**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 3 (Resident 1, 12, 3) of 6 residents or resident representatives reviewed were fully informed orally and in writing of the potential risks associated with the use of psychotropic medications (medications that alter the thought process). In addition, based on interview and record review the facility failed to obtain informed consent for devices used for 1 (Resident 1) of 4 residents reviewed for devices. These failures prevented residents and/or legal representatives from making informed decisions about the use of multiple antidepressant medications, and precluded them from exercising their right to refuse/decline the proposed medications. Findings included . Review of the facility policy titled, Informed Consent for Psychotropic Drugs, updated 09/2017, showed the facility would obtain informed consent form the resident or resident representative before the drug prescribed is administered. The licensed nurse would review the drug, dosage and frequency, discuss the rationale/benefits for the order and discuss the potential risk factors of taking the prescribed drug with the resident or resident representative, and obtain their signature if they agree to take the prescribed drug. The policy showed the psychotropic drug consent would be signed and placed in the resident's medical record. Review of a facility policy, titled, Devices, updated 09/2017, showed devices were implemented after consent was obtained addressing the risks and benefits with the resident or the resident representative. The policy showed an individual consent would be obtained for each device. <Resident 1> <Psychotropic Medications> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 10/23/2024, showed Resident 1 admitted to the facility on [DATE], had severe impairments to their decision making, was rarely or never understood, and had a Collateral Contact (CC) for decision making. The MDS showed Resident 1 had verbal behavioral symptoms directed at others that occurred 1 to 3 days of the 7 day look back period that significantly disrupted care and the living environment. The MDS showed Resident 1 had no physical behaviors directed towards others and did not refuse care. The MDS showed Resident 1 had medically complex conditions, including, a brain dysfunction that caused confusion and memory loss, anxiety, and depression. Review of section N, medications of the MDS, showed Resident 1 used an antipsychotic, antianxiety, and antidepressant medications. Review of an antipsychotic Care Plan, (CP), revised 11/09/2024, showed Resident 1 used an antipsychotic for behavior management and directed staff to monitor the effectiveness of the medication. The CP directed staff to discuss with the physician and the family the need for on-going use of the medication and review behaviors, interventions, and alternate therapies attempted to determine the effectiveness. Review of a Nursing Progress Note (NPN), dated 12/04/2024 at 10:54 AM, showed Staff F (Licensed Practical Nurse, LPN) documented Resident 1 was screaming at the top of their lungs, kicking, swinging arms and legs. Staff F documented multiple attempts to redirect were unsuccessful, a call was placed to the behavioral health support, and a new physician order was received for a one time dose of an antipsychotic and to increase Resident 1's an antidepressant (a class of depressant drugs used to treat anxiety, insomnia, and seizures) medication from every six hours to every four hours as needed for an anxiety. The NPN showed Staff F left a message with Resident 1's CC to call the facility. Review of Resident 1's December 2024 Medication Administration Record (MAR), showed Staff J (Registered Nurse, RN) administered the one time dose of the antipsychotic medication at 11:00 AM. Review of Resident 1's record showed no documentation of informed consent was obtained from Resident 1's CC before facility staff administered the one time dose of antipsychotic medication and increased the frequency of Resident 1's antidepressant medication. In an interview on 12/12/2024 at 10:45 AM, Resident 1's CC stated they received a call from the facility on 12/04/2024 that Resident 1 had crawled out of bed and stated no one discussed medications with them at this time. During an interview on 12/12/2024 at 4:18 PM, Staff B (Director of Nursing) stated medications that require informed consent should not be given before consent obtained so the resident or resident representative can make an informed decision about the medication. Staff B stated no documentation could be found that showed Resident 1's CC was informed and consented to the medications before given by staff. <Devices> Review of Resident 1's fall CP, revised 11/05/2024, showed Resident 1 had seven devices including; a bed alarm, a chair alarm, tilt-n-space (a wheelchair that reclines) wheelchair, a perimeter mattress, bed in lowest position, fall mat, and bed against the wall. Review of Resident 1's record from admission, dated 07-24-2024-12/09/2024, showed no consent was obtained from resident 1's CC for the use of a fall mat at the bedside, bed against the wall, or perimeter mattress. In an interview on 12/12/2024 at 4:20 PM, Staff B stated all devices should have informed consent before being implemented. <Resident 12> Review of a significant change MDS, dated [DATE], showed Resident 12 was not able to make their needs known, not able to make own decisions, rarely made themselves understood, and rarely understood others. The MDS showed Resident 12 had no behaviors, and medically complex conditions that included dementia, anxiety, depression, and paraplegia (an impairment in motor or sensory function of the lower extremities). The MDS showed Resident 12 was dependent on staff for all care, including toileting, dressing, eating, and transfers. Review of hospital transfer orders and documents, dated 12/03/2024, showed Resident 12 was being treated under hospice care with comfort as the goal. A physician's order, dated 12/03/2024, showed Resident 12 was prescribed an antipsychotic medication to be given every two hours as needed. Review of Resident 12's December 2024 MAR, showed on 12/05/2024 at 1:15 PM and 9:30 PM, and on 12/06/2024 at 9:28 AM, Resident 12 received the antipsychotic medication. Review of Resident 12's medical record from readmission on [DATE] to 12/06/2024, showed no consent was obtained from Resident 12's CC before staff administered the antipsychotic medication. During an interview on 12/12/2024 at 4:25 PM, Staff B stated all antipsychotic medications should have informed consent before medication was administered. <Resident 3> Review of the quarterly MDS, dated [DATE], showed Resident 3 was able to make needs known, own decisions, spoke a different primary language, and could understand and be understood by others. The MDS showed Resident 3 had no behaviors, and medically complex conditions including' end stage renal disease, diabetes, and high blood pressure. The MDS showed Resident 3 was dependent on staff for toileting and lower extremity dressing, and maximum assist for personal hygiene, and bed mobility. Review of a physicians order, dated 11/15/2024, showed Resident 3 was prescribed an antianxiety medication as needed every six hours for adjustment disorder with anxiety. Review of Resident 3's MAR, dated November 2024, showed Resident 3 received the antianxiety medication five times from 11/15-11/25/2024. Review of Resident 3's medical record, dated 11/15/2024-12/12/2024, showed no documentation consent was obtained for Resident 3's antianxiety medication before staff administered the medication. In an interview on 12/12/2024 at 4:27 PM, Staff B stated they would expect staff to obtain consent and document before administering the antianxiety medication. WAC: REFERENCE 388-97-0260 .

**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 identification, investigation, protecting, and reporting of abuse and neglect incidents. The facility failed to thoroughly investigate incidents and allegations of abuse, sexual abuse, and neglect for 7 of 9 residents (Resident 2, 1, 4, 3, 5, 6, 7) reviewed for incidents, failed to identify and report incidents as potential for abuse or neglect related to falls and bruises for 2 of 2 residents (Resident 2, 8), and failed to ensure facility staff implemented abuse policies and procedures and protected residents from further abuse by staff for 1 (Staff D) of 6 staff involved in incidents, when Staff D went back to Resident 4 and Resident 5's room despite an allegation of verbal abuse, and failed to timely report allegations of sexual abuse to local authorities as required for 1 of 2 residents ( Resident 2) reviewed for sexual abuse allegations. 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 facility policy, Abuse Investigations, dated 10/2022, showed the facility would conduct a thorough investigation of potential or suspected allegations of abuse and neglect in accordance with state and federal rules. The policy showed staff would identify and interview all persons involved, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. The facility would protect the alleged victim during the investigation, determine if abuse or neglect occurred and maintain complete and thorough documentation of the investigation. Review of the facility policy, Investigations of Alleged Sexual Abuse, dated 10/2022, showed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy directed staff to immediately protect the resident, report to the facility administrator, supervisor, state survey agency, and the local police department. The policy showed the facility would conduct a thorough abuse investigation to determine if sexual abuse occurred by conducting a physical exam for potential injuries of sexual abuse. The policy showed the facility would provide additional medical follow-up including sending the resident to the hospital emergency room for a rape kit as indicated. <Resident 2> Review of Resident 2's quarterly Minimum Data Set (MDS, an assessment tool), dated 10/14/2024, showed Resident 2 had impairments to their thought process, had adequate hearing, vision, clear speech, and was able to make themselves understood, and able to understand others. The MDS showed Resident 2 had no behaviors, had no impairments to their extremities, and was dependent on facility staff for toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS showed Resident 2 had medically complex conditions, including; anxiety, schizophrenia, and adult failure to thrive. Review of an Activities of Daily Living (ADL) Care Plan (CP), dated 10/30/2024, showed Resident 2 was dependent on two staff members to turn, reposition, and provide incontinence care. Review of an at risk for trauma/re-traumatization CP, dated 09/12/2024, showed Resident 2 was at risk for re-traumatization due to past and current trauma the resident experienced. The CP directed staff to listen to resident concerns and notify the Licensed Nurse (LN) or Social Worker (SW) when the resident reported feelings of re-traumatization or displayed changes in behavior or mood. The CP did not indicate what type of trauma Resident 2 experienced and did not identify what triggered the resident for potential re-traumatization. Review of a facility investigation, dated 11/11/2024, showed Resident 2 told a caregiver (Staff E, Certified Nursing Assistant, CNA/Restorative Nursing Aide) they were raped. Staff F (Licensed Practical Nurse, LPN) interviewed Resident 2 who stated an old man raped them the other day. Resident 2 stated the old man took off my brief that was full of poop and smelled it. Staff F asked Resident 2 if they were touched inappropriately and Resident 2, replied yeah they were wiping down there but denied anything being inserted vaginally. The investigation showed the facility administrator, director of nursing, and Resident 2's collateral contact was notified of Resident 2's allegation of sexual abuse. The investigation showed the facility identified one staff member (Staff G, CNA) that worked with Resident 2. Staff G denied providing bowel incontinence care during that time. The investigation showed local police were notified on 11/14/2024, three days after Resident 2 alleged rape and the Interdisciplinary Team (IDT) concluded that Resident 2 described routine incontinence care, denied anything inserted vaginally or rectally, and it was reasonable to believe the allegation resulted from Resident 2's medical diagnoses and a recent medication change. Review of a late entry Nursing Progress Note (NPN), dated 11/11/2024 and entered on 11/13/2024, showed Staff F documented that Resident 1 stated they were raped by an old man the other day, when Staff F asked Resident 2 what they looked like, Resident replied an old man. The progress note showed Staff F informed the administrator, director of nursing, and Resident 2's collateral contact. Review of Staff E's investigation interview, dated 11/15/2024, showed Staff H (Social Services Assistant, CNA) interviewed Staff F to see if they heard or observed any inappropriate behavior with staff and residents, Staff E stated no. Review of the nursing staff schedule from 11/04/2024-11/11/2024, showed eight other male staff members worked with Resident 2 during the time the allegation was made. The scheduled showed on 11/09/2024, Staff I (LPN) was Resident 2's nurse the night the facility determined Staff G was assigned to Resident 2. In an interview and observation on 11/20/2024 at 10:45 AM, Resident 2 was observed in bed and stated, when I was asleep an old man came into the room, removed their brief and smelled it. Resident 2 stated this made them mad and the old man left. During an observation and interview on 12/12/2024 at 1:36 PM, Resident 2 stated the old man was average height, Caucasian with black hair that walked in the room with no devices. Resident 2 stated they had never seen this old man before and has not seen them since the incident. Resident 2 stated the old man did not say anything during the incident and repeated the same encounter as the previous interview. Resident 2 stated they had trauma in their past and did not want to discuss their trauma. In an interview on 12/12/2024 at 1:50 PM, Staff A (Administrator) stated when a resident alleged sexual abuse they would expect staff to report to the state hotline, the resident's provider, resident representative, and police. The staff should perform a physical assessment, suspend the alleged perpetrator, and monitor the resident for psychological harm. Staff A stated the police should have been notified immediately after the allegation was made and acknowledged the facility waited four days to report to the police. Staff A stated Resident 2's provider was notified the next day (11/12/2024) of the allegation, would expect staff to notify the provider immediately after the allegation, and would expect staff to document the notifications in the investigation. Staff A stated they determined Staff G as the perpetrator because he was the only male assigned to Resident 2 a few days prior that could fit the description of an old man. Staff A stated the investigation was not thorough, should have but did not include the possibility of a resident in the facility or other male staff that cared for Resident 2. Staff A was not sure if Resident 2's collateral contact was asked if they would like Resident 2 to be evaluated further at the emergency room and would expect staff to document thoroughly on the investigation. Staff A stated they were not sure who the other aides were when Staff G was providing incontinence care to Resident 2 as they required two staff members for bed mobility and incontinence care. Staff A stated they would expect staff to follow the CP if the resident required two aides they would expect two aides for bed mobility and incontinence care. Staff A would expect the other aides to be identified in the investigation and interviewed about the incident. Staff A stated Staff H helped with interviews, asked very broad questions, and did not seek further information or details specific to the event. <Resident 1> Review of Resident 1's quarterly MDS, dated [DATE], showed Resident 1 had impairments to their decision making ability and thought process, was rarely understood by others, had adequate hearing, vision, and clear speech. The MDS showed Resident 1 had no physical behaviors directed towards others, had verbal behaviors directed at others occurring one to three days of the seven day look back period, and had no other behavioral symptoms, such as disrobing, screaming, rejecting care or throwing food. The MDS showed the behaviors did not put the resident at significant risk of injury, did not interfere with their care or with the resident's participation in activities, and the behaviors significantly disrupted the living environment. The MDS showed Resident 1 required maximum assistance from staff with toileting, personal hygiene, bed mobility, and transfers. The MDS showed Resident 1 had medically complex conditions including a brain dysfunction that caused confusion and memory loss, anxiety, and depression that required treatment with antipsychotic, antianxiety, antidepressant, and pain medications. Review of facility fall assessment, dated 11/05/2024, showed Resident 1 was assessed as a high fall risk due to severe impairments to their decision making, poor safety awareness, and balance problems. Review of a facility fall CP, revised 11/05/2024, showed Resident 1 had a history of crawling on the floor. The CP showed Resident 1 had a bed and wheelchair alarm to alert staff of Resident 1 rising from the bed or chair. The CP directed staff to keep Resident 1 in high visible areas when awake, provide activities that promote exercise, and when a fall occurred monitor, document, and report the fall to the provider. Review of a NPN, dated 11/30/2024, showed Staff J (Registered Nurse, RN) documented Resident 1 was trying to get out of their wheelchair during the day shift, Resident 2 wanted to be laid down, and was put into bed. Staff J documented at 2:35 PM Resident 2 crawled out of bed and almost by the door when another resident called and reported Resident 2 was crawling on the floor. Staff J documented Resident 2 was placed in the wheelchair by the nurse station so they could be closely monitored. The NPN showed no indication the provider, Resident 1's collateral contact, administrator or Director of Nursing (DON) were notified Resident 2 was found crawling on the floor into the hallway. The NPN note showed no indication Resident 1 was assessed for an injury after they were found crawling in the hallway. Review of a NPN, dated 12/4/2024, showed Staff J documented Resident 1 was yelling and trying to jump out of their wheelchair and was laid down at 1:00 PM. Staff J documented Resident 1 crawled out of bed to the doorway, into the hallway, and was transferred into the wheelchair in the middle of the hallway. The NPN showed no indication Resident 1 was assessed for an injury or Resident 1's CC was notified of Resident 1 crawling out of bed into the hallway. Review of a NPN, dated 12/8/2024, showed Staff J documented Resident 1 was given medications at 7:00 PM, by 7:30 PM crawled out of bed to the room doorway an started screaming. The NPN showed no indication the provider, Resident 1's collateral contact, administrator or Director of Nursing (DON) was notified of Resident 2 found crawling on the floor into the hallway. The NPN note showed no indication Resident 1 was assessed for an injury after found crawling in the hallway. Review of the facility abuse log, dated November 2024 and December 2024, showed Resident 1's crawls out of bed were not observed on the log. During an interview on 12/12/2024 at 10:45 AM, Resident 1's CC stated on 12/11/2024 Resident 1 crawled into the bathroom and then out into the hallway where they had a bowel movement. The CC stated they were aware that a bed and chair alarm was used with Resident 1. The CC suspected the bed alarm was turned off if the staff didn't realize the resident was out of the bed and already in the hallway. During an observation and interview on 12/12/2024 at 1:39 PM, Resident 1 was observed sleeping in bed with their eyes closed. Observations showed no bed alarm or chair alarm. Staff J was asked where the bed and chair were located, looked under Resident 1 in the bed, and no bed alarm was observed under Resident 1. Staff J did not find the chair alarm for Resident 1. Staff A and Staff B (DON) confirmed no bed or chair alarm was observed in the room or being used on Resident 1 as ordered by the provider. Staff A stated they would expect Resident 1's bed and chair alarms to be in use and functioning. During an interview on 12/12/2024 at 2:35 PM, Staff A stated Resident 1 had behaviors of crawling out of bed, they were not able to tell the staff if they fell, and this behavior should be treated as a fall to rule out injury. Staff A stated all falls should be on abuse log, reported to provider and resident's responsible party, and investigated. Staff B stated they would expect staff to assess the resident for injury after found crawling on the ground. Staff A acknowledged Resident 1's crawls out of bed on 11/30/2024, 12/04/2024, and 12/08/2024, were not logged, investigated or reported to the provider or CC as they would expect. <Resident 4> Review of Resident 4's admission MDS, dated [DATE], showed Resident 4 was able to make their needs known, own decisions, could understand, and be understood by others. The MDS showed Resident 4 had diagnoses including; chronic respiratory failure, difficulty walking, and chronic lung disease. The MDS showed Resident 4 required maximum staff assistance with dressing toileting, and personal hygiene. Review of a facility investigation documents, dated 11/21/2024, showed Resident 4 reported a few nights ago that Staff D (CNA) yelled at them stating you are going to get my mom (Staff K, CNA) fired. Resident 4 denied reporting Staff D or Staff K. Review of the incident report showed blank areas for mental status, predisposing situation factors, and statements. The incident report did not indicate the provider was notified of the incident and the investigation did not rule out abuse and neglect. Per the investigation, no other residents had concerns about Staff D or Staff K, Resident 4 did not express psychosocial harm during monitoring, and both alleged staff members would not be allowed to work with the resident. Review of a resident interview, dated 11/21/2024, showed Resident 9 had concerns about Staff K stating they made excuses or said they were busy when Resident 9 needed help. Review of a typed note from Staff L (Social Services Director) showed when they revisited Resident 4, the resident reported that Staff D came back into their room with another CNA to make the bed while they were in the bathroom. Review of Resident 4's NPN's showed no documentation of the incident, no psychological monitoring, and no follow up or monitoring for Staff D returning to Resident 4's room after the incident. In an interview and observation on 12/04/2024 at 3:00 PM, Resident 4 was observed in the room, sitting on the bed with their phone. Resident 4 stated they had concerns about Staff D and Staff K. Resident 4 said Staff D yelled at them about going to get their mom fired and was not sure why Staff D was yelling at them because they did not report anything to staff. Resident 4 stated Staff D and Staff K have not provided care after the incident but Staff D came into the room to talk to the CNA that was making their bed. Resident 4 stated Staff D didn't say anything to them but they felt uncomfortable and went into the bathroom. Resident 4 stated they were told that Staff D would not be allowed back in my room. During an interview on 12/12/2024 at 2:45 PM, Staff A stated both Resident 4 and their roommate (Resident 5) had issues with Staff D, and Resident 4 was targeting Staff D. Staff A stated there was no documentation about the incident, that the provider was notified, and no monitoring for psychological harm to support the investigation conclusion of no psychological harm during monitoring. Staff A stated Staff D went into Resident 4's room because Resident 4 was care in pairs (two staff at all times with care) and they were the second caregiver. Staff A stated Staff D should not have gone back in the room, there was no staff follow-up after Staff L was informed that Staff D returned to the room, and no staff followed up on Resident 9's concerns about Staff K. Staff A stated the investigation should rule out abuse and neglect and acknowledged the investigation did not rule out abuse or neglect. <Resident 5> Review of the admission MDS, dated [DATE], showed Resident 4 was able to make needs known own decisions, and had no behaviors. The MDS showed Resident 5 had medically complex conditions including depression, renal insufficiency, and lymphedema (swelling in an extremity). The MDS showed Resident 5 was dependent on staff for toileting, and required max assistance with upper extremity dressing. Review of a facility investigation, dated 11/21/2024, showed Resident 5 requested help with changing their gown when Staff D tossed the gown to the resident and told Resident 4 to figure out themselves how to put it on. The incident report documents provided, did not include all pages, blank areas for mental status and predisposing environmental, physiological, and situation factors. The investigation documents did not show indication the provider was notified of the incident and showed Staff D denied tossing a gown at the resident and assisted them to put on the gown. Review of the investigation documents showed Staff D would no longer work with the resident, the resident had no psychological harm, and discharged the day after the incident. The investigation did not rule out abuse and neglect. In an interview and observation on 12/04/2024 at 3:42 PM, Resident 5 was observed in their bed, and stated they had concerns with Staff D, they did not like how they talked on their phone in a different language while providing care. Resident 5 stated they were told Staff D would not come to their room after the incident and Staff D came back in the room with another CNA who was changing the bed. Resident 5 stated their roommate Resident 4 went into the bathroom. In an interview on 12/12/2024 at 2:50 PM Staff A stated Resident 5 had issues with Staff D, the provider should have been notified of the incident, and the investigation should rule out abuse and neglect. Staff A stated Staff D went into Resident 5's room because Resident 4 was care in pairs (two staff at all times with care) and they were the second caregiver. Staff A stated Staff D should not have gone back into Resident 5's room. <Resident 6> Review of a admission MDS, dated [DATE], showed Resident 6 was able to make needs known, own decisions, and had no behaviors. The MDS showed Resident 6 had diagnoses including orthopedic after care, osteoporosis, anxiety, and diabetes. The MDS showed Resident 6 was dependent on staff for toileting and required max assistance with bed mobility. Review of a facility investigation, dated 11/22/2024, showed Resident 6 reported a staff member put three briefs on them during the night and told Resident 6 they would be changed when the third brief was wet. The investigation showed Staff M (CNA) was identified as the staff providing this care. Staff M denied putting three briefs on Resident 6. The investigation showed that Staff N (CNA) did not observe multiple briefs on Resident 6 although their statement showed they only helped reposition the resident. The investigation showed other residents were interviewed and had no concerns for their care. The investigation concluded that Staff M would no longer work with Resident 6 and did not rule out abuse or neglect. Review of the resident interview questions for the investigation, undated showed two residents (Resident 7 and Resident 10) had concerns for staff not changing their brief when needed and when Resident 7 requested help they were told everyone was gone. Resident 10's CC had concerns with how long Resident 10 was up in the wheelchair, staff didn't know how to use the mechanical lift, and it took an hour for staff to help the resident. Review of resident interviews, dated 11/22/2024, showed residents were asked if they had any issues with their care on night shift. During an interview on 12/04/2024 at 3:42 PM, Resident 5 stated staff used multiple briefs on the resident before. Resident 5 stated it happened more often in the evening and during the night shift and staff would double the briefs to make it look like one brief. Resident 6 was not available for an interview. In an interview on 12/12/2024, at 3:00 PM, Staff A stated the incident report should be thorough, when asked if residents were asked about staff applying multiple briefs, they were not sure. Staff A stated the resident interview questions should be more specific to the allegation, Staff N should have additional follow up questions to determine if they provided care or changed Resident 6's brief. Staff A stated the investigation did not but should have ruled out abuse and neglect. Staff A stated an investigation was started for Resident 7's concern but would have to look into Resident 10's concerns. <Resident 3> Review of the quarterly MDS, dated [DATE], showed Resident 3 was able to make needs known, own decisions, spoke a different primary language, and could understand and be understood by others. The MDS showed Resident 3 had no behaviors, and medically complex conditions including' end stage renal disease, diabetes, and high blood pressure. The MDS showed Resident 3 was dependent on staff for toileting and lower extremity dressing, and maximum assist for personal hygiene, and bed mobility. Review of a facility investigation, dated 11/22/2034 showed Resident 3 reported that Staff N (CNA) pushed them, they started to fall, and Staff N refused to help prevent Resident 3 from falling. Resident 3 reported Staff N pulled them up by the waist and put them back in bed. The investigation showed Staff N stated they found Resident 3 crying, wanted help to be pulled up in bed but was a two person assist and Staff N needed to get help. Staff N stated Resident 3 started to pull themselves up in bed and Resident 3's legs started to fall off the bed and slid to the point that Staff N had to stop the resident and put their feet back in bed. Staff L followed up with Resident 3 who was uncomfortable stating Staff N was rough, did not listen to them, and was scared. The investigation showed Staff N would not provide care to Resident 3, no other resident interviews showed concerns with care, and the investigation did not rule out abuse or neglect. Review of investigation resident interviews, dated 11/22/2024, showed Resident 11 answered, no staff did not treat them with respect or dignity. In an observation and interview on 12/12/2024 at 1:18 PM, Resident 3 was observed in bed and stated Staff N passed by their room and looked upset and annoyed that they needed to be changed after a bowel movement. Resident 3 stated Staff N started to change them, and pushed them as they were turning, causing their legs to fall out of bed. Resident 3 said their knees were on the ground with their belly and upper body on the bed. Resident 3 stated they asked why they pushed them and Staff N was quiet and quickly put them in the bed. Once in the bed Resident 3 stated Staff N got really close to their face and was aggressive. Resident 3 stated they told Staff N they would report them and Staff N replied, do it. Resident 3 stated they felt insulted, discriminated against, and didn't understand what they did to make Staff N mad. Review of a social services progress note, dated 11/26/2024, showed Staff L documented they followed up with Resident 3 who stated they had psych harm related to the care received at the facility and did not want to receive care from Staff N. Staff L documented Resident 3 was offered behavioral health services but declined. Review of progress notes showed no staff follow up on Resident 3's psych harm statements. In an interview on 12/12/2024 at 2:55 PM, Staff A stated the investigation should have documentation that abuse and neglect was ruled out. Staff A stated they believed Resident 3 had prior issues with Staff N and did not like them. Staff A stated they think a grievance was made for Resident 11's CC's concern and would have to look. Staff A stated facility staff should have but didn't follow up with Resident 3's statement of experiencing psych harm. <Resident 7> Review of quarterly MDS, dated [DATE], showed Resident 7 was able to make needs known, own decisions, and no behaviors. The MDS showed Resident 7 had diagnoses including chronic obstructive pulmonary disease, diabetes, anxiety, and depression. The MDS showed Resident 7 was dependent on staff for toileting, dressing, bed mobility, and transfers. Review of a facility investigation, dated 11/25/2024, showed Resident 7 complained that on two separate occasions they waited three hours to be changed by facility staff. The facility conducted an investigation that showed abuse and neglect was ruled out. The investigation documents showed five residents were asked if they experienced long call light wait times, all five of five residents replied yes. Two out of five residents stated they were not able to be toileted when they asked facility staff. In an observation and interview on 12/04/2024 at 2:49 PM, Resident 7 was observed in bed and stated the staff the facility identified in the investigation were not the staff involved. When asked who staff were, Resident 7 replied name tags are not always visible and stated they didn't want to go there. When asked about the staff the facility identified, Resident 7 stated they had not seen them since the incident. During an interview on 12/12/2024 at 3:10 PM Staff A stated the investigation information should be reviewed for further concerns. Staff A stated they would expect staff to follow up on the resident interviews gathered during the investigation to get more details about concerns with toileting and call light response. <Resident 8> Review of a quarterly MDS, dated [DATE], showed Resident 8 was not able to make their needs known, not able to make own decisions, was non-verbal with severely impaired vision and hearing. The MDS showed Resident 8 had medically complex conditions including dementia, schizophrenia, and diabetes. The MDS showed Resident 8 self propelled in a wheelchair for mobility, was dependent on staff for toileting, dressing, personal hygiene, bed mobility, and transfers. In an observation on 12/04/2024 at 2:27 PM Resident 8 was observed sitting in their wheelchair in the hallway, a large dark purple area was observed on their forehead near the hairline. During an interview on 12/04/2024 at 2:33 PM Staff J stated they did not know about a bruise on Resident 8's forehead and stated the bruise was not there earlier when Staff J gave Resident 8 their medications. Review of the facility December 2024 abuse log, showed the facility logged Resident 8's bruise as a bruise of deep color and depth. The facility did not report to the state hotline as the bruise was in an area not generally vulnerable to trauma, such as the face or neck. In an interview on 12/12/2024 at 4:00 PM, Staff A stated Resident 8 is very vulnerable because they prefer to self propel around the facility with impaired vision. Staff A stated the facility had tried a helmet with Resident 8 but they refused to wear it. Staff A stated the facility should have but didn't report the bruise to Resident 8's forehead. WAC: REFERENCE 388-97-0640(2)(b)(5)(6)(a)(b)(7)(b)(i)(ii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 5 of 6 residents (Resident 1, 3, 12, 14, 15 ) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to document identified target behaviors, monitor all target behaviors, document when behaviors occurred, implement and document behavioral interventions before administering medications, assess the effectiveness of the interventions before increasing medications, and to have as needed psychotropic medication (affects behavior, mood, thoughts, or perception) orders with stop dates and physician reassessment for extended use. These failures left residents at risk for unnecessary medications, adverse side effects, unmet needs, and diminished quality of life Findings included . Review of the facility policy titled, Psychotropic Drugs, updated 10/2022, showed the facility would evaluate and implement interventions for residents on psychotropic medications. Treatment would include the use of environmental and/or behavioral interventions prior to initiating psychotropic medications. Prior to initiating any psychotropic medication the Interdisciplinary Team (IDT) would review the resident's medical record, including behavior monitoring, investigate the causal factors triggering the behavior symptoms, and evaluate the resident's medication regime to validate the resident was not receiving duplicate drug therapy. The policy shoed the IDT would hold at a minimum a monthly psychotropic review to ensure residents had appropriate diagnosis, consent, and supporting documentation for resident's taking psychotropics. As needed psychotropic drugs were limited to fourteen days except when the physician believed it was appropriate to extend treatment. The physician would document their rationale in the resident's medical record. The policy showed the physician would be onsite to reevaluate the resident for the continued use and did not include just replacement of the current order <Resident 1> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 10/23/2024, showed Resident 1 admitted to the facility on [DATE], had severe impairments to their decision making, was rarely or never understood, and had a Collateral Contact (CC) for decision making. The MDS showed Resident 1 had verbal behavioral symptoms directed at others that occurred one to three days during the seven day look back period that significantly disrupted care and the living environment. The MDS showed Resident 1 had no physical behaviors directed towards others and did not refuse care. The MDS showed Resident 1 had medically complex conditions, including, a brain dysfunction that caused confusion and memory loss, anxiety, and depression. Review of section N, medications of the MDS, showed Resident 1 used an antipsychotic, antianxiety, and antidepressant medications, kicking and hitting Review of Resident 1's medical record, dated 07/17/2024 through 12/06/2024, showed six Care Plans (CP) for antipsychotic, antianxiety, and antidepressant medication use and three behavior CP's. Resident 1's CP for antipsychotic use showed Resident 1 used an antipsychotic for behavior management. The CP's directed staff to monitor and record the number of occurrences of target behaviors that included screaming, throwing items, disrobing, inappropriate response to verbal communication, violence or aggression towards staff, anxiousness/agitation, restlessness, impulsivity, and poor safety awareness, yelling, crawling out of bed, refusing care, showers, and medications. The CP directed staff to administer medications as ordered and monitor the effectiveness of the medications, monitor the behavior episodes, attempt to determine the underlying cause, and consider the location, time of day, persons involved, and the situation. Review of Resident 1's physician orders showed Resident 1 was prescribed seven psychotropic medications including an antipsychotic medication twice daily, an antidepressant to treat depression, another antidepressant to treat insomnia, and an antianxiety medication to treat anxiety as needed. Review of Resident 1's as needed antianxiety medication, dated 11/14/2024, showed Resident 1 was prescribed an antianxiety medication 2 milligrams (mg) as needed for agitation, restlessness related to anxiety, every six hours for fourteen days. The antianxiety medication was re-ordered on 11/29/2024 for an additional fourteen days and on 12/04/2024 was changed to as need every four hours and routinely twice daily. Review of a physician progress notes, dated 11/12/2024, showed the physician discontinued the as needed antianxiety medication for Resident 1. No additional progress notes were observed to indicate why Resident 1's as needed anti-anxiety medication was re-started on 11/14/2024. Review of a 12/04/2024 nursing progress note showed the physician was called because Resident 1 was screaming, kicking and hitting, attempts to re-direct the resident were unsuccessful, and the physician ordered a one time dose of antipsychotic medication and to increase the antianxiety medication from every six hours to every four hours as needed for anxiety. Review of Resident 1's Medication Administration (MAR), dated November 2024 showed two behavior monitors that directed staff to monitor behaviors of crying, withdrawn, refusing care or medications, yelling, and anxious/agitated. The behavior monitoring directed staff to implement interventions of providing a calm space, encourage family visits, one on one socialization, sensory stimulation/activities, and counseling/therapy. The MAR showed on 11/14/2024 at 6:32 PM, 11/15/2024 at 6:00 PM, 11/19/2024 at 4:45 PM, 11/21/2024 at 8:05 AM, 11/26/2024 at 3:31 PM, 11/27/2024 at 3:31 PM, 11/28/2024 at 3:46 PM , 12/02/2024 at 3:24 PM, and 12/05/2024 at 1:05 PM, facility staff administered Resident 's as needed antianxiety medication without documenting behaviors or when staff did document behaviors, did not document non-medicinal interventions attempted, or their effectiveness before medicating Resident 1. During an interview on 12/12/2024 at 4:25 PM, Staff B (Director of Nursing) stated Resident 1 had behaviors of crying, withdrawn, refusing medications, refusing care, yelling, and crawling. Staff B reviewed Resident 1's CP and stated staff were not but should be monitoring all of Resident 1's identified behaviors. Staff B stated they would have to look into because they were not sure if there was a transcription error with the as needed antianxiety medication when reviewing the MAR, the medication showed as needed every fours and to be given twice daily. Staff documentation showed the antianxiety medication was increased to every fours as needed, and did not mention that it was to be given twice daily. Staff B stated there should be documentation to support why the medication was reordered on 11/14/2024, two days after another physician discontinued it. <Resident 3> Review of the quarterly MDS, dated [DATE], showed Resident 3 was able to make needs known, made their own decisions, spoke a different primary language, and could understand and be understood by others. The MDS showed Resident 3 had no behaviors, and had medically complex conditions including' end stage renal disease, diabetes, and high blood pressure. The MDS showed Resident 3 was dependent on staff for toileting and lower extremity dressing, and maximum assist for personal hygiene, and bed mobility. Review of a physician's order, dated 11/15/2024, showed Resident 3 was prescribed an antianxiety medication as needed every six hours for adjustment disorder with anxiety. The as needed antianxiety physician's order had no stop date. Review of Resident 3's MAR, dated November 2024, showed Resident 3 received the antianxiety medication five times from 11/15-11/25/2024. The MAR showed no medication side effect monitoring or behavior monitoring for Resident 3's anxiety. Review of Resident 3's medical record, dated 11/15/2024-11/25/2024, showed no consent was obtained from Resident 3 for the antianxiety medication. In an interview on 12/12/2024 at 1:30 PM, Staff P (Certified Nursing Assistant) sated Resident 3 cried all the time, usually from pain from a medical issue. Staff P stated they worked with the resident often because they spoke the same language. During an interview on 12/12/2024 at 4:27 PM, Staff B stated Resident 3 had behaviors of crying and heightened emotions. Staff B stated, staff were not but should be monitoring Resident 3's behaviors and interventions to ensure the medication was effective. Staff B stated they would expect the as needed antianxiety medication to have a stop date of 14 days, and physician documentation for any extended use in the resident's record. <Resident 12> Review of the significant change MDS, dated [DATE] showed Resident 12 was not able to make needs known, had no speech, rarely made self understood, and rarely understands. The MDS showed Resident 12 had impairments to all extremities and was dependent on staff for toileting, personal hygiene, bathing, dressing, and bed mobility. The MDS showed Resident 12 had medically complex conditions including; soft tissue disorder, paraplegia (no feeling or use of lower extremities), dementia, anxiety, and depression. Review of Resident 12's MAR, dated December 2024, showed Resident 12 had an order for an as need antianxiety medication every two hours as needed for agitation. Review of the MAR showed Resident 12 was administered the medication three times. The MAR showed no stop date for the as needed antianxiety medication, no behavior monitoring, or interventions developed for staff to implement before medicating Resident 12. In an interview on 12/12/2024 at 4:28 PM, Staff B stated they would expect the as needed antianxiety medication to have a stop date of 14 days. Staff B stated staff were not but should be monitoring behaviors, attempting interventions before administering medications, and documentation in the resident's medical record. <Resident 14> Review of a quarterly MDS, dated [DATE], showed Resident 14 was able to make needs known, own decisions, had no behaviors, clear speech, made self understood, and was able to understand others. The MDS showed Resident 2 needed moderate assistance with toileting and dressing, and was independent with transfers. The MDS showed Resident 14 had medically complex conditions that included; cancer, high blood pressure, anxiety, and depression. Review of Resident 14's MAR, dated November 2024 and December 2024, showed Resident 14 was started on an as needed antianxiety medication on 10/11/2024 for 14 days. Review of the MAR showed the as needed antianxiety medication was re-ordered on 10/25/2024, 10/29/2024, 11/15/2024, and 12/01/2024, to be extended an additional 14 days. The MAR's showed Resident 14 received the antianxiety medication almost daily or twice a day. Review of the behavior monitoring, dated November 2024, showed staff were directed to monitor the resident for anxiety and staff documented Resident 14 had no behaviors in the month of November. Review of the behavior monitoring, dated December 1st through the 6th 2024, showed Resident 14 had no behaviors during that time. Review of Resident 12's medical record, dated 10/25/2024 through 12/06/2024, showed one note from the physician, dated 11/26/2024, that Resident 14 was on chronic antianxiety medications, facility staff were monitoring the resident for target symptoms including restlessness, hitting staff or others, verbal aggression with staff, cussing, using racial slurs, delirium, and refusal if care. The physician progress note showed to continue the antianxiety medication as needed for anxiety but did not give a rationale for extended use. No other physician notes were observed in Resident 12's record for the extended use of the antianxiety medication that was reordered four times. During an interview on 12/12/2024 at 4:29 PM, Staff B stated they would expect staff to be monitoring the identified target behaviors, implementing interventions, and documenting before the medication was administered. Staff B stated the as needed medication should only be renewed when the physician did an onsite visit and documented their rationale for continued use in the resident's record. <Resident 15> Review of an admission MDS, dated [DATE], showed Resident 15 discharged from the facility on 12/07/2024. No additional information from the MDS was observed. Review of Resident 15's record showed they had diagnoses including; liver failure, kidney failure, and a recent skin surgery/ Review of Resident 15's physician's orders, dated 11/30/2024, showed an order for an as needed antianxiety medication, with no stop date. Review of the physician's orders showed no behavior monitoring. During an interview on 12/12/2024 at 4:30 PM, Staff B stated they would expect the as needed medication to have a stop date of 14 days, and staff were not but should have monitored behaviors, implemented intervention, and document before the as needed antianxiety medication was administered. In an interview on 12/12/2024 at 4:32 PM, Staff B stated resident's on psychotropics should be monitored for medication side effects, effectiveness of medication, and behavior monitoring. Staff B stated behavior monitoring should include all behaviors observed and identified by staff, and when a resident had behaviors they would expect staff to document behaviors, attempt interventions, if interventions were not effective, try something different, and document. Staff B stated they would expect staff to attempt interventions before medicating the resident. Staff B stated as needed psychotropic medications are only valid for fourteen days, after fourteen days the physician should review the resident's record and make a decision to discontinue or extend the medication and document the reason in the resident's record. WAC: REFERENCE 388-97-1060(3)(k)(i). Refer to F-552

