discontinued. Staff B acknowledged the staff was signing for a monitor of side effects when there was nothing to monitor. Staff B stated the facility does not have a system to complete monthly review of physician orders for accuracy. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). Resident 40 According to the 11/22/2021 Quarterly MDS the resident was assessed with severe cognitive impairment, sometimes could understand and was sometimes understood in conversation. Resident 40 had diagnoses including multiple sclerosis and hemiparesis (limited mobility on one side of the body). An 08/04/2021 PO directed staff to administer Protein powder and mix in 4-8 ounces of fluid. The PO was incomplete, and the amount/dose of protein powder was missing. In an interview on 01/12/2021 at 8:30 AM Staff B stated staff administered a packet of protein powder and would expect the PO to include the dose so staff knew how much to administer. Resident 60 According to the 12/14/2021 Quarterly MDS the resident was assessed as cognitively intact, was able to understand and was understood in conversation. Resident 60 and had diagnoses including end-stage renal disease (ESRD), diabetes and depression. Review of a 10/19/2021 revised ESRD CP showed the resident received dialysis services 3 times a week. In an interview on 01/03/2021 at 12:30 PM Resident 60 stated they go to dialysis at 5:00 AM on Tuesdays, Thursdays and Saturdays. Review of the October 2021 MAR showed the resident had four medications (Aspirin, Lexapro (anti-depressant), Lasix (diuretic), and Coreg (treats high blood pressure) that were scheduled at 6-11 AM and had 4 medications ( Seroquel (an anti-psychotic), Calcium Carbonate, Valsartan (for blood pressure) and a Renal Multivitamin) that were scheduled at 8 AM. The resident had a PO that directed staff to check the residents blood sugar at 7:30 AM. According to the MAR chart code key, a 1 indicated absent from facility without meds, a 3 indicated absent from facility with meds and a 9 indicated see progress note. The facility staff documented either a 1, a 3 or a 9 on 4 days (10/02/2021, 10/05/2021, 10/09/2021 and 10/12/2021) for medications scheduled at 6-11 AM and on 9 days (10/02/2021, 10/05/2021, 10/07/2021, 10/09/2021, 10/12/2021, 10/14/2021, 10/21/2021, 10/28/2021 and 10/30/2021) for medications scheduled at 8 AM. Documentation indicated facility staff did not check the residents blood sugar on 9 days (10/02/2021, 10/05/2021, 10/07/2021, 10/09/2021, 10/12/2021, 10/14/2021, 10/21/2021, 10/28/2021 and 10/30/2021). In an interview on 01/06/2022 at 1:19 PM, Staff B stated that the resident's medication should have been adjusted on dialysis days, but it was not. They would expect a PO to adjust medication times on dialysis days. Resident 268 Resident 268 was admitted to the facility on [DATE]. According to the 12/22/2021 admission MDS Resident 268 was assessed to require extensive physical assistance with personal hygiene and required total dependence for bathing. An observation on 01/04/2022 at 8:43 AM showed Resident 268 with long untrimmed nails to both hands that extended past fingertips. Review of the January 2022 Medication Administration Record (MAR) showed staff were directed to perform fingernail care weekly. On 01/06/2022 staff signed this order as completed. An observation on 01/11/2022 at 8:42 AM still showed Resident 268 with the long untrimmed fingernails. In an interview on 01/11/2022 at 1:55 PM, Staff Y (Resident Care Manager) verified that Resident 268's fingernails were long, extending past fingertips, and had not been trimmed. In an interview on 01/12/2022 at 1:45 PM, Staff B stated nursing staff should not sign for tasks that were not performed. Resident 18 Resident 18 was admitted to the facility on [DATE]. According to the 10/28/2021 admission MDS Resident 18 had multiple medically complex diagnoses including stroke (bleeding in the brain) and hemiplegia (paralysis of one side of the body). The MDS assessed Resident 18 as cognitively intact with clear speech, able to be understood and understand conversation. In an interview on 01/03/2022 at 1:05 PM, Resident 18 stated they had been admitted to facility in October after experiencing a stroke. Review of hospital discharge orders dated 10/21/2021 and scanned into Resident 18's medical record on 10/22/20221 showed an order for Nicotine 14 mg (milligram)/ 24 hours patch to be applied daily for 30 days. Review of Resident 18's January 2022 MAR showed this order was transcribed without the 30-day time frame per hospital discharge orders and continued to be administered. Record review on 01/07/2022 revealed no clarification that the Nicotine order was to continue past 30 days. In an interview on 01/07/2022 at 11:07 AM, Staff B confirmed order should have, but was not, transcribed correctly from hospital discharge orders. On 01/08/2022 the order for nicotine patches was discontinued. In an interview on 01/07/2022 at 11:50 AM, Resident 18 stated they had not been out of the facility for any appointments since admission. According to a hospital Discharge summary dated [DATE], directions were given that Resident 18 should have a stroke clinic follow up four weeks after discharge and indicated the referral was already made. Record review on 01/07/2022 revealed no indication that Resident 18 had gone to the stroke clinic since admission. In an interview on 01/07/2022 at 11:40 AM, Staff QQ (Medical Records/ Transportation), stated they had not received any paperwork on Resident 18 and was unaware the resident had any follow up appointments that needed to be arranged. Staff QQ indicated they only arrange the transportation once nursing staff makes the appointment. In an interview on 01/10/2022 at 10:53 AM, Staff B stated it did not appear that Resident 18 was seen by the stroke clinic since admission. Staff B confirmed the stroke clinic follow up appointment should have been transcribed into Resident 18's orders on admit. Resident 61 According to the 11/17/2021 Quarterly MDS, Resident 61 had diagnoses including diabetes (DM), and required insulin to manage blood glucose levels. A 11/27/2021 PO showed Insulin Glargine Solution 100 ML [milliliter] /unit inject 22 units subcutaneously at bedtime related to [DM] with other diabetic kidney complication. Review of the 01/2022 MAR revealed a blank box on 01/06/2022 for Resident 61's Insulin Glargine, indicating the medicine was not administered. In an interview on 01/12/2022 at 07:25 AM, Staff B stated that Resident 61 did not, but should have, received their insulin dose as ordered on 01/06/2022. Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were implemented for 9 (Residents 61, 18, 40, 60, 35, 13, 268, 14, & 38) of 24 residents reviewed. Failure to follow physician orders, clarify physician orders, document injection sites, ensure follow up appointments were scheduled and signing for tasks that were not completed placed residents at risk for medication errors, delay in treatment, and adverse outcomes. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS- an assessment tool) Resident 14 admitted to the facility on [DATE] and was assessed with diagnoses including heart disease, diabetes mellitus (DM), and lung disease. According to the resident's Physician Orders (PO) dated 10/23/2021, staff were directed to administer Insulin daily at bedtime related to diabetes. Review of December 2021 and January 2022 Medication Administration Records (MARs) showed there were no directions to nursing staff to document the location or site of injections. In an interview on 01/07/2022 at 11:20 AM, Staff B (Director of Nursing) confirmed, nursing staff should, but did not, document injections sites to ensure rotation of sites.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 55 Resident 55 re-admitted to the facility on [DATE]. According to the 11/28/2021 Significant Change MDS, the resident had severe cognitive impairment, and required extensive assistance with ADLs. On 01/04/2022 at 11:21 AM and 01/05/2022 at 1:43 PM, Resident 55's toenails were observed to be long and untrimmed, the toenails to the 2nd digit on each foot were beginning to curve around the end of the toes. In an interview on 01/06/2022 at 1:48 PM, Staff B explained it was the expectation that resident's nails be cut on shower days, unless diabetic, then the nails care would be signed for by a nurse on the Medication Administration Record (MAR). Review of Resident 55's January 2022 MAR and Treatment Administration Record (TAR) showed there was no instruction to nurses to trim/cut Resident 55's nails. On 01/06/22 at 01:20 PM, Staff SS (Licensed Practical Nurse) observed Resident 55's toenails and stated, Yes, it looks like they need to be trimmed. On 01/06/22 at 01:39 PM, Staff TT (Evening Manager, Registered Nurse) also observed the resident's toenails and stated, No it didn't look like they received weekly toenail care. Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 12/12/2021 5 day MDS, the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and bathing. On 01/03/22 at 02:26 PM Resident 16's toenails were observed to be very long, thick, untrimmed and yellow/tan in color. The great toe on the left foot, and to a lesser extent the great toe on the right foot, was distorted protruding forward off the end of the great toe, then curved/jutted sharply (45 degrees) laterally. When asked about nail care Resident 16 stated facility staff offer and perform specifically toenail care yearly. The resident shared there used to be a nurse that trimmed their toenails routinely but the nurse no longer worked at the facility. On 01/06/2022 at 1:48 PM, Staff B observed Resident 16's toenails and stated, No it didn't appear that Resident 16 received weekly nail care. Resident 55 Resident 55 re-admitted to the facility on [DATE]. According to the 11/28/2021 Significant Change MDS, the resident was cognitively impaired and required extensive assistance with ADLs. On 01/04/22 at 11:21 AM and 01/05/22 at 01:43 PM, Resident 55 was observed lying in bed with unkempt hair, with an oily appearance. According to the ADL self-care performance deficit CP, revised 11/24/2021, Resident 55 preferred two bed baths (bb) a week, in the AM. According to the bathing records for December 2021 and January 2022 showed Resident 55 was offered/provided bathing as follows: 12/01/2021- bb; 12/22/2022- bb (21 days later); 12/29/2021 (7 days); and 01/05/2022 (7 day). In an interview on 01/12/2022 at 11:52 AM, Staff B acknowledged the facility provided less than one shower a week in December 2021, including a 21-day period between 12/01/2021- 12/22/2022, in which facility staff failed to offer and/or provide bathing to Resident 55. Resident 43 Resident 43 re-admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact (predominantly Spanish speaking), required extensive assistance with ADLs, and decisions related to bathing were assessed to be very important. According to the ADL self-care performance deficit CP, revised 09/02/2021, Resident 43 preferred two showers a week, if unable to tolerate, staff were to provide a sponge bath. According to the bathing records for December 2021 and January 2022 [Resident 43] prefers two showers a week. Review of the documents showed Resident 43 was offered/provided bathing as follows: 12/08/2021- shower (first shower/bath provided in December 2021); 12/15/2021- shower (7 days later); 12/28/2021- shower (13 days later; 01/11/2022- shower (14 days later). In an interview on 01/12/2022 at 11:52 AM, Staff B acknowledged the 25-day period between 12/16/2021- 01/10/2022, the resident was only offered/ provided one shower. Resident 38 According to the 11/22/2021 Quarterly MDS, Resident 38 was assessed to have impaired mobility and dementia with severe cognitive impairment. Resident 38 was assessed to require assistance of two people with eating and oral hygiene. Eating An observation on 01/05/2022 at 12:51 PM showed Staff O (Certified Nursing Assistant) set up the lunch tray on the overbed table for Resident 38. The silverware was upside-down to the resident, the bread was not removed from a white bag on the tray, there was a straw in the lid of the juice and the cover was left on the ice-cream. When staff O left the room, Resident 38 grabbed the straw and pulled it out of the cup, then was not able to put it back in the cup. Resident 38 spent five minutes holding the straw and trying to put the straw in the lid, then fell asleep. At 1:38 PM Staff O entered the room, woke the resident and was talking with Resident 38 about the food. Staff O placed food on the fork and handed to Resident 38, who did not take the fork, so set it on the plate with a bite set up to eat and then left the room. At 2:04 PM Staff NN (Nurse Aide in Training) entered the room, asked Resident 38 if they wanted help, and cut the bread in the bag into finger food size pieces. Resident 38 picked up one piece and ate it. Staff NN left the room. Resident 38 reached for the bread and picked up a handful, squished it over the tray into crumbs. Resident 38 did not eat any more of the food on the tray. At 2:10 PM Staff NN came back and helped Resident 38 drink cocoa with the straw. Staff NN collected the tray and exited the room. In an interview at 2:18 PM Staff NN described the tray, ate a few carrots, ate some cake (bread), a little milk. Staff NN stated I had to help with the cocoa, with cueing and help (they) drank most of it. Staff NN stated Resident 38 needs help with eating. In an interview 01/06/2022 at 9:47 AM, Staff B reviewed Resident 38's CP and stated there were no directions for staff on how to assist Resident 38 with eating and what level of assistance was needed. Staff B stated there are no ADL instructions on the CP for Resident 38. Staff B stated staff would not know what to do for Resident 38 at mealtime according to the CP and it needed to be updated. Observation on 01/05/2022 at 12:20 PM showed Resident 38 in bed. There were saliva crusts at the corners of Resident 38's lips. Resident declined to show their teeth or open their mouth. Resident 38 stated, leave me alone and let me sleep. An observation at 12:25 PM showed no oral care cleaning supplies at the sink. No oral care supplies were found in Resident 38's room. An interview on 01/05/2022 at 12:30 PM, Staff Z (Licensed Practical Nurse) stated Resident 38 was unable to do their own oral care and needed assistance. Staff Z did not know if Resident 38 had oral care yet that day but stated they would check with the aide and if not, it would be done after lunch. Staff Z searched for any oral care supplies in Resident 38's room and was not able to locate a toothbrush or toothpaste. At 12:55 PM Staff NN delivered a small basin with a toothbrush, holder, and toothpaste and set it by the sink. Staff NN stated oral care was not done that morning and would be done after lunch. At 3:58 PM Staff NN was at the nurse's station on the computer. Resident 38's oral care supplies were by the sink still unopened and unused. Staff NN stated the next shift would do it. In an interview on 01/06/2022 at 9:47 AM, Staff B stated it was expected that Resident 38 would have oral care at least once on day shift. Resident 35 A review of the 11/23/2021 admission MDS showed Resident 35 received nutrition by tube into their abdomen and did not eat food by mouth. The MDS showed Resident 35 did not have their own natural teeth and was assessed to require extensive assistance with personal hygiene. In an interview on 01/03/2022 at 12:50 PM, Resident 35 stated they had dentures over by the sink and preferred to wear them even though they did not eat food by mouth. Resident 35 stated they needed help to get the dentures from the sink and to put them in their mouth. Resident 35 stated, They do not help me with the dentures unless I ask. They think because I do not eat, I do not need them. Yes, I want to wear them. In multiple observations on 01/03/2022 at 12:50 PM, 01/04/2022 at 9:16 AM, 01/05/2022 8:29 AM, and 01/06/2022 at 12:00 PM Resident 35 was observed not wearing their dentures. In an interview on 01/11/2022 at 1:04 PM, Staff B stated Resident 35 should have received assistance with cleaning their dentures. REFERENCE: WAC 388-97-1060(2)(c). Resident 268 Resident 268 was admitted to the facility on [DATE]. According to the 12/22/2021 admission MDS Resident 268 was assessed to require extensive physical assistance with bed mobility, toileting, and personal hygiene and required total dependence for bathing. Nailcare Observations on 01/04/2022 at 8:43 AM showed Resident 268 with a full beard and had long untrimmed nails to both hands that extended past fingertips with nails curving downward. The left-hand thumb nail and third fingernails were jagged and broken. In an interview at this time, Resident 268 stated, I would do myself if I had a clipper. Similar observations were noted on 01/11/2022 at 8:42 AM when Resident 268 made a gesture with fingers showing a claw and stated, Screeeeech, I could go scratch my nails down a chalkboard. In an interview at this time, Resident 268 indicated they wanted nails trimmed. According to a 12/16/2021 CP for Impairment to skin integrity, staff were directed to keep fingernails short. Review of January 2021 Medication Administration Record (MARs) showed staff were directed to perform fingernail care weekly. Bathing/ Shaving In an interview on 01/11/2022 at 8:43 AM, Resident 268 stated, I would actually like a shave and haircut. I'm tired of looking like a gorilla. Resident indicated they used to shave at the end of the month, but reports it has been awhile. Resident 268 stated they have not had any showers since admission and stated, when I was well, I was showering every day, but now I would need some assistance. Resident 268 indicated they were unaware they could get a shower with assistance. According to an undated facility shower schedule, provided by staff, Resident 268 was scheduled for twice weekly bathing on Monday and Thursday. Review of bathing records for Resident 268, showed Resident 268 had one documented bed bath on 12/21/2021, refused bathing on 12/30/2021 and 01/06/2022, and had no other documentation of showers since admission. In an interview on 01/12/2022 at 1:45 PM, Staff B stated it did not appear that staff provided showers as scheduled for Resident 268, and indicated that staff should have, but did not trim fingernails weekly. Resident 32 Resident 32 was admitted to the facility on [DATE]. According to the 10/31/2021 admission MDS, Resident 32 was cognitively intact and was assessed to required extensive physical assistance with bathing. In an interview on 01/04/2022 at 9:04 AM, Resident 32 reported they only receive one shower per week on Wednesdays and indicated they would like showers twice weekly. Resident 32 stated, I feel unclean sometimes, especially my hair. I wish my hair was clean. According to an undated facility shower schedule, provided by staff, Resident 32 was scheduled for twice weekly bathing on Wednesday and Saturday. Review of bathing records showed Resident 32 was showered on 12/08/2021, 12/22/2021, and 12/29/2021. This documentation showed Resident 32 only received three showers in four weeks. In an interview on 01/12/2022 at 1:45 PM, Staff B stated staff should be providing showers per facility schedule and confirmed it did not appear Resident 32 received showers twice weekly as scheduled. Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs), related to cleanliness and grooming for 8 (Residents 2, 14, 23, 118, 268, 32, 55, & 16) of 11 sample and 3 (43, 38, 35) supplemental residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (268), nail care (2, 14, 23, 118, 268, 55 & 16), bathing (2, 14, 23, 118, 268, 32, 55 & 43), and eating (43) placed the residents at risk for poor hygiene, soiled long nails, embarrassment and diminished quality of life. Findings include . Resident 2 According to the 12/20/2021 admission Minimum Data Set (MDS - an assessment tool), Resident 2 was cognitively intact, had multiple wounds, and required extensive 2-person assistance with bed mobility, transfers, mobility on and off unit, dressing, toilet use and personal hygiene. According to this MDS, bathing did not occur during the assessment period. Observations on 01/03/2022 at 12:55 PM showed the resident sitting at the bedside with long soiled fingernails and long toenails. Observations on 01/04/2022 at 9:14 AM showed the resident had long fingernails with dark debris under the nails of both hands. The resident stated they received only one bed bath since admission, that they didn't feel clean, and that their skin was dry and flaky, and they were dependent on staff to apply lotion, which they did not do. Review of facility bathing records showed the resident received only one bed bath, on 12/22/2021, from admission on [DATE] through 01/05/2021. According to Baseline Care Plan (CP) documents dated 12/14/2021, staff were directed to apply lotion to dry skin. In an interview on 01/05/2022 at 10:34 AM Staff B (Director of Nursing) confirmed the resident was dependent on staff and should have received assistance with bathing. During an observation on 01/05/2022 at 10:01 AM, Staff B confirmed the resident had toenails to the left foot which were long and required trimming, the resident's lower legs were dry and flaky, and the resident's fingernails were soiled with brown debris. Resident 14 Resident 14 admitted to the facility on [DATE] and according to the 10/18/2021 admission MDS, Resident 14 was cognitively intact, had a right, above-the-knee, leg amputation and required extensive two-person assist with bed mobility and toileting and extensive one-person assistance with personal hygiene. Observations on 01/04/2022 at 8:19 AM showed the resident's hair was trimmed short, was oily and did not appear clean. The resident's fingernails were of medium length, with polish that was chipped and grown out. The resident's toenails were covered and not observable. The resident stated they did not receive bathing regularly and they did not feel clean. Observations on 01/05/2021 at 10:15 AM with Staff B showed the resident's hair was uncombed, toenails were long, with the left foot third and fourth toes were jagged. During this observation Staff B confirmed the nails on the left foot should be filed. In an interview on 01/05/2022 at 10:34 AM Staff B indicated the resident did not receive bathing twice a week and staff should have, but did not, provide nail care. Resident 23 According to the 11/02/2021 admission MDS, Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, had limited range of motion, and required extensive two-person physical assistance with transfers, bed mobility, and extensive one-person physical assist with personal hygiene. Staff documented on this assessment that bathing did not occur during the assessment period. Observations on 01/04/2022 at 10:14 AM showed the resident lying in bed, the resident's fingernails on the right hand were soiled and long, all fingernails on the left hand except the thumb, were long. The resident's hair appeared greasy and unbrushed. At this time the resident indicated it had been a few weeks since they had gotten out of bed and was not sure when their hair was last washed. Similar observations of long soiled nails and unkempt hair were noted on 01/05/2022 at 9:05 AM. At this time the resident's toenails were noted as long, and jagged polish 3/4 grown out only on tips. During observations on 01/05/2022 at 9:33 AM, Staff B confirmed Resident 23 had long uneven toenails on both feet which required trimming and four of the fingers on the left hand required trimming. In an interview on 01/05/2022 at 10:25 AM, Staff B reported the bathing records for Resident 23 were inconsistent, and was unable to confirm or refute the consistency of when the resident's hair was last washed. Resident 118 Resident 118 admitted to the facility on [DATE] and according to the 01/04/2022 admission MDS was assessed with severe cognitive impairment, required extensive two-person physical assistance with bed mobility, transfers, and one-person extensive assistance with personal hygiene. Staff documented that bathing did not occur during the assessment period. Observations on 01/03/2022 at 2:12 PM showed the resident sitting in a wheelchair at the bedside. In an interview at that time, the resident stated they would like to trim their nails but couldn't. Observations on 01/05/2022 at 9:27 AM with Staff B showed Resident 118 had thick, fungal toenails, with long nails noted on the left and right feet. On the left foot, the 4th and 5th toes were noted to be jagged and stuck to the sock when it was removed. In an interview on 01/05/2022 at 9:48 AM, Staff B stated nursing staff should trim resident's nails on bath days and if they are unable to do so, the resident should be referred to podiatry, and stated, We can try little at a time. At this time, Staff B referenced bathing records and confirmed there was no evidence of showers or bed baths since admission on [DATE]. Staff B stated the resident should have, but did not, received assistance with nail care and bathing.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 18 Resident 18 was admitted to the facility on [DATE]. According to a 10/28/2021 admission MDS Resident 18 was cognitively intact and assessed with no vision problems and did not use corrective lenses. In an interview on 01/04/2022 at 11:08 AM, Resident 18 stated they needed glasses because they were only able to see things up close. Resident 18 reported they used to have glasses, but they broke before admission. Resident 18 indicated they talked with staff about glasses but have not been seen by the eye doctor yet. In an interview on 01/07/2022 at 11:07 AM, Staff B confirmed staff should have, but did not identify Resident 18 should be referred for vision services on admission. Resident 25 Resident 25 was admitted to the facility on [DATE]. According to a 10/18/2021 Modification of Admission/ Medicare - 5 Day MDS, Resident 25 was cognitively intact, able to understand and be understood in conversation. In an interview on 01/04/2022 at 10:32 AM, Resident 25 stated they need eyeglasses as they can only see up close. Resident 25 indicated they were seen by the eye doctor a couple months ago and stated I was supposed to get my glasses a while ago, but I haven't heard anything. In an interview on 01/11/2022 at 12:15 PM Resident 25 stated, I need something to help me see, I can't see the tv [television] across the room. Review of Resident 25's electronic records on 01/05/2022 revealed no indication that Resident was seen by an eye doctor. On 01/06/2022 an eye doctor consultation was scanned into Resident 25's record that indicated they were seen on 11/09/2021. This consultation identified the plan was for new glasses. In an interview on 01/11/2022 at 12:41 PM, Staff L (Social Services) stated the facility typically receives their glasses within two weeks after appointments and was unaware that Resident 25 had not received their glasses. In an interview on 01/12/2022 at 1:45 PM, Staff B stated staff should have, but did not follow up to assure Resident 25 received corrective lenses as indicated on consultation. REFERENCE: WAC 388-97-1060(3)(a). Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and assistive devices to maintain vision abilities for 6 (Residents 18, 19, 55, 23, 25 & 14) of 8 residents reviewed for vision and hearing. Failure to ensure residents received assistance with the use of corrective lenses left residents at risk for unmet needs and diminished quality of life. Findings included . Resident 14 According to the 10/18/2021 admission Minimum Data Set (MDS - an assessment tool), Resident 14 was cognitively intact and assessed with no vision problems and did not use corrective lenses. Observations on 01/04/2022 at 8:54 AM showed Resident 14 had glasses at at the bedside. In an interview at this time, the resident indicated the glasses were not correct stating, I can't focus very well, I need new ones. I saw an eye doctor months before I had my fall and I haven't gotten a new pair of glasses .I talked to the staff here and they never done anything about it . In an interview on 01/11/2022 at 7:48 AM Staff B (Director of Nursing) indicated the glasses were apparent at the bedside, the resident used the glasses and staff should have been aware of the glasses. Staff B stated the admission nurse should have asked the resident about the need for new glasses and referred the resident for vision services. Resident 23 According to the 11/02/2021 admission MDS Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, and had adequate vision without the need for corrective lenses. Observations on 01/04/2022 at 10:33 AM showed Resident 23 had glasses at bedside next to a book. The resident stated at this time, they needed to see an eye doctor as they hadn't seen one in years and things were blurry. Similar observations of the resident with corrective lenses were made on 01/05/2022 at 12:35 PM and 01/07/2022 at 8:45 AM. In an interview on 01/11/2022 at 7:40 AM, Staff B confirmed the presence of corrective lenses at the bedside. In an interview at this time, and stated staff should have, but did not identified the resident's glasses were present. When asked if the resident should be referred for vision services, Staff B replied, Yes. Resident 19 Resident 19 admitted to the facility on [DATE]. According to the 10/22/2021 Quarterly MDS, the resident was cognitively intact, and had adequate vision with the use of corrective lenses. In an interview on 01/04/2022 at 10:21 AM, Resident 19 indicated he was seen by optometry at the facility approximately two months prior and was told new prescription glasses were ordered. Resident 19 appeared irritated and stated, , I .