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 32> Review of Resident 32's records showed an electronically signed form dated 05/24/2021, titled Authorizations and Designations that indicated the resident did not provide an AD to the Facility. Review of Resident 32's notes from the following Care Conferences; 01/10/2024 (admission), 02/01/2024 (quarterly), 04/26/2024 (annual), and 07/29/2024 (quarterly), showed the box indicating a review of Annual and admission paperwork reviewed with resident for AD was not marked for any of the care conferences, indicating a review was not completed with the resident. Review of Resident 32's records showed no AD. According to the 09/07/2024 Quarterly MDS, Resident 32 was understood, had clear comprehension, had multiple medically complex conditions and was admitted to the facility on [DATE]. In an interview on 10/02/2024 at 1:21 PM, Staff D stated AD should be provided to residents on admission and social services should follow up every quarter with the resident for changes. Staff D stated it was very important to know the resident's wishes so the facility could follow the resident's directives. Staff D stated the facility should have checked on this quarterly for Resident 32, but did not. REFERENCE: WAC 388-97-0280 (3)(c)(i-ii). Based on interview and record review the facility failed to ensure residents had the appropriate Advanced Directive (AD) in place for 2 (Residents 16, & 32) of 10 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, or offered assistance to formulate an AD. This failure 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> According to the facility policy titled, Advance Directive, revised April 2023, the Admission's Director would educate and offer assistance on formulating an Advance Directive (AD) to residents that did not have one upon admission to the facility. The policy showed the facility would review and discuss AD's during resident care conferences. <Resident 16> According to the 08/07/2024 admission Minimum Data Set (MDS -an assessment tool), Resident 16 admitted to the facility on [DATE] and was severely cognitively impaired. Resident 16 had diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression. The MDS showed Resident 16 was unable to respond and the Resident Representative (RR) participated in assessment and goal planning. Review of Resident 16's records showed no AD. Resident 16's records showed no AD was offered or discussed with the RR upon admission. There was no AD care plan and no review of ADs at the care conferences with Resident 16 and RR's on 08/06/2024, 08/30/2024, or 09/13/2024. In an interview on 09/29/2024 at 7:20 PM Resident 16's RR stated the facility staff did not discussed or offered assistance to formulate an AD. Resident 16's RR stated the facility had been utilizing them to guide Resident 16's care and goals. In an interview on 10/02/2024 at 12:28 PM Staff D (Social Services Director) stated they did not offer, educate, or discuss ADs with Resident 16 or their RR. Staff D stated they usually discuss AD during CC's, but they did not with Resident 16's RR.

Based on observation, interview, and record review the facility failed to implement their Grievance policy for 3 of 3 residents (Resident 54, 70, & 53) reviewed for Grievance reporting. The failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievance resolution delayed or incomplete, feelings of frustration, and a diminished quality of life. Findings included . <Facility Policy> Review of a facility policy titled, Grievance Procedure, updated November 2016, showed residents had the right to voice grievances orally regarding their care and treatment, interactions with other residents, and other concerns during their stay. Staff would be trained at orientation and periodically on the center's grievance procedure which included the need to take grievances seriously, what to do with grievances, when to put grievances in writing, and when to report to their supervisor. <Resident 54> According to the 07/18/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 54 was understood, had clear comprehension, and had no cognitive impairment. On 09/29/2024 at 12:44 PM, Resident 54 stated the resident next to his room (Resident 69) crawled into their room, naked from the waist down, and bleeding during the night. Resident 54 stated Resident 69 emitted a blood curdling scream when they came into their room. Resident 54 stated they pushed their call light and screamed for help from night staff, but staff did not arrive right away. When the nurse arrived for the next shift during the day, Resident 54 stated the nurse on duty talked to them and made them feel like the event did not happen at all. Resident 54 stated the event was very stressful as they were asleep at the time of the event. Resident 54 stated the staff did not do anything about that incident and Resident 69 continues to scream. Resident 54 stated they don't believe the event was resolved and no other staff have talked to them about the event. Resident 54 stated they let the nursing staff know they were not very happy about the event. Review of a 09/01/2024 progress note showed Resident 69 crawled out of bed and all the way to their door. Review of Resident 54's progress notes did not show an entry for the event on 09/01/2024. Review of the facility's grievance log did not show a grievance report for Resident 54 for the event that occurred with Resident 69. In an interview on 10/01/2024 at 1:55 PM, Staff J (Resident Care Manager) stated they reviewed the incident report for Resident 69 but did not have a grievance report for Resident 54 and did not believe the event occurred in Resident's 54 room. Staff J stated the Director of Nursing would have a full investigation of the occurrence. In an interview on 10/04/2024 at 9:39 AM, Staff B (Director of Nursing) stated they were told Resident 69 never left their room, they did not know that Resident 54 had a grievance. Staff B stated they would expect staff to report the grievance when it occurred. <Resident 70> According to a 08/09/2024 admission MDS, Resident 70 had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 70 to have no memory impairment. In an interview on 09/30/2024 at 11:08 AM, Resident 70 stated they were frustrated about some missing clothes. Resident 70 stated they told staff, about a week ago, but they had not located the missing clothes yet. Resident 70 stated they were missing their underwear and a t-shirt. In interviews on 10/01/2024 at 8:53 AM and 10/04/2024 at 9:17 AM, Resident 70 stated the items were still missing, they kept asking staff, but nobody was able to find them yet. Review of an 08/06/2024 Personal Inventory form for Resident 70 showed the resident brought one shirt and one pair of underwear upon admission to the facility. Review of the grievance log on 10/01/2024 showed no grievance reports were logged for Resident 70 regarding their missing clothes. In an interview on 10/04/2024 at 2:55 PM, Staff N (Certified Nursing Assistant - CNA) stated they had just found Resident 70's underwear this morning. Staff N stated Resident 70 reported the missing clothes a few weeks ago and indicated the resident stated at that time, the clothes were already missing for about two weeks. Staff N stated they found Resident 70's shirt last week but was unable to find the underwear until today. <Resident 53> According to a 09/02/2024 admission MDS, Resident 53 had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 53 to have no memory impairment. In an interview on 09/29/2024 at 10:31 AM, Resident 53 stated they had some clothes come up missing that was not resolved. Resident 53 stated they were still really mad about it. Resident 53 stated when staff were assisting them to get ready for a recent doctor appointment, the staff had to run and try to find the resident's shirt and pants. Resident 53 stated staff found their pants but were unable to locate their shirt and hoodie. Resident 53 was unable to identify which staff members, but reported it was different staff assisting them with getting ready, and one that rode with them to the appointment. Resident 53 stated they asked a lot of different staff about the missing clothing. In an interview on 10/04/2024 at 9:26 AM, Resident 53 stated they were still missing the clothes, and they had several staff go look for the items without locating them. Resident 53 stated staff did not offer to assist them to file a grievance and stated, it's really a bummer the clothes were missing. Review of an 08/28/2024 Personal Inventory form for Resident 53 showed the resident brought one shirt and one hoodie upon admission to the facility. Review of the grievance log on 10/01/2024 showed no grievance reports were logged for Resident 53 regarding their missing clothes. In an interview on 10/04/2024 at 2:55 PM, Staff N stated Resident 53 told them a couple of days ago they were missing a black zipper sweater and a t-shirt. Staff N stated they let laundry know, but did not report it to anyone else. Staff N stated they do not complete grievance forms when a resident reports missing items and indicated they give it a week or so to keep looking around. In an interview on 10/02/2024 at 1:30 PM, Staff D (Social Service Director) stated their expectation was for a grievance to be completed and on the log, when a resident reports missing items and clothing. Staff D stated a report of missing items should be addressed at least within 72 hours and followed up by staff to assure resolution. In an interview on 10/04/2024 at 3:20 PM, Staff A (Executive Director) stated the facility process was for staff to fill out a grievance form anytime they hear of missing clothing. Staff A stated the CNA or any staff notified of the missing clothes, should complete a grievance form, turn it in to the social services department, who will log it, and assign it to staff for follow-up and resolution with the resident. Staff A stated their expectation was for the grievance form to be completed and addressed timely. REFERENCE: WAC 388-97-0460(2). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to report significant injury of unknown origin for 1 of 1 resident (Resident 16) reviewed. The facility's failure to report a large hematoma of unknown origin on Resident 16's right calf, placed Resident 16 and all residents at risk for repeated incidents and unidentified abuse and/or neglect. Findings included . <Facility Policy> Review of the facility policy titled, Abuse Reporting and Response, published September 2017, showed staff would immediately report all alleged or suspected violations to the supervisor and Executive Director (ED). The policy showed the ED or designee would report injuries of unknown source to the state agency immediately, but no later than two hours. This policy showed the facility would identify the staff responsible for implementation of corrective actions, expected date of implementation, and those responsible for monitoring. The policy showed failure to report potential abuse/neglect timely by staff would result in disciplinary action. Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, revised October 2022, showed an injury was classified as an injury of unknown source if the injury was not observed, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury. This policy showed an injury of unknown source could indicate potential abuse. Review of the facility policy titled, Abuse Identification, revised October 2022, showed staff would identify and report indicators of abuse such as an injury that is suspicious because the source of the injury was not observed, or the extent or location of the injury was unusual. <Resident 16> According to the 08/07/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 16 admitted to the facility on [DATE] and was severely cognitively impaired. Resident 16 had diagnoses of paraplegia, non-Alzheimer's dementia and chronic pain syndrome. The assessment showed Resident 16 was taking blood thinner medications during the assessment period. The MDS showed no hematomas or other non-pressure skin concerns were identified at time of the assessment. In an interview on 09/29/2024 at 6:56 PM, the Resident Representative (RR) for Resident 16 stated they found a large hematoma on Resident 16's right calf on 08/10/2024. The RR stated they reported to the nurse on duty on 08/10/2024. The RR stated they reported the hematoma to Staff B (Director of Nursing) on 08/13/2024. In an interview on 10/02/2024 at 1:47 PM Staff B stated the RR reported the hematoma on 08/10/2024. Staff B stated they did not report the significant injury of unknown origin to the state agency. In an interview on 10/04/2024 at 10:33 AM Staff A (ED) stated they should have reported Resident 16's significant injury of unknown origin to the state agency within two hours, but they did not. Refer to F610 - Investigate Abuse. Refer to F684 - Quality of Care. REFERENCE: WAC 388-97-0640(2). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate and rule out abuse/neglect for 2 of 12 sampled resident's (Resident 16 & 4) reviewed for investigations. Facility failure to complete thorough investigations placed residents at risk for potential abuse and other negative health outcomes. Findings included . <Facility Policy> Review of the facility policy titled, Abuse Investigation, revised October 2022, showed the facility maintained complete and thorough documentation of the investigation. The policy showed the facility would determine, through investigation, if the abuse/neglect had occurred, the extent, and the cause of the injury. <Resident 16> According to the 08/07/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 16 admitted to the facility on [DATE] and was severely cognitively impaired. Resident 16 had diagnoses of paraplegia, non-Alzheimer's dementia, and chronic pain syndrome. The assessment showed Resident 16 was taking blood thinner medications during the assessment period. The MDS showed no hematomas or other non-pressure skin concerns were identified at time of the assessment. In an interview on 10/02/2024 at 1:47 PM Staff B (Director of Nursing) provided investigation documents that showed an incomplete incident report, dated 08/13/2024 with a completion date of 08/26/2024, eight days outside of the five-day regulatory requirement. The incident report showed no injuries observed at time of incident, no pain assessment, no skin assessment, no mental status assessment for Resident 16, no predisposing environmental factors were checked, no predisposing physical factors were checked, no predisposing situation factors were investigated, and no resident interviews were included. The investigation summary showed Resident 16's Resident Representative (RR) called Staff B to notify them of Resident 16's large hematoma to their right calf on 08/13/2024. The summary stated the RR questioned the cause of the hematoma and suggested the hematoma may have happened during a transfer for a shower on the previous day, 08/09/2024. The summary showed Staff B interviewed the shower aide who reported Resident 16 was not transferred for a shower but received a bed bath and they did not see a bruise on 08/09/2024. Staff B determined that abuse/neglect was ruled out. In an interview on 10/03/2024 at 8:40 AM Staff A (Executive Director) stated the investigation of Resident 16's right calf hematoma was not completed in five days. Staff A stated the incident report was not complete or thorough. Staff A stated they investigated the shower aide transfer which did not happen, and they did not continue the investigation to determine the root cause of the hematoma, but they should have. In an interview on 10/04/2024 at 10:33 AM Staff A stated they should have started the investigation immediately to rule out abuse and neglect, but they did not. <Resident 4> According to the 09/04/2024 Quarterly MDS, Resident 4 was assessed to require maximum assist with transfers to the toilet, used a wheelchair for ambulation, and was cognitively intact with no behaviors. Review of the 08/08/2024 Care Plan (CP) showed Resident 4 required a sit to stand lift (equipment that assists staff with resident transfers) for all transfers and care in pairs. The CP showed the wheelchair footrests were padded to prevent skin issues. The CP showed Resident 4 was to wear long sleeves to protect their arms for skin safety, and use caution during transfers to prevent striking arms, legs, and hands, against sharp and hard surfaces. Review of the 07/2024 facility incident log showed a skin investigation occurred for Resident 4 on 07/22/2024. An observation and interview on 09/29/2024 at 9:31 AM showed Resident 4 was sitting in a wheelchair with both feet on the elevated footrests, the footrests were padded. Resident 4 was wearing socks and pants; their lower legs were not covered. Both the lower legs were observed to have significant edema, the outside of the left lower leg had a large bruise, and both legs had red marks, scars, and scabs. Resident 4 stated the staff bangs their legs on the wheelchair footrests when they take me to the bathroom with the sit to stand lift. Resident 4 stated the staff do not remove the leg rests from the wheelchair and it caused injuries to their legs. Review of the 07/22/2024 facility incident investigation showed Resident 4's right shin was bumped on the wheelchair during a transfer, first aid was administered, and the medical doctor and RR were notified. The investigation conclusion was dated 08/08/2024, 18 days after the incident with injury. The conclusion summary showed Resident 4's right leg injury was consistent with contact with the wheelchair during a transfer and abuse and neglect was ruled out. In an interview on 10/04/2024 at 11:53 AM, Staff B stated the caregivers were not interviewed to gather a statement of how the injury occurred. Staff B stated the sit to stand lift was not considered as contributing to the injury and was not evaluated for function. Staff B stated the caregivers were not evaluated for their ability to safely transfer Resident 4 with the sit to stand lift to prevent future injuries. Staff B stated there was no assessment if the sit to stand lift continued to be a safe method to transfer Resident 4. Staff B stated the lift, transfers, and caregiver evaluation should be, but were not, included in the investigation. Refer to F609 - Reporting of Alleged Violations Refer to F684 - Quality of Care REFERENCE: WAC 388-97-0640(6)(a)(b). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 for 3 (Residents 65, 16, & 53) of 4 residents and notify the Office of the State Long-Term Care Ombudsman (LTCO) for 2 of 4 residents (Resident 16 & 53) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the Resident's Representative (RR) of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to ensure required LTCO notification was completed, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Resident 65> According to the 09/25/2024 Discharge Return Anticipated Minimum Data Set (MDS - an assessment tool), Resident 65 admitted on [DATE] and had no memory impairment. The MDS showed Resident 65 was discharged to an acute care hospital on [DATE]. Review of Resident 65's records showed a nursing note stating Resident 65 discharged to an acute care hospital on [DATE] at 7:30 PM. Resident 65's records showed no information about a written transfer notification being provided to the resident or RR. <Resident 16> According to the 08/15/2024 Modified Discharge Return Anticipated MDS, Resident 16 was severely cognitively impaired. The MDS showed Resident 16 was discharged to an acute care hospital on [DATE]. Review of Resident 16's records showed a nursing note stating they were transferred to an acute care hospital on [DATE] at 5:30 PM. Resident 16's records showed no written transfer notification was provided to the RR for the 08/15/2024 re-hospitalization. In an interview on 09/29/2024 at 6:56 PM Resident 16's RR stated they were transferred out of facility to an acute care hospital on [DATE]. Resident 16's RR stated they did not receive a written transfer notification for this discharge. In an interview on 10/02/2024 at 12:31 PM, Staff D (Social Service Director) stated the Social Service Department was not responsible for written transfer notifications, but they were responsible for notifying the LTCO, but they did not for Resident 16. In an interview on 10/02/2024 at 12:35 PM, Staff B (Director of Nursing) stated the nursing department was not responsible for providing written transfer notifications. In an interview on 10/02/2024 at 12:36 PM, Staff A (Executive Director) stated they would find out who was responsible for the written transfer notification and get back to this surveyor, no further information was provided.<Resident 53> Review of Resident 53's records showed a 09/24/2024 progress note indicating the resident was sent to the hospital for treatment and was picked up by transportation in stable condition. Review of Resident 53's records showed no documentation a written notice before transfer form was provided to the resident. In an interview on 10/02/2024 at 1:30 PM, Staff D stated they were unsure of what a written notice of transfer form was and indicated it was not something they provided to the residents. Staff D stated they did the notification to the LTCO when a resident is transferred or discharged from the facility. Staff D reviewed their log from September 2024 and stated Resident 53 was not included on the list of residents reported to the LTCO. REFERENCE: WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 16> According to the 08/15/2024 Modified Discharge Return Anticipated MDS, Resident 16 was severely cognitively impaired. The MDS showed Resident 16 was discharged to an acute care hospital on [DATE]. Review of Resident 16's records showed a nursing note stating they were transferred to an acute care hospital on [DATE] at 5:30 PM. Resident 16's records showed no indication the facility provided Resident 16 information regarding the facility's bed hold policy upon transfer to the hospital as required. In an interview on 09/29/2024 at 6:56 PM Resident 16's RR stated they were transferred out of facility to an acute care hospital on [DATE]. Resident 16's RR stated they did not return to the same room and facility staff did not discuss their bed-hold policy with them or give them the option to return to the same room. In an interview on 10/02/2024 at 12:38 PM Staff K (Admissions Director) stated bed-hold notification was the responsibility of the Admissions Department, and their assistant was managing those. In an interview on 10/02/2024 at 1:00 PM Staff K & Staff L stated they did not discuss their bed-hold policy with Resident 16 and/or the RR, but they should have. Staff K stated it was important to offer a bed-hold to accommodate resident's rightsBased on interview and record review, the facility failed to provide the resident and/or the Resident's Representative (RR) a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 (Residents 67, 16, & 53) of 4 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 that was necessary for decision making. Findings included . <Facility Policy> According to page 6 of the facility's admission Agreement, updated 05/2017, the facility would provide a bed-hold notice in accordance with applicable regulations and discuss bed-hold rates with the resident and their representative at the time of transfer to an acute hospital. <Resident 67> Review of Resident 67's 09/19/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed no documentation or indication the facility provided Resident 67 written information regarding the facility's bed-hold policy upon transfer to the hospital as required. In an interview on 10/02/2024 at 10:09 AM, Staff L (Admissions Assistant) stated it was important to offer bed-holds because the resident was at risk of losing their room to a new admit or the facility might not have a bed available upon the resident's return without signing the bed-hold agreement. Staff L stated they were responsible for providing bed-hold information to residents who were sent to the hospital. Staff L confirmed Resident 67 was not provided a bed-hold policy as required when transferred to the hospital. <Resident 53> Review of a 09/24/2024 progress note showed staff documented Resident 53 was being sent to the hospital for treatment and was picked up for transport in stable condition. Record review showed no documentation or indication the facility provided Resident 53 or their resident representative written information regarding a bed-hold prior to their transfer to the hospital as required. In an interview on 10/02/2024 at 1:30 PM, Staff D (Social Services Director) stated the admissions department was responsible for providing bed-hold information to residents if they were being sent to the hospital. Staff D reviewed Resident 53's records and was not able to locate a bed-hold form for Resident 53. REFERENCE: WAC 388-97-0120(4). .