[and] I see double. Review of the 11/09/2021 Optometry Consult showed the plan was for New Glasses to be made for Resident 19.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 35 The 11/23/2021 admission MDS showed Resident 35 was cognitively intact, had clear speech and was able to understand and be understood. Resident 35 had a diagnosis of Multiple Sclerosis (a nerve disorder) and needed extensive assistance with all mobility and care. In an interview on 01/03/2022 at 12:50 PM, Resident 35 stated, I cannot move my right side, the arm, or the leg. Resident 35 stated they had therapy but was not currently doing any exercise or ROM with the staff. A review of the 12/25/2021 Physical Therapy (PT) discharge summary showed a restorative program was developed on discharge to maintain Resident 35's ROM in upper and lower body. A review of the December 2021 and the January 2022 restorative program schedule, provided by Staff S(Restorative Aide), showed Resident 35 was not scheduled for restorative services. In an interview on 01/06/2022 at 10:44 AM, Staff B explained the PT team was asked to look at Resident 35's right hand contracture before therapy ended. Staff B reviewed Resident 35's records and stated the RP had not been initiated yet and Resident 35 had not received range of motion exercises since 12/25/2021. Staff B further stated an on-call Restorative nurse was needed due to the staffing shortage and management is looking at all resources to maintain programs like Restorative Nurse Services. REFERENCE: WAC 388-97-1060(3)(d), (j)(ix). .Resident 40 According to the 11/22/2021 Quarterly MDS, the resident was assessed with severe cognitive impairment, sometimes able to understand and be understood in conversation, and had diagnoses including Multiple Sclerosis (MS), paralysis (loss of muscle function) and required extensive assistance from staff for bed mobility, dressing and personal hygiene. Resident 40 was dependent on staff for transfers, toileting and eating. This MDS showed the resident received restorative services of passive range of motion (PROM) and splinting four of seven days of the assessment period. Review of a 10/31/2019 ADL (Activities of Daily Living) self-deficit CP, showed the resident had ROM impairments to their bi-lateral upper extremities (BUE) and to their left side lower extremity (LE). A 09/06/21 revised Impaired Mobility CP showed the resident had decreased ROM secondary to MS and paralysis and received restorative services to include PROM to BUE and BLE 3-6 times per week and a splint placed to the resident's bi-lateral wrists and hands and knees seven times per week. Review of Restorative documentation for December 2021 showed the resident was not offered ROM 6 times a week as care planned or offered splints to hands/ wrists and knees seven times a week as care planned. Similar findings were made for November 2021 and October 2021. Review of Resident 40's clinical record showed no indication the facility had assessed and reviewed the resident's response and progress of the restorative program at a minimum of quarterly. In an interview on 01/12/2022 at 8:30 AM Staff B stated that they would expect Resident 40's ROM and splinting to be done as care planned and acknowledged it was not. Staff B confirmed there was no quarterly review of the resident's restorative program and stated they would expect one to be done quarterly and with changes. Resident 59 According to the 12/14/2021 Quarterly MDS, the resident was assessed as cognitively intact, able to understand and be understood in conversation, and had diagnoses including amputation, venous insufficiency (improper functioning of vein valves in LE) and required extensive assistance from staff for bed mobility, transfers, dressing, and personal hygiene, and was dependent on staff for toileting. This MDS showed the resident received restorative services of AROM one of seven days of the assessment period. Review of a revised 09/06/2021 Impaired mobility related to decreased ROM CP showed an intervention that directed staff to provide AROM to BUE and BLE 3-6 times a week. Review of Restorative documentation for December 2021 showed the resident was not offered AROM 6 times a week as care planned. Similar findings were made for November 2021 and October 2021. Review of Resident 59's clinical record showed no indication the facility had assessed or reviewed the resident's response and progress of the restorative program at a minimum of quarterly. In an interview on 01/12/2022 at 8:30 AM Staff B confirmed Resident 59's restorative program was not being offered as care planned and would expect staff to offer the program as written and for a monthly review to be completed at least quarterly. Resident 60 According to the 12/14/2021 Quarterly MDS, the resident was assessed as cognitively intact, able to understand and be understood in conversation, and had diagnoses including end stage renal disease, diabetes, and paralysis following a cerebral vascular accident (disrupted blood flow to the brain). Resident 60 was assessed to require extensive assistance with bed mobility, transfers, dressing and personal hygiene, and was dependent on staff for toileting. This MDS showed the resident received restorative services of a splint one of seven days of the assessment period. Review of a 11/03/2021 Impaired Mobility CP showed the resident had decreased ROM affecting the right side related to paralysis and received restorative services to include PROM to BLE and apply splint to the right knee seven times a week. Review of Restorative documentation for December 2021 showed the resident was not offered PROM and the knee splint as care planned. In an interview on 01/12/2022 at 8:30 AM Staff B confirmed the resident did not receive restorative services as care planned and stated they would expect staff to offer the restorative program as written. Based on observation, interview, and record review the facility failed to ensure 5 (Residents 14, 23, 40, 60, & 35) of 9 sample residents and 2 (Residents 59 & 18) supplemental residents reviewed for Restorative Nursing Services received the services as they were assessed to require. These failures placed residents at risk for decline in Range of Motion (ROM), a reduction in mobility, increased dependence on staff and decreased quality of life. Findings included . Resident 23 According to the 11/02/2021 admission Minimum Data Set (MDS - an assessment tool) Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, and experienced one sided functional limitations of ROM for both upper and lower extremities. According to self-care performance Care Plans (CP) dated 10/26/2021 indicated Resident 23 was identified with a stroke (brain bleed) with left sided paralysis. There was no indication facility staff identified the resident required care or services related to contractures or had any type of Restorative Program (RP). Observations on 01/03/2022 at 2:23 PM showed Resident 23 lying in bed with the left wrist curled inward and fingers that were curled in toward the palms without benefit of any splinting or hand protective device. The resident stated at that time they were unable to move their left arm or leg and received no exercises or ROM from staff. Similar observations of stiff and immobile left extremities were noted on 01/04/2021 at 10:43 AM and 2:10 PM. In an interview on 01/05/2022 at 11:56 AM, Staff B (Director of Nursing) stated Resident 23 had a Restorative Program (RP) that was developed by therapy when [they] came off of therapy on December 10, 2021. Staff B stated, We didn't implement it until yesterday (01/04/2022) because my Restorative Nurse that helps with that isn't working full time. I looked yesterday and saw it wasn't implemented. Staff B confirmed the RP should have been implemented within 48 hours of the 12/10/2021 discharge from therapy. Review of the RP implemented on 01/04/2022 showed instructions to staff to perform Active (when a resident is able to move limbs on their own) ROM to the resident's bilateral LE (Lower Extremity) and Passive (when staff moves the limb or body part) ROM to bilateral UE (Upper Extremity). In an interview on 01/05/2022 at 12:57 PM, Staff AA (Director of Rehab) was asked how the resident could perform Active ROM to the paralyzed lower left extremity or why assistance would be needed for the upper right extremity. Staff AA stated Resident 23's Restorative Program (RP) was incorrectly written. Record review showed no indication the resident was assessed for, or received Restorative services to prevent decline in range of motion of the left extremities or to prevent decline of the contracted left hand/wrist. Therapy notes dated 10/28/2021 described Resident 23 had no active ROM to the left upper arm and that the left upper extremity was fixed in internally rotated and pronated [turned inward] position and had limited elbow extension and hand/wrist extension. In an interview on 01/05/2022 at 12:01 PM, Staff B confirmed the resident had contractures to the left hand/wrist stating the resident, . doesn't have anything (splint, handroll) for the hand. In an interview on 01/05/2022 at 12:57 PM, Staff AA was asked why there were no interventions for the resident's left hand/wrist. At this time Staff CC (Certified Occupational Therapy Assistant) stated the resident was previously evaluated for a resting hand splint, stating, [They] had one, we may have discontinued it due to [their] resistance. According to 11/23/2021 Occupational Therapy notes, the resident was provided a resting hand splint. While the resident was assessed to require, and was provided, a resting hand splint, record review showed no mention of the resting hand after discharge from therapy on 12/20/2021. On 01/05/2022 at 1:31 PM, Staff AA confirmed there was no documentation to support the resting hand splint was discontinued by therapy. Staff AA confirmed the splint was not, but should have been, carried over to nursing when therapy was stopped on 12/10/2021. Resident 14 According to the 10/18/2021 admission MDS Resident 14 admitted to the facility on [DATE] was assessed with multiple medically complex diagnoses including amputation of the right leg above the knee and one sided altered ROM of the lower extremity. Observations on 01/04/2022 at 8:47 AM showed Resident 14 lying in bed and was noted to have a right leg amputation above the knee. The resident indicated at this time she received exercises, maybe twice a week. A CP dated 11/30/2021 identified the resident had impaired mobility related to decreased ROM and decreased bed mobility with intervention that included Active ROM to BLE [Bilateral Lower Extremities] 2 sets of 15 repetitions [reps], may use dowel exercises with 2 lbs [pounds] or any activity equivalent to. Offer program 3-6 x/week for 15 minutes. Review of December 2021 Restorative documentation showed the resident was offered and received the program nine times rather than the minimum 12 as directed. In an interview on 01/10/2022 at 10:46 AM Staff AA (Director of Therapy), was asked how staff could provide a RP to bilateral lower extremities, or how dowel exercises could be implemented with legs that couldn't grasp the dowels. Staff AA replied, The program shouldn't have been bilateral lower extremity, there were two programs. Staff AA explained there should have been a separate program for the dowels for the upper extremity, but it was transcribed incorrectly. Resident 18 Resident 18 was admitted to the facility on [DATE]. According to the 10/28/2021 admission MDS Resident 18 had multiple medically complex diagnoses including stroke (bleeding in the brain) and hemiplegia (paralysis of one side of the body). This MDS assessed Resident 18 as cognitively intact with clear speech, able to be understood and understand conversation. In an interview on 01/03/2022 at 1:05 PM, Resident 18 stated they had started a restorative program on 12/31/2021, but haven't seen them since. According to a 12/30/2021 impaired mobility CP, Resident 18 had decreased ROM to right side with interventions directing staff to provide active ROM five to seven days a week. Review of electronic records on 01/07/2022 for Resident 18's restorative program showed staff signed the resident only received active ROM three times in the previous seven days. In an interview on 01/07/2022 at 11:07 AM, Staff B confirmed staff should have, but did not provide Resident 18's restorative plan five to seven days a week as directed in CP and stated the restorative program was not currently intact.