<Clarifying Orders> <Resident 29> According to the 07/10/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 29 had medically complex diagnoses including cancer and high cholesterol. Review of the physician's orders showed a 08/15/2024 order for a fiber supplement, give one pill as needed. The order did not include a dosage. In an interview on 10/04/2024 at 2:13 PM Staff B (Director of Nursing) stated the order should include a dose and needed clarification <Following Orders> <Resident 4> According to the 09/04/2024 Quarterly MDS, Resident 4 had medically complex diagnoses including a chronic ulcer. The MDS showed Resident 4 received opioid medications. Record review showed a 12/06/2023 order for an opioid pain medication, give twice a day for chronic pain. The order showed staff should hold the medication if Resident 4's respiratory rate was lower than 14 breaths per minute. Observation of medication pass on 10/03/2024 at 8:22 AM showed Staff H (Registered Nurse) failed to measure Resident 4's respirations prior to administering the opioid pain medication. In an interview on 10/04/2024 at 2:13 PM Staff B stated it was important for orders to be followed, including adhering to the parameters for administration. <Resident 3> According to the 06/26/2024 Annual MDS, Resident 3 had diagnoses including heart failure, high blood pressure, and difficulty swallowing. The MDS showed Resident 3 took regular and as needed pain medications. Review of the July 2024 Medication Administration Record (MAR) showed a 09/01/2022 order for a medication to treat Resident 3's high blood pressure. The order directed nurses to hold the medication if Resident 3's heart rate dropped below 60 Beats Per Minute (BPM). The MAR showed on 07/28/2024 the medication was administered when Resident 3's heart rate was measured at 59 BPM. The September 2024 MAR showed Resident was given the blood pressure medication on 09/22/2024 for a heart rate of 51 BPM. The July 2024 MAR included a calorie-dense supplement, give 90 Cubic Centimeters (CC) twice a day. This MAR showed on 29 occasions Resident 3 was given 60 CC, on 17 occasions was given 120 CC, and one occasion 15 CC. The August 2024 MAR showed on 21 occasions Resident 3 was given 120 CC and on 33 occasions was given 60 CC. The September MAR showed on six occasions Resident 3 was given 120 CC of the calorie dense supplement, on three occasions was given 60 CC, and on one occasion was given 100 CC. In an interview on 10/04/2024 at 2:13 PM Staff B stated they expected staff to check Resident 3's respiration rate prior to giving the blood pressure medication. Staff B stated they expected nurses to follow orders and adhere to physician's ordered parameters. REFERENCE: WAC 388-97 -1620(2)(b)(i)(ii),(6)(b)(i). Based on observation, interview, and record review the facility failed to ensure physician's orders were clarified for 1 of 21 sample residents (Resident 29), or followed for 2 of 21 sample residents (Residents 4 &3). These failures placed residents at risk for unneeded care and unmet care needs. Findings included .

Based on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 1 of 5 sample residents (Resident 32) reviewed for activities. Failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's updated July 2015 Activities Program policy the facility would provide an ongoing program of activities designed to meet the interests as well as physical, mental, and psychosocial well-being of each resident. For residents confined to their room, the Activity Department would provide and assist with in-room activities in keeping with needs, abilities, and interests of residents. <Resident 32> According to a 05/15/2024 Quarterly admission Minimum Data Set (MDS - an assessment tool) activities were very important for Resident 32. The MDS showed Resident 32 preferred to have books and newspapers, listen to music, and participate in their activities of choice. The assessment showed Resident 32 had moderate memory impairment and could communicate their needs, be understood by others, and had a diagnosis of depression. Record Review showed a physician's order dated 01/08/2024 for Resident 32 to participate in activities as tolerated. Review of a revised 05/21/2024 Activities Care Plan (CP) showed goals for Resident 32 to participate in one-on-one activities two-to-three times weekly including painting, arts and crafts, and coloring. The CP included interventions showing Resident 32 should receive assistance with activity functions, was dependent on staff for bed mobility, and had limited range of motion. Review of the activity participation records showed staff provided one-on-one activities to resident every day from 09/24/2024 through 10/04/2024. In an interview on 09/30/2024 at 9:07 AM Resident 32 stated they would like more activities; they enjoyed puzzles and music. Resident 32 stated staff did not bring puzzles to them, and they did not receive the daily activity sheet. In an interview on 10/01/2024 at 9:18 AM Resident 32 stated staff gave them a puzzle once, and the puzzle was no longer in their room. Observation at that time showed Resident 32 had their television on in their room, and no puzzles, books, or magazines were available. Observation on 10/03/2024 at 10:00 AM showed no daily activity sheet in the resident's room with no other activities available in the resident's room except a completed painting from 10/02/2024 on the cabinet behind Resident 32. Observation on 10/04/2024 at 9:13 AM showed the daily activity sheet was not provided to the resident. Observation on 10/04/2024 at 10:51 AM showed Staff Y (Certified Nursing Assistant) walk past Resident 32's room with a rolling cart of activities including puzzles, coloring, art supplies, and other items. Staff Y did not stop at Resident 32's room to offer any activities or to provide a calendar. In an interview on 10/04/2024 at 10:53 AM, Staff Y stated they just started helping with the activities department. Staff Y stated they handed out activity calendars at 9:00 AM and stated they did provide Resident 32 with an activity calendar. Staff Y stated when a resident was interested, they provided activities to the resident. Staff Y stated Resident 32 was not on the schedule to receive activities that day and that was why they passed Resident 32's room. Staff Y stated the prior day (10/03/2024) they provided an activity sheet to Resident 32 and provided one-on-one time. In an interview on 10/04/2024 at 10:56 AM Resident 32 stated they did not receive an activity sheet that day. No activity sheet was observed in Resident 32's room. In an interview on 10/02/2024 at 8:50 AM Staff X (Activities Director) stated Resident 32 should have one-on-one activities. Staff X stated Resident 32 liked painting and should be provided with activities. For residents that were bed bound, activity staff should deliver the activities schedule to the resident daily rather than posting it on the resident's door. Staff X stated activities staff should document the activities they provided for the resident. Staff X stated care staff were expected to turn on the television and see what activities they could set up for a resident. In an interview on 10/04/2024 at 2:06 PM, Staff X stated they would talk with their activities team about providing activities with Resident 32. Staff X stated activities should be provided two to three times weekly for the resident and staff should check the daily activities and offer activities at that time. REFERENCE: WAC 388-97-0940 (1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Observation on 09/29/2024 at 9:23 AM, showed the [NAME] hall shower room door was unlocked. One spray can of White Lithium Grease Lubricant and Anti-Corrosion Agent was found on the bookcase stored in the shower room. The spray can had a danger warning label that read harmful or fatal if swallowed. Observation on 10/02/2024 at 10:55 AM showed the spray can of White Lithium Grease Lubricant and Anti-Corrosion Agent was still in shower room on the bookshelf. In an interview on 10/02/2024 at 11:58 AM Staff M stated the spray can should not be in the shower room as it could be hazardous to residents. In an interview on 10/02/2024 at 12:01 PM Staff N (Certified Nursing Assistant) stated they did not know why the spray can was in the shower room and that it should not be. In an interview on 10/04/2024 at 9:33 AM, Staff B stated chemicals should be locked up and out of reach of residents. Staff B stated when staff see medications or chemicals that are not locked up, they expect staff to make sure the items were kept away and out of reach of residents. REFERENCE: WAC 388-97-1060(3)(g). <West Hall Shower Room/Unsecured Chemicals> Observation on 10/03/2024 at 5:17 AM showed the shower room door in the [NAME] hallway was unlocked. There were bottles of shampoo, body wash, moisturizer, shaving cream, and a razor on the counters. In an interview on 10/03/2024 at 5:28 AM, Staff Q (Registered Nurse) confirmed the shower room was unlocked and stated the keypad was not working. Staff Q stated a razor and chemicals should not be left on the counters in an unlocked shower room and stated the door should be locked but it was not. <Air Mattresses> <Resident 57> Review of the 09/03/2024 Significant Change MDS showed Resident 57 started hospice care for a terminal illness, was at risk of falls, had two non-injury falls since the prior assessment, and was cognitively impaired. The MDS showed Resident 57 weighed 108 pounds. The MDS showed Resident 57 was assessed to require complete staff assistance with all bed mobility and personal care. Review of the 09/04/2024 Care Plan (CP) showed Resident 57 had actual falls and required a perimeter mattress (mattress with raised edges). The CP did not show any information about the use of an air mattress. Review of the 09/05/2024 device assessment form showed Resident 57 had confusion, dementia, history of falls, and poor safety awareness. The assessment showed the interdisciplinary team recommended the perimeter mattress. The assessment did not show any information about an air mattress. Review of Resident 57's records showed no assessments were completed for an air mattress. In an observation and interview on 09/29/2024 at 1:24 PM, Resident 57 was lying in bed on an inflated air mattress with a pump hanging on the foot of the bed. The pump showed various setting options and had a red flashing light indicator of low air pressure. Observation showed the pump was set to 150 pounds and there was an option to set the pump at 100 pounds. Resident 57 stated they had a fall and now had a new bed. Observations on 09/30/2024 at 9:07 AM, 10/01/2024 at 8:23 AM, 10/02/2024 at 8:23 AM, 10/03/2024 at 5:27 AM, 10/04/2024 at 7:54 AM, and 10/04/2024 at 8:04 AM, showed Resident 57 in bed. The pump on the end of the bed showed a setting of 150 pounds and the red light was flashing for low air pressure. Review of Resident 57's 10/2024 physician orders showed no order for an air mattress, no settings, or directions to staff to monitor for safety or function of the air mattress. <Resident 43> Observation on 09/30/2024 at 9:25 AM showed Resident 43 lying on an air mattress. Similar findings for Resident 43's records showed no air mattress settings in the physician orders, no nurse monitoring for safety, settings, or pump functioning every shift, and no consent received with risks and benefits reviewed. <Resident 16> Observation on 10/01/2024 at 9:13 AM showed Resident 16 lying on an air mattress. Similar findings for Resident 16's records showed no air mattress settings in the physician orders and no nurse monitoring for safety, settings or pump functioning every shift. In an interview on 10/04/2024 at 11:34 AM, Staff B stated when a resident received a new device, including an air mattress, a device assessment was completed, consent with risks and benefits were reviewed with the resident or their decision maker, and an order was obtained from the physician. The nurse staff would monitor the device each shift for proper settings and functioning of the mattress and pump, and document in the resident's record. Staff B stated an air mattress should have pump settings according to the resident's weight and settings should be written in the physician's order. Staff B stated the nurse staff should monitor on the pump each shift and if there was an issue with the pump, the staff should notify the maintenance staff. Review of findings in Resident 57, 16 and 43's records with Staff B, who confirmed the system for implementing and monitoring resident's use of air mattresses was not intact. <Unsecured Sharps> Observations on 10/01/2024 at 2:01 PM showed items in a clear bag with a biohazard label sitting on an isolation bin in the hallway outside of room [ROOM NUMBER]. This bag was visible to others walking by in the hallway. On 10/01/2024 at 2:07 PM a staff member entered room [ROOM NUMBER], passing the bag on the cart, provided assistance to a resident, exited the room at 2:20 PM, and walked away from the area. Observations on 10/01/2024 at 2:26 PM showed two nurses walking in the hallway passing the room with the bag visibly sitting on the isolation cart. In an observation and interview on 10/01/2024 at 2:30 PM, Staff MM (Resident Care Manager) picked up the bag and identified the following items inside: 15 blood collection needles, five blood collection sets, and one push button needle collection set. Staff MM stated the items should not be out in the hallway unsecured and indicated the bag of sharps was probably left there by the lab draw company. Staff MM stated there was a risk for safety if residents passed by and picked up the bag.Based on observation, interview and record review the facility failed to ensure residents were free of accident hazards for 4 (Residents 41, 57, 43, & 16) supplemental residents reviewed. The failure to ensure residents were free from potential restraints (Resident 41), ensure staff safely used and monitored air mattresses (Residents 57, 16, & 43), ensure sharps (syringe needles, razors etc.), and chemicals were stored safely, placed residents at risk for potential restraints, injury, exposure to soiled medical equipment, and unsafe chemicals. Findings included . <Resident Mattress> <Resident 41> According to the 06/27/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 41 had moderate memory impairment and needed substantial assistance from staff to roll from side to side in bed. Observation on 09/30/2024 at 2:21 PM showed a folded blanket placed under the right side of Resident 41's mattress between the mattress and the bed frame. The blanket raised the right side of the mattress one-to-two inches. Observation on 10/03/2024 at 12:19 PM showed a folded blanket between Resident 41's mattress and their bed frame. In an interview at that time, Staff M (Licensed Practical Nurse) stated staff should not place a blanket between the mattress and the bed frame. In an interview on 10/04/2024 at 11:02 AM Staff B (Director of Nursing) stated they were unaware of the blanket placement concern. Staff B stated it was not facility practice to put blankets between the mattress and bed frame because it could be a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 5 of 5 sample residents (Residents 32, 45, 53, 185, & 22) reviewed for oxygen administration were provided care consistent with professional standards of practice. Failure to provide oxygen treatments and maintain oxygen equipment left residents at risk for respiratory discomfort, oxygen-related accidents, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's December 2017, Oxygen Administration Policy, oxygen would be provided in accordance with physician's orders, state and federal regulations, and standards of practice. Safety precautions and care of oxygen delivery equipment were performed according to state and federal regulation and manufacturer guidance, equipment that was soiled would be replaced. Oxygen liter flow would be set by a licensed nurse in accordance with physician's orders including liter flow and parameters for duration and frequencies. <Providing Oxygen as Ordered> <Resident 32> According to the 09/07/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 32 had respiratory failure, heart failure, low oxygen saturation (measure of oxygen levels in the blood), and required oxygen therapy. Review of the revised 06/03/2024 Respiratory Care Plan (CP) showed Resident 32 required aerosol contact precautions (precautions to prevent the spread of COVID-19 using personal protective equipment and hand hygiene) related to congestion, and respiratory failure. The CP included interventions to administer oxygen at two Liters Per Minute (LPM) and to maintain oxygen saturation above 92%. Review of the physician orders showed a 01/08/2024 order to administer oxygen at two LPM via tubing that delivered oxygen through the nostrils as needed. Review of a 09/23/2024 progress note signed by Staff R (Registered Nurse - RN) showed Resident 32 was drowsy, and their oxygen level was low. Staff R increased the oxygen administered to four LPM, and documented they would adjust when oxygen levels were stable. Staff R documented they were waiting for further orders from provider and would continue to monitor. Review of progress notes from 09/23/2024 through 10/01/2024 did not show further documentation regarding monitoring Resident 32's oxygen saturation levels, did not show further documentation by the nurse practitioner regarding adjusting oxygen levels, and did not show any change in the oxygen orders. Observation on 09/30/2024 at 12:37 PM showed Resident 32's oxygen set at four LPM. Observation on 10/01/2024 at 9:18 AM showed Resident 32's oxygen at 4.25 LPM. The oxygen filter located on the back of oxygen concentrator was observed to be dusty. In an interview on 10/01/2024 at 2:01 PM, Staff J (Resident Care Manager) verified the physician orders for Resident 32 and stated the oxygen should be at two LPM. Staff J verified Resident 32's oxygen was set to four LPM. Staff J stated this was not correct, and the oxygen should be set to two LPM. Staff J stated if the nurse increased the oxygen to four LPM, there should be communication with the doctor to discuss the increase. Staff J verified the oxygen filter on the back of the concentrator was covered with dust and stated they were not aware of how often the filter on the back of the concentrator needed to be cleaned. Observation on 10/02/2024 at 9:06 AM showed Resident 32's oxygen tubing was on the floor next to their bed. Observation on 10/04/2024 at 9:13 AM showed Resident 32's oxygen tubing was placed incorrectly on their head rather than under their nose. In an interview on 10/04/2024 at 9:18 AM Staff H (RN) stated the resident would not keep their oxygen tubing in place. In an interview on 10/04/2024 at 9:40 AM Staff B (Director of Nursing) stated nurses should check oxygen orders and concentrator levels continuously. Staff B stated if nurses saw a resident's oxygen saturation dropping, they could increase the amount of oxygen provided for urgent issues, but the nurse would have to obtain physician's orders and document their actions. <Resident 45> Review of Resident 45's records showed a 05/24/2024 physician's order for oxygen to be administered at two LPM. According to an 08/24/2024 Quarterly MDS, Resident 45 admitted to the facility on [DATE] with no memory impairment. The assessment showed Resident 45 received oxygen therapy during the assessment period. The MDS showed Resident 45 had diagnoses of anxiety, depression, Chronic Obstructive Pulmonary Disease (COPD), and respiratory failure. Observations on 09/30/2024 at 10:12 AM, on 10/01/2024 at 10:32 AM, and on 10/04/2024 at 8:17 AM showed Resident 45's oxygen was administered at 3.5 LPM. In an interview on 10/04/2024 at 8:18 AM Staff E (Licensed Practical Nurse) stated Resident 45 was administered 3.5 LPM. Staff E stated the physician's order was for oxygen at two LPM so it should not be set at 3.5 LPM. Staff E stated it was important to administer the correct dose of oxygen per physician's order because Resident 45 had COPD and administering more than the ordered dose risked the resident retaining carbon dioxide which would not be beneficial and could cause them to have respiratory distress. <Oxygen Equipment Maintenance> <Resident 45> Observations on 09/30/2024 at 10:12 AM, 10/01/2024 at 10:32 AM, and 10/04/2024 at 8:17 AM showed Resident 45's oxygen concentrator had a thick layer of dust on top of the machine and the oxygen filter was full of dust. In an interview and observation on 10/01/2024 at 11:15 AM, Staff BB (Resident Care Manager) confirmed Resident 45's oxygen concentrator had a layer of dust on top of the machine and an unclean filter that was full of debris. Staff BB stated their expectation was for staff to clean oxygen concentrators and filters weekly and as needed. Staff BB stated Resident 45's oxygen concentrator and filter needed to be cleaned. In an interview on 10/04/2024 at 8:59 AM Staff B stated they expected staff to follow physician orders when administering oxygen. Staff B stated they expected oxygen concentrators and filters to be cleaned weekly. Staff B stated it was important to administer oxygen as ordered and maintain oxygen equipment for residents' respiratory health and safety. <Resident 32> Observation on 10/01/2024 at 9:18 AM showed Resident 32's oxygen at 4.25 LPM. The oxygen filter located on the back of oxygen concentrator was observed to be dusty. In an interview on 10/01/2024 at 2:01 PM, Staff J verified that the oxygen filter on back of concentrator was covered with dust and stated they were not aware of how often the filter on the back of the concentrator needed to be cleaned. <Resident 53> According to a 09/02/2024 admission MDS, Resident 53 had multiple medically complex diagnoses including heart failure and required the use of oxygen during the assessment period. This MDS showed staff assessed Resident 53 with no memory impairment. Observations on 09/29/2024 at 10:05 AM showed an oxygen concentrator machine with a filter area on the side visible from Resident 53's doorway. The filter inlet had a thick layer of grayish debris and fuzz, preventing visualization of the machine's actual filter. Resident 53 was in bed wearing their oxygen tubing that was undated. In an interview at this time, Resident 53 stated they did not recall staff changing and/or cleaning their oxygen tubing. In an interview on 10/01/2024 at 11:15 AM, Staff BB stated their expectation was for staff to clean oxygen concentrators and filters weekly and as needed. <Resident 185> According to a 09/24/2024 admission MDS, Resident 185 had multiple medically complex diagnoses including lung disease and required the use of oxygen during the assessment period. This MDS showed staff assessed Resident 53 with no memory impairment. Observations on 09/30/2024 at 9:45 AM showed Resident 185 lying in bed wearing oxygen with tubing that was undated. In an interview at this time, Resident 185 stated they did not recall staff changing and/or cleaning their oxygen tubing. In an interview on 10/04/2024 at 2:13 PM, Staff B stated oxygen concentrator filters should be cleaned weekly and oxygen tubing should be dated by staff. <Resident 22> According to the 08/12/2024 Quarterly MDS Resident 22 had diagnoses including respiratory failure with low oxygen saturation and a cough. The MDS showed Resident 22 used supplemental oxygen. Record review showed an 11/07/2023 order for Resident 22 to receive oxygen via tubing to the nose at four LPM every shift to treat their respiratory failure. Observation on 09/29/2024 at 9:24 AM showed Resident 22 in bed using supplemental oxygen via tubing to their nose. There was no date on the tubing to indicate when it was started or to indicate when it needed to be replaced. In an interview on 10/04/2024 at 2:13 PM, Staff B stated oxygen tubing should be dated by staff. REFERENCE: WAC 388-97-1060 (3)(j)(vi). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents consistent with professional standards of practice including the failure to offer nonpharmacological interventions, identify parameters for administration of as needed (PRN) pain medications, and administer pain medications timely for 1 of 2 residents (Resident 16) reviewed for pain management. These failures placed residents at risk for experiencing untreated pain and a decreased quality of life. Findings included . <Resident 16> According to a 09/03/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 16 admitted [DATE] and was severely cognitively impaired. The assessment showed Resident 16 received pain medications routinely and PRN. The MDS showed Resident 16 did not receive non-medication interventions for pain. The MDS showed a pain assessment interview should not be conducted with Resident 16/Resident Representative (RR) at the time of the assessment. The MDS showed Resident 16 had diagnoses of chronic pain syndrome and pressure wounds to their sacrum. Record review of Resident 16's records showed no nonpharmacological interventions for pain management. Resident 16's records showed a 09/18/2024 physician order for an PRN pain medication. Resident 16's records showed no care plan for chronic pain. In an interview on 09/29/2024 at 7:07 PM, Resident 16's RR stated they had to request PRN pain medication for Resident 16 when they were showing signs of pain, or the staff would not give it to them. Resident 16's RR stated the staff would tell them Resident 16 did not reported any pain. Resident 16's RR stated they told staff multiple times Resident 16 was unable to report their pain and staff needed to assess Resident 16 based on physical signs of pain such as breathing hard, restlessness, or excessive sweating. In an observation on 10/02/2024 at 9:51 AM, Resident 16 appeared sweaty and had heavy/labored respirations. Resident 16's RR requested their PRN pain medication from Staff E (Licensed Practical Nurse) at this time. Observation on 10/02/2024 at 10:01 AM showed Staff E enter Resident 16's room and provide wound care. Staff E did not administer Resident 16's pain medication at this time. Staff E completed Resident 16's wound care at 10:18 AM. Observation on 10/02/2024 at 10:30 AM showed Staff E return to Resident 16's room with their pain medication and stated it took them 40 minutes to bring the pain medication for Resident 16 because they had to change their bandage. Staff E stated they should have administered the pain medication when the RR requested and before they provided the wound care. In an interview on 10/03/2024 at 9:34 AM Staff BB (Resident Care Manager) stated Resident 16 should have an order for nonpharmacological pain interventions, but they did not. Staff BB stated nonpharmacological pain interventions were important to not administer unnecessary pain medication that could be treated without medications. In an interview on 10/04/2024 at 8:59 AM Staff B (Director of Nursing) stated Resident 16 had a diagnosis of chronic pain so they would expect staff to initiate a pain care plan to make sure they were addressing the specific needs for Resident 16's pain management but they did not. Staff B stated they expected staff to administer pain medication when a resident requests or was showing signs of pain as soon as possible but not later than 15 minutes. Staff E stated it was important to administer pain medications timely so the resident would not suffer in pain. REFERENCE: WAC 388-97-1060(1). .

Based on interview and record review, the facility failed to ensure 2 of 20 sample residents (Residents 23 & 72) were free from significant medication errors. These failures placed residents at risk for incorrect dosage, adverse side effects, and other negative health outcomes. Findings included . <Facility Policy> Review of the 01/2024 facility, Medication Administration Guidelines policy showed medications should be administered in accordance with written orders of the prescriber. Medications should be verified three times before administering; when pulling medication package from medication cart, when dose is prepared, and before dose is administered. <Resident 23> According to the 09/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 23 had diagnoses including stroke with communication deficits, dementia, a history of alcohol dependence, psychotic disorder, and a disorder related to personality and behaviors. The MDS showed Resident 23 was administered routine antipsychotic medication. Review of the September 2024 Medication Administration Record (MAR) showed Resident 23 received an antipsychotic medication, 37.5 Milligram (mg) immediate release at 8:00 AM and 8:00 PM from 09/01/2024 through 09/30/2024 AM. Resident 23 received the antipsychotic medication, 50 mg immediate release at 2:00 PM from 09/01/2024 through 09/24/2024. The September 2024 MAR showed on 09/24/2024 the antipsychotic medication dose was increased to 75 mg twice daily. The antipsychotic medication was changed from an immediate release tablet to a 24-hour extended release tablet twice daily at 8:00 AM and 8:00 PM. The antipsychotic 37.5 mg immediate release tablet twice daily was not discontinued. The MAR showed both the 37.5 mg immediate release tablet and the 75 mg 24-hour extended release tablet were given twice daily at 8:00 AM and 8:00 PM. The September 2024 MAR showed on 09/30/2024 the antipsychotic medication 24-hour extended release dose was increased a second time from 75 mg twice daily to 100 mg twice daily. The MAR showed Resident 23 was administered both the 100 mg 24-hour extended release tablet and the 37.5 mg immediate release tablet twice daily. The October 2024 MAR showed Resident 23 was administered 50 mg 24-hour extended release tablets, two tablets (100 mg), twice daily at 8:00 AM and 8:00 PM. This MAR showed the 37.5 mg immediate release tablet twice daily was discontinued on 10/01/2024. In an observation and interview on 10/04/2024 at 1:36 PM, Staff R (Registered Nurse) was at the medication cart and showed the medication cards for Resident 23. There was a card for the antipsychotic medication 50 mg immediate release tablets with instructions to administer once daily. Staff R stated that dose was discontinued and removed the card from the cart. Staff R verified the discontinue date of the 50 mg was on 09/24/2024. Staff R showed another card for the antipsychotic medication 50 mg 24-hour extended release tablets with two tablets (100 mg) in each bubble (individual dose). The instructions directed nurses to give two 24-hour extended release tablets (100 mg) twice daily. Staff R stated the 100 mg 24-hour extended release tablets was the new order. Staff R looked at the antipsychotic medication order on their computer and compared to the antipsychotic card of medication. Staff R stated the physician order matched the card of medication and Resident 32 received 100 mg of the 24-hour extended release tablets twice a day. Staff R was asked if a 24-hour extended release tablet should be given twice a day, or if the instructions should be clarified with the practitioner. Staff R stated the nurse should have clarified the order with the practitioner and that a 24-hour tablet should not be given twice a day. In a phone interview on 10/04/2024 at 2:02 PM, the facility pharmacist stated a 24-hour extended release tablet should only be administered once a day. The pharmacist stated a person could take either the immediate release tablet multiple times per day or the 24-hour extended release medication once a day but should not take them together, that dosage would be excessive. The pharmacist looked at Resident 23's prescriptions in the pharmacy ordering system and confirmed the antipsychotic 24-hour extended release was ordered by the practitioner to be given twice a day. The pharmacist stated the order should have been clarified with the practitioner by the nurse or the pharmacist. <Resident 72> According to an 08/20/2024 admission MDS, Resident 72 had multiple medically complex diagnoses including high Blood Pressure (BP), end stage kidney failure, a thyroid disorder, and a seizure disorder. This MDS showed staff assessed Resident 72 with a history of falls on admission. Review of Resident 72's September 2024 MAR showed the resident was taking both a beta-blocker (a medication that causes the heart to beat slower) and a calcium channel blocker (a medication that causes the heart and arteries to relax) due to their high BP related to kidney failure. Observations during medication pass on 10/01/2024 at 9:45 AM showed Staff FF (Licensed Practical Nurse) prepared medications for Resident 72. During the preparation, Staff FF was observed to administer double the ordered dose of Resident 72's beta-blocker and omitted the ordered dose of the resident's calcium channel blocker. Staff F documented Resident 72's BP of 130/75 into the computer and stated they were ready to administer the medications to Resident 72. The medication administration was stopped, and Staff FF confirmed they mistakenly doubled Resident 72's beta-blocker and omitted the resident's calcium channel blocker. In an interview at this time, Staff FF stated giving BP medications incorrectly could negatively affect a resident's condition. In an interview on 10/04/2024 at 2:13 PM, Staff B (Director of Nursing) stated it was their expectation staff administer medications as ordered. Refer to F758 Free from Unnecessary Psychotropic Medication. Refer to F759 Free Of Medication Error Rates 5 Percent Or More. REFERENCE: WAC 388-97-1060(3)(k)(iii). .

Based on interview and record review, the facility failed to obtain timely laboratory services to meet the needs of 1 (Resident 3) of 5 residents reviewed for unnecessary medications. Failure to obtain physician ordered blood tests for residents who were assessed to require this service, placed residents at risk for delayed treatment and services. Findings included . <Resident 3> According to a 06/29/2024 Annual Minimum Data Set (an assessment tool), Resident 3 had multiple medically complex diagnoses including heart failure, high blood pressure, diabetes (a chronic disease in which the body has trouble controlling blood sugars), lung disease, and a thyroid disorder. Review of Resident 3's September 2024 Medication Administration Records showed a 09/05/2024, STAT [immediate] order for a Complete Blood Count (CBC - a comprehensive blood test), a Comprehensive Metabolic Panel (CMP - a blood test that measures chemical balance in your blood), and a Thyroid-Stimulating Hormone level (TSH - a blood test to measure how well the thyroid is functioning) related to the resident having feelings of constant exhaustion and sleepiness. This lab order was signed as completed by staff on 09/05/2024. The MAR showed a second lab order from 09/11/2024 for staff to obtain a CMP, CBC, TSH, and vitamin D level related to weight loss. This lab order was signed as completed by staff on 09/12/2024. Record review showed no test results for the labs ordered by the provider on 09/05/2024 or 09/11/2024 in Resident 3's records. In an interview on 10/04/2024 at 11:27 AM, Staff J (Resident Care Manager) stated their expectation was for lab tests to be obtained if they were ordered. Staff J stated a STAT order should be called to the lab and was usually obtained the same day it was ordered by the physician. A routine lab order would be expected to be obtained on the next scheduled lab day. Staff J reviewed Resident 3's records and confirmed there were no lab test results for the ordered labs on 09/05/2024 or 09/11/2024. Staff B stated they would call the lab to obtain further information. In an interview on 10/04/2024 at 11:40 AM, Staff J stated they called the lab, and no lab tests were performed for Resident 3's 09/05/2024 or 09/11/2024 orders. Staff J stated they were unable to locate lab requisition slips or documentation as to why the labs were not obtained as ordered. In an interview on 10/04/2024 at 12:02 PM, Staff B (Director of Nursing) stated they should, but do not currently have a system in place to check or audit the receipt of lab test results after the test was performed. Staff B stated their expectation was for documentation to be in place and follow up to occur if a lab test was not completed. In an interview on 10/04/2024 at 2:13 PM, Staff B stated lab tests were an important part of monitoring a resident's condition and were used to determine if a resident required interventions to be implemented. Staff B stated it was their expectation lab tests would be obtained as ordered. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii). .

Observation on 10/03/2024 at 8:50 AM showed the ice machine in the main kitchen was not clean, had mold, black, sticky debris along the opening of the inside the ice machine that was able to be scratched off. In an interview on 10/03/2024 at 8:52 AM, Staff T (Dietary Manager) observed and confirmed the mold inside the ice machine and stated it should be clean. Staff T stated they would check with the maintenance staff about the ice machine cleaning schedule. In an interview on 10/03/2024 at 10:02 AM, Staff T stated maintenance staff were supposed to clean the ice machine every month and the last time the ice machine was cleaned was August 2024. Staff T stated the ice machine should be cleaned and there should not be mold inside the ice machine. REFERENCE: WAC 388-97-1100(3), -2980. <Uncovered Food> Observations on 09/29/2024 at 1:05 PM showed staff passing out lunch trays on the East unit from a meal tray cart. Staff pulled a meal tray out of the cart, with an uncovered dessert, and carried the tray past three other rooms and residents to deliver to a resident. Observations on 09/29/2024 at 1:09 PM showed staff passing out lunch trays on the South [NAME] unit from a meal tray cart. This unit was currently experiencing a contagious respiratory outbreak. Staff pulled a meal tray out of the cart, with an uncovered fruit cup, and carried the tray past three rooms to deliver. Staff returned and pulled out another meal tray out of the cart, with an uncovered dessert, and carried the tray past three rooms to deliver. On 09/30/2024 at 8:26 AM, staff were observed carrying a breakfast tray on the East unit, past two rooms and the nurse's station, prior to delivering the meal tray to a resident. Observations at this time showed a sign posted on the side of the meal tray cart that directed staff to bring the cart to each room to deliver meal trays rather than carrying trays through the hallways.Based on observation, interview, and record review the facility failed to ensure food and drinks served to residents were stored and distributed under sanitary conditions for 1 of 1 facility kitchen. The failure to store canned and frozen food appropriately, ensure food was covered when distributed in the hall, and ensure the ice machine was clean, placed residents at risk for spoiled food and foodborne illness. Findings included . <Facility Policy> According to the facility's February 2011 Dented Cans policy, all canned food items should be inspected by dietary staff upon delivery. The policy showed cans with significant dents should not be used and instead returned to the vendor <Dry Storage> Observation of the facility's dry food storage area on 09/29/2024 at 9:27 AM showed one large can of apricots, one large can of sliced apples, and three cans of diced pears that were all significantly dented. In an interview at that time Staff CC (Food and Nutrition Service Aide) stated cans with dents should be discarded. Staff CC said the dented cans should not be in the dry storage.

Based on interview and record review, the facility failed to ensure residents records were complete and accurate and readily accessible for 3 of 20 residents (Resident 16, 43, & 45) whose records were reviewed. The facility failed to ensure Task Care Record documentation was complete and accurate. Failure to ensure residents records were complete and accurate placed residents at risk for unmet care needs and inaccurate assessments. Findings included . <Resident 16> Review of Resident 16's August 2024 Task Care Records (documentation of resident specific cares offered/provided) showed staff failed to document multiple cares on multiple days. Similar findings were noted on Resident 16's September 2024 and October 2024 Task Care Records. <Resident 43> Review of Resident 43's July 2024 Task Care Records showed staff failed to document multiple cares on multiple days. Similar findings were noted on Resident 43's August 2024, September 2024, and October 2024 Task Care Records. <Resident 45> Review of Resident 45's June 2024 Task Care Records showed staff failed to document multiple cares on multiple days. Similar findings were noted on Resident 45's July 2024, August 2024, September 2024, and October 2024 Task Care Records. In an interview on 10/03/2024 at 9:14 AM Staff BB (Resident Care Manager) stated Staff B (Director of Nursing) reviewed the staff Task Care Records and notified staff of their missing documentation. Staff BB stated it was important for the Task Care Records to be documented accurately to ensure residents were getting the cares they were assessed to require. In an interview on 10/04/2024 at 8:59 AM Staff B stated Resident's 16's August, September, and October 2024 Task Care Records were not accurate or complete. Staff B stated Resident's 43's July, August, September, and October 2024 Task Care Records were not accurately documented or complete. Staff B stated Resident's 45's June, July, August, September, and October 2024 Task Care Records were not accurately documented or complete. Staff B stated they expected staff to accurately document the cares provided after completion/offered. Staff B stated they expected staff to complete their care documentation by the end of their shift or leaving work. Staff B stated accurate and thorough documentation in resident records was important to ensure they didn't miss any cares that needed to be provided. REFERENCE: WAC 388-97-1720(1)(a)(i-iv)(b). .