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 8 (Residents 14, 23, 118, 36, 32, 59, 35 & 38) of 15 sampled residents, and 2 supplemental residents (Residents 61 and 66), reviewed for nutrition and/or hydration, maintained acceptable parameters of nutritional status or were adequately monitored for hydration status. Failure to ensure accurate intakes were documented, identify and act on significant weight changes, and notify physicians of changes, placed the residents at risk for delayed identification of interventions for continued weight loss. Findings included . According to the facility's Weight Assessment and Intervention- Foundation policy, nursing staff will obtain resident weights on admission, the next day, and weekly for four weeks thereafter. This policy directs staff that any weight change of five pounds (Lbs.) for residents that weight 100 Lbs. or greater and three Lbs. for residents who weigh less than 100 Lbs. since the last weight assessment will be reweighed the next day for confirmation. This policy directs nursing staff to contact the registered dietician (RD) and provider if the weight is verified. Resident 14 admission Minimum Data Set, (MDS, an assessment) Resident 14 admitted to the facility on [DATE] with multiple medically complex diagnoses including heart and lung disease, diabetes, vascular (blood vessel) disease, and had an amputation of the leg. Review of weight records showed staff assessed the resident with the following weights: 133 lbs (10/12/2021); 140.0 Lbs. (10/13/2021); 121.0 Lbs. (10/19/2021); 120.8 Lbs. (11/4/2021); 119.8 Lbs. (11/22/2021); and 118.0 Lbs. (11/25/2021). Progress notes dated 12/09/2021 showed that, based on the 11/25/2021 weight, the resident was identified with a significant weight loss of over 22 Lbs. since admission. According to a 12/09/2021 Nutrition Hydration Skin Committee form, the resident was reviewed for weight loss and was subsequently placed on an appetite stimulant. In an interview on 01/06/2022 at 9:27 AM, Staff B (Director of Nursing) confirmed staff should have, but did not re-weigh the resident after the 10/19/2021 weight showed a 19 lb. weight loss. Staff B indicated nursing staff should have done an assessment and interventions after the initial weight loss was identified in October and the resident should have weekly weights. Staff B confirmed staff should have, but did not, obtain weights and assess the resident's nutritional status after the 11/25/2021 weight. Resident 23 According to the 11/02/2021 admission MDS, Resident 23 admitted to the facility on [DATE] and had moderate cognitive impairment and had multiple medically complex diagnoses including right sided paralysis following a stroke (brain bleed), weighed 173 Lbs., and required a therapeutic, mechanically altered diet. Record review showed the following weights: 173.2 Lbs. on (10/26/2021); 173.6 Lbs. on (10/29/2021); and 173.4 Lbs. on (10/30/2021) In an interview on 01/06/2022 at 9:38 AM, Staff B confirmed no weight was obtained since 10/30/2021 stating I can't say why it wasn't done. Staff B indicated the Dieticians review the weights but, I don't have a system for weights, I am trying to create a system, I only have one RCM (Resident Care Manager); my plan is to do weights weekly for all residents. We do weights three days in a row on admission then weekly. For now, everyone should be weekly until I get more RCMs. I am looking at significant weight changes, not for missed weights . Resident 118 Record review showed Resident 118 was originally admitted to the facility on [DATE], discharged to the hospital and re-admitted to the facility on [DATE]. Record review on 01/06/2021 showed facility staff failed to obtain any weights since the time of re-admission on [DATE]. In an interview on 01/06/2022 at 9:19 AM Staff B confirmed, but was unable to explain why, facility staff failed to assess the resident's weights since re-admission. Staff B confirmed that staff failure to assess resident's weights detracted from staff's ability to promptly identify residents with, or at risk for, impaired nutrition which could cause delays by the interdisciplinary team to develop and implement interventions to stabilize or improve nutritional status before complications arose. Resident 36 According to the 11/22/2021 Quarterly MDS, Resident 36 was assessed as cognitively intact, able to understand and be understood in conversation, and had multiple medically complex diagnoses including End Stage Renal Disease (ESRD), and required dialysis services. Review of a 11/19/2021 Nutritional Problem Care Plan (CP) showed an intervention that directed staff to monitor, record and report to the MD (Medical Doctor) significant weight loss of 3 lbs. in one week, greater than 5% weight loss in one month, greater than 7.5% in 3 months and greater than 10% in 6 months. Review of weight records showed staff assessed the resident with the following weights: 348.04 Lbs. on (01/07/2021); 341.0 Lbs. on (01/14/2021); 330.66 on (01/21/2021); 329.34 on (01/30/2021); 330 Lbs. on (02/06/2021); 327.8 Lbs. on (02/11/2021). According to the weight records, Resident 36 had a weight loss of 18. 7 Lbs. (5.4%) from 01/07/2021 at 348.04 Lbs. to 01/30/2021 at 329.34. The resident was not re-weighed the next day for confirmation. On 02/11/2021 the resident weighed 327.8, this was a 20.2 lb. (5.8%) weight loss from 01/07/2021 weight of 348.04. The resident was not re-weighed the next day for confirmation. Review of the resident's progress notes showed the RD wrote a note on 01/31/2021 addressing the resident's labs. The RD documented the resident's weight at 150.9 kg (kilograms) or 331.98 Lbs. The RD did not address the residents possible weight loss of 5.4 % from 01/07/2021. Review of the clinical record showed no indication the facility staff notified the Physician or the RD for the resident's weight loss of 20.2 Lbs. on 02/11/2021 or that the resident was on a physician prescribed weight loss program. In an interview on 1/12/2022 at 8:30 AM Staff B stated Resident 36 lost 20 Lbs. due to dialysis and it should be identified as a planned weight loss, and that the facility should have made a nutrition note because the dry weight (weight after dialysis) is the goal by the kidney center. Staff B stated they would expect the RD and MD to be notified of the weight loss, and the RD to coordinate with the kidney center to determine the cause of the weight loss. Staff B acknowledged there was no PO for a weight loss program, or a care plan for intended weight loss and that neither the RD or MD was notified of the residents 20.2 Lb. weight loss on 02/11/2021. Resident 61 According to the 11/17/2021 Quarterly MDS, Resident 61 had diagnoses including Morbid Obesity, a thyroid disorder, and Diabetes Mellitus. Resident 61's Physician's Orders (POs) included a 05/24/2021 order to collect weights every Monday day shift. Resident 61's comprehensive CP included a 08/03/2021 [resident] has a nutritional problem or potential nutritional problem r/t [related to] obesity and hypothyroidism CP. This CP directed to weigh Resident 61 as ordered and report significant weight changes as ordered. Review of Resident 61's 12/2021 Medication Administration Record (MAR) no weight collected as ordered. In an interview on 1/11/2022 at 09:45 AM, Staff B stated that weights should be collected weekly, that they would expect to see a refusal noted on the MAR, or in a progress note. Staff B stated there was nothing in Resident 52's chart indicating a refusal and nursing staff should have, but did not, obtain a weight for the resident as ordered. Resident 32 Resident 32 was admitted to the facility on [DATE]. According to the 10/31/2021 admission MDS had medically complex diagnoses including lung disease, diabetes, and dysphagia (difficulty swallowing) and required a therapeutic mechanically altered diet. Review of the 11/03/2021 nutritional problem CP showed a goal that Resident 32 will maintain adequate nutritional status as evidenced by maintaining weight without significant weight changes, no signs or symptoms of malnutrition, and consuming at least 51% of at least one meal daily. Observation on 01/05/2022 at 9:09 AM showed Resident 32 left their breakfast tray untouched except for consuming a small portion of the hot cereal. Similar observations were made on 01/06/2022 at 9:56 AM of Resident 32's breakfast tray with only a small portion of hot cereal gone. According to meal percentage documentation, on 01/05/2022 at 7:45 AM, prior to the resident finishing their meal, staff indicated Resident 32 consumed 76%-100% of breakfast. On 01/06/2022 at 1:30 PM staff documented Resident 32 consumed 51%-75% of breakfast. In an interview on 01/07/2022 at 11:00 AM, Staff B confirmed staff should document an accurate percentage of a meal consumed by a resident and stated, It's important to get an accurate picture of the residents nutritional status. Resident 66 According to the 11/16/2021 Quarterly MDS, Resident 66 was assessed to be cognitively intact and to require set up assistance to eat. The comprehensive CP included the following: an At Risk for alteration in food and fluid intake CP that directed CNAs and nurses to document Resident 66's intake in a Meal Monitor; a Nutrition Risk . CP that directed CNAs to encourage Resident to eat meals. Report if resident eats less than 50%. On 01/10/2022 at 11:47 AM, Resident 66 was observed to return her tray to the cart, stating they could not eat what was on their tray. Resident 66 was offered and refused an alternative, and instead requested, and were provided, with their own personal snack (a can of bean dip.) Review of the Meal Intake Monitor revealed Staff UU (agency CNA) documented Resident 66 consumed 51-75% of their meal at 12:19 PM on 01/10/2022. Resident 66's chart also included a Snack Monitor. This Monitor included no documentation that a snack was provided and consumed by Resident 66 on 01/20/2022. Resident 59 According to the 12/14/2021 Quarterly MDS, the resident was assessed as cognitively intact, able to understand and be understood in conversation and had diagnoses including amputation, venous insufficiency (improper functioning in the vein valves of the lower legs), heart failure and diabetes. Review of a 10/27/2021 Nutritional Problem CP showed an intervention that directed staff to monitor, record and report to the MD significant weight loss of 3 lbs. (pounds) in one week, greater than 5% weight loss in one month, greater than 7.5% in 3 months and greater than 10% in 6 months. Review of weight records showed staff assessed the resident with the following weights: 271.6 Lbs. on (03/04/2021); 257 Lbs. on (05/04/2021); 260.2 Lbs. on (05/14/2021); 252 Lbs. on (06/12/2021); 248.4 Lbs. on (07/06/2021); 242.8 Lbs. on (08/19/2021); 238.3 Lbs. on (09/29/2021); 236.5 Lbs. on (10/22/2021); 225.2 Lbs. on (12/31/2021). According to the weight records, Resident 59 had a weight loss of 24.7 Lbs. (8.4%) in 3 months from 11/07/2020 to 03/04/2021, for which there was no evidence of a re-weigh for confirmation in Resident 59's chart. On 06/12/2021 the resident had weight loss of 32.6 Lbs. (11.1%) in 6 months from 11/07/2020 to 06/12/2021. Review of the clinical record showed no indication facility staff notified the MD or the RD of the significant weight loss. In an interview on 01/12/2022 at 8:30 AM Staff B stated they would expect the resident to re-weighed to confirm and notify the MD and RD of the weight loss. Resident 35 The 11/23/2021 admission MDS assessed Resident 35 to require a gastric tube placed in the stomach for nutrition and hydration. The gastric tube provided over 51% of the resident's nutrition. A review of Resident 35's weight log showed no weights were recorded after 12/17/2021. In an interview on 01/06/2022 at 10:37 AM, Staff B reviewed the weight log for Resident 35 and confirmed no weight was obtained after 12/17/2021. Staff B stated all residents are expected to be weighed weekly and Resident 35 was not. A review of Resident 35's 12/16/2021 diet order showed a pureed diet with thin liquid consistency with chocolate ice cream for recreational feeding. In an interview on 01/03/2022 at 12:50 PM, Resident 35 stated they did not eat food or drink fluids and all medication was given thru the gastric tube. Resident 35 had a pole next to the bed with feeding formula, water in a bag and a pump that is used for nutritional feeding thru a gastric tube. Resident 35 did not have any fluids to drink in the room. An observation on 01/04/2022 12:00 PM (lunch), showed Resident 35 did not receive a meal tray. Resident 35 still did not have any fluids to drink in the room. In an interview on 01/04/2022 at 9:16 AM, Staff Z (LPN) stated Resident 35 does not eat and is NPO (nothing by mouth). Staff Z stated Resident 35 does not get meal trays at mealtimes and all nutrition is given thru the gastric tube. In an interview on 01/05/2022 at 8:47 AM, Staff Z clarified Miralax (a medication for bowels) was thru the gastric tube because Resident 35 is NPO. An observation on 01/05/2022 at 8:29 AM, showed Resident 35 sleeping and the tube feeding pump was connected and infusing formula and water. An observation on 01/05/2022 at 12:47 PM, showed Resident 38 was in the room and the pole for tube feeding was next to the bed with the pump not connected and running. Resident 35 did not receive a meal tray for lunch. In an interview on 01/06/2022 at 10:37 AM, Staff B (DNS) confirmed the diet order for recreational feeding started on 12/21/2021 and Resident 35 was to receive a pureed lunch and dinner tray sent by the kitchen. Staff B stated it was reported on 01/05/2022 that Resident 35 was not receiving meal trays or any food or fluids by mouth. Staff B stated the staff thought Resident 35 was NPO and confirmed the recreational eating plan was not implemented as ordered. Resident 38 A review of Resident 38's weight log showed a 12/25/2021 weight of 113.4 Lbs and a 12/31/2021 weight of 104.0 Lbs. There was no re-weight documented to assess if Resident 38 had a confirmed weight loss of 9.6 Lbs. in one week. In an interview on 01/05/2022 at 12:17 PM, Staff Z reviewed the weight log and stated, Resident 38 should have been re-weighed on 12/31/2021 and instead, it would be obtained that evening on 01/05/2022. In an interview on 01/06/2022 at 9:47 AM, Staff B stated the nurse should have identified Resident 38 had a weight loss on 12/31/2021. Staff B stated the expectation is the nurse should re-weigh the resident, and if confirmed the change, then the nurse notifies the physician, the nurse manager and a dietician referral is made. Staff B acknowledged this process was not followed for Resident 38. REFERENCE: WAC 388-97-1060(3)(h). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure a system of documentation that included the amount of formula and water administered to each resident to met nutrition and hydration requirements for 2 (Residents 40 & 35) of 2 residents reviewed for enteral tube feeding (nutrition delivered into stomach or intestine by tube). The failure to not have directions for and documentation of the amount of formula infused, water infused, amount of water for flushing the tube, and amount of water provided with medications, placed residents at risk for metabolic complications from inadequate calorie or protein intake and/or inadequate hydration. Findings included . Resident 40 According to the 11/22/2021 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 40 had severe cognitive impairment, was sometimes able to understand and be understood, and had an enteral feeding tube. Resident 40 received 51% or more of their nutritional intake through tube feeding. An 08/28/2021 Physician's order (PO) showed Diabetisource at 85 cc (cubic centimeter) per hour for 18 out of 24 hours. The PO directed staff to provide 1440 cc of Diabetisource in 24 hours, infusion to start at 3:00 PM and turned off at 9:00 AM, or until total amount of cc was infused. Every shift was instructed to document the amount of formula infused per a schedule: day shift 255 cc, evening shift 595 cc and night shift 680 cc. Another 08/28/2021 PO directed staff to infuse water at 70 cc per hour for a total of 1260 cc per day, turn on at 3:00 PM and off at 9:00 AM or until all water was infused. Review of a revised 02/12/2019 Tube Feeding Care Plan (CP) showed an intervention to record intake and water flush on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). Review of the December 2021 MAR or TAR showed no indication the facility recorded the shift total or the 24 hour total amount of tube feeding infused. The December 2021 MAR or TAR did not show the amount of water flushed before or after tube feeding or the water given with medications. Similar findings were made for November 2021 and October 2021. In an interview on 01/12/2022 at 8:30 AM, Staff B (Director of Nursing) acknowledged the amount of formula infused and the amount of water administered with flushes and medications was not documented for Resident 40. Staff B confirmed the missing documentation did not ensure Resident 40 received the prescribed amount of nutrition and hydration. Resident 35 A review of the 11/23/2021 admission MDS showed Resident 35 received all nutrition and hydration thru a gastric tube placed in the stomach. The gastric tube provided over 51% of the resident's nutrition. A 11/24/2021 PO showed an enteral tube feeding order: Isosource infused at 47 mL (milliliters) for 20 hours via gastric tube (off at 9:00 AM, on at 1:00 PM) (provides 940 mL, 1410 kcal (calories), 63 grams protein, 718 mL free water). The order did not direct how much formula was to be administered or documented per shift. A 11/24/2021 PO showed another enteral tube feed order: Water flush to total 800 cc per shift for 20 hours, off at 9:00 AM and on at 1:00 PM or until water flush infused, additional fluids given with medications. There were no POs to instruct staff how much water was to be given with medications or how much to flush before starting or stopping the 20 hours of continual tube feeding. Review of the 11/19/2021 Tube Feeding CP showed an intervention to record intake and water flush on the MAR or TAR. Another 11/19/2021 intervention showed Resident 35 is dependent with tube feeding and water flushes. An observation on 01/04/2022 at 9:31 AM showed Staff Z (Licensed Practical Nurse) administered a water flush after disconnecting the tube feeding. A 10:10 AM observation showed Staff Z administered more water by syringe, then administered a liquid pain medication and followed that with more water. On interview, Staff Z stated they administered 30 cc of with a syringe into the tube before and 30 cc of water after the pain medication. In an interview on 01/04/2022 at 10:10 AM, Staff Z stated the pump is turned off at 9:00 AM and back on at 1:00 PM. When asked how much formula is expected to infuse on the day shift, Staff Z stated, I turn it off at 9:00 AM and back on at 1:00 PM and it runs at 47 mL an hour. Staff Z stated day shift does not document the amount infused per shift or the 24 hour amount when the pump is turned off. Staff Z stated the amount of water flushes and water with meds are not listed on the MAR for documentation, and it is not documented. A review of the December 2021 and the January 2022 MAR showed no directions for each shift to document the actual amount of formula infused each shift, or document total amount infused over 24 hours. The MARs did not instruct staff to document the amount of water flushed before or after tube feeding or amount administered with medications. In an interview on 01/06/2022 at 10:37 AM, Staff B acknowledged the MAR did not show documentation of the amount of formula infused each shift or the amount of water administered with medications or the amount of water flushes before and after the tube feedings. Staff B stated without documentation of the amount infused, staff cannot ensure the PO is followed or that Resident 35's nutritional and hydration needs were met. In the interview on 01/06/2022 at 10:37 AM, Staff B reviewed the 11/19/2021 CP direction for hold tube feeding if over 100 cc residual and compared to the 11/21/2021 hold tube feeding if residual is over 500 cc. Staff B stated they should match, and the tube feeding should be held if residual is over 100 cc. REFERENCE: WAC 388-97-1060(3)(f). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 2 (Residents 16 & 54 ) of three residents reviewed for respiratory care, were provided respiratory care, in accordance with professional standards of practice. The facility failed to ensure: Oxygen (O2) therapy was provided in accordance with physician orders (PO); Providers were notified of resident refusals of oxygen therapy; O2 humidifier bottle fluid levels were monitored to ensure functionality; and that O2 concentrator filters were clean and functional. These failures resulted in residents receiving the incorrect amount of oxygen and placed residents at risk for dry mucosa (nose and mouth), discomfort and respiratory distress. Findings included . Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 12/12/2021 5-day Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of chronic respiratory failure, and required the use of supplemental O2. Record review showed Resident 16 had a 11/26/2021 order for: O2 at 2L (liters) per minute via nasal cannula (NC- a tube that delivers oxygen to the nostrils) to keep O2 saturation (SpO2) greater than 90%; and to change, date and initial the O2 tubing, and humidifier set weekly. No order was directing nurses to remove and clean O2 concentrator filter. An observation on 01/03/2022 at 2:15 PM, Resident 16 was lying in bed with a Nasal Cannula (NC) in place. The resident's O2 concentrator showed the resident was receiving O2 at 3.5 L per minute, the O2 tubing, and humidifier bottle were undated, the humidifier bottle had only a scant amount of fluid and was not bubbling as expected; the filter on the right side of the concentrator was heavily soiled with a stringy gray debris, and large dust bunnies were noted in the plastic venting that covered the filter. Resident 16 indicated they did not believe their O2 order was for 3.5 L per minute and stated, No actually it was 1-2 [L per minute] for a while, I think it should be 1-2. Review of the December 2021 and January 2022 Medication and Treatment Administration Records (MAR/TAR) showed the resident's SpO2 was checked three times a day and ranged from 92-100 % on 2 L of O2. During and observation and interview on 01/03/2022 at 3:05 PM, Staff V (Resident Care Manager) confirmed Resident 16 was receiving O2 at 3.5 L per minute via NC, the O2 tubing, and humidifier bottle were undated, and the humidified did not have enough fluid to bubble. Staff V observed the O2 concentrator filter and vent and described Heavy dust coating the filter and the vent that covered it. Staff V acknowledged Resident 16's SpO2 ranging from 92-100 % there was no rationale to support why the resident's O2 was titrated up to 3.5 L, and stated it was at the wrong dose. Resident 54 According to the 12/7/2021 Quarterly MDS, Resident 54 had diagnoses including asthma, COPD and bronchiectasis (a condition of the lungs caused by persistent infection resulting in increased likelihood of further lung infection). The MDS assessed Resident 54 to have Shortness of Breath (SOB) when lying flat, and to require O2 therapy. Resident 54's electronic health record (EHR) included a 11/22/2021 PO for O2 via NC. According to the 11/22/2021 resident has COPD CP, Resident 54 was to receive oxygen via NC, at 2 L per minute. On 01/04/2022 at 10:26 AM, Resident 54 was observed in bed with no NC in place. The NC was observed laying in the resident's wheelchair. A similar observation was made on 01/07/2022 at 07:53 AM, when Resident 54 again was observed lying in bed without the NC in place. Review of Resident 54's 11/2021, 12/2021 and 01/2022 MARs showed Resident 54 had refused oxygen therapy daily from 11/22/2021- 01/07/2022 (46 consecutive days.) In an interview on 01/07/2022 at 10:53 AM, Resident 54 stated that they refused oxygen therapy during the day because they did not feel they required it but reported they did need it at night. In an interview on 01/07/2022 at 12:30 PM, Staff B (Director of Nursing) reported they were unaware Resident 54 had consistently refused oxygen therapy and stated that the nurses should have notified them and the physician of the resident refusals and clarified the order but did not. Reference: WAC 388-97-1060(3)(j)(vi). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure Dialysis policies and procedures were developed and implemented to ensure timely communication and coordination of care with kidney centers and provide consistent monitoring after dialysis treatments according to professional standards of practice for 4 (Residents 36, 60, 13, & 50) of 4 residents reviewed for dialysis services (a mechanical process of filtering the blood when the kidneys are not functioning). Failure to coordinate communication between the facility and the dialysis center on days of treatment and failure to monitor and document the resident's condition after dialysis placed the residents at risk for delayed identification of serious complications. Findings included . According to the facility Dialysis Policy (undated), the facility communicates with the dialysis center by completing the Dialysis Transfer Form to send with the resident to the appointment. The form includes any medication changes, medical or mental status changes and labs since the last dialysis appointment. The facility requires the dialysis center to provide information from the dialysis treatment including: pre and post dialysis weights, lab results, medications given, and instructions for follow up care to be done upon return to the facility. The policy showed, if the facility nurse does not receive the dialysis information sheet, a call is made to request it from the dialysis center, if the requested information is not received, then the Director of Nursing (DNS) or designee will follow up with the Dialysis center to obtain the information. The facility Dialysis Policy (undated) showed the facility provides ongoing monitoring of the dialysis access site, completes dressing changes and care of the access site per physician orders. Review of the facility Dialysis policy (undated) showed that a written agreement was maintained between the facility and the dialysis center. A copy of the written agreement with each contracted dialysis center was requested from the management on three separate days: 01/03/2022, 01/06/2022 and 01/11/2022. No copies of any dialysis agreements were provided. Resident 13 The 10/14/2021 Quarterly Medicare 5-day Minimum Data Set (MDS- an assessment tool) showed Resident 13 was cognitively intact, was able to make themselves understood and understand others. Resident 13 had a diagnosis of end-stage renal disease (ESRD) and received dialysis. Review of the 10/08/2021 dialysis care plan (CP) showed Resident 13 went to dialysis on Tuesdays, Thursdays, and Sundays. The CP directed staff to use the post dialysis weight related to fluctuations of dialysis. The CP directed staff to check and change the dressing daily at the access site. The CP did not identify where the dialysis access site was located for Resident 13. In an interview on 01/04/2022 at 11:37 AM, Resident 13 stated the access site is in the right side of my neck. Resident 13 stated the nurses at the facility do not change the bandages or look at the access site in my neck. Resident 13 stated only the dialysis staff cared for the access site during the appointments. A review of the December 2021 and January 2022 Medication Administration Records (MAR) and Treatment Administration Records (TAR) showed no documentation staff monitored the dialysis access site for infection, bleeding, or circulation according to the facility policy and professional nursing standards. There was no documentation staff assessed the access site or provided dressing changes as indicated in the CP. A review of Resident 13's medical record showed no run sheets or weights for Resident 13 in the medical record for dialysis treatments on 12/28/2021, 12/30/2021, 01/01/2022, 01/04/2022 and 01/06/2022. Copies of the missing run sheets were requested from facility management on 01/07/2022. The facility obtained the records from the dialysis clinic for the 12/28/2021 to 01/06/2022 treatments and added them to the medical record on 01/08/2022. In an interview on 01/06/2022 at 10:44 AM, Staff B (Director of Nursing) stated the dialysis clinic sends batches of run sheets and the weight log to the facility every week and not daily on the day of treatment. Staff B acknowledged the current system does not provide the nurses with the information needed to complete thorough monitoring after dialysis. Staff B stated nurses should have the run sheet when the resident returns from dialysis, there should be a system for post-dialysis assessments and monitoring and the facility does not have one. Staff B confirmed there is not a system in place to use the Dialysis Transfer Form to send status updates to the dialysis clinic as stated in the facility policy. Resident 50 Similar findings for Resident 50 showed no monitoring of dialysis access site for signs of infection, bleeding, and circulation, no directions for maintaining the dialysis access site, and no communication or coordination of care with the dialysis clinic for care of Resident 50. Resident 36 According to the 11/22/2021 MDS Resident 36 was assessed as cognitively intact, able to understand and be understood in conversation. Resident 36 had diagnosis of ESRD and received dialysis services. A 02/04/2020 PO directed staff to obtain the information sheet from dialysis (pre and post weights), document the receipt, and if the sheet is not returned call the Dialysis center every Tuesday, Thursday, and Saturday. Review of the December 2021 TAR showed facility staff documented the receipt of the dialysis information sheet every Tuesday, Thursday, and Saturday, (except on 12/14/2021 and 12/21/2021). Similar findings were found for November and October 2021. Review of the Resident 36's clinical record showed the weight log and the dialysis run sheets for 11/13/2021 through 12/11/2021 (12 days) were printed by the dialysis clinic on 12/11/2021. The facility scanned the document into the record on 12/11/2021. Similar findings were found for scanned dialysis records of multiple dates of service in one scanned document on 10/16/2021, 11/13/2021, 11, 04/2021, 01/08/2021 and 01/11/2021. The documents were not received by the facility on day of treatment. Resident 60 Similar findings for Resident 60 showed multiple dates of dialysis services in one scanned document on a later date. There was no evidence the facility received the information on the date of treatment to use for post-dialysis monitoring. In an in interview on 01/12/2022 at 8:30 AM Staff B stated the facility nurse does not send a transfer sheet with the resident to dialysis. Staff B expected the dialysis clinic to send the dialysis run sheet, including the pre/post dialysis weight, medications administered, lab results and any change in mental status after dialysis, so facility staff were aware of the resident's condition. REFERENCE: WAC 388-97-1900(1), (6)(a-c). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to maintain eight hours of Registered Nurse (RN) coverage to directly supervise resident care, for 3 of 30 days (10%) reviewed for RN coverage. This failure placed residents at risk for inadequate assessments, delay in identification and response to changes in medical conditions and unmet needs. Findings included . Review of document titled, Staffing Pattern provided on 01/04/2022 had the review dates of staffing pattern from 12/04/2021 thorugh 01/04/2022. The document further showed that the facility did not have a RN on duty to assist with assessment of resident conditions on 12/04/2021, 12/05/2021 and 12/26/2021. During an interview on 01/11/2022 at 7:46 AM, Staff B (Director of Nursing) stated she was aware that there were staffing issues and the facility was working on actively recruiting. Review of a document provided by Staff A (Administrator) on 01/ at 5:00 PM, showed that there was not RN coverage on 05/09/2021, 05/23/2021 and 05/31/2021. REFERENCE: WAC 388-97-1080(3)(a). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13 Trazodone The 10/14/2021 Quarterly Medicare 5-day MDS showed Resident 13 did not have an enteral tube (tube into stomach) or a diagnosis of insomnia. This MDS showed Resident 13 had a diagnosis of depression and was administered an antidepressant. A 12/30/2021 physician order (PO) showed Resident 13 was prescribed Trazodone (an antidepressant) 50 milligrams (MG) enterally at bedtime for insomnia. The PO showed it was entered into the medical record directly from the physician. Review of Resident 13's medical record showed no documentation for the indication of insomnia. There was no documentation found for a sleep assessment, sleep monitor or progress notes of a discussion with the resident about sleep. There were also no physician encounter notes that addressed sleep or insomnia. There was no signed consent form found informing the resident of the risks and benefits of a psychotropic medication. In an interview on 01/11/2022 at 1:02 PM, Staff B (Director of Nursing) stated the physician entered the order to the electronic medical record and it was reviewed by an agency nurse before being placed on the MAR. Staff B also stated the order is reviewed by the pharmacist when the prescription is filled. Staff B stated the agency nurse and the pharmacist missed that the route listed enteral, and resident does not have a tube. Staff B acknowledged there was no documentation why the physician prescribed Trazodone, no sleep monitor to determine effectiveness and no consent form. Staff B stated these steps were missed and should have been completed. Lexapro A 12/06/2021 PO showed Resident 13 was prescribed Lexapro (an antidepressant) 10 MG daily for depression. The 10/08/2021 care plan directed staff to monitor/document side effects and effectiveness of the antidepressant every shift. The care plan showed the behavior to monitor was tearfulness. A review of the 12/2021 and 01/2022 MAR and Treatment Administration Record (TAR) showed no documentation each shift that staff monitored for tearfulness. In an interview on 01/11/2022 at 1:02 PM, Staff B confirmed behavior monitoring for Lexapro should, and was not, being documented for Resident 13. REFERENCE: WAC 388-97-1060(3)(k)(i). Resident 60 According to the 12/14/2021 Quarterly MDS, the resident admitted to the facility on [DATE] and was assessed as cognitively intact, able to understand and be understood in conversation, and had verbal behaviors directed towards others. Resident 60 had diagnoses that included end stage renal disease, diabetes, depression, and adjustment disorder. Review of physician orders (PO) showed a 11/08/2021 PO for Seroquel (an anti-psychotic) 12.5 milligrams (mg) twice daily and a 09/03/2021 PO for Seroquel 50 mg nightly for depression. Resident 60 had a 12/14/2021 PO for Lexapro 20 mg daily for depression. Review of a 08/26/2021 Behavior CP showed the resident had behaviors of verbal agitation and aggressiveness towards staff and was easily irritable related to depression . In an interview on 01/05/2022 at 11:46 AM Resident 60 stated they get mad and had assaulted staff because they just don't listen, the staff want to do things their own way. Review of October 2021 and November 2021 Behavior monitoring showed staff documented a check mark, indicating behaviors were monitored. Review of December 2021 Behavior monitoring showed a check mark indicating staff were monitoring for behaviors and on 12/22/2021 staff started documenting an n or y or 0 . In an interview on 01/12/2022 at 8:30 AM Staff B stated Resident 60 had behaviors of yelling and spitting at staff. Staff B could not determine if the resident's behaviors had occurred, or how often, due to staff documenting a check mark. Staff B stated the documentation should be either a Y for yes or N for no. Staff B acknowledged the resident should have, but did not have, psychotic behaviors and did not have an appropriate diagnosis for Seroquel. Resident 32 Resident 32 was admitted to the facility on [DATE]. According to the 10/31/2021 admission MDS Resident 32 had medically complex diagnoses including an anxiety disorder and depression which required the use of psychotropic medications. Review of January 2022 MAR showed Resident 32 received Buspirone (for anxiety), Fluoxetine (for depression), and Trazodone (for sleep) daily. According to a 10/25/2021 CP Resident 32 was identified with a problem area for using anti-depressants and anti-anxiety medications related to depression, insomnia and anxiety and listed the TB of restlessness, lack of sleep and tearfulness. This CP included interventions that directed staff to monitor and document side effects and effectiveness every shift. A separate CP dated 10/25/2021 identified an anti-anxiety problem which included interventions that staff, Monitor/ record occurrence of for TB symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/ aggression towards staff/ others, etc.) and document per facility protocol. Record review on 01/07/2022 revealed no evidence that staff monitored or documented individualized TB for the psychotropic medications Resident 32 received. In an interview on 01/07/2022 at 11:07 AM, Staff B stated it was their expectation that residents on psychotropic medications have individualized TB and that staff document on these behaviors daily to allow effectiveness to be determined. Staff B confirmed Resident 32 did not have monitoring in place and indicated the system for psychotropic medications is not currently intact. Resident 18 Similar findings were noted for Resident 18, who was taking psychotropic medications without individualized target behaviors monitored daily by staff. Based on interview and record review, the facility failed to ensure 3 (Residents 62, 43, & 13) of 5 residents reviewed for unnecessary medications, plus 3 (Residents 18, 60 & 32) supplemental residents, were free from unnecessary psychotropic drugs related to the failure to: develop and monitor individualized Target Behaviors (TBs), monitor for adverse side effects, ensure adequate indications for use, or implement non-drug interventions prior to the use of as needed psychotropic medication use. These failures placed residents at risk for receiving unnecessary psychotropic medications, unnecessary psychotropic medication side effects and a diminished quality of life. Findings included . Resident 43 Resident 43 re-admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly Minimum Data Set (MDS- an assessment tool), the resident was cognitively intact, had diagnoses of depression and anxiety disorder, demonstrated no behaviors and received antipsychotic and antidepressant medication on seven of seven days during the assessment period. Record review showed Resident 43 had a 09/03/2021 order for Celexa (an antidepressant) daily for major depressive disorder, and a 10/26/2021 order for Seroquel (an antipsychotic) for major depressive disorder. A The resident uses Antipsychotic Care Plan (CP), revised 12/16/2021, staff were directed to monitor for adverse side effects (ASE) of antipsychotic medications, and to monitor TBs for any change or worsening and notify social work and the provider if noted. However, no TBs were identified. A The resident uses antidepressant medication r/t [related to] Depression CP, revised 12/16/2021, directed staff to monitor for ASEs of antidepressant medication, and to Will monitor target behavior for worsening, notify social work and the provider if noted. No TBs were identified. A The resident has a behavior problem r/t major depressive disorder, lack of motivation, tearfulness CP, revised 12/16/2021, had a goal of Resident will have no evidence of behavior problems (specify) but no behavior was specified. Additionally, staff were directed to Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. The facility did not indicate what specific behaviors to monitor for. Review of Resident 43's December 2021 and January 2022 Medication Administration Record (MAR) showed no indication facility staff were monitoring for ASE associated with the use of antipsychotic and antidepressant medications as required. A 09/22/2021 order directed staff to document each shift, the number of episodes the resident had of the TB lack of motivation. There was no direction on how to quantify the behavior (e.g., if the resident slept all shift, was that demonstrating a lack of motivation, and would it be considered only one episode.) Additionally, the facility failed to identify which medication, the antipsychotic or antidepressant, was used to treat which TB. Similarly, there was a 09/22/2021 order directing staff to document the number of tearful episodes Resident 43 had each shift. Review of the MAR showed the order was input without providing a place to document the number of episodes, only an initial box was provided. The order also failed to indicate which medication, the antipsychotic or antidepressant, was treating this TB. In an interview on 01/10/2022 at 4:12 PM, Staff B (Director of Nursing) shared the importance of accurately identifying TBs that a psychotropic medication is used to treat, and explained effectively decreasing the prevalence of the TB, is the primary way the effectiveness and/or need for continued use of the medication is determined. Thus, when residents received more than one psychotropic medication, there needed to be clear delineation which medication was treating which TB. In an interview on 01/10/2021 at 4:18 PM, after reviewing Resident 43's record Staff B stated that lack of motivation was not an appropriate TB for the use of an antipsychotic medication, and acknowledged the facility failed to: 1) Monitor for ASEs associated with the use of antipsychotic and antidepressant medications. 2) Identify which medication was implemented to treat which TB. 3) To monitor the number of times Resident 43 demonstrated the TB tearfulness. Although there was direction on the MAR to document the number of episodes, no one identified that a space was not provided to do so. Staff B agreed the failures detracted from the facility's ability to assess the effectiveness of the medications, as well as the need for continued use. Resident 62 According to the 10/16/2021 Quarterly MDS, Resident 62 had diagnoses of anxiety and depression. The MDS assessed Resident 62 had moderate depression. Review of the January 2022 MAR revealed orders for the following psychotropic medications: Buspirone 15 MG by mouth four times a day for anxiety, and Cymbalta Delayed Release 60 MG by mouth one time a day for Major Depressive Disorder. Review of Resident 62's EHR (electronic health record) revealed no Adverse Side Effect (ASE) monitoring for Buspirone. In an interview on 0/10/2022 at 08:42 AM, Staff B stated that there was no ASE monitoring for Buspirone, and that the facility should be monitoring for ASEs.