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 implemented, and incorporated into the Care Plan (CP) for 1 of 7 (Resident 23) residents reviewed for PASRR Level II. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Facility Policy> According to the facility's July 2015 Mental Health Rehabilitation Services policy, residents diagnosed with a mental illness or developmental disability would be prescreened through the PASRR process and receive the treatment they were assessed to require from the evaluation. The policy showed the social services department was responsible for reviewing all residents receiving a Level II PASRR screening. <Resident 23> According to the 09/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 23 had medically complex diagnoses including a history of stroke, alcohol dependence, and a psychotic disorder. The MDS showed Resident 23 took antipsychotic medication. Record review showed Resident 23 had a 10/04/2024 physician's order for an antipsychotic medication, give 100 milligrams two times a day. Record review showed a 01/19/2023 PASRR Notification of Determination form that showed Resident 23 was assessed to have a significant change in their behavioral health. The form showed Resident 23 met the requirements for Level II services. Record review showed no Level II referral was completed for Resident 23 and no recommendations. In an in interview on 10/03/2024 at 9:34 AM Staff U (Divisional Director of Social Services) stated, after reviewing the record, they could not find a PASRR Level II for Resident 23. Staff U stated they would expect a referral and evaluation to be completed after the 01/29/2023 Notification of Determination. REFERENCE: WAC 388-97-1915 (4). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 13> According to the 09/02/2024 Quarterly MDS, Resident 13 had diagnoses of anxiety, PTSD, bipolar disorder, and schizophrenia. The assessment showed Resident 13 was taking antipsychotic, antianxiety, and antidepressant medications. The MDS showed Resident 13's most recent admission to the facility was 09/13/2023. Review of Resident 13's 09/30/2024 physician orders showed the resident was receiving two different medications for anxiety, an antidepressant medication, one medication to treat bipolar disorder, and two different medications to treat their schizophrenia disorder. Review of Resident 13's 09/07/2023 Level I PASRR showed the evaluator marked no, indicating the resident did not have a SMI. The PASRR did not indicate Resident 13 had schizophrenia, mood, or anxiety disorders. The PASRR did not show whether Resident 13 had evidence of a SMI. In an interview on 10/02/2024 at 12:17 PM, Staff D (Social Services Director) reviewed Resident 13's PASRR and confirmed the form was incomplete. Staff D stated if Resident 13's Level I PASRR was completed, the resident would have a PASRR Level II assessment. <Resident 185> According to a 09/24/2024 admission MDS, Resident 185 admitted to the facility on [DATE]. This MDS showed Resident 185 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication during the assessment period. Review of Resident 185's September 2024 MAR showed the resident was receiving three different medications for depression. Review of a 09/18/2024 PASRR Level 1 showed Resident 185 had no SMI indicators. Staff did not identify the PASRR Level 1 was inaccurate on admission and did not include Resident 185's diagnosis of depression. In an interview on 10/02/2024 at 1:30 PM, Staff D stated an accurate PASRR Level 1 was important so a resident would get the services they required. Staff D stated their expectation was for a PASRR Level 1 to be accurate. Staff D reviewed Resident 185's PASRR Level 1 and stated it was inaccurate and needed to be revised. <Resident 53> According to a 09/02/2024 admission MDS, Resident 53 admitted to the facility on [DATE]. This MDS showed Resident 53 had multiple medically complex diagnoses including depression and an anxiety disorder and required the use of antidepressant medications during the assessment period. Review of Resident 53's September 2024 MAR showed the resident was receiving an antidepressant medication for depression. Review of a 08/25/2024 PASRR Level 1 showed Resident 53 was identified with SMI indicators of a mood disorder, which included depression, and an anxiety disorder. Section four on the PASRR Level 1 was marked Resident 53 did not show indicators of SMI and no Level II evaluation was indicated. Staff did not correct section four of the 08/25/2024 PASRR Level 1 and refer Resident 53 for a PASRR Level II as required. In an interview on 10/04/2024 at 2:40 PM, Staff U reviewed Resident 53's records and stated staff should have, but did not correct the residents PASRR Level 1 and refer Resident 53 for a Level II evaluation. REFERENCE: WAC 388-97-1915(1)(2)(a-c). . Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 7 (Residents 22, 57, & 13) residents and 2 supplemental residents (Resident 185 & 53) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 22> According to the 08/12/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 22 had diagnoses including depression, bipolar disorder, and Post Traumatic Stress Disorder (PTSD). The MDS showed Resident 22 took antidepressant medications. This MDS showed Resident 22 admitted on [DATE]. According to the September 2024 Medication Administration Record (MAR), Resident 22 took two antidepressant medications (one first prescribed on 07/30/2022 and the second first prescribed on 05/10/2023), a medication to treat PTSD first prescribed on 05/24/2024, and an antianxiety medication first prescribed on 09/25/2024. Record review showed an 08/02/2022 Level I PASRR for Resident 22. This PASRR listed only a diagnosis of depression under the Serious Mental Illness [SMI] Indicators section. It did not include Resident 22's PTSD or bipolar diagnoses. A new Level I PASRR was completed by facility staff on 09/23/2024. This Level I PASRR had an admission date of 11/06/2023. In an interview on 10/04/2024 at 2:40 PM Staff U (Divisional Director of Social Services) stated it was important for PASRR forms to be accurate and updated with changes. Staff U reviewed Resident 22's chart and stated their PASRR should be updated when new SMI indicators were identified but was not. <Resident 57> According to the 09/03/2024 Significant Change MDS, Resident 57 had severely impaired memory, received hospice services, and had medically complex diagnoses including anxiety, bipolar disorder, and schizophrenia. The MDS showed Resident 57 received antipsychotic and antianxiety medications. Review of the physician's orders showed a 03/10/2024 order for an antipsychotic medication, a 07/25/2024 order for a second antipsychotic medication, and a 07/10/2024 order for a medication to treat anxiety. Record review showed a 10/24/2023 Level I PASRR form. This PASRR showed Resident 57 had anxiety, bipolar, and schizophrenia diagnoses, and dementia. The Level I PASRR showed Resident 57 did not require a Level II Evaluation. In an interview on 10/04/2024 at 2:40 PM Staff U stated it was important for Level I PASRRs to be accurate. Staff U stated Level I PASRRs should be updated when necessary, including when a significant change was identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and/or implement comprehensive Care Plan's (CP) for 6 of 20 sampled residents (Residents 53, 70, 32, 43, 45, & 16) whose CPs were reviewed. The failure to develop comprehensive, individualized, or implement CPs with resident-specific goals and/or interventions, placed residents at risk for unmet care needs and a decreased quality of life. Findings included . <Care Plan Development> <Resident 53> According to a 09/02/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 53 was admitted to the facility on [DATE] with multiple medically complex diagnoses. Review of Resident 53's comprehensive CP showed an Establish the baseline Plan of Care problem was initiated by staff on admission. This CP, over 30 days after Resident 53's admission, did not have any measurable or individualized goals established by staff. <Resident 70> According to an 08/09/2024 admission MDS, Resident 70 was admitted to the facility on [DATE] with multiple medically complex diagnoses. This MDS showed staff assessed Resident 70 had a functional limitation in range of motion to one side of the lower extremity, and normally used a wheelchair during the assessment period. Review of Resident 70's comprehensive CP, almost two months after the resident's admission to the facility, did not direct staff to the current ambulation status or what mobility device Resident 70 was assessed to require. In an interview on 10/04/2024 at 10:32 AM, Staff MM (Resident Care Manager - RCM) stated it was important to have a comprehensive CP, so staff were aware of the care and needs a resident requires. Staff MM stated CPs should be comprehensive, individualized, and have measurable goals. <Resident 32> Review of a 09/07/2024 Quarterly MDS showed Resident 32 admitted to the facility on [DATE] and had functional limitation in range of motion for upper and lower extremities, was dependent on staff for rolling left to right, was dependent on staff for Activities of Daily Living (ADLs), and had an unhealed pressure wound. Review of a Functional CP, revised on 05/22/2024, showed Resident 32's problem as resident has Establish the Baseline Plan of Care with functional abilities. Review of the revised 09/13/2024 Restorative CP for ADLs showed Resident 32's goal as resident will maintain current level of function with interventions for nursing staff to Refer to Baseline of care functional abilities. Review of the revised 11/08/2023 Physical Mobility CP showed Resident 32's task interventions as Refer to Baseline of care functional abilities. Review of Resident 32's records showed the most recent Baseline CP dated 07/07/2023 showed a handwritten 48 Hour Baseline CP form with checkboxes indicating Resident 32 needed two-person assistance with a mechanical lift for transfers and had a wheelchair. <Resident 43> According to a 07/03/2024 admission MDS, Resident 43 admitted on [DATE] and had no memory impairment. The MDS showed Resident 43 was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear, and transfers. The MDS showed Resident 43 required maximal assistance from staff for showers/bathing, turning side to side in bed, going from a sitting position to a lying position, and going from lying in bed to sitting on side of bed. The assessment showed Resident 43 required setup for upper body dressing. Review of Resident 43's records showed a 07/06/2024 Impaired Physical Mobility CP and a revised 09/23/2024 ADL CP with refer to baseline CP as the only intervention listed. Review of Resident 43's records showed an 08/05/2024 physician order for a treatment to skin for Eczema (an inflammatory skin condition). Resident 43's records did not show a CP for the skin condition. <Resident 45> According to an 08/24/2024 Quarterly MDS, Resident 45 admitted on [DATE] and had no memory impairment. The MDS showed Resident 45 required supervision with some staff assistance for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS showed Resident 45 required maximal staff assistance with showers/bathing. Review of Resident 45's records showed a 06/03/2024 ADL CP with refer to baseline CP as the only intervention listed. <Resident 16> Review of Resident 16's records showed an 08/01/2024 diagnosis of paraplegia and chronic pain syndrome. Review of Resident 16's records showed no pain management CP. According to an 08/15/2024 Modified Discharge MDS, Resident 16 admitted on [DATE] and was severely cognitively impaired. The MDS showed Resident 16 was dependent on staff for toileting hygiene, upper/lower body dressing, putting on/taking off footwear, transfers, showers/bathing, turning side to side in bed, and going from a sitting position to a lying position. Review of Resident 16's records showed an 08/09/2024 Impaired Physical Mobility CP and a revised 09/13/2024 ADL CP with refer to baseline CP as the only intervention listed. Review of Resident 16's records showed a 09/06/2024 referral for a Restorative Nursing Program (RNP) for both hand/arm and leg contractures. Review of Resident 16's records showed no RNP or contractures CP. In an interview on 10/03/2024 at 9:45 AM Staff BB (RCM) stated they were expected to develop comprehensive CPs within 14 days. Staff BB stated refer to baseline CP was not an acceptable CP and needed to list specific interventions for the residents as they progress with their cares. In an interview on 10/04/2024 at 8:59 AM, Staff B (Director of Nursing) stated Resident 16 did not have a pain CP but should because of their chronic pain diagnosis. Staff B stated it was important to develop a pain CP, so staff were providing individualized care to ensure their pain is managed appropriately. Staff B stated they expected staff to develop a comprehensive CP within 48-72 hours after admission. Staff B stated an intervention showing refer to baseline CP was not a comprehensive CP and staff should not be documenting that on the CP's. Staff B stated it is important to develop more individualized CPs to meet the specific resident needs with their treatment and cares. <Care Plan Implementation> <Resident 16> Review of an 08/01/2024 Baseline CP directed staff to keep Resident 16's heels elevated/floating. Review of a 09/13/2024 Actual Skin Impairments CP showed Resident 16 had pressure ulcers to both heels. The CP showed an intervention for Resident 16 was to follow facility policies/protocols for the prevention/treatment of skin breakdown. Observations on 10/02/2024 at 8:59 AM showed Resident 16 lying in bed without their heels elevated. A foam wedge cushion was lying on the floor by the table in the resident's room. In an interview on 10/02/2024 at 9:06 AM Staff BB stated Resident 16 should have both heels elevated at all times on the foam wedge cushion, but night shift did not have their heels elevated. In an observation and interview on 10/03/2024 at 5:21 AM, the foam wedge was lying on the floor and Resident 16's heels were lying directly on their bed. Staff AA (Registered Nurse - RN) stated Resident 16 should have both of their heels floating at all times, but they are not. Staff AA stated it was important to help in healing Resident 16's pressure ulcers to both of their heels. In an interview on 10/03/2024 at 5:28 AM Staff Z, (Certified Nursing Assistant - CNA) stated they did not know what Resident 16's CP directed them to do to relieve pressure from the resident's heels. Staff Z stated they were expected to implement care as directed by residents CP's. Staff Z stated they should have read through the CP to ensure they were providing care per Resident 16's CP. <Resident #32> Review of a 09/07/2024 Quarterly MDS showed Resident 32 had functional limitation in range of motion for upper and lower extremities, was dependent on staff for rolling left to right, was dependent on staff for ADLs. The MDS showed the Resident 32 was understood, had clear speech, and had moderate memory impairment. Review of the Functional CP, revised on 05/22/2024, showed Resident 32 needed two people to assist with bed mobility, rolling from left to right, turning, and repositioning routinely. Review of a Pressure wound CP, revised on 06/04/2024, showed staff were to reposition Resident 32 every two hours. Review of a Pain CP, revised on 05/21/2024, showed Resident 32 had a potential for pain related to limited and decreased mobility, interventions were to turn and reposition resident every two hours and as needed. Review of a Respiratory CP, revised on 05/22/02024, showed Resident 32 was on oxygen therapy for respiratory failure with interventions to change resident's position every two hours to facilitate lung secretion movement and drainage. Review of September 2024 Treatment Administration Record (TAR) showed routine turning and positioning was ordered for Resident 32 on 01/09/2024. Resident 32's TAR showed staff initialed this task was completed every shift. Observation on 09/30/2024 at 9:17 AM showed Resident 32 sitting up in bed with the head of bed elevated. Resident 32 stated the staff did not come in to reposition them, but they should be. Observation on 10/01/2024 at 9:18 AM showed Resident 32 was sitting up with head of bed elevated. Observation on 10/02/2024 at 9:00 AM showed Resident 32 sitting up. Resident 32 was unable to reach the bed control remote to raise the head of bed up and do their painting activity. In an interview on 10/03/2014 at 10:00 AM Resident 32 stated the staff do not help the with turning, they used to, but they do not anymore. Observation on 10/03/2024 at 11:29 AM showed Resident 32 telling Staff J (RCM) they would like staff to turn them. In an interview on 10/03/2024 at 11:03 AM, Staff P (CNA) stated they turned Resident 32 every two hours. Staff P stated the resident was confused and did not know they were turned. Staff P stated they did not document if the resident refused to be repositioned. In an interview on 10/03/2024 at 11:13 AM Staff J stated Resident 32 needed two people to reposition the resident and expected the care staff to reposition the resident every two to three hours. Staff J stated staff should be turning the resident every two hours and before and after meals. In an interview on 10/04/2024 at 9:18 AM Staff H (RN) stated the staff try to turn Resident 32 but the resident refuses staff assistance. REFERENCE: WAC 388-97-1020(1), (2)(a-f). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 43> According to a 07/03/2024 admission MDS, Resident 43 admitted on [DATE] and had no memory impairment. The MDS showed Resident 43 had diagnoses of pressure ulcers, lower spinal cord injury, and chronic pain syndrome. In an interview on 09/30/2024 at 9:10 AM, Resident 43 stated they had a care conference when they first admitted but did not hear anything about scheduling another one. Resident 43 stated they would appreciate a care conference so they could know where they were at towards their goal of returning to their home. In an interview on 10/02/2024 at 12:33 PM, Staff D stated Resident 43 was overdue for their quarterly care conference. Staff D stated they usually had an assistant that arranged care conferences, but they did not have an assistant for about three weeks, so care conferences were not being done per regulation, and Resident 43 did not have one scheduled. In an interview on 10/04/2024 at 10:33 AM Staff A (Executive Director) stated they expected care conferences to be done upon admission within the first few days of being at the facility, quarterly, and as needed if residents/resident representatives request or the resident had a change of condition. Staff A stated they expected CP's to be updated and revised to reflect the resident's current conditions. REFERENCE: WAC 388-97-1020(2)(c)(d), (4)(c)(i-ii). <Resident 13> According to the 09/02/2024 Quarterly MDS, Resident 13 had no memory loss. This MDS showed Resident 13 was taking antipsychotic, antianxiety, and antidepressant medications. The MDS showed Resident 13 experienced two falls during the assessment period. Review of a 06/12/2024 incident report showed Resident 13 experienced a fall when observed by facility staff putting themselves on the floor next to their bed. Review of a 07/31/2024 incident report showed Resident 13 had an unwitnessed fall when they were found lying next to their bed by staff. Review of Resident 13's 04/06/2023 High Risk for Falls CP showed interventions including to remind the resident about safety measures, follow the facility fall protocol, ensure the resident's call light was within reach, and review information on past falls and attempt to determine cause of falls . This CP showed no new interventions after Resident 13 fell in June 2024 and July 2024. <Care Conferences> <Resident 21> According to the 08/21/2024 Annual MDS, Resident 21 had no memory impairment, was understood, and could understand others in conversation. The MDS showed Resident 21 had diagnoses including heart failure, high blood pressure, the inability to control their blood sugars, anxiety, and depression. In an interview on 09/30/2024 at 9:34 AM, Resident 21 stated they were unfamiliar with care conferences and stated they did not have a care conference while at the facility. Review of a 03/14/2024 quarterly Care Conference evaluation form showed the resident, their significant other, and a social services staff person attended the care conference. The form showed the resident was invited to the care conference on 03/14/2024, the same day the care conference occurred. The nursing section of the form showed staff documented the resident was stable this quarter. This document showed no licensed nurses, direct care staff, dietary, therapy, or activities staff attended the care conference. The evaluation showed the care conference did not include the IDT. Review of a 06/03/2024 quarterly Care Conference evaluation form showed Resident 21 was invited to the care conference on 06/03/2024, the same day the care conference occurred. The nursing section of the form showed staff documented the resident was stable this quarter. This document showed the only staff member present was Staff D (Social Services Director). This document showed no licensed nurses, direct care staff, dietary, therapy, or activities staff attended the care conference. The evaluation showed the care conference did not include the IDT. In an interview on 10/02/2024 at 10:47 AM, Staff D stated care conferences usually included the social services assistant and the resident. Staff D stated RCMs would attend the care conference only if there were nursing concerns. Staff D stated it was important to include the IDT as part of care conferences because if residents had any issues or concerns, the resident's needs could be met at that time. In an interview on 10/04/2024 at 10:48 AM, Staff B (Director of Nursing) confirmed care conferences should consist of the IDT. Staff B stated residents should have prior notice of the care conference meetings. Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 4 (Residents 70, 53, 185, & 13) of 20 sample residents whose CPs were reviewed. The facility failed to ensure residents received and/or participated in care conferences that included the Interdisciplinary Team (IDT) for 2 (Residents 21 & 43) residents reviewed. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Care Plan Revision> <Resident 70> According to an 08/09/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 70 was admitted to the facility on [DATE] with multiple medically complex diagnoses. Review of Resident 70's comprehensive CP showed an Establish the baseline Plan of Care problem was initiated by staff on admission. This CP listed an intervention that Resident 70 was on isolation precautions for having a Peripherally Inserted Central Catheter (PICC - a long, thin, flexible tube that's inserted into a vein in the upper arm and threaded into a larger vein above the heart). Review of Resident 70's records showed this PICC line was discontinued on 08/20/2024. <Resident 53> According to a 09/02/2024 admission MDS, Resident 53 had multiple medically complex diagnoses including heart failure and required the use of oxygen during the assessment period. Observations on 09/29/2024 at 10:05 AM showed Resident 53 lying in bed using oxygen and an unplugged humidifier container next to an oxygen concentrator machine. Review of Resident 53's 09/04/2024 oxygen therapy CP showed the resident had oxygen therapy r/t [related to]. Staff did not complete the reason the resident required the oxygen therapy. This CP listed an oxygen setting intervention for, humidified (SPECIFY). Staff did not specify if the oxygen was to be used with a humidifier. <Resident 185> According to a 09/24/2024 admission MDS, Resident 185 admitted to the facility on [DATE] and had multiple medically complex diagnoses. This MDS showed staff assessed Resident 185 to require substantial assistance from staff to roll side to side in bed and was dependent on staff for toileting hygiene. Review of Resident 185's 09/18/2024 Baseline CP showed an intervention for: TOILETING SCHEDULE: (SPECIFY) and COMMUNICATION: PRIMARY LANGUAGE: (SPECIFY). Staff did not indicate what the toileting schedule was or the primary language for Resident 185. In an interview on 10/04/2024 at 10:32 AM, Staff MM (Resident Care Manager - RCM) stated their expectation was for CPs to be updated and revised to reflect the resident's current conditions. Staff MM stated Resident 70, 53, and 185's CP's needed to be updated and revised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 43> According to a 06/27/2024 Baseline CP, Resident 43 was to receive showers, per their preference, two times a week on Mondays and Thursdays. The CP showed Resident 43 required two staff assistance with transfers for showers and one-person maximal assistance with the shower. According to a 07/03/2024 admission MDS, Resident 43 stated it was very important for them to be able to choose between a bed bath or shower. The MDS showed Resident 43 required maximal staff assistance with showers. Review of a facility bathing schedule showed Resident 43 would be offered showers every Monday and Thursday on evening shift. Review of Resident 43's July 2024 bathing records showed they were only offered and received a bed bath on 07/01/2024 and 07/11/2024 and a shower on 07/12/2024. Resident 43's August 2024 records showed they were only offered and received a bed bath on 08/05/2024, 08/15/2024, and 08/26/2024. Resident 43's September 2024 records showed they were only offered but refused bathing on 09/09/2024 and 09/19/2024. In an interview on 09/30/2024 at 9:15 AM Resident 43 stated they preferred showers, but staff told them they could not have showers. Resident 43 stated the few times staff had offered them a bed bath, they would only wipe their back after changing their brief and not provide a full body bed bath. Resident 43 stated when they developed maggots in their wound the contracted wound Physician Assistant told them they were very dirty and needed to be cleaned, but staff would not shower them or give them a full, thorough bed bath. In an interview on 10/03/2024 at 9:49 AM Staff BB (RCM, RN) reviewed Resident 43's records and stated the CP showed they preferred showers and were supposed to be offered showers every Monday and Thursday. Staff BB reviewed Resident 43's records and stated Resident 43 was not offered bathing seven of the nine assigned days for July 2024, six of the nine assigned days for August 2024, and seven of the nine assigned days for September 2024. Staff BB stated it was important to offer showers per Resident 43's preferences to ensure they were honoring the resident's rights. Staff BB stated Resident 43 should have been offered showers twice weekly, but they were not. <Resident 16> Review of Resident 16's CP showed an 08/01/2024 Baseline CP that instructed staff Resident 16 was dependent on staff for bathing. Resident 16's baseline CP did not direct staff on their bathing preferences or their assigned days/times. Resident 16's 08/09/2024 ADL CP showed refer to baseline CP as the only ADL intervention listed. According to a 08/07/2024 admission MDS, Resident 16 admitted to the facility on [DATE] and was severely cognitively impaired. The assessment showed a Resident Representative participated for the facility to obtain Resident 16's goals/wishes. The MDS showed it was very important to Resident 16 to choose between a bath or a shower. The assessment showed Resident 16 was dependent on staff for bathing/showers. The MDS showed Resident 16 had diagnoses of Alzheimer's dementia, paraplegia, anxiety disorder, depression, pressure ulcers, adult failure to thrive, and chronic pain syndrome. Review of a facility bathing schedule showed Resident 16 would be offered showers every Monday and Thursday on evening shift. In an interview on 10/03/2024 at 9:45 AM Staff BB reviewed Resident 16's records and stated Resident 16 was not offered bathing two of nine assigned days for September 2024 per bathing schedule but should have been. Staff BB stated Resident 16's CP should reflect their bathing preference and the assigned bathing days/times per facility bathing schedule of every Monday and Thursday evening shift. <Resident 45> According to a 08/24/2024 Quarterly MDS, Resident 45 admitted to the facility on [DATE] with no memory impairment. The MDS showed it was very important to Resident 45 to choose between a bath or a shower. The assessment showed Resident 16 required maximal assistance from staff for bathing/showers. The MDS showed Resident 45 had diagnoses of yeast infection to skin and nails, morbid obesity, depression, and anxiety disorder. Review of Resident 45's CP showed a 05/24/2024 baseline CP with bathing (specify). Resident 45's baseline CP showed bathing frequency, days of week and time of day were all left blank. Resident 45's revised 05/31/2024 baseline CP for bathing transfer showed res dependent on 2 staff for transfers and a revised 08/08/2024 baseline cp for bathing assistance showed res required maximal assist from two staff with their shower/bath. Resident 45's records showed a revised 09/23/2024 ADL CP, without bathing addressed and refer to baseline CP as the only ADL intervention listed. Review of a facility bathing schedule showed Resident 45 would be offered showers every Monday and Thursday on evening shift. Review of Resident 45's May 2024 records showed they were only offered and received a bed bath on Thursday 05/30/2024. Resident 45's June 2024 records showed they were not offered bathing on 06/03/2024, 06/24/2024, or 06/27/2024, per shower schedule. Resident 45's July 2024 records showed they were not offered bathing on 07/08/2024, 08/15/2024, 07/22/2024, or 07/25/2024, per bathing schedule. Resident 45's August 2024 records showed they were not offered bathing on 08/01/2024, 08/05/2024, 08/08/2024, 08/19/2024, or 08/29/2024, per bathing schedule. Resident 45's September 2024 records showed they were not offered bathing on 09/02/2024, 09/09/2024, 09/12/2024, or 09/16/2024, per bathing schedule. Resident 45's October 2024 records showed they were not offered bathing on 10/03/2024, per bathing schedule. In an interview on 10/03/2024 at 9:45 AM Staff BB reviewed Resident 45's records and stated Resident 45 was not offered bathing one of the two assigned days for May 2024, three of the eight assigned days for June 2024, four of the nine assigned days for July 2024, five of the nine assigned days for August 2024, and four of the nine assigned days for September 2024. Staff BB stated Resident 45's CP should reflect their bathing preference and the assigned bathing days/times per facility bathing schedule of every Monday and Thursday evening shift. Staff BB stated their expectation of staff was to offer bathing per resident preference and document if the resident refused or what type of bathing they accepted. Staff BB stated they expected staff to document on the assigned days and any additional days that bathing was needed or requested by the resident. Refer to F725 - Sufficient Nursing Staff REFERENCE: WAC 388-97-1060(2)(c). <Bathing/Showers> <Resident 21> Review of the 08/21/2024 Annual MDS showed Resident 21 had no cognitive impairment. This MDS showed it was very important to Resident 21 to choose between a shower or bed bath and the resident was dependent on staff for bathing assistance. This MDS showed Resident 21 did not reject care during the lookback period of the assessment. Review of Resident 21's 12/22/2023 Baseline Plan of Care CP showed Resident 21 preferred showers or bed baths and preferred bathing twice weekly. This CP showed the resident would receive bathing assistance on Tuesday and Friday evenings. In an interview on 09/30/2024 at 9:13 AM, Resident 21 stated they would like to go to the shower and that they have only been to the shower a couple of times. Resident 21 stated they mostly received bed baths and said their hair was never clean enough with a bed bath. Review of the June 2024 bathing task record showed Resident 21 received bathing assistance on two of eight opportunities for the month. Three of the bathing opportunities showed blank documentation and three opportunities show staff documented N/A [not applicable]. There were no progress notes or cither documentation showing Resident 21 refused bathing assistance from staff. Review of the July 2024 bathing task record showed Resident 21 received bathing assistance on three of nine bathing opportunities for the month. Three of the bathing opportunities show blank documentation by staff and three opportunities show staff documented N/A. There were no progress notes or documentation showing Resident 21 refused bathing assistance from staff. Review of the August 2024 bathing task record showed Resident 21 received bathing assistance on three of nine bathing opportunities for the month. On six of the bathing opportunities, staff documented N/A. There were no progress notes or documentation showing Resident 21 refused bathing assistance from staff. <Resident 13> Review of the 09/02/2024 Quarterly MDS showed Resident 13 had no cognitive impairment. This MDS showed it was very important for Resident 13 to choose between a shower and bed bath and the resident required partial/moderate assistance from staff to shower/bathe themselves. This MDS showed Resident 13 rejected care one to three days during the assessment's lookback period. Review of Resident 13's 10/03/2023 Baseline Plan of Care CP showed the resident preferred showers twice weekly on Tuesday and Friday evenings. Observation on 09/30/2024 at 8:49 AM showed Resident 13 lying in bed asleep. Their hair was unkempt and greasy. Resident 13's room had an overwhelming smell of body odor and urine. Similar observations were made on 10/01/2024 at 10:25 AM. Review of Resident 13's July 2024 bathing task record showed the resident received one shower per their preferred schedule and three as needed showers for the month of July. This record showed on six occasions, Resident 13 was not offered a shower. On two occasions, staff documented N/A. There were no progress notes or documentation showing Resident 13 was offered and refused a shower. Review of Resident 13's August 2024 bathing task record showed the resident received zero showers per their stated schedule and received two as needed showers for the month of August. This record showed on six occasions, Resident 13 was not offered a shower. On two occasions, staff documented N/A. There were no progress notes or documentation showing Resident 13 was offered and refused a shower Review of Resident 13's September 2024 bathing task record showed Resident 13 received one scheduled bed bath and three as needed showers. The documentation shows on eight occasions, the resident was not offered a shower per their preferred schedule. The documentation shows Resident 13 refused one shower, on 09/18/2024. <Resident 22> According to the 0/12/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 22 had intact cognition and showed no rejection of care during the assessment's lookback period. The MDS showed Resident 22 was dependent on staff for ADL assistance and did not receive a bath or shower during the assessment's lookback period due to safety concerns. The MDS showed Resident 22 had frequent bowel incontinence. Review of Resident 22's comprehensive Care Plan (CP) showed a 03/10/20024 ADL CP. This CP showed Resident 22 was scheduled to receive bathing assistance twice a week on Wednesday and Saturdays from two Certified Nursing Assistants (CNAs). In an interview on 09/29/2024 at 12:17 PM Resident 22 stated they were supposed to get bathing assistance Wednesdays and Saturdays. Resident 22 stated they normally received a shower Saturday but had difficulty getting bathing assistance on Wednesdays. Resident 22 stated they had to demand bathing assistance on occasion. on Record review showed in August 2024 Resident 22 received bathing assistance on three of five Saturdays (the 3rd, 24th, and 31st), and on two of four Wednesdays (the 14th and 21st). Resident 22 did not receive bathing assistance between 08/03/2024 and 08/14/2024, a wait of 11 days between baths. There were no documented refusals. Record review showed in September 2024 Resident 22 did not receive bathing assistance until 09/14/2024. Resident 22 went 13 days with no documented refusals. Resident 22 received bathing assistance on one Saturday (the 14th), and one Wednesday (the 25th) with refusals documented on 09/21/2024 and 09/25/2024 (Resident 22 accepted bathing assistance later that day.) In an interview on 10/04/2024 at 10:54 AM, Staff B (Director of Nursing) stated if residents refuse shower/bathing assistance, staff should be documenting the refusals. Staff B stated it was their expectation staff honored resident preferences for showering and bathing. Staff B stated shower aides were sometimes pulled to work the floor if staff called off from their scheduled shifts. <Nail Care> <Resident 20> According to the 9/20/2024 Quarterly MDS, Resident 20 had limited range of motion and depended on staff to complete all personal hygiene. Record review showed the 07/18/2024 skin integrity CP included a goal for Resident 20's nails to be kept short, related to their hand contracture (permanent tightening of the tendons, causing the fingers to curl in) to maintain intact skin. The CP showed staff should keep Resident 20's hands from excessive moisture and keep their fingernails short. According to a 09/03/2024 physician's order, staff should do a weekly audit of Resident 20's skin for new impairment every Tuesday. Review of the September 2024 Treatment Administration Record (TAR) showed Staff documented that skin audits were completed on 09/03/2024, 09/10/2024, 09/17/2024, and 09/24/2024. Observation on 10/04/2024 at 11:14 AM, showed Resident 20's fingernails were long, extending half an inch above the end of the fingertip. The nail edges were rough and uneven. The fourth fingernail on Resident 20's left hand had a jagged sharp corner that corresponded with a cut on their left palm. Resident 20 had indentations in the palm of their right hand that corresponded with the second, third, and fourth fingernails on the right hand. The nails on both thumbs were long and chipped. Staff H (Licensed Practical Nurse - LPN) stated Resident 20's fingernails were too long and needed to be trimmed and filed. In an interview on at, Staff I (Occupational Therapist) stated Resident 20 should have gauze or a washcloth in their left hand. Staff I stated Resident 20's nails should be kept short to prevent skin injuries to the palm. <Assistance With Getting Out of Bed> <Resident 70> According to an 08/09/2024 admission MDS, Resident 70 had no memory impairment, was assessed with a functional limitation in range of motion to one side of the lower extremity and had no rejection of care. This MDS showed staff assessed Resident 70 required substantial assistance to roll side to side in bed, was dependent on staff for upper and lower dressing, and transfers from bed to chair were not attempted due to medical condition or safety concerns. Observations on 09/29/2024 at 9:45 AM and 12:58 PM, 09/30/2024 at 8:26 AM showed Resident 70 lying in bed wearing a gown. In an interview on 09/30/2024 at 10:58 AM, Resident 70 stated they were frustrated staff did not assist them to get up out of bed daily. Observations on 10/01/2024 at 8:53 AM showed Resident 70 lying in bed wearing a gown. In an interview on 10/04/2024 at 9:17 AM, Resident 70 stated the last time staff assisted them to get dressed and out of bed was for their last appointment out of the facility on 09/24/2024, 10 days previously. Resident 70 stated the staff did not offer them to get up and indicated they would get out of bed if offered. Review of an 08/12/2024 functional ability Care Area Assessment (CAA) for Resident 70 showed staff documented the resident required assistance from staff to roll from side to side in bed and required dependent assistance to move from sitting to standing with chair/bed transfers. This CAA showed staff assessed Resident 70 to require assistance with upper and lower body dressing. Review of Resident 70's comprehensive Care Plan (CP) on 09/30/2024 showed no directions to staff regarding the resident's ambulation status or interventions to encourage or assist the resident to get up out of bed daily. In an interview on 10/04/2024 at 2:55 PM, Staff N (Certified Nursing Assistant) stated, physical therapy gets them [the residents] up, they [the residents] are already up when asked if any residents required assistance on Resident 70's unit. Staff N stated Resident 70 never asked them to get up out of bed. In an interview on 10/04/2024 at 10:32 AM, Staff MM (Resident Care Manager - RCM, Registered Nurse - RN) stated it was their expectation that staff assist residents who require help to get dressed and out of bed daily. Staff MM stated Resident 70 required staff help and should be assisted each morning. Observations on 10/04/2024 at 2:11 PM showed Resident 70 in the hallway sitting in their wheelchair smiling. <Resident 21> According to the 08/21/2024 Annual MDS, Resident 21 had no cognitive impairment. The assessment showed Resident 21 had clear speech, was understood, and could understand others in conversation. The assessment showed Resident 21 was totally dependent on staff assistance for transferring from their bed to wheelchair and had no rejection of care during the assessment period. Review of Resident 21's [NAME] (directions to care staff) on 09/30/2024 showed the resident required the assistance of two staff members and a mechanical lift to be transferred from the bed to their wheelchair. The [NAME] directed staff to assist the resident out of bed every Tuesday, Thursday, and Saturday evening. In an observation and interview on 09/30/2024 at 9:13 AM, Resident 21 was lying in bed. Resident 21 stated they have not been out of bed and the staff do not offer to get them up. Resident 21 stated it would be nice if [staff] would get me out of bed for an hour or so. An observation and interview on 10/01/2024 at 9:01 AM showed Resident 21 lying in bed. Resident 21 stated they had a brand-new wheelchair in their bathroom that they have never used. Observation at that time showed a wheelchair in the resident's bathroom. The chair appeared brand-new. There were no signs of wear and tear, and the product packet was resting on the seat of the wheelchair. In an interview on 10/03/2024 at 7:57 AM, Staff J (RCM) stated it was their expectation direct care staff offered to assist resident's out of bed every day. In an interview on 10/04/2024 at 10:51 AM, Staff B stated it was their expectation staff offered to assist residents out of bed each day if the resident was able/willing. Staff B stated staff should document if a resident refuses to get out of bed. Based on observation, interview, and record review the facility failed to ensure assistance with Activities of Daily Living (ADL - personal hygiene and other daily routines) was provided for 8 of 11 residents reviewed for ADL (Residents 70, 21, 20, 13, 22, 43, 16, & 45). The failure to provide assistance with getting out of bed, nail care, and bathing placed residents at risk of poor hygiene, diminished sense of self-worth, skin impairment, and frustration. Findings included .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 16> According to an 08/07/2024 admission MDS, Resident 16 admitted on [DATE] and was severely cognitively impaired. The MDS showed Resident 16 had diagnoses of Alzheimer's dementia, paraplegia, anxiety disorder, depression, pressure ulcers, adult failure to thrive, and chronic pain syndrome. Review of Resident 16's records showed a RNP referral was placed on 09/06/2024. The referral was for Resident 16 to have both hands splinted for 12 hours a day and for the Restorative Nursing Aide (RNA) to provide stretching to Resident 16's hands/arms and both legs for their contractures five times a week. In an interview on 09/29/2024 at 7:13 PM Resident 16's Representative (RR) stated both of Resident 16's hands were severely contracted. Resident 16's RR stated their right thumb nail had started growing and curled under because of their contracture. Observations on 09/29/2024 at 8:51 AM, 09/29/2024 at 11:23 AM, 09/29/2024 at 2:12 PM, 09/30/2024 at 8:13 AM, 09/30/2024 at 9:59 AM, 09/30/2024 at 1:33 PM, 10/01/2024 at 8:36 AM, 10/01/2024 at 12:36 PM, 10/01/2024 at 1:59 PM, 10/02/2024 at 9:22 AM, 10/02/2024 at 9:53 AM, 10/02/2024 at 12:07 PM, on 10/03/2024 from 5:11 AM to 7:42 AM, 10/03/2024 at 9:22 AM, and 10/03/2024 at 11:01 AM showed Resident 16's splints on the table in their room. In an interview on 10/02/2024 at 9:53 AM, Resident 16's RR stated the hand splints on Resident 16's table came from the hospital with the resident. Resident 16's RR stated staff did not put the hand splints on Resident 16 since they were at the facility. In an interview on 10/02/2024 at 12:03 PM, Staff BB (Resident Care Manager) stated they did not know if Resident 16 was supposed to have the hand splints on. In an interview on 10/04/2024 at 8:02 AM, Staff BB stated they checked on the hand splints and found a 09/06/2024 referral in Resident 16's records for a RNP that included the hand splints and stretching exercises. Staff BB stated the referral for Resident 16 was not initiated but was supposed to be initiated on 09/06/2024. Staff BB stated the RNP was important to prevent further deformity of Resident 16's hands/arms and legs. <Resident 43> According to a 07/03/2024 admission MDS, Resident 43 admitted on [DATE] and had no memory impairment. The MDS showed Resident 43 had diagnoses of chronic pain syndrome and damaged nerves below the spinal cord. Review of Resident 43's records showed a RNP referral placed on 07/06/2024. The referral was for Resident 43 to have elastic band exercises to both arms, three times a week. Review of an 08/06/2024 Impaired Physical Mobility CP, Resident 43 would be offered a RNP three times a week. The CP showed Resident 43 had decreased range of motion to both arms. In an interview on 09/30/2024 at 9:32 AM, Resident 43 stated they had decreased range of motion to their upper extremities. Resident 43 stated the staff were not offering or providing a RNP. In an interview on 10/04/2024 at 8:59 AM Staff B (Director of Nursing) stated they expected RNPs to be carried out as ordered. Staff B stated it was important to complete RNPs to maintain a resident's level of care. In an interview on 10/04/2024 at 11:59 AM Staff HH (RNA) stated they were expected to offer RNPs per referral. Staff HH stated they were not able to complete the RNPs because of their workload. Staff HH stated they were expected to document each time they offered and when a resident refused. Staff HH stated they did not offer Resident 43 their RNP as ordered but should have. In an interview on 10/04/2024 at 8:59 AM Staff B stated they expected RNPs to be carried out as ordered. Staff B stated it was important to complete RNPs to maintain a resident's level of care. In an interview on 10/04/2024 at 11:59 AM Staff HH stated they were expected to offer RNPs per referral. Staff HH stated they were not able to complete RNPs because of their workload. Staff HH stated they were expected to document each time they offered and when a resident refused. Staff HH stated they did not offer Resident 43 their RNP as ordered but should have. Based on observation, interview, and record review the facility failed to ensure 3 of 7 residents (Resident 70, 16, & 43) reviewed for Range of Motion (ROM) and 1 supplemental resident (Residents 46) received a Restorative Nursing Program (RNP) as ordered. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Facility Policy> According to the facility's March 2019 Restorative Program policy, residents would be evaluated for restorative needs on admission, quarterly, and with significant changes. The policy showed restorative nursing assistants and other staff would provide RNPs to residents and document on a restorative flow sheet. <Resident 70> According to an 08/09/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 70 had multiple medically complex diagnoses including muscle weakness and difficulty in walking. This MDS showed Resident 70 had a recent surgical procedure involving tendons, ligaments, or muscles, had a functional limitation in ROM to one side of their lower extremity, and had no rejection of care. In an interview on 09/30/2024 at 11:03 AM, Resident 70 stated they were frustrated they were no longer getting physical therapy, and they expressed a desire to work on mobility to reach their discharge goals. Resident 70 stated they were only receiving their RNP once weekly. According to an undated Restorative Program referral form, Resident 70 was referred for a restorative program to maintain strength and ROM three times a week. This referral form indicated instructions and training were provided by the therapy department on 09/06/2024. Nursing staff signed the form as noted on 09/18/2024, 12 days after the referral was made. Review of a revised 09/18/2024 impaired mobility Care Plan (CP) showed Resident 70 had interventions that directed staff to provide an active ROM program three times a week with a goal to maintain present muscle strength and endurance. Review of September 2024 restorative documentation showed staff only provided the restorative program to Resident 70 on two of six occurrences once the program was implemented by nursing staff. In an interview on 10/04/2024 at 10:32 AM, Staff MM (Resident Care Manager) stated restorative programs were important to follow up with mobility, assist with strengthening, and to help prevent contractures. Staff MM stated once a referral was made for a restorative program, they expected the program to be established and to be completed as directed.<Resident 46> According to the 09/19/2024 Quarterly MDS Resident 46 had diagnoses including paraplegia. This MDS showed Resident 46 received a RNP. According to the 07/16/2024 Impaired Mobility . CP Resident 46 had a goal to maintain muscle strength in their legs. The CP showed Resident 46 was scheduled to receive a RNP three times a week incorporating various stretches on their legs and feet. Review of the September 2024 RNP documentation showed no RNP program was provided on any day that month. On 09/03/2024 staff documented NA (Not Applicable). There were no documented refusals. In an interview on 10/04/2024 at 10:57 AM Staff B stated it was important to provide a RNP when required to prevent worsening ROM. Staff B stated RNP documentation should be accurate, and refusals should be documented. REFERENCE: WAC 388-97-1060 (3)(d). .

<Resident 18> In an interview on 09/29/2024 at 10:10 AM Resident 18 stated the facility had long wait times, after pushing the call light resident stated they had waited up to 3 hours. Resident 18 stated sometimes the staff don't see or hear call lights in the hallways. <Resident 54> In an interview on 09/29/2024 at 12:44 PM Resident 54 stated there was an incident where another resident entered their room during the middle of the night. Resident 54 stated they pushed their call light for staff to assist the other resident back to their own room, a staff member did not come. Resident stated they had to scream for help and still a staff member did not come. <Resident 62> In an interview on 09/29/2024 at 10:02 AM Resident 62 stated sometimes a call light will stay on too long and may not be answered for 3 hours. Resident 62 stated the wait for a staff member seems to be longer during the middle of the night. <Resident Grievances> <Resident 21> Review of a 06/04/2024 grievance form showed Resident 21 filed a grievance related to long call light wait times on night shift. This grievance showed the staff were educated on call light response times. <Resident 35> Review of a 09/13/2024 grievance form showed Resident 35 and their significant other filed a grievance for having to wait greater than 30 minutes for the call light to be answered. This grievance form showed education was provided to staff. <Resident 71> Review of a 09/13/2024 grievance form showed Resident 71 filed a grievance for call light response taking 30-40 minutes, stating the staff do not respond often. This grievance showed staff were educated on call light response times. <Resident 61> Review of a 09/16/2024 grievance form showed Resident 61 filed a grievance for call light response times taking 20 minutes during the day and more that 30 minutes at night. This grievance showed staff were educated on call light response times. In an interview on 10/04/2024 at 8:59 AM Staff B (Director of Nursing) stated call lights should be answered within 15 minutes and no longer than 30 minutes if they were busy. Staff B stated staff should not ever be sleeping at the nursing station or while on duty. Staff B stated they expected the night shift supervisor to ensure staff were doing their work when on the floor and taking their breaks in the break room. Refer to F677 - ADL Care Provided for Dependent Residents REFERENCE: WAC 388-97-1080(9). <Resident 45> In an interview on 09/29/2024 at 11:43 AM Resident 45 stated the average call light response time varied but they had to wait three hours for their call light to be answered by staff. Resident 45 stated their main concern was the wait time to be changed after an incontinent episode in their brief. Resident 45 stated they had severe edema to both legs but had not accepted an increase in their water pill dose because they had to wait in a soiled brief for three hours. <Resident 72> Observation on 10/01/2024 at 2:20 PM showed Resident 72's call light turned on. At 3:00 PM, 40 minutes later, a staff member answered Resident 72's call light.Based on observation, interview, and record review the facility failed to have sufficient nursing staff to provide timely assistance to residents, supervise care of residents, meet Activities of Daily Living (ADL) needs including showering/bathing, assisting residents out of bed, and call light response time as evidenced by information provided by 13 (Resident 21, 234, 38, 45, 72, 185, 18, 54, 62, 21, 35, 71, & 61) residents interviewed. These failures placed residents at risk for unmet care needs, accidents, and a decreased quality of life. Findings included . <Staff and Call Light Observations> Observation on 10/03/2024 at 5:03 AM showed Staff LL (Certified Nursing Assistant) asleep at the East Hall nurse's station. Three call lights were going off and no other staff members were observed in the hallways. In an interview at that time, Staff LL acknowledged they were asleep and stated they were responsible for answering call lights on the East unit. Staff LL stated they did not feel like there were enough staff at night as they were unable to take all of their breaks. In an interview on 10/03/2024 at 5:11 AM, Staff AA (Registered Nurse) stated they were the night shift supervisor for East and Southeast wings and were expected to supervise the night shift staff assigned to these wings. Staff AA stated staff should not be sleeping at the nursing station. In an interview on 10/04/2024 at 2:41 PM, Staff A (Executive Director) confirmed staff should not sleep while on shift. <Call Light Response Time> Resident 21 In an interview on 09/30/2024 at 9:10 AM, Resident 21 stated they felt the care they received was less since they had moved to the long term care side of the building. Resident 21 stated they waited for three hours on night shift to be changed. Resident 21 stated the aid told me they were getting supplies and be back. Resident 21 stated the aid did not return for three hours and told the resident, they were tired, so they took a nap before assisting the resident to be changed. <Resident 234> In an interview on 09/29/2024 at 11:51 AM, Resident 234 stated sometimes their call light went unanswered for hours. Resident 234 stated they have had to go in their brief before because their call light was not answered timely. <Resident 38> In an interview on 10/01/2024 at 8:15 AM, Resident 38 stated they have waited 30-40 minutes for their call light to be answered. <Resident 185> According to a 09/24/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 185 had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 185 with no memory impairment. In an interview on 09/30/24 at 9:45 AM, Resident 185 stated they felt the facility did not have enough staff, especially at shift change, on the night shift. Resident 185 stated they would have to wait anywhere from 15 minutes to one hour to get assistance from staff with their toileting needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 16> According to a 09/03/2024 Significant Change MDS, Resident 16 admitted [DATE] and was severely cognitively impaired. Resident 16 had diagnoses of high blood pressure and chronic pain syndrome. Record review of Resident 16's records showed no MRRs by the pharmacy. Resident 16's records showed an 08/28/2024 physician order for a blood pressure medication to be administered three times a day at 7:00 AM, 3:00 PM, and 11:00 PM. On 10/02/2024 Staff B (Director of nursing) provided paper copies of pharmacy medication regimen reviews that were not in Resident 16's records. The 08/14/2024 pharmacy review recommended that Resident 16's blood pressure medication be administered every three to four hours apart and no later than 6:00 PM. In an interview on 10/04/2024 at 8:59 AM Staff B stated Resident 16's pharmacy recommendation was not initiated. Staff B stated the blood pressure medication recommendations were not addressed by the provider or initiated for Resident 16, and were not scanned into their records but should be. <Resident 13> According to the 09/02/2024 Quarterly MDS, Resident 13 had diagnoses including psychiatric and mood disorders, and a thyroid disorder. This MDS showed Resident 13 was taking antipsychotic medications. Review of Resident 13's 09/30/2024 physician order summary showed two 09/13/2023 orders for two different medications to treat side effects caused by their antipsychotic medications. The order summary showed Resident 13 had a 09/18/2024 order for a medication to treat their thyroid disorder. Review of a 09/11/2024 MRR showed the facility's pharmacist reviewed the two different medications Resident 13 took to treat side effects caused by antipsychotic medications. The MRR showed the pharmacist provided information that long term use of the medications in elderly patients could increase the resident's risk for dementia. The pharmacist recommended if both medications were to remain ordered by the physician, a risk versus benefit should be provided to Resident 13 along with justification for continued use of the medications. Review of Resident 13's August 2024 and September 2024 Medication Administration Records (MARs) showed staff monitored the resident every shift for adverse side effects of the antipsychotic medication. The MAR showed Resident 13 experienced no side effects in August or September 2024. Review of an 08/13/2024 MRR showed the facility's pharmacist noted Resident 13 had high thyroid levels and recommended the facility consider an increase in the resident's thyroid medication and rechecking their thyroid levels. A 09/11/2024 MRR showed a repeated recommendation of the 08/13/2024 recommendation. Review of Resident 13's record showed no progress notes, orders, or risks versus benefits indicating the MRR was acknowledged or followed up on by the facility staff regarding the medications used to treat the side effects caused by antipsychotic medications. Review of Resident 13's record showed the facility did not implement the recommendation to increase the resident's thyroid medication until 09/18/2024, over five weeks after the original 08/13/2024 MRR. In an interview on 10/04/2024 at 11:18 AM, Staff B (Director of Nursing) stated the facility's process for MRRs was that Staff B obtained the MRR, placed it in the provider's box. Once the MRR was reviewed and signed by the provider, facility staff were to process the orders as soon as possible and at least within 48 hours. <Resident 23> Record review showed a September 2024 MRR created between 9/10/2024 and 9/11/2024 that recommended discontinuing an iron supplement. On 10/02/2024 the physician annotated their agreement with the recommendation. In an interview on 10/04/2024 at 2:13 PM Staff B stated they expected MRRs to be reviewed by the end of the month they were completed by the pharmacist. Based on interview and record review, the facility failed to ensure licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and followed up timely for 3 of 5 residents (Residents 3, 13, & 23) whose medication regimens were reviewed and 2 supplementary residents (Residents 46 & 16). This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects, and negative outcomes. Findings included . <Resident 3> According to a 06/29/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 3 had multiple medically complex diagnoses including dementia, depression, a bipolar disorder (a mental illness characterized by extreme mood swings) and a psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and required the use of antidepressant and antipsychotic medications during the assessment period. Review of Resident 3's records showed no documentation that pharmacy MRRs were completed monthly and/or if there were any recommendations made for the resident since March 2024. On 10/02/2024 Staff B (Director of Nursing) provided paper copies of the pharmacy MRRs not in Resident 3's records for March 2024, May 2024, June 2024, July 2024, August 2024, and September 2024. Review of a printed 03/26/2024 MRR showed a recommendation to Resident 3's physician to review the resident's psychotropic medications and to indicate a clinical rationale if the resident was not a candidate for dose reductions at that time. There was no clinical rationale documented on the form or acknowledgment the physician reviewed the March 2024 recommendation for Resident 3. Review of a printed 05/28/2024 MRR showed a second recommendation to Resident 3's physician to review the resident's psychotropic medications for possible reduction. This form had a title of, **Duplicate Note**Original from 03/20/2024 **No response scanned into [electronic records] ** There was no clinical rationale documented on the form or acknowledgment the physician reviewed the May 2024 recommendation for Resident 3. Review of a 06/10/2024 MRR showed a recommendation to Resident 3's physician to consider a trial dose reduction of an acid-reducing medication from twice daily to once daily or to provide clinical rationale for continued need as Resident 3 was not having any documented active stomach acid symptoms. There was no clinical rationale documented on the form or acknowledgment the physician reviewed the June 2024 recommendation for Resident 3. Review of a 07/12/2024 MRR showed a third recommendation to Resident 3's physician to review the resident's psychotropic medications for possible reduction. This form had a title of, **Duplicate Note**Original from 03/20/2024** No response scanned into [electronic records] ** There was also a second request under a pending section included in the July 2024 MRR's indicating the recommendation for a trial dose reduction of the acid-reducing medication for Resident 3 still needed to be addressed by the facility. There was no clinical rationale documented on the form or acknowledgments the physician reviewed the July 2024 recommendations for Resident 3. Review of an 08/13/2024 MRR showed a third request to the physician to consider a trial dose reduction of the acid-reducing medication for Resident 3. There was no clinical rationale documented on the form or acknowledgments the physician reviewed the August 2024 recommendations for Resident 3. Review of a pending section from a printed 09/11/2024 MRR showed, This is a repeat recommendation from June. If this was already addressed, please disregard recommendation. This form listed a fourth request to consider a trial dose reduction of the acid-reducing medication for Resident 3. There was no clinical rationale documented on the form or acknowledgments the physician reviewed the September 2024 recommendations for Resident 3. According to the September 2024 Medication Administration Records, Resident 3's psychotropic medications were unchanged since January 2024 and the acid reducing medication remained unchanged since 2022. In an interview on 10/04/2024 at 2:13 PM, Staff B (Director of Nursing) stated their expectation was for pharmacy MRRs to be followed up as soon as possible and to be addressed before the end of the month of when the recommendation was received. Staff B stated the pharmacy recommendations should be readily available in the resident records. Staff B stated they would have expected Resident 3's pharmacy recommendations to be followed up timely. <Resident 46> According to the 09/19/2024 Quarterly MDS Resident 46 admitted to the facility on [DATE] and had diagnoses including Diabetes Mellitus (a condition making managing blood sugar more difficult). The MDS showed Resident 46 took insulin. Review of the September 2024 MAR showed Resident 46 had a 06/13/2024 order for insulin to be administered on a sliding scale (adjusting the dose depending on the resident's blood sugar level). Record review showed a 09/10/2024 MRR recommending consideration of the risks and benefits of using sliding scale insulin without a longer acting insulin. This MRR was acknowledged by the physician on 10/02/2024. In an interview on 10/04/2024 at 2:13 PM Staff B stated they expected MRRs to be reviewed by the end of the month they were completed by the pharmacist. REFERENCE: WAC 388-97-1300 (4)(c). .

<Resident 23> According to the 09/03/2024 Quarterly MDS, Resident 23 had diagnoses including stroke with communication deficits, dementia, history of alcohol dependence, psychotic disorder, and a disorder related to personality and behaviors. The MDS showed Resident 23 had no behaviors related to acute delirium, no physical or verbal behaviors directed to self or others, no behaviors that affected Resident 23's care, no rejection of care, no wandering, and no changes in behavior compared to the prior assessment. The MDS showed Resident 23 was administered routine antipsychotic medication, did not have a GDR of antipsychotic medications, and did not have physician documentation of a GDR being clinically contraindicated. The MDS showed Resident 23 did not have a drug regimen review completed by the pharmacist to review clinically significant medication issues. Review of the 08/27/2024 Care Plan (CP) for behaviors showed Resident 23 had a history of behavior problems including aggressive, threatening, irritability, refusing medications and medical care, allegations of physical abuse, and verbal altercations with other residents. The CP showed interventions to Resident 23's behaviors included: determine root cause of behavior, anticipate and meet Resident 23's unmet needs, provide space to Resident 23 when escalating and protect other residents, encourage calmness and provide rewards to decrease anxiety, monitor and document behaviors, look for trends such as time of day, persons involved, location and situation, activity engagement to distract behaviors, and provide simple conversation and yes/no questions. Review of the 09/2024 behavior monitoring documented on the MAR showed Resident 23 had no documented behaviors observed on any day, evening, or night shifts from 09/01/2024 through 09/30/2024, except on 09/27/2024. The MAR showed on 09/27/2024 Resident 23 had worry and angry outbursts without any associated triggers, interventions provided, or outcomes documented. Review of the 09/2024 MAR showed Resident 23 was administered an antipsychotic medication three times per day from 09/01/2024 through 09/30/2024. The MAR showed two changes in the antipsychotic medication with increases in dosage and change from immediate release tablets to 24 hour extended release tablets on 09/24/2024 and 09/30/2024, six days apart. Review of the 09/18/2024 psych evaluation note from the behavioral health specialist showed a routine follow up visit was conducted for medication evaluation, behaviors were assessed as uncooperative, attitude is disinterested and shows impulsivity. The note showed a recommendation to increase the antipsychotic medication to 75 milligrams (mg) by mouth twice daily. Review of a 09/23/2024 nursing progress note showed Resident 23 tested positive for COVID-19 (a respiratory infection) and was started on antiviral medication. The progress note showed Resident 23 was not feeling well, not able to get out of bed, had decreased appetite, and refused a shower. Review of a 09/24/2024 nursing progress note showed Resident 23 had behaviors triggered by being placed on isolation, was yelling, and refused to keep their room door closed. Review of a 09/24/2024 nursing progress note showed the behavioral health practitioner increased the antipsychotic medication. The new antipsychotic medication dose entered to the 09/24/2024 physician orders was 75 mg 24- hour extended release tablet by mouth twice daily, noted difference from the 09/18/2024 behavior health specialists' recommendation that did not specify 24-hour extended release tablets. Review of the 09/25/2024 through 10/01/2024 nursing progress notes showed Resident 23 had one behavior episode of yelling and agitation triggered by wanting a spoon. The progress note showed a spoon was provided and there was no further documentation of behaviors after 09/29/2024. Review of a 09/30/2024 practitioner order showed Resident 23's antipsychotic medication was increased to 100 mg 24-hour extended release tablet by mouth twice daily. This was only six days after the last increase of the antipsychotic medication. There was no documentation found that staff notified the practitioner of the prior increased dose on 09/24/2024. Review of the 09/30/2024 through 10/04/2024 practitioner progress notes showed no progress notes were entered into Resident 23's record by the prescribing practitioner. There was no documentation of the rationale of increasing the antipsychotic medication on 09/30/2024, after the antipsychotic medication was increased six days earlier. In an interview on 10/04/2024 at 12:02 PM with Staff B and Staff PP (Divisional Director of Clinical Operations), Staff PP stated nursing staff were expected to document resident behaviors, identify triggers, provide non-pharmacological interventions, and document outcomes on the behavior monitor for Resident 23. Staff PP stated behavior monitoring and non-pharmacological interventions should be used before increasing any antipsychotic medications. Staff B stated an interdisciplinary team review is used to review antipsychotic medication dosages and recommendations. Staff B stated new orders were reviewed by the resident care managers daily and discussed in morning status meetings with follow up as required. Review of the 04/22/2024 Medication Regimen Review (MRR - a review of medications completed by the pharmacist) showed Resident 23 was prescribed an antipsychotic medication 37.5 mg three times daily. The MRR showed there was no attempt at reduction of dosage since 02/2023, when Resident 23 was changed from one antipsychotic med to another antipsychotic medication, over one year prior to the MRR. The MRR showed guidelines require that psychotropic medications undergo a GDR attempt in two separate quarters [with at least one month between the attempts] during the first year of initiation or admission, then annually thereafter, unless clinically contraindicated. The practitioner signed the document, declined the recommendation of a GDR, and wrote on the MRR, Patient has failed past GDR attempts. Benefit of correct therapy outweighs risks. Currently researching possibility of transitioning to another [antipsychotic]. Review of the 04/25/2024 MRR showed Resident 23 was prescribed an antipsychotic 37.5 mg at 8:00 AM, 50 mg at 12:00 PM, and 37.5 mg at 8:00 PM. The MRR showed the guidelines for psychotropic medication requirement for GDR. The MRR showed in bold underlined instructions for the practitioner to indicate with a clinical rationale if the resident was a candidate for a GDR at this time. The practitioner did not complete the choice selection for a GDR or a clinical rationale, and wrote Benefits outweigh the risks of continuing therapy. In an interview on 10/04/2024 at 12:02 PM, Staff B stated there should be documentation in Resident 23's records for a failed GDR if it was attempted. Staff B was asked to provide all documentation of attempted GDRs on Resident 23's AP medication, none was provided. Refer to F760 Residents are free from Significant Med Errors. REFERENCE: WAC 388-97-1060(3)(k)(i). Based on interview and record review, the facility failed to ensure 2 (Residents 3 & 23) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes. Findings included . <Resident 3> According to a 06/29/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 3 had multiple medically complex diagnoses including dementia, depression, a bipolar disorder (a mental illness characterized by extreme mood swings) and a psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and required the use of antidepressant and antipsychotic medications during the assessment period. This MDS showed staff documented the last Gradual Dose Reduction (GDR) was 05/16/2023, over a year ago, and a GDR was not documented by a physician as clinically contraindicated. Review of Resident 3's September 2024 Medication Administration Records (MAR) showed the resident received the same dose of an antidepressant since 08/01/2018 and the same dose of an antipsychotic since 01/12/2024. Review of the 03/13/2024, 04/17/2024, and 05/08/2024 Psychotropic Drug and Behavior Monthly reviews completed by staff showed the team recommendations were to continue to monitor recent change in the antipsychotic medication, then consider to discontinue it if no significant behaviors. Review of the 06/19/2024 Psychotropic Drug and Behavior Monthly review showed Resident 3's mood and behaviors were managed by their medications. The review showed sometimes Resident 3 was particular about how their room was cleaned but the resident was easily redirected. The review's Target Behavior (TB - the behaviors a medication was prescribed to treat) Summary/Trend since last review section on the form showed staff documented none for Resident 3. This review was not signed as completed by staff until 07/08/2024, almost three weeks later. Review of the 07/12/2024 Psychotropic Drug and Behavior Monthly review showed Resident 3's mood and behaviors were managed by their medications. The review showed sometimes Resident 3 was particular about how their room was cleaned but the resident was easily redirected. The TB Summary/Trend since last review section showed staff documented, none for Resident 3. Review of the 08/14/2024 Psychotropic Drug and Behavior Monthly review showed Resident 3's mood and behaviors were managed by their medications. The review showed sometimes Resident 3 was particular about how their room was cleaned but the resident was easily redirected. The TB Summary/Trend since last review section showed staff documented, none for Resident 3. This review was not signed as completed by staff until 09/03/2024, over one month later. Review of the 09/11/2024 Psychotropic Drug and Behavior Monthly review showed Resident 3's mood and behaviors were managed by their medications. The review showed sometimes Resident 3 was particular about how their room was cleaned but the resident was easily redirected. The TB Summary/Trend since last review section showed staff documented, none for Resident 3. Review of Resident 3's June 2024, July 2024, August 2024, and September 2024 MARs showed only two days, over the past four months, when staff documented Resident 3 had TBs. There was no documentation that staff monitored the resident's behaviors related of the antidepressant. Review of pharmacy medication regimen reviews showed the pharmacist recommended Resident 3's physician review the resident's psychotropic medications and indicate a clinical rationale if the physician assessed Resident 3 was not a candidate for dose reductions in March 2024, May 2024, and July 2024. There was no clinical rationale documented on the recommendation forms or acknowledgment the physician reviewed the pharmacy reviews for Resident 3. In an interview on 10/04/2024 at 2:13 PM, Staff B (Director of Nursing) stated GDRs were important to meet regulatory requirements. Staff B stated it was important to determine nonpharmacological interventions to treat resident behaviors and medications were a last resort. Staff B stated the facility process was to meet monthly with the pharmacist and interdisciplinary team (a team composed of various facility departments) to review residents' psychotropic medications to determine appropriate GDRs. Staff B stated it was their expectation GDRs be attempted when appropriate.

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 7 of 26 medications for 2 of 5 residents (Resident 72 & 4) observed during medication pass resulted in a medication error rate of 26.92 %. 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> Review of the 01/2024 facility, Medication Administration Guidelines policy showed medications should be administered in accordance with written orders of the prescriber. Medications should be verified three times before administering; when pulling a medication package from the medication cart, when the dose is prepared, and before the dose is administered. The policy showed long-acting, extended released, or enteric coated dosage forms should not be crushed. <Resident 72> Observations of medication pass on 10/01/2024 at 9:45 AM, showed Staff FF (Licensed Practical Nurse) prepare medications for Resident 72. Staff FF put one 25 milligram (mg) tablet of an extended-release beta-blocker (a medication that causes the heart to beat slower) Blood Pressure (BP) medication, in a cup and then put the medication card back into the cart. While Staff FF continued to add other medications, they grabbed the same beta-blocker BP medication card out of the cart and stated, here is the [calcium channel blocker - a different BP medication that causes the heart and arteries to relax]. Staff FF did not realize they were holding the same beta-blocker BP medication card from earlier, rather than the calcium channel BP medication. Staff FF then added a second 25 mg tablet of the extended-release beta-blocker into a cup. Once Staff FF completed preparing the medications for administration, they crushed all of Resident 72's medications, including the following: an enteric coated iron tablet; an extended-release beta-blocker BP medication; and a delayed release anticonvulsant medication (a medication used to treat mental illness characterized by extreme mood swings). Staff FF then picked up some applesauce to mix in with the medications, while they were still separated, and stated they were ready to go administer the medications to Resident 72 after mixed. In an interview at this time, Staff FF was asked to stop and pull out the medication card for the calcium channel BP medication from the medication cart. Staff FF opened the drawer and was unable to locate a calcium channel BP medication for Resident 72. Staff FF confirmed they had accidentally doubled the dose of Resident 72's beta-blocker BP medication and omitted the resident's calcium channel BP dose. Review of Resident 72's September 2024 Medication Administration Record (MAR) revealed directions to staff to administer only 25 mg of the beta-blocker BP medication, rather than the 50 mg Staff FF almost administered. This MAR showed directions to staff to also administer 10 mg of a calcium channel BP medication, which Staff FF omitted. In an interview on 10/01/2024 at 10:31 AM, Staff FF was asked if they had a list of what medications could be crushed available to them, Staff FF stated they were not aware of any lists. In an interview on 10/01/2024 at 2:01 PM, Staff FF indicated they reviewed the medications and stated they should not have crushed the iron tablet or any extended or delayed released medications. On 10/02/2024 at 9:08 AM, Staff B (Director of Nursing) provided a copy of the facility's pharmacy list of medications that should not be crushed or altered. Review of the list showed the enteric coated iron tablet, the extended-release beta-blocker BP medication, and the delayed release anticonvulsant medication were on the list. <Resident 4> Observation of medication pass on 10/03/2024 at 8:22 AM showed Staff H (Registered Nurse) prepare and administer multiple medications by mouth to Resident 4. During administration, Staff H handed the medication cup to Resident 4 and then looked away towards a television in the room. Resident 4 brought the cup of medications to their mouth to take the pills, and one white tablet fell and landed on the floor when Staff H was not looking. Resident 4 had the other pills on their tongue and was trying to tell and show the nurse the first pill fell out, when a second pill fell and landed on their shirt. Staff H assisted Resident 4 to retrieve the pill on their shirt and stated, there you go. In an interview at this time, Staff H stated Resident 4 got all their medications. Observations at this time, showed the white pill that fell on the floor near the bed. Staff H moved the bed and located the dropped pill. Staff H confirmed the omitted medication was a vitamin D tablet. Review of Resident 4's September 2024 MAR revealed directions to staff to administer 1000 units of vitamin D and 1000 micrograms of vitamin B every morning. Both of these medications were omitted when Staff H administered Resident 4's medications. In an interview on 10/03/2024 at 11:05 AM, Staff H stated they must have clicked both medications on the computer since the names and doses looked similar. Staff H stated it was important to observe a resident during medication administration in order to ensure all medications were administered and did not fall out. In an interview on 10/04/2024 at 2:13 PM, Staff B stated it was their expectation staff administer medications as ordered, observe as medications were administered, and not crush uncrushable medications. Refer to F760 Residents Are Free Of Significant Medication Errors. REFERENCE: WAC 388-97-1060 (3)(k)(ii). .