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for 11 (Residents 14, 23, 19, 16, 43, 55, 62, 66, 25, 32, & 59) of 24 residents whose records were reviewed. The Facility failed to ensure: staff completed and maintained resident inventories; documents were accurate with identifiable initials; or entered into resident records timely. Failure to ensure clinical records were complete and accurate placed residents at risk for unmet care needs and lost property. Findings included . Resident 14 According to the 10/18/2021 admission MDS (Minimum Data Set - an assessment tool) Resident 14 was assessed with multiple medically complex diagnoses including an above the knee leg amputation and required extensive two-person assistance with bed mobility and toileting. Review of bathing records showed staff provided Resident 14 with two showers each day on 12/06/2021, 12/07/2021, 12/10/2021,12/13/2021 but no bathing support was provided. Staff documented the resident received two showers on 12/09/2021, with staff providing one-person physical assistance for one, for which the resident was assessed as totally dependent on staff, and no support/assistance for the other. On 12/14/2021 staff documented the resident was provided a shower, but no staff assistance and did not document the resident's level of dependence on staff. Additionally, record review showed no evidence of a personal items /inventory. Failure to complete an inventory of resident's belongings detracted from staff's ability to determine if resident had missing items. In an interview on 01/05/2022 at 9:58 AM Staff B (Director of Nursing) indicated the bathing documentation was inconsistent and staff in servicing was required to ensure documentation accurately reflected resident's level of participation and staff provision of bathing. Resident 23 According to the 11/02/2021 admission MDS Resident 23 had paralysis of the left upper and lower extremities, required extensive two person physical assist with transfers, bed mobility, and toilet use and bathing did not occur during the assessment period. According to bathing records, staff documented the resident received two showers on 12/06/2021. Staff documented the level of assistance and support provided as, Not Applicable. Bathing records showed Resident 23 received two bed baths on 12/09/2021 but staff documented the level of assistance and support provided as, Not Applicable. Similar findings of staff documenting some type of bathing was provided, but no level of staff assistance or support for 12/10/2021 or 12/14/2021. On 12/13/2021 staff documented the resident received a shower, but was not provided any staff assistance or support. In an interview on 01/05/2022 at 9:58 AM Staff B was asked if the resident received a shower with no assistance on this day. Staff B stated the documentation made no sense as the resident required two person assistance with bathing. Inaccurate Initials on: Medication Administration Records (MARs); Treatment Administration Records (TARs); Progress Notes; and Point of Care Charting. Resident 19 Review of the December 2021 Point of Care charting for Resident 19 showed on 20 of the 31 days, there was charting by the initials CNA3. CNA3 usually charted on 2 of the 3 shifts, and occasionally (e.g. 12/12/2021) on all 3 shifts. Similar findings were noted with LN1 and LN2 in November 2021. During an interview on 01/05/2021 at 12:25 PM, Staff B (Director of Nursing) acknowledged until around 12/01/2021, the companies Information Technology (IT) did not provide unique logins for agency nurses making it difficult to determine who the actual nurse was that signed for the tasks as complete. Staff B then acknowledged that agency CNAs were still sharing computer logins, which was why CNA3 appeared to work most days and sometimes all 3 shifts. Failure to have unique logins for individual agency staff resulted in an inability to timely determine what agency staff signed for what care as completed. Similar findings were noted in the Electronic Health Records (EHRs) of Residents 16, 43 & 55. Inaccurate Risks vs Benefits Resident 19 Record review showed the facility had Resident 19 sign a Risk and Benefits (R vs B) form on 11/06/2021. According to the document the Issue was the resident required one person assist with a sit to stand mechanical lift for transfers. The form went on to list potential risks if the resident continued to self-transfer and not adhere to facility recommendations for safe transfers, as well as the benefits if they did (adhere to the recommendations). According to the 10/22/2021 Quarterly MDS (14 days prior to the R vs B), the resident was assessed to require only supervision for transfers, bed mobility, dressing and toileting. During an interview 01/10/2021 at 3:07 PM, Staff B acknowledged Resident 19 did not require a mechanical lift for transfers on 11/06/2021 and that the R vs B presented to Resident 19 to sign was inaccurate. Resident 62 Resident 62's January 2022 MAR included a Phrygian Order (PO) to monitor for adverse side effects (ASE) of an anti-anxiety medication. Nursing staff were directed to mark either Y or N to indicate the presence of ASEs. Review of the MAR revealed that of the 12 opportunities to add monitoring data from 01/01/2022 through 01/04/2022, nurses answered 0 rather than Y or N as directed. In an interview 01/10/2022 at 8:47 AM, Staff B stated that nurses should complete the MAR as directed, but had not. Resident 66 Review of Resident 66's EHR revealed a quarterly care conferences dated 08/11/2021. In an interview with on 01/10/2021 at 1:15 PM, Staff L (Social Services), stated the facility had coordinated a more recent, 11/18/2021 care conference, and that they did not yet complete the paperwork and add it to Resident 66's record. Staff L stated this was not timely. Resident 25 Resident 25 was admitted to the facility on [DATE]. According to the 10/18/2021 Modification of Admission/ Medicare - 5 Day MDS had Progressive Neurological conditions and was assessed as cognitively intact. In an interview on 01/04/2022 at 10:20 AM, Resident 25 stated they saw a dentist and wanted their teeth pulled so they could get dentures. Resident 25 indicated it was about a month ago. Resident 25 stated they also saw the eye doctor a couple months ago and stated, I was supposed to get my glasses a while ago, but I haven't heard anything. Review of Resident 25's electronic records on 01/05/2022 revealed no indication that Resident was seen by an eye doctor or dentist. On 01/06/2022 an eye doctor consultation was scanned into Resident 25's record that indicated they were seen on 11/09/2021. On 01/12/2022 a dental consultation was scanned into Resident 25's record that indicated they were seen by dental on 12/07/2021. In an interview on 01/11/2022 at 12:41 PM, Staff L confirmed it was very important to have consultations readily available in resident records and stated, so staff can look back, see what happened, follow up as needed, and make follow up appointments. In an interview on 01/12/2022 at 1:45 PM, Staff B stated staff should have, but did not get the consultations into the resident records timely. Resident 32 Resident 32 was admitted to the facility on [DATE] and according to the 10/31/2021 admission MDS was cognitively intact, able to understand and be understood in conversations. In an interview on 01/03/22 01:24 PM, Resident 32 stated they had a bed sore to lower back. Review of a 12/23/2021 actual impairment of skin integrity Care Plan (CP), directed staff to monitor and document location, size and treatment of skin injury. In an interview on 01/05/2022 at 12:30 PM, Staff Y (Licensed Practical Nurse) stated they had completed wound measurements for Resident 32 on 01/04/2022. Record review on 01/12/2022 revealed no wound measurements were documented in Resident 32's medical record since 12/28/2021. In an interview on 01/12/2022 at 1:45 PM, Staff B confirmed staff should have, but did not document wound measurements and assessments in Resident 32's medical records timely. Similar findings were noted for Resident 32 for Risk and Benefit forms. Record review revealed a form dated 11/08/2021 for refusal of showers and weights, a form dated 12/8/2021 regarding falls, and a 12/24/2021 form for declining interventions for skin breakdown. These forms were not scanned into Resident 32's medical record until 01/03/2022. In an interview on 01/12/2022 at 1:45 PM, Staff B confirmed staff should have scanned the forms into the resident's medical records timely and stated, we're behind, we don't have medical records staff, we've been trying to hire. Resident 59 According to the 12/14/2021 Quarterly MDS, the resident was assessed as cognitively intact, able to understand and be understood in conversation. Observations on 01/04/2022 at 9:25 AM showed Resident 59 had two open areas to the resident's right outer lower leg. Review of a 09/13/2021 Venous/Stasis Ulcer CP showed the resident had a venous ulcer to the right lower extremity. Interventions directed staff to monitor and document location, size and treatment of skin injury. Review of the clinical record showed no weekly wound documentation for the weeks of 01/06/2021, 01/13/2021, 03/10/2021, 03/17/2021, 03/24/2021, 04/14/2021, 04/21/2021, 04/28/2021, 05/05/2021, 05/12/2021, 06/16/2021, 06/23/2021, 06/30/2021, 07/14/2021, 07/21/2021, 07/28/2021, 08/04/2021, 09/15/2021, 09/22/2021, 09/29/2021, 10/26/2021, 11/16/2021, 11/23/2021, 11/30/2021, 12/07/2021, 12/21/2021, and 12/28/2021. In an interview on 01/12/2022 at 8:30 AM Staff B stated they would expect the wound documentation to be part of the resident's medical record and acknowledged it was not for Resident 59 on multiple occasions. WAC: REFERENCE 388-97-1720(1)(a)(i-iv)(b). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. Thirteen facility staff members (Staff KK, OO, MM, Y, I, PP, LL, O, H, BB, V, RR & E) were observed to fail to do one or more of the following: consistently perform hand hygiene before and after resident care/contact; apply/remove Personal Protective Equipment (PPE) in accordance with the Transmission Based Precaution (TBP) notice posted outside of resident rooms; appropriately apply and/or wear the model N95 respirator they were fit tested for; ensure contaminated resident bedding ( pillows, positioning wedges, blankets) found on the floor was washed or replaced before placing them back on the resident's bed; and maintain infection control during wound care and medication pass. Additionally, staff failed to ensure resident equipment was stored off the floor and maintained in good condition with cleanable surfaces (Residents 40, 55 & 2), and ensure risk assessments (used to assess COVID 19 risk for residents) were consistently performed for 3 (Residents 36, 60 & 13) of 3 residents reviewed who routinely went out into the community for medical appointments. These failures placed all residents and staff at risk for contracting communicable diseases, including COVID 19, during a global pandemic. Findings included . Isolation Precautions According to the facility's undated Isolation - Notices of Transmission-Based Precautions policy, when transmission based precautions are implemented the Infection Preventionist (IP) determines the appropriate notification to be placed on the room entrance door (sign identifying the type of isolation required (e.g. Airborne, droplet, Quarantine). to ensure personnel and visitors are aware of the type of precautions required. Each notification gives specific direction as to what PPE is required. On 01/04/2022 at 12:23 PM, facility staff were observed placing PPE kits and hanging TBP notices outside resident rooms on the south unit. Staff J (IP) explained a staff member tested positive for COVID 19 and worked on the South unit the day prior. Staff J explained all resident's on the South unit (Rooms 216-224) were to be placed on isolation for potential exposure. Observation of the notice posted outside of Resident 216's room read Quarantine Precautions, which directed Everyone must: including visitors, doctors & staff-clean hands when entering and leaving room; wear fit tested N95 respirator, wear face shield or goggles; gown and glove when providing direct resident care; and use resident dedicated or disposable equipment, or clean and disinfect shared equipment. On 01/05/2022 Staff J, explained that all personnel in resident care areas, identified as the second floor of the building, were required to wear their N95 fit tested respirators. Staff Fit-Tested N95 Respirators Staff E On 01/05/22 at 09:19 AM, Staff E (Maintenance Director) was observed on the second floor wearing a 3M N95 8210V respirator. Review of the Staff N95 fit test list showed Staff E was fit tested for a Sekura N95. Staff V On 01/11/2022 at 08:00 AM, Staff V (Unit Manager) was observed working the floor with a 3M N95 8210V. Review of the staff fit test list showed, Staff V was fit tested with a BYD N95, not a 3M 8210V. In an interview on 01/13/2021 at 8:47 AM, Staff J stated that it was the expectation that staff wore the model of N95 respirator they were fit tested with. Staff RR On 01/12/22 at 10:35 AM, Staff RR (Housekeeping) was observed wearing a BYD N95 respirator. Both straps were observed pulled above their ears, causing the bottom of the N95 to fall away loosely from the bottom of the chin revealing an observable space between mask and Staff RRs chin. PPE Use On 01/04/2022 at 9:58 AM Staff KK (Certified Nursing Assistant-CNA) was observed in the hall with gloves on, they proceeded to the soiled utility room, opened the door with their gloved hands and grab a bag of soiled linen. Staff KK took the bag of soiled linen down the hall and pushed the elevator button with their gloved hand. After the elevator door opened Staff KK pushed the button and the elevator door closed. On 10/05/2022 at 8:20 AM Staff LL (Agency CNA) was observed wearing a blue isolation gown going into posted quarantine rooms to other posted quarantine rooms checking for breakfast trays. Staff LL was not observed changing PPE in between resident rooms. On 01/05/2022 at 9:53 AM Staff LL was observed walking into a posted quarantine room without putting on PPE and emptied the garbage. In an interview on 01/11/2022 at 1:45 PM Staff J stated they would expect staff to follow the posted precaution signs and should wear an N-95 mask, eyewear, gown and gloves when entering the room. Staff should remove PPE before leaving the room and perform hand hygiene. Observation on 01/03/2022 at 12:22 PM, showed Staff O (CNA), entered room [ROOM NUMBER] without gloves or a gown on. There was a sign posted at doorway which indicated the resident was on Quarantine Precautions and directed staff to wear gown and glove when providing direct resident care. Staff O was in close contact and assisting Resident 268 with positioning in their wheelchair. On 01/03/2022 at 1:34 PM, Staff H (Housekeeping Aide) was observed in room [ROOM NUMBER] cleaning without gloves or a gown on. There was a sign posted at doorway which indicated the resident was on Contact Precautions and an isolation bin was located next to door. The contact precaution sign directed staff they must put on gloves and gown before entering room and remove upon exit. In an interview at this time, Staff H stated the resident was on precautions and went down hall to sanitize hands. On 01/05/2022 at 12:16 PM, Staff BB (Physical Therapy Assistant) was observed in room [ROOM NUMBER] without gloves or a gown on. The Quarantine Precaution sign remained posted at doorway. Staff BB was working in close proximity to Resident 268, assisting them with set up on a hand bicycle machine. Staff BB then sanitized, exited room, placed gown and gloves on, and went back in to work with the resident. In an interview on 01/03/2022 at 1:43 PM, Staff Z (LPN), verified the signs at doorways, and stated, if the sign is up, people should be following the directions given on the sign. On 01/05/2022 at 1:28 PM, Staff OO (CNA), removed meal tray from room [ROOM NUMBER], a quarantine precaution room, and placed tray on isolation cart in hall. Staff OO removed gloves and gown and without performing hand hygiene picked the tray back up and placed on meal cart down the hall. Staff OO then entered room [ROOM NUMBER], a non-quarantine room. At 1:32 PM, Staff Y, approached room [ROOM NUMBER] and placed clear bag of wound supplies on the soiled isolation cart and put on gown and gloves. Staff Y proceeded to enter room [ROOM NUMBER] with bag and set on resident's bed to begin wound care. Similar observations were made on 01/06/2022 at 1:12 PM and 1:14 PM when Staff OO removed meal trays from