<Unsecured Medications in Shower Room> Observation on 09/29/2024 at 09:23 AM west shower room door was unlocked. Observed showed an unlocked cabinet in the shower room contained five bottles of various resident's prescription medicated shampoo bottles. In an interview on 10/02/2024 12:02 PM, Staff N (Certified Nursing Assistant) stated the medicated shampoos were not locked in the cabinet. Staff N stated they thought the cabinet was too high for residents to reach. In an interview on 10/02/2024 at 12:00 PM, Staff M (Licensed Practical Nurse) stated the medication shampoos should be locked up. In an interview on 10/04/2024 at 09:33 AM, Staff B stated prescription shampoo should be locked up and out of reach of residents. Staff B stated if staff saw medication or chemicals that were unsecured, they should make sure these items were locked up and kept out of reach. REFERENCE: WAC 388-97-1300(2). <East Medication Cart> Observation on 09/30/20204 at 1:55 PM of the East medication cart showed an 08/31/2024 expired lubricating jelly and eight medicated patches that expired 08/2024 with one of them opened and placed back into their box. In an interview at this time, Staff H (Licensed Practical Nurse) stated they were expected to dispose of all expired medications immediately upon expiration. The East medication cart drawers had spilled sticky liquids in the bottom of them and the outside of the cart was dirty with splatters. During a change of shift narcotic count observation on 09/30/2024 at 2:27 PM, Staff H was counting off with Staff OO (Registered Nurse). During this observation, review of the East wing narcotic count book showed multiple medications transferred to other pages without the new page or the prescription number being documented. Staff H stated they were expected to complete documentation for all the boxes/questions on the narcotic book page. Staff H stated they should have documented which page the medication was transferred to and the prescription number so they could accurately keep track of the medication. In an interview on 10/04/2024 at 8:59 AM Staff B (Director of Nursing) stated they expected staff to place expired medications in a box in the medication room that identified them as expired medications and return them to the pharmacy as soon as possible. Staff B stated they expected staff to complete all boxes on the narcotic page, including the page they transferred to and the prescription number, when staff were transferring a medication from one page to another. Staff B stated it was important to document all the boxes to be able to keep track of the narcotic medications.Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured, dated when opened, expired medications and biologicals were disposed of timely in accordance with professional standards, medications were stored at beside only for assessed residents, and ensure medication carts were locked and secured when staff were not present for 2 of 4 medications carts, 1 of 2 medication rooms, and 1 shower room. These failures placed residents at risk for receiving expired medications and access to unsecured, prescription medications. Findings included . <Facility Policy> Review of the facility's Medication Storage policy, dated 01/2024, showed medications and biologicals would be stored properly to support safe, effective drug administration. The medication supply would only be accessible to licensed nursing personnel. The policy showed medications would be stored so that various routes of administration would be separated. Internally administered medications would be stored separately from medications such as creams, lotions, and ointments. Outdated and discontinued medications would be removed from stock. Review of the facility's Medication Storage - Bedside Medication Storage policy, dated 01/2024, showed bedside medication storage was only permitted for residents who were able to self-administer medications upon a doctor's order and when deemed appropriate by nursing staff. <Unlocked Medication Carts> Observation on 10/03/2024 from 5:00 AM to 5:12 AM showed the Southwest and [NAME] medication carts unlocked. Both carts contained over-the-counter medications and prescription medications containing resident information, unsecured by staff. There were two unsecured medications sitting on top of the Southwest cart. There were no staff or residents observed in the hallways during this time. In an interview on 10/03/2024 at 5:12 AM, Staff Q (Registered Nurse) stated they were the nurse assigned to the Southwest and [NAME] medication carts that night. Staff Q stated they just returned from their break did not remember to lock the carts. Staff Q stated they should not leave the medication carts unlocked. Staff Q stated they should not leave medications on top of the cart, unattended. In an interview on 10/04/2024 at 10:43 AM, Staff B (Director of Nursing) stated it was important to ensure medication carts were locked for resident safety. Staff B stated residents could have access to medications they were not supposed to have when carts were unsecured and unattended. Staff B stated medication carts should be locked when not attended by licensed nurses. <Southwest/West Medication Room> Observation on 09/30/2024 at 1:56 PM of the Southwest/West medication room showed one vial of tuberculin (serious, highly transmissible respiratory illness) testing solution in the medication fridge. The vial was opened and did not have an open or discard date. In an interview on 09/30/2024 at 1:56 PM, Staff R (Registered Nurse) confirmed the tuberculin vial should contain an open date. Staff R stated they believed the solution was good for 30 days once opened. In an interview on 10/04/2024 at 10:44 AM, Staff B stated it was their expectation tuberculin vials were dated upon opening. <West Medication Cart> Observation on 09/30/2024 at 2:12 PM of the [NAME] medication cart showed a prescription anti-platelet medication for a resident who discharged on 09/18/2024. The [NAME] medication cart also had an uncontained a bottle of topical antifungal powder next to oral medications. In an interview at that time, Staff M (Licensed Practical Nurse) confirmed the discharged resident's medication and removed the medication from the cart. Staff M confirmed the antifungal powder should not be stored with the oral medications. In an interview on 10/04/2024 at 10:44 AM, Staff B stated oral and topical medications should be stored separately. <Medications at Bedside> <Resident 53> Observations on 10/04/2024 at 9:26 AM showed two brown pills in a clear medicine cup at Resident 53's bedside. Resident 53 stated, oh, I was supposed to take those. In an interview on 10/04/2024 at 9:28 AM, Staff W (Licensed Practical Nurse) removed the medications at Resident 53's bedside and stated they should not be left unsecured in a resident room.

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 4 of 5 residents (Resident 37, 48, 35, & 59) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . <Facility Policy> The facility's updated September 2022 Arbitration Agreement policy in the admission Agreement packet showed the admissions coordinator would review the arbitration agreement with the resident upon admission to the facility. The policy showed the admissions coordinator was responsible for any questions the resident had about the contract. <Resident 37> According to the 04/09/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 37 was alert and oriented with an intact memory. The assessment showed Resident 37 had adequate vision and hearing, and had clear speech during communication. Review of a 04/03/2024 electronically signed arbitration agreement showed Resident 37's name was captured in the signature line and indicated the resident was bound by the terms and condition of the agreement. In an interview on 10/02/2024 at 9:30 AM, Resident 37 stated staff asked them to sign so many papers upon admission, they could not remember signing an arbitration agreement or knew what the arbitration agreement was about. Resident 37 was presented with a copy of their signed arbitration agreement and the resident read the details. Resident 37 stated, .waiving my right to a court hearing, now why would I do that? Resident 37 stated if that was the case, they would not want anyone taking away their right. When asked if the admissions coordinator educated them about the facility's arbitration agreement and/or gave them enough time to read through the contract before having them sign the agreement, Resident 37 stated, No, I do not remember anyone discussing this agreement with me. If I knew it, I would not agree to it. <Resident 48> According to the 04/23/2024 admission MDS, Resident 48 was alert and oriented with an intact memory. The assessment showed Resident 48 had no issues with their vision or hearing and had clear speech during communication. Review of Resident 48's arbitration agreement showed the contract was electronically signed by the resident on 04/18/2024. In an interview on 10/02/2024 at 9:41 AM, Resident 48 stated they did not remember signing an arbitration agreement or knew what an arbitration agreement was about. Resident 48 stated the pile of paperwork they were presented with upon admission was very overwhelming and it was difficult to keep up with all the papers. Resident 48 was presented with a copy of their signed arbitration agreement and the resident read the details. Resident 48 stated they did not remember ever signing this paper and why would they sign this paper. Resident 48 stated they did not remember any staff member talking to them about this agreement. <Resident 35> According to the 05/11/2024 admission MDS, Resident 35 was alert and oriented with an intact memory. The assessment showed Resident 35 had no vision or hearing issues and had clear speech during communication. Review of Resident 35's arbitration agreement showed the contract was electronically signed by the resident on 05/10/2024. In an interview on 10/02/2024 at 10:48 AM, Resident 35 stated they did not remember anyone talking to them about the arbitration agreement. Resident 35 stated they did not remember signing an arbitration agreement or knew what an arbitration agreement was about. Resident 35 stated the facility staff might have talked to their family member but not to them. Resident 35 wanted this surveyor to talk to their family (spouse). In an interview on 10/02/2024 at 12:01 PM, Resident 35's spouse stated they did not know what an arbitration agreement was and no one in the facility talked to them about an arbitration agreement. Resident 35's family stated their spouse would never sign an arbitration agreement if they knew what the contract was about. <Resident 59> According to the 12/21/2023 admission MDS, Resident 59 was alert with an impaired memory, impaired vision, but had clear speech during communication. Review of Resident 59's arbitration agreement showed the contract was electronically signed by the resident's representative on 12/15/2023. In an interview on 10/02/2024 at 11:49 AM, Resident 59's representative stated they did not sign an arbitration agreement with the facility. Resident 59's representative was explained with a copy of their electronically signed arbitration agreement. Resident 59's representative stated they may have signed upon admission, but they did not remember signing an arbitration agreement at all. Resident 59's representative stated if they knew what an arbitration agreement was, they would never sign an arbitration agreement. In an interview on 10/02/2024 at 12:52 PM, Staff L (admission Assistant) stated they were responsible for the facility's arbitration agreement process, and they assisted residents to sign the admission papers including the arbitration agreement upon admission. Staff L stated they explained the details about an arbitration agreement to residents/their representatives before they sign an arbitration agreement. In an interview on 10/04/2024 at 10:21 AM, Staff K (admission Director) stated it was important to ensure the residents had full understanding of the arbitration agreement because it involved giving up their right to court. Staff K stated they were unsure where the disconnect was with all the residents arbitration agreement and they needed to do a better job explaining the contract in a form and manner that the resident best understood. REFERENCE WAC: 388-97-1620(2)(a)(b)(i), -0180(1-4). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 3> According to a 09/21/2024 progress note, Resident 3 tested positive for COVID-19. Resident 3 was under droplet precautions since 09/21/2024 according to the facility's census, resident was immediately placed on Aerosol Contact Precautions on 09/21/2024. Review of the September 2024 Treatment Administration Record showed aerosol contact precautions was scheduled for every shift for COVID positive residents for 10 days starting 09/21/2024. Observation on 09/29/2024 at 11:55 PM showed Resident 3's room had aerosol precautions sign outside of their room with instructions for anyone entering room to put on gloves, gown, eye protection, N95 face mask and to keep door to room closed. Observed Staff GG (CNA) go into Resident 3's room to turn off call light in room with N95 and gloves on only. Observed on 09/29/2024 at 12:56 PM Resident 3's room door was open as they came out to hallway with no mask on. Resident 3 stated in hallway that their wheelchair was not working so needed staff to assist them. Staff V (CNA) helped Resident 3 with wheelchair in hallway and then went into Resident 3's room without any PPE on. In an interview on 10/03/2024 at 9:04 AM, Staff C stated all staff were expected to follow the instructions posted on the sign on resident's door before entering into resident's rooms. REFERENCE: WAC 388-97-1320(1)(a-c)(2)(a-c). <Hand Hygiene> <Resident 16> In an observation and interview on 10/02/2024 at 10:01 AM Staff G (CNA) was providing Resident 16 personal care after a Bowel Movement (BM). Staff G placed double gloves on, cleaned BM off Resident 16's skin then removed the top layer of gloves and proceeded to place a clean brief on Resident 16. Staff G stated they should not wear two pairs of gloves and should perform hand hygiene between dirty and clean cares, but they did not. Staff G stated it was important to perform hand hygiene between dirty and clean cares and glove change for infection control purposes. In an observation and interview on 10/02/2024 at 10:17 AM Staff E (LPN) provided wound care to Resident 16. Staff E was observed to remove the resident's soiled bandages, clean the wound, and change their gloves without performing hand hygiene before placing the new bandage on Resident 16's wounds. Staff E stated they should have washed their hands after removing the dirty gloves and before they placed the new gloves on, but they did not. Staff E stated hand hygiene was important between glove change to prevent infections. In an interview on 10/04/2024 at 9:38 AM Staff C stated they expected staff to wash hands with soap and water between dirty and clean cares during wound care, peri care, and before and after glove change. Staff C stated hand hygiene before and after glove change and between dirty and clean care was important to prevent infections. <Soiled Linen and Garbage Disposal> In an observation and interview on 10/03/2024 at 5:08 AM Staff Z (CNA) had bags full of dirty linen and garbage placed on the floor in the hall outside of rooms 120,121, & 124. Staff Z stated they did not normally put the garbage and dirty linens on the floor in the hallway and stated they should not place bags of garbage and dirty linen on the floor because doing so could increase the risk of infections. In an interview on 10/04/2024 at 9:38 AM Staff C stated they expected staff to remove garbage and soiled linens from the resident's rooms immediately. Staff C stated setting the bags of garbage and dirty linens on the floors in the hallways was placing residents at risk of infection. 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 including COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases, could cause difficulty breathing resulting in impairment or death) and other infections. The facility failed 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- 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 wound care and medication pass. These failures placed all residents and staff at risk for contracting and spreading communicable diseases, including COVID 19, during a COVID 19 outbreak in the facility. Findings included . <Facility Policy> According to the facility's 09/06/2023 revised Prevention and Management of COVID- 19 policy, when TBPs were implemented, the Infection Preventionist (IP) determined the appropriate notification to be placed on the resident's room door sign identifying the type of isolation required (e.g. Airborne, Droplet, or Contact) to ensure staff and visitors were aware of the type of precautions required. The policy showed the facility followed Aerosol Contact Precautions during a COVID-19 infection outbreak. The sign showed all staff and visitors 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 door closed to prevent spreading the infection. <PPE> During survey, residents in the facility were placed on TBPs from the date of entrance on 09/29/2024, through 10/04/2024. TBP signage outside resident rooms instructed staff to don (put on) a gown, gloves, face shield and an N 95 mask prior to entering a resident room. Upon exit, signage directed staff to doff (remove) and dispose of the gown, N 95 mask, and gloves, and directed staff to disinfect their face shields prior to reuse. Observation on 10/01/2024 at 10:20 AM showed Staff DD (Medical Director) sitting on the [NAME] nurse's station. Staff DD had their mask below their nose, and had no face shield on. In an interview on 10/01/2024 at 10:22 AM, Staff DD stated they were aware of the facility's COVID outbreak and knew about the facility's policy for staff to wear N 95 mask and face shield or goggles inside the facility. Staff DD pulled their mask to their chin while talking to this surveyor. When asked if they were supposed to wear the N 95 mask properly and wear a face shield, Staff DD stated they were supposed to wear the mask properly and wear a face shield inside the facility, but they forgot to wear a face shield. Staff DD stated they pulled their mask down because they were sneezing. Staff DD fixed their mask towards their nose and stated they should wear the mask properly and wear face shield. In an interview on 10/03/2024 at 9:00 AM, Staff C (Infection Preventionist) stated they already talked to Staff DD a few times for not following the instructions regarding PPE. Staff C stated Staff DD should wear the mask properly and wear a face shield in the building. Observation on 10/03/2024 at 6:03 AM showed Staff Q (Registered Nurse) exiting resident room [ROOM NUMBER] wearing a gown, face shield, and N-95 mask. Staff Q removed the gown, sanitized their hands, and walked to the nurse's station. Staff Q did not clean the face shield when exiting the room and did not change their mask. room [ROOM NUMBER] had sign posted on the door for aerosol precautions and instructed staff to don a gown, gloves, face shield, and an N 95 mask prior to entering the resident's room. Upon exit, signage directed staff to doff and dispose of the gown, N 95 mask, and gloves, and to disinfect their face shields prior to reuse. In an interview on 10/03/2024 at 6:07 AM, Staff Q stated it was the facility's process to remove PPE including gloves, gowns, face mask and to clean the face shield when exiting the room. Staff Q stated they removed the gown and gloves inside the room, changed their mask inside the room, and did not clean their face shield. Staff Q stated they were supposed to clean their face shield, but they forgot. Staff Q stated they should follow the sign posted on the resident's door. In an interview on 10/03/2024 at 9:04 AM, Staff C stated the correct way to remove PPE was posted on the wall outside of the resident rooms. Staff C stated all staff were expected to follow the posted method of removal of PPE. Staff C stated face shields were expected to be cleaned after resident care when leaving the resident room. Staff C stated staff should change their masks when exiting the resident's rooms. <PPE> In an interview on 09/29/2024 at 9:36 AM, Staff A (Executive Director) stated the facility was having an outbreak of COVID and all staff were to wear fit-tested respirator masks and eye protection. Observations on 09/29/2024 at 9:17 AM showed Staff W (Licensed Practical Nurse - LPN) walking in the hallway with their fit-tested respirator mask positioned under their nose. On 09/29/2024 at 11:54 AM, Staff W came out of a resident's room with their mask positioned under their nose. Observations on 09/30/2024 at 2:31 PM showed Staff I (Occupational Therapist) walking in the hallway wearing no eye shield or protective goggles. Staff I entered room [ROOM NUMBER], closed the door, and remained in the room until 2:59 PM without protective eyewear. Observations on 10/01/2024 at 10:10 AM showed Staff KK (Physical Therapist Assistant) exiting a resident's room with their eye protection worn on the top of their head, rather than covering the eyes for protection. Observations on 10/01/2024 at 11:15 AM showed Staff DD standing at the counter of the nurse's station on the East unit with no face shield. Residents were sitting nearby the nurse's station. Observations on 10/01/2024 at 11:20 AM showed Staff JJ (Housekeeping Aide) was exiting room [ROOM NUMBER], a room with an Aerosol precaution sign, due to the residents having COVID. Staff JJ changed their face shield, but did not change their mask. They were wearing a yellow adhesive mask. In an interview at this time, Staff JJ stated they wore masks they purchased themselves, and only changed them on their breaks due to the expense. In an interview on 09/29/2024 at 2:48 PM, Staff C stated they were in charge of infection control and stated their expectation was for staff in all departments to wear a fit-tested respirator mask and face shield or goggles when in the facility. <TBP> Observations on 09/29/2024 at 9:21 AM showed staff entering room [ROOM NUMBER], without a gown or gloves on, put on gloves once inside the room, and then closed the door. This room had a sign posted at the door which indicated the resident was on Contact Enteric precautions (a set of procedures that prevent the spread of germs that can cause intestinal upset). The sign directed staff to put on a gown and gloves prior to entering the room. Observations on 09/29/2024 at 1:09 PM showed the door to room [ROOM NUMBER] was open. Sign posted on the door indicated the resident was on Aerosol precautions. The sign directed staff to keep the resident's door closed. In an interview on 09/29/2024 at 2:48 PM, Staff C stated prior to entering a room of a resident on Aerosol precautions, staff were expected to put on all their PPE, dispose of their gown and gloves in the room prior to exit, after exit they were to clean their shield, and change their fit-tested respirator mask to a new one. Staff C stated the door should be shut if a resident was on Aerosol precautions, to help reduce the risks of spreading infection. Observations during medication pass on 10/01/2024 at 9:28 AM showed Staff FF (LPN) put on PPE to deliver medications to a resident on Aerosol precautions due to a contagious respiratory infection. Upon exiting the resident's room, Staff FF changed their face shield but kept the same fit-tested respirator mask on they wore inside the isolation room. Staff FF walked from the unit with several COVID positive residents over to another unit on the other side of the building while wearing the same soiled mask. While Staff FF was preparing medications for another resident, they touched their soiled mask with their hand, touched the medication cart keys, and then put them back in their pocket. Observations on 10/03/2024 at 7:45 AM showed Staff II (LPN) put on PPE to enter room [ROOM NUMBER] to assist a resident with medication administration. This room had a posted Contact Enteric precaution sign at the door which gave directions for staff to wash their hands with soap and water upon leaving the room. Upon finishing, Staff II removed PPE, exited the room and returned to their medication cart to use hand sanitizer. Staff did not wash their hands with soap and water as the posted sign directed. Observations on 10/03/2024 at 7:48 AM showed Staff EE (Certified Nursing Assistant - CNA) put on a gown and gloves prior to entering room [ROOM NUMBER]. This room had a posted Contact Enteric precaution sign at the door which gave directions for staff to wash their hands with soap and water upon leaving the room. Staff EE provided toileting assistance to the resident and upon finishing, removed their gown and gloves, and only used hand sanitizer when exiting the room. Staff did not wash their hands with soap and water as directed, and then went into room [ROOM NUMBER] to provide assistance. In an interview on 10/04/2024 at 10:17 AM, Staff C stated it was their expectation staff follow the TBP signs posted and to wash their hands with soap and water when exiting a room with Contact Enteric precautions in place in order to reduce the risk of spreading contagious infections <Uncleanable Surfaces> Observations on 09/29/2024 at 12:15 PM showed a vinyl cover over a linen cart across from room [ROOM NUMBER]. The cover had cracked material at the creases, exposing the material underneath. Similar observations of the cracked material on the linen cart were made on 09/30/2024 at 8:30 AM, and 10/01/2024 at 9:28 AM. In an interview on 10/04/2024 at 10:17 AM, Staff C stated the linen cart covers should not have cracked, uncleanable surfaces. <Medication Administration> Observations during medication pass on 10/01/2024 at 9:28 AM showed Staff FF preparing medications for a resident. During preparations, one pill missed the cup and landed on top of the medication cart. Staff FF picked up the pill with their bare fingers, placed it inside the medication cup, and then delivered it to a resident for administration. In an interview on 10/04/2024 at 10:17 AM, Staff C stated staff should absolutely not touch medications with their bare fingers and their expectation was for staff to use sanitizer and gloves when touching pills directly.<Transmission Based Precautions> According to a 09/21/2024 progress note, Resident 34 tested positive for COVID-19 on that date. The note showed necessary precautions were put in place for Resident 34. According a 09/21/2024 progress note Resident 25 was placed on aerosol contact precautions on that date related to their roommate Resident 34 testing positive for COVID-19. A 09/28/2024 progress note showed Resident 25 tested positive for COVID-19 on that date. Observation on 09/30/24 02:23 PM showed an Aerosol Contact Precaution sign outside room [ROOM NUMBER], both residents in that room were isolated. The sign directed anyone entering the room to put on a gown, gloves, eye protection and an N-95 respirator prior to entering the room. The sign directed everyone to remove all their PPE before leaving the room and replace their eye protection and respirator. At that time Staff O (CNA) heard one of the residents in the room cry out. Staff O already wore eye protection and a respirator and put on a gown and gloves prior to entering the room room. Observation on 09/30/24 at 2:28 PM showed Staff O leave room [ROOM NUMBER] with their gown and gloves removed but still wearing the same or respirator after exiting. Staff O then entered room [ROOM NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services in accordance with professional standards of practice. The facility failed to ensure physician orders were followed, implemented timely, or were clarified as needed; Care Plans (CP) developed for 3 (Resident 2, 4, 3) of 3 residents reviewed; medications were not provided as ordered, for 1 (Resident 5) of 3 residents reviewed; and to monitor weights and bowels, act on, or implement their policies for 4 (Residents 3, 2, 1, 4 ) of 4 residents reviewed. These failures placed all residents at risk for unmet care needs, and decreased quality of life. Findings included . <Following, Implementation & Clarification of Physicians Orders & CP> <Resident 2> Review of an admission Minimum Data Set (MDS, an assessment tool) showed Resident 2 admitted to the facility on [DATE], was able to make their needs known, make their own decisions, and had behaviors of rejecting care four to six days out of a seven day look back. The MDS showed Resident 2 was dependent on staff for toileting hygiene, bathing, bed mobility, and transfers. The MDS showed Resident 2 had medically complex conditions, including surgical after care following intestinal perforation (a hole passing through) , acid reflux, and muscle weakness. The MDS showed Resident 2 had surgical wounds, received surgical wound care with the application of medications, and was not on a specialized diet. Review of a baseline CP, dated 07/24/2024, showed Resident 1 had a regular diet with regular textured food and thin liquids. Review of a Nutrition Hydration risk CP, dated 08/26/2024, implemented 32 days after Resident 2 admitted to the facility showed Resident 2 was at risk for nutritional issues related to diuretic (water pill, induces urination) use, inflammation of the large intestine with an abscess (collection of pus), obesity, and muscle weakness. The CP directed staff to provide diet as ordered by the physician, refer to the facility Registered Dietician (RD) as appropriate, and weights per the facility protocol. Review of a hospital after visit summary and hospital transfer orders, dated 07/24/2024, showed a physician order for Resident 2 to continue with a high protein diet. Review of a hospital Nutritional Assessment, dated 08/07/2024, showed Resident 2 had increased nutritional needs due to surgical wounds healing, unintended weight loss, and poor intake by mouth. The nutritional assessment showed Resident 2 was on a regular diet with high calories and high protein. On a subsequent re-admission to the facility on [DATE], no diet order was on the hospital transfer orders and facility staff did not identify or clarify Resident 2's diet. During an interview on 09/12/2024 at 1:10 PM, Staff F (Registered Dietician (RD)) stated Resident 2 was on a regular diet, acknowledged the 07/24/2024 hospital transfer orders showed a a high protein diet should be continued but Resident 2 was not on a high protein diet as ordered. Staff F stated residents nutritional status was assessed within the first fourteen days of admission, the fourteen day period would start over if the resident was re-admitted to the facility. Staff F stated Resident 2 was not assessed by the RD or a CP developed until 08/23/2024, 29 days after Resident 2 admitted to the facility. In an interview on 09/12/2024 at 1:14 PM, Staff B (Director of Nursing) stated Resident 2 was not on the high protein diet per the hospital transfer orders. Staff B stated Resident 2 was not discussed or reviewed in the facility nutrition/hydration skin committee meetings. <Resident 4> Review of an admission MDS, dated [DATE], showed Resident 4 admitted to the facility on [DATE], was able to make their needs known, make their own decisions, and had behaviors of rejecting care one to three days of a seven day look back. The MDS showed Resident 4 required staff assistance with toileting hygiene, transfers, and ambulating. The MDS showed Resident 4 had medically complex conditions, including a gastrointestinal infection, high blood pressure, and anxiety. Review of an anxiety CP, dated 09/06/2024, showed Resident 4 had anxiety due to effects of the current disease processes and an unfamiliar environment. The CP directed staff to encourage family to visit, have the resident attend social activities, and encourage the resident to identify and express causes of anxiety. Review of a care conference evaluation, dated 09/03/2024, under section titled resident/resident representative issues and concerns showed, Resident 4 and the CC had concerns with Resident 4's anxiety and wanted a medication to treat the anxiety. The care conference evaluation showed on 09/03/2204, Resident 4 was referred to behavioral health services for anxiety, medication management, mood and behavior management. Resident 4 was not currently prescribed any medications for anxiety. Review of a psychiatric provider note, dated 09/04/2024, showed Resident 4 was seen by a provider for an anxiety disorder and depression. The note showed the provider assessed Resident 4 with difficulty falling asleep, sadness, fatigue, racing thoughts, difficulty relaxing, and restlessness. The provider recommended Resident 4 start two medications to manage their anxiety and depression. Review of Resident 4's physician orders , showed a physician orders, dated 09/10/2024 for Resident 4 to start an anti-anxiety medication, this was six days after the psychiatric provider made recommendations. An additional physician orders, dated 09/10/2024, showed an anti-depressant medication for Resident 4 ordered six days after recommendations were made. In an interview on 09/10/2024 at 1:45 PM, Resident 4's Collateral Contact (CC) stated the resident had increased anxiety that affected their eating, sleeping, and therapy progress. The resident was afraid to move at times when they had an indwelling catheter (tube that drains urine from the bladder). During an interview on 09/12/2024 at 2:45 PM, Staff B stated they were not sure why the psychiatric providers recommendations were implemented six days after but would expect staff to implement provider orders after they are written. <Resident 3> Review of an admission MDS, dated [DATE], showed Resident 3 admitted to the facility on [DATE], was able to make their needs known, had a decision maker, and had no behaviors. The MDS showed Resident 3 was dependent on staff for toileting, bed mobility, and transfers. The MDS showed Resident 3 had medically complex conditions, including surgical aftercare following blood vessel surgery, diabetes. pain, and carpal tunnel syndrome. Review of a baseline CP, dated 07/18/2024, showed interventions that directed staff to report verbal and physical signs of pain. The CP showed Resident 3 had chronic pain in their left leg. Review of Resident 3's comprehensive CP showed no specific CP for Resident 3's pain. Review of a pain evaluation, dated 07/18/2024, showed Resident 3 was assessed with pain that was aching, chronic and affected their activities and appetite. The evaluation showed Resident 3 was prescribed three different types of pain medications, and rest and medications improved their pain. Review of Resident 3's Medication Administration Record (MAR), dated 07/2024, showed a physician orders that directed staff to monitor Resident 3 for side effects of opioid use, such as delirium, over sedation, change in mental status, and reduced respirations. The physician orders directed staff when side effects were observed, document a y for yes and add a progress note. The MAR showed staff documented y for side effects for 12 days. Review of nursing progress notes, dated 07/18/2024-07/29/2024, showed no documentation on what side effects Resident 3 experienced, who or when they were notified, and what staff did to manage the side effects. A nursing progress note dated 07/29/2024, showed Staff D (Registered Nurse (RN)/Resident Care Manager (RCM)) documented they were informed by Resident 3's Collateral Contact (CC) that Resident 3 was very sleepy and would like their pain medication changed. Staff D contacted the physician and had the medication changed to a less stronger medication. In an interview on 08/16/2024 at 1:35 PM, Resident 3's CC stated Resident 4 had no tolerance for pain medications and was drowsy when they visited. The CC stated they informed numerous staff about Resident 4 being overly sleepy and not acting like their normal self. The CC stated they told Staff D on 07/29/2024, and Staff D contacted the physician who changed the pain medication to something not as strong. During an interview on 09/12/2024 at 2:55 PM, Staff B stated they were not sure what the side effects were that Resident 3 experienced. Staff B stated depending on what the side effect were observed would direct how staff should respond. Staff B stated they expected staff to follow the physician orders and when side effects were observed staff should notify the physician and document. <Medications Provided as Ordered> <Resident 5> Review of an annual MDS< dated 08/21/2024, showed Resident 5 admitted to the facility on [DATE], was able to make their needs known, own decisions, and had no behaviors. The MDS showed Resident 5 was dependent on staff for toileting, personal hygiene, bed mobility, and transfers. The MDS showed Resident 5 had medically complex conditions, including heart failure, diabetes, anxiety, and depression. Review of a diabetes CP, revised on 07/29/2024, showed the goal for Resident 5 was to have no complications related to their diabetes. The CP directed staff to administer diabetes medications as ordered by the physician, and monitor and report any signs of low or high blood sugar levels to the physician. Review of Resident 5's physician orders showed a physician orders, dated 08/31/2024, that directed staff to administer 44 units of insulin to Resident 5 twice daily. Review of Resident 5's September 2024 MAR, showed on 09/01/2024 day shift staff documented a 9, which indicated other, see progress note according to the MAR chart codes. On 09/06/2024 day shift, staff documented OO, which indicated the medication was on order from the pharmacy, and on 09/07/2024 day shift staff documented a 9. Review of Resident 5's nursing e-mar (electronic medication administration record) notes, dated 09/01/2024, showed Staff G (RN/RCM) documented that Resident 5 received 45 units of insulin, the insulin dose was clarified with the pharmacists, and the physician was notified regarding the dosage. The note did not indicate what the pharmacy or physician responded to the insulin dose of 45 units. Review of e-mar notes, dated 09/06/2024, showed no notes regarding Resident 5's insulin administration, if pharmacy was called to determine where medication was or to clarify with the physician on the missed insulin dose. Review of e-mar notes showed on 09/07/2024, Staff H (RN) documented order clarified with the pharmacist, who called on-call provider, insulin now increased to 45 units twice daily. Review of Resident 5's September 2024 MAR, showed facility staff updated Resident 5's insulin order on 09/07/2024, six days after insulin orders were clarified on 09/01/2024. During an interview on 09/10/2024 at 3:00 PM, Staff D stated the emergency medication kit had insulin available. Staff D stated when a resident ran out of insulin staff are expected to check the emergency medication kit, if none available there, the staff should call the pharmacy to have the medication sent right away. In an interview on 09/10/2024 at 3:25 PM, Resident 5 stated they missed four doses of insulin, their blood sugars had been low, and were told by staff there was no extra insulin in the emergency kit. Resident 5 stated they got upset when staff didn't inform them of running out of medications and was worried about their blood sugar levels and had staff check their blood sugar every few hours. During an interview on 09/12/2024 at 3:00 PM Staff B stated they facility had an emergency medication kit (Cubex) available. When the medication was not available in the Cubex, staff were expected to call the pharmacy to have the medication sent to the facility as soon as possible. Staff B stated staff should call and inform the physician of the medication not being available and implement any orders given for an alternative medication. <Monitoring & Implementation on Weight and Bowel changes> According to the facility policy, titled Weights, revised 07/30/2024, showed new admission residents were weighed on the day of admission, then weekly for one month. The policy showed for residents on dialysis, the facility used the weights from the dialysis center. The policy showed any weight with a five pound (lb) variance, the resident would be re-weighed in 24 hours. Once the re-weigh was completed the weight would be recorded in on the permanent weight record. When a significant weight variance was identified, staff were expected to document in the medical record, revise the CP, refer the resident to the nutrition hydration skin committee, and notify the physician and the resident representative. <Resident 3> Review of an admission MDS< dated 07/24/2024, showed Resident 3 admitted to the facility on [DATE], was able to make needs known, had a decision maker, and no behaviors. The MDS showed Resident 3 was dependent on staff for toileting, bed mobility, and transfers. The MDS showed Resident 3 had medically complex conditions, including surgical aftercare following blood vessel surgery, diabetes. pain, and carpal tunnel syndrome. The MDS showed Resident 3 had no or unknown weight loss or gain. Review of Resident 3's nutrition/hydration risk CP, dated 07/31/2024, showed Resident 3 was at risk for nutrition and hydration deficits related to their current medical condition, history of bariatric surgery, diabetes, pressure ulcer, and history of a kidney transplant. The CP goal was for Resident 3 to have no significant weight loss or gain, and directed staff to weigh Resident 3 per the facility policy. Review of Resident 3's weight record, showed on 071/19/2024, Resident 3 weighed 191.2 lbs. A second weight was completed on 07/29/2024, Resident 3 weighed 152.1 lbs., a loss of 39.1 lbs. No additional weights were observed in the record and no additional weight documents were provided when requested from Staff B. Review of a Nutritional Evaluation, dated 07/31/2024, showed Staff F (Registered Dietician (RD)) evaluated Resident 3 with a significant weight loss of 20.4% percent of their body weight in one month. Staff F requested a re-weigh to verify current weight. In an interview on 09/12/2024 at 1:30 PM, Staff B stated residents were weighed within the first 24 hours of admission. When asked to clarify the weight policy, Staff B stated residents should be weighed the day of admission to the facility and weekly thereafter. When asked where the weekly weight for 07/26/2024 was documented, Staff B stated Resident 3 refused, and it might be documented in a restorative binder, as the restorative aides weighed the residents. No additional weights were provided and Staff B stated we missed it. When asked about Resident 3's significant weight loss, Staff B stated the re-weigh would have been done on 08/01/2024 but the resident was discharged to the hospital with increased confusion. When asked when the significant weight loss was found on 07/29/2024 what actions did staff take, Staff B replied the re-weigh should have been done on 07/30/2024, and acknowledged no re-weigh was completed as recommended by the RD. <Resident 2> Review of an admission MDS, dated [DATE], showed Resident 2 admitted to the facility on [DATE], was able to make needs their known, make their own decisions, and had behaviors of rejecting care four to six days of a seven day look back. The MDS showed Resident 2 was dependent on staff for toileting hygiene, bathing, dressing, bed mobility, and transfers. The MDS showed Resident 2 had medically complex conditions, including abdominal surgery, acid reflux, and muscle weakness, The MDS showed Resident 2 had no or unknown weight loss or gain. Review of Resident 2's nutrition/hydration CP, dated 08/26/2024, showed Resident 2 was at risk for nutrition and hydration deficits related to diuretic medication use, recent abdominal surgery, obesity, and difficulty walking. The CP directed staff to weight the resident per the facility policy and refer to the RD as appropriate. Review of Resident 2's weight record showed Resident 2's first weight was 426 lbs on 07/26/2024, two days after Resident 2 admitted to the facility. Resident 2 weighed 419.1 lbs on 08/01/2024, a loss of 6.9 lbs. The document showed no re-weight was obtained after the 6.9 lb loss. Review of Resident 2's weights showed on 08/10/2024 Resident 2 weighed 424.4 lbs, and the weight was completed a day after Resident 2 re-admitted to the facility. The weight record showed no weight was obtained weekly on 08/17/2024 and a 08/25/2024 weight showed Resident 2 weighed 415 lbs, a loss of 9.4 lbs. Review of nursing progress notes, dated 07-24/2024-08/25/2024, showed no documentation that staff attempted to weigh Resident 2 on admission and re-admission to the facility. The documentation did not support staff informed the physician or Resident 2 about the 6.9 lb weight loss or the additional 9.4 lb weight loss. During an interview on 09/12/2024 at 1:45 PM, Staff B stated Resident 2 was not weighed on the date of admission and re-admission to the facility and expected weights to be completed on the day of admission. Staff B stated the weights should be in the residents record, re-weighs should be documented in the record within the next 24 hours, and the resident should be weighed weekly. When asked what the facility did about Resident 2's 9.4 lb weight loss, Staff B Stated Resident 2 should be re-weighed and acknowledged the weight was not in the record. <Resident 1> Review of Resident 1's admission MDS, dated [DATE], showed Resident 1 admitted to the facility on [DATE], was able to make their needs known and required assistance with decision making. The MDS showed Resident 1 was always incontinent of bowels, had no behaviors of rejecting care and required maximum assistance from staff for toileting hygiene, bed mobility, and transfers. The MDS showed Resident 1 had medically complex conditions, including respiratory failure, end stage renal disease requiring dialysis (removing excess water, solutes and toxins from the blood when kidneys no longer work), anxiety, and muscle weakness. The MDS showed Resident 1 had no or unknown weight loss or gain. Review of Resident 1's nutrition/hydration CP, dated 07/25/2024 showed Resident 1 was on a 2 liter daily fluid restriction. The CP directed staff to monitor Resident 1's weights per the facility policy and refer to the facility RD as appropriate. Review of Resident 1's weight record, showed on 07/26/2024, a day after admission, Resident 2 weighed 136.7 lbs. The weight record showed a day later on 07/27/2024, Resident 2 weighed 141.8 lbs, a weight gain of 5.1 lbs in one day. Two additional weights were documented on the weight record and showed on 07/30/2024 Resident 2 weighed 141.3 and on 08/02/2024 Resident 2 weighed 139.8 lbs. No additional weights were observed in Resident 2's record. In an interview on 09/12/2024 at 1:55 PM, Staff B stated when a resident was receiving dialysis the facility used the weights obtained at the dialysis center. Staff B stated Resident 1 attended dialysis three times a week, weights should be sent back with the resident and if not, the nurse was expected to call the dialysis center to obtain the weight information. Staff B acknowledged dialysis weight records were not in Resident 1's record but should be. Staff B stated Resident 1 was not weighed on the day of admission or re-admission to the facility on [DATE]. <Resident 4> Review of an admission MDS, dated [DATE], showed Resident 4 admitted to the facility on [DATE], was able to make needs known, own decisions, and had behaviors of rejecting care one to three days of a seven day look back. The MDS showed Resident 4 required staff assistance with toileting hygiene, transfers, and ambulating. The MDS showed Resident 4 had medically complex conditions, including clostridium difficile (c.diff, a contagious gastrointestinal infection causing diarrhea), high blood pressure, and anxiety. Review of a nursing progress note, dated 08/22/2024, showed Resident 4 admitted to the facility following a gastrointestinal infection, required antibiotics, and therapy for weakness. The nursing progress note showed Resident 4 had a formed stool on 08/22/2024. Review of Resident 4's bowel monitoring, dated 09/04/2024-09/09/2024, showed on 09/04/2024 Resident 4 had multiple loose stools on day, evening, and night shift. The bowel monitoring showed Resident 4 continued to have loose stools on 09/05/2024, on day, evening, and night shift. The bowel monitor showed Resident 4 continued to have loose stools on 09/06/2024, 09/07/2024, 09/08/2024, and four loose stools on 09/09/2024. Review of a 09/10/2024, lab result for stool testing, showed Resident 4 was positive for c.diff. Review of a 09/10/2024 infection control note showed, Staff C (Infection Preventionist) documented Resident 4 continued on contact precautions (intended to prevent the transmission of infectious agents). In an interview on 09/10/2024 at 1:45 PM, Resident 4's CC stated the resident continued to have a lot of diarrhea, The CC stated they informed staff but had to tell the staff multiple times about the diarrhea and eventually asked the facility to re-test Resident 4 for c.diff, as the resident recently completed antibiotics for their c.diff infection. The CC expressed concern that the infection was not resolved after completing the antibiotics. In an observation and interview on 09/10/2024 at 4:15 PM, Resident 4 was observed in their bed resting. Resident 4's room was observed with a contact precautions sign that directed staff to put on a gown and gloves upon entering the room. Resident 4 stated they continued to have diarrhea, their tail bone was very sore, and had difficulties sleeping. During an interview on 09/10/2024 at 4:40 PM, Staff I (Registered Nurse) stated when a resident had multiple loose stools the nurse should assess the resident and check bowel tones and stool for consistency and smell. The nurse should take vital signs, check for signs of dehydration, determine a potential cause of the diarrhea, notify the physician and implement any orders. In an interview on 09/12/2024 at 2:00 PM, Staff C stated bowel monitors were reviewed in the morning meetings and the protocol for c.diff was three or more loose stools in a 24 hour period. Staff C stated all staff should know the protocol and initiate contact isolation if c.diff was suspected. Staff C reviewed Resident 4's bowel monitoring and stated Resident 4 should have been put on contact isolation on 09/04/2024, when the resident had multiple loose stools and met the criteria for contact isolation. Staff C stated no other residents were positive for c.diff and Resident 4 would remain in a private room on contact isolation. REFERENCE: WAC 388-97-1060(3)(h)(k) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 3 of 3 (Residents 3, 4, 1) residents reviewed for Pressure Ulcers (PU, injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, implement wound provider recommendations, and preventative skin measures placed all resident's at risk for deterioration in skin condition(s), pain, and diminished quality of life. Findings included . Review of the facility policy titled, Skin Integrity, updated 10/2022, showed to maintain the resident's skin integrity and promote healing of skin ulcers/PU's/wounds the facility would use a systematic approach and monitoring process to evaluate and document skin integrity. When a resident admitted to the facility with or developed a skin ulcer/PU/wound the facility would provide care to treat, heal, and prevent, when possible the further development of skin ulcers/PU's/wounds. The policy showed when a resident was identified with a skin impairment upon admission the Licensed Nurse (LN) would document the skin impairment that included measurements, color, presence of odor, drainage, and pain in the nursing notes and complete a weekly wound evaluation. The LN would notify the resident or resident's responsible party and physician, obtain, and implement a treatment order, evaluate and identify and implement interventions to promote wound healing, and document on the residents Care Plan (CP). <Resident 3> Review of the admission Minimum Data Set (MDS, an assessment tool), dated 07/24/2024, showed Resident 3 admitted to the facility on [DATE], was able to make their needs known, and required assistance with decision making. The MDS showed Resident 3 had no behaviors of rejecting care, was frequently incontinent of their bowels, had impairments to one side of their upper extremities, and was dependent on staff for toileting hygiene, bed mobility, and transfers. The MDS showed Resident 3 had medically complex conditions, including surgical aftercare, peripheral vascular disease (progressive disorder of blood vessels, causing narrowing or blockage affecting the legs and feet), diabetes, history of bariatric surgery, and a kidney transplant. The MDS showed Resident 3 was at risk for developing PU's, had one unhealed stage 4 PU (skin injury that extends down to the muscle, bone or tendons), had one venous or arterial ulcer (result of irregular blood flow), and had surgical wounds. The MDS showed Resident 3 received PU and surgical wound care that required the application of medications. Review of an admission skin assessment, dated 07/18/2024, showed Resident 3 had non-blanchable (oxygen does not perfuse to skin tissue) redness to their tailbone, a skin tear above their tailbone, a stage 1 PU (intact skin that may be painful and red) to the left heel, a surgical incision to their lower abdomen and left thigh. Review of Resident 3's CP, imitated 07/18/2024, showed no CP developed for Resident 3's skin impairments. The CP showed no interventions that directed staff how to manage, heal and prevent further worsening of Resident 3's skin impairments. Review of an outside wound provider note, date 07/25/2024, showed Resident 3 was assessed with a surgical wounds to the left thigh, left groin, left lower leg, an arterial wound to the left lower leg, a stage 2 PU (a shallow open ulcer with a red wound bed) to the left heel, and a stage 4 PU to their tailbone. The wound provider ordered a treatment for the left heel and tailbone PU's. Review of Resident 3's physician orders, dated 07/31/2024, directed staff to provide a treatment for Resident 3's tailbone PU. A second physician order, dated 08/01/2024, directed staff to provide a treatment to Resident 3's left heel PU. Review of the July 2024 Treatment Administration Record (TAR, documentation of treatment orders and staff signatures of completion), showed staff did not implement the wound providers recommendations on 07/25/2024 when treatments were ordered until seven days later. Review of Resident 3's Activities of Daily Living (ADL) bed mobility documentation, dated 07/18/2024-07/31/2024, showed on multiple occasions staff documented NA (not applicable) in response to assisting Resident 3 with rolling from side to side in the bed. Staff documented NA on 07/19/2024 night shift, 07/21/2024 day and night shift, 07/24/2024, 07/25/2024, 07/27/2024, 07/29/2024, and 07/30/2024 night shift. During an interview on 08/16/2024 at 1:35 PM, Resident 3's Collateral Contact (CC), stated when they visited Resident 3 they were swimming in their own stool, was worried about the stool soiling the surgical incisions, and staff would tell Resident 3 we will let you finish before changing the resident. The CC stated Resident 3 had no history of PU's, and the one on their bottom got really bad from just laying there. The CC stated that Resident 1 would make comments that staff ignored them and would not reposition them in the bed. The CC stated Resident 3 was seen by the wound provider on 08/01/2024, was very confused, and the facility sent Resident 3 to the hospital to be evaluated. In an interview on 09/12/2024 at 1:30 PM, Staff B (Director of Nursing Services) stated Resident 3 admitted to the facility following a surgery and needed care for wounds and antibiotic therapy. When asked what skin prevention measures were in place when Resident 3 admitted , Staff B replied the facility implemented wound care orders. Staff A (Administrator) stated all the resident beds at the facility were graded for pressure relief up to a stage 2 PU. Staff B stated Resident 3 should have a CP for their pressure and surgical wounds with interventions, and was not sure why it took six days to implement the would care providers recommendations but would expect staff to implement recommendations as soon as possible. Staff B stated they expect staff to turn and reposition residents every two hours and as needed on all shifts when the resident was in bed, and acknowledged seven of 14 days staff documented NA for bed mobility. Staff B stated they were not sure how Resident 3's tailbone PU went from a Stage 1 to a Stage 4 in one week. <Resident 4> Review of an admission MDS, dated [DATE], showed Resident 4 admitted to the facility on [DATE], was able to make their own decisions, and had behaviors of rejecting care one to three days of a seven day look back period. The MDS showed Resident 4 was occasionally incontinent of bowels, required staff supervision and assistance with toileting hygiene, bed mobility, and moderate assistance with transfers. The MDS showed Resident 4 had medically complex conditions, including clostridum difficile (c.diff, an infectious bacteria causing abdominal discomfort and diarrhea), anxiety, muscle weakness, and difficulty in walking. The MDS showed Resident 4 had no PU's, was at risk for developing PU's, and had an application of a non-surgical dressing. Review of an admission assessment, dated 08/22/2024, showed Resident 4 was assessed with blanchable (oxygen perfuse to skin tissue when pressure applied with finger tip) redness to their tailbone. Review of Resident 4's CP, imitated 08/22/2024, showed no CP developed for Resident 4's risk for skin impairments. The CP showed no interventions that directed staff how to manage and prevent skin impairments for Resident 4. Review of a Nursing Progress Note (NPN), dated 08/22/2024, showed Staff D (Registered Nurse, Resident Care Manager (RCM)) documented Resident 4 was alert, oriented, able to answer questions appropriately, and complained of discomfort to their tail bone. Staff D documented Resident 4 was repositioned on their side, which helped with the pain. Review of Resident 4's physician orders, dated 08/22/2024, showed a physician order that directed staff to apply a foam dressing to resident 4's tail bone every seven days and as needed. Review of Resident 4's August 2024 TAR, showed on 08/23/2024 staff documented a dressing was applied to Resident 4's tail bone. The TAR showed on 08/30/2024, staff documented 1, according to the TAR chart codes, indicated the resident was absent from home without meds. Review of Resident 4's NPN's, dated 08/30/2024, showed Resident 4 was out of the facility for an appointment . The NPN did not address Resident 4 missing their dressing change to their tail bone. Review of NPN, dated 09/03/2024, showed Resident 4 was seen by a urologist, the NPN did not address the new wound found on Resident 4's tail bone at the urology appointment. Review of a wound provider note, dated 9/5/2024, showed Resident 4 was assessed with a Stage 2 PU to their tailbone and ordered a treatment for the PU. During an interview on 09/10/2024 at 1:45 PM, Resident 4's CC stated they were present at a doctors appointment on 09/03/2024, when a wound was discovered on Resident 4's tail bone. The CC stated the doctor's nurse measured the wound at five inches in length and three inches in width. The CC was not aware Resident 4 had the wound. The CC stated Resident 4 complained multiple times to staff of their tail bone hurting. The CC stated Resident 4 couldn't move well by themselves, needed more help, and had a lot of diarrhea lately since being sick. During an interview on 09/12/2024 at 1:40 PM, Staff B stated it was not very common to have a dressing be changed every 7 days, and it should be changed when the dressing was soiled or after a shower. Staff B stated they would expect staff to report to the next shift or re-schedule the dressing change when the resident was out of the facility for a doctors appointment. Staff B stated the facility had knowledge of the wound on 09/03/2024. Staff B stated Resident 4 was referred to the wound provider. Staff B stated Resident 4 did not have a CP with interventions to manage the Stage 2 PU and would expect there to be a CP developed. <Resident 1> Review of Resident 1's admission MDS, dated [DATE], showed Resident 1 admitted to the facility on [DATE], was able to make their needs known and required assistance with decision making. The MDS showed Resident 1 was always incontinent of bowels, had no behaviors of rejecting care and required maximum assistance from staff for toileting hygiene, bed mobility, and transfers. The MDS showed Resident 1 had medically complex conditions, including respiratory failure, end stage renal disease, anxiety, and muscle weakness. The MDS showed Resident 1 had one unhealed Stage 1 PU, was at risk for PU, received PU care, and applications of dressings. Review of Resident 1's skin integrity CP, dated 07/25/2024, showed Resident 1 had an actual impairment to the skin integrity but did not identify what type of wound, wound characteristics or wound location. The CP directed staff to follow facility protocols for treatment of injury, monitor/document the location, size, and treatment of the skin injury, and directed staff to report any abnormalities to the physician. The CP directed staff to monitor the wound weekly and document the wound characteristics. Review of hospital transfer PO's, dated 07/25/2024, showed Resident 1 had PO that directed staff to provide wound care and a referral to wound care for their stage 2 PU. Review of a NPN, dated 07/25/2024, showed Staff E (Licensed Practical Nurse, RCM) documented Resident 1 admitted to the facility with a Stage 2 PU to their tail bone. The NPN showed Resident 1's wound measured four centimeters (cm) in length, three cm in width, and 0.1 cm in depth. Review of Resident 1's medical record showed no documentation of weekly wound assessments for Resident 1's stage 2 PU after the first assessment was completed on admission. Resident 1's stage 2 PU was not assessed on 08/01/2024 or 08/08/2024. During an interview on 09/12/2024 at 1:30 PM, Staff B stated Resident 1 should have a CP that identified the type and location of the wound. Staff B stated Resident 1's weekly wound assessments were missed and they would expect wounds to be assessed weekly with documentation. Staff B stated resident's with a stage 2 or higher PU were referred to a wound provider and Resident 1 was not referred to a wound provider as they would expect. REFERENCE: WAC 388-97-1060(3)(b) .

**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 for nutrition maintained acceptable parameters of nutritional status. Failure to ensure consistent, timely weights and re-weights, identify significant weight changes timely, notify interested parties timely, and implement Registered Dietician's (RD) recommendations placed the residents at risk for delayed identification of interventions to prevent continued weight loss and decreased quality of life. Findings included . Review of the facility policy titled, Weights, revised on 10/12/2023, showed weighing criteria included obtaining a weight on the day of admission then weekly for one month. The policy showed guidelines for residents who may need to be weighed weekly due to; food intake declined and persisted, slow trending weight loss or gain, significant weight loss or gain, multiple stage two Pressure Ulcers (PU, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) and any stage 3 PU (full thickness loss of tissue) or stage 4 PU (full thickness skin loss that extended to the muscle, bone and tendons). The policy showed any weight with a five pound variance would be