Quarantine Precaution rooms and placed trays on a chair at end of hallway. Staff OO did not sanitize the chair after removing the trays. On 01/11/2022 at 8:27 AM, Staff O, was observed removing a meal tray from a Quarantine room. Staff O placed tray on an isolation cart in hall, removed gloves and gown, picked tray up and went down hall without sanitizing the isolation cart. In an interview on 01/11/2022 at 1:45 PM, Staff Y, confirmed staff should have sanitized the isolation carts and chair after placing soiled items down, and stated it is important for infection control. Medication Administration On 01/11/2022 at 9:00 AM Staff Y (Licensed Practical Nurse/Wound Nurse) was observed administering medication to Resident 12. Staff Y had 5 pills in a medicine cup, 1 cup of water and 2 patches; one nicotine patch and a pain patch on a plastic tray. Staff Y brought the tray into the room with a posted Quarantine sign. After putting on the required Personal Protective Equipment (PPE), Staff Y set the pink tray on the resident's over bed table. Resident 12 took their medication and refused the pain patch. Staff Y went to get the nicotine patch when it fell on the floor. After picking up the patch off the floor Staff Y was unable to open the nicotine patch. Staff Y removed PPE, picked up the pink tray containing the nicotine patch and set it down on a pile of clothes near the hand sanitizer pump on the wall. At 9:17 AM on 01/11/2022 Staff Y took the pink medicine tray and placed it in the medication cart, retrieved a pair of scissors from a drawer, cut the nicotine package open and replaced the scissors in the cart drawer. Staff Y proceeded to Resident 12's room, put on PPE, enter the room and place the pink tray on the resident's over bed table. Staff Y applied the nicotine patch, removed PPE, used hand sanitizer and returned back to the medication cart. The pink tray was placed on top of the cart. Staff Y proceeded to continue their medication pass. In an interview on 01/11/2022 at 12:38 Staff Y stated they did not clean the pink medication tray when going into a posted quarantine room, taking the tray out and placing it on the medication cart, and agrees the pink tray should have been wiped clean before placing on the medication cart. Staff Y stated they should have cleaned off the nicotine patch and scissors after it fell on the floor. Ice Chest On 01/02/2022 at 1:51 PM Resident 66 was observed in the hallway in front of a large cooler filled with ice. Resident 66 took the scoop, opened the ice chest and proceeded to fill their water pitcher up with ice. A staff member was observed standing at a doorway next to the ice chest, they glanced at the resident but did not stop the resident or assist the resident with getting ice. No box of gloves were observed near the ice chest for staff or residents to use. On 01/05/2022 at 8:19 AM the ice chest was observed in the hallway with the lid open. On 01/10/2022 at 9:05 AM Staff I (Central Supply) was observed using the ice scoop to fill a water pitcher, no gloves were observed being used. In an interview on 01/11/2022 at 1:40 PM Staff J stated they would expect staff to stop the resident and assist them with ice. Staff J would expect staff to use gloves when getting using the scoop to get ice from the ice chest. COVID-19 Risk Assessments According to the 10/07/2021 [NAME] Safe Start Long Term Care COVID-19 Response Plan, Providers must use the Risk Assessment Template to assess each resident for any COVID-19 exposure prior to and after returning from offsite visits to determine if the resident is low or high risk. The Plan further stated that upon resident's return to the facility a risk assessment should be completed. Resident 36 Record review showed Resident 36 had a 05/14/2020 Physicians Order (PO) for Dialysis every Tuesday, Thursday and Saturday at an outside dialysis provider. Review of Resident 36's clinical record showed risk assessments were completed on 09/25/2021, 10/09/2021, 11/30/2021, 12/07/2021, 12/09/2021, and 01/04/2022. An average of one assessment per month. Resident 60 In an interview on 01/05/2022 at 9:29 AM the resident stated they admitted to the facility on [DATE] and go to Dialysis every Tuesday, Thursday and Saturday. Review of Resident 60's clinical record showed no risk assessments were completed until 10/09/2021. Of the risk assessments completed 2 were observed for October 2021, 3 risk assessments were observed for November 2021, and 7 assessments for December 2021. In an interview on 01/11/2022 at 1:45 PM Staff J stated they expect community risk assessments to be completed every time a resident goes to dialysis and agrees the assessments have not been completed consistently. Resident 13 A record review showed Resident 13 did not have COVID-19 risk assessments in chart for all medical appointments outside the facility, which occurred three times per week for dialysis appointments. In an interview on 01/06/2022 at 10:44 AM, Staff B (Director of Nursing) stated, We do not have a system to complete the risk assessments. Staff B verified risk assessments were not completed for Resident 13 and Resident 50 for their dialysis appointments. Hand Hygiene Resident 268 Observation on 01/11/2022 at 1:12 PM showed Staff MM (CNA - Certified Nursing Assistant) performing incontinence care after Resident 268 had a bowel movement. Staff MM was wearing gloves and used wipes during care provided. After completing the care, Staff MM did not remove soiled gloves and reached over touched the bedside table, grabbed a tube of barrier cream, and then returned it to the table. Staff MM then picked up a new brief, touched the resident's hip with one hand and began positioning the brief into place under the resident. Staff MM continued wearing the soiled gloves until care completed and covered Resident 268 with their blanket. Staff MM then removed gloves and washed hands. In an interview on 01/11/2022 at 1:45 PM, Staff Y (LPN - Licensed Practical Nurse), who was present in the room during observation, confirmed Staff MM did not remove gloves and perform hand hygiene as expected. Resident 40 Observations made on 01/07/2022 at 10:07 AM showed Staff Y providing wound care to Resident 40, with Staff I's assistance turning the resident. Staff Y was observed removing the soiled wound dressing and placed it on top of a plastic bag on the bed. Staff Y proceeded to clean the wound and apply a new dressing. Staff Y used their right hand to hold the resident on their side and placed their left hand on the residents shoulder, no observations were made of Staff Y changing their gloves or performing hand hygiene after removing the soiled dressing. On 01/07/2022 at 10:16 AM Staff I was observed performing incontinence care to the resident. After completing the care, Staff I removed their soiled gloves and put a new pair of gloves on without washing their hands. At this time Staff Y removed their soiled gloves and placed a new pair of gloves on, no hand hygiene was performed. Staff Y proceeded to measure the resident's wound. Resident 59 On 01/07/2022 at 10:36 AM Staff Y was observed measuring Resident 59's wound with gloved hands. After measuring the wound Staff Y removed their gloves, put on a new pair and used a stethoscope to listen to the resident's bowel sounds. No hand hygiene was observed after Staff Y removed their soiled gloves. In an interview on 01/11/2022 at 1:40 PM Staff J stated they would expect staff to perform hand hygiene after removing their gloves, especially when during wound and incontinence care. Resident 38 An observation on 01/05/2022 at 12:51 PM showed Staff O (Certified Nursing Assistant) exited room [ROOM NUMBER] after assisting Resident 38 in bed, removed gloves, and did not do hand hygiene. Staff O walked down the hall to get a clothing protector and returned to the room, did not do hand hygiene. Staff --- then set up the Resident 38's meal tray, used hand sanitizer and left the room. An observation on 01/05/2022 at 1:07 PM showed Staff O enter room [ROOM NUMBER], turned on cold water, took soap from the dispenser, rubbed palms together for 5-10 seconds, took a paper towel from the dispenser and dried hands, held the towel in left hand, turned off faucet with clean right hand and then wiped both hands with the same towel. Staff O then went to pull the curtain and provided after meal care to the Resident 38. An observation and interview on 01/05/2022 at 1:11 PM showed Staff O leave room [ROOM NUMBER] and did not do hand hygiene upon exit. Staff O was asked about hand hygiene and stated hands should be washed for 20 seconds, before and after using gloves and before and after Resident 38's care. Staff O acknowledged the above observations and stated they should have used hand sanitizer. In an interview on 01/06/2022 at 10:44 AM, Staff B (Director of Nursing) stated staff is expected to do hand hygiene when entering and exiting a resident's room, before/after resident care and when changing gloves. Resident Equipment Resident 40 On 01/05/2022 at 2:15 PM Resident 40's wedge cushion (used to elevate heels) was observed on the floor leaning against the resident's bedside table. On 01/07/2022 at 10:29 AM Resident 40's wedge cushion was observed sitting on the floor, leaning against the wall. After providing care to the resident Staff Y placed the wedge cushion on the bed and assisted the resident to rest their legs on the cushion. No observations were made of Staff Y cleaning the wedge cushion before placing it on the bed. In an interview on 01/11/2022 at 1:48 PM Staff J stated they would expect staff to clean the wedge cushion if it was on the floor before placing it on the resident's bed. Resident 2 Observations on 01/04/2022 at 9:20 AM showed Resident 2's wound vac (a machine which provides vacuum like suction to a would facilitating drainage) on the floor next to the resident's bed. The machine was not in it's protective bag nor was in placed where it would not be knocked over. Observations on 01/04/2022 at 9:25 AM showed Staff Z (Licensed Practical Nurse) pick the wound vac off the floor stating it should be, but was not, in the bag and off off the floor. In a joint interview and observation on 01/12/2022 at 09:13 AM, a wheelchair (w/c) in room [ROOM NUMBER] was observed with the right arm rest to be heavily taped with duct tape, including a 6-inch long section of attached tape which hung freely below the handle. Staff DD (Corporate Support Staff) stated that the tape was not cleanable. Resident 55 Similar observations were made of Resident 55's w/c. On 01/04/2022 at 10:54 AM and 01/06/2022 at 1:06 PM, the right armrest on the resident's w/c was observed to be covered with tan and pink tape. REFERENCE: WAC 388-97-1320(1)(a-c)(2)(a-c)(3).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure 7 (Staff G, I, O, R, J, K, & M) of 7 staff reviewed, received training regarding recognizing, reporting, and preventing resident abuse. The failure placed residents at risk for unidentified abuse, a lack of intervention in response to allegations of abuse or neglect, as well detracting from staff's ability to prevent abuse and or neglect of residents. Findings included . During an interview on 01/10/2022 at 11:43 AM, Staff I (Certified Nursing Assistant) indicated Abuse was discussed during meetings, but no formal inservicing was done since the former owners (a Change of Ownership occurred in February 2021) provided it. In an interview on 01/12/2022 at 10:39 AM, Staff A (Administrator) stated new hires received abuse education provided by Staff X (Office Clerk) via videos on hire. Staff A stated Staff J (Staff Development) provide these inservices annually to existing staff. In an interview on 01/12/2022 at 10:55 AM, Staff J stated they did not do abuse inservices and had not since they were hired. On 01/12/2022 at 10:42 AM, Staff X indicated they were unaware of how to provide documentation to support Staff received abuse training on hire or annually. In an interview on 01/12/2022, Staff T (Business Office Manager) was asked to provide Abuse inservice documents for Staff J whose hire date was 10/15/2021. No information was provided. Facility staff was asked to provide documentation to support Staff G, I, O, R, J, K, & M received training that, at a minimum, educated staff on activities that constituted abuse, neglect, exploitation, and misappropriation of resident property. No information was provided. REFERENCE: WAC 388-97-0640 (2)(a)(b). .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 7 harm violation(s), $392,410 in fines. Review inspection reports carefully.
• 123 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $392,410 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Auburn Post Acute's CMS Rating?

CMS assigns AUBURN POST ACUTE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Auburn Post Acute Staffed?

CMS rates AUBURN POST ACUTE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Washington average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Auburn Post Acute?

State health inspectors documented 123 deficiencies at AUBURN POST ACUTE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 7 that caused actual resident harm, and 115 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Auburn Post Acute?

AUBURN POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 96 certified beds and approximately 76 residents (about 79% occupancy), it is a smaller facility located in AUBURN, Washington.

How Does Auburn Post Acute Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, AUBURN POST ACUTE's overall rating (1 stars) is below the state average of 3.2, staff turnover (56%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Auburn Post Acute?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.

Is Auburn Post Acute Safe?

Based on CMS inspection data, AUBURN POST ACUTE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Auburn Post Acute Stick Around?

Staff turnover at AUBURN POST ACUTE is high. At 56%, the facility is 10 percentage points above the Washington average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Auburn Post Acute Ever Fined?

AUBURN POST ACUTE has been fined $392,410 across 6 penalty actions. This is 10.6x the Washington average of $37,003. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Auburn Post Acute on Any Federal Watch List?

AUBURN POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 96
Avg. Residents: 76
Occupancy: 80.0%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
7 Actual Harm citations: -35
123 Deficiencies: -10
Fines ($392,410): -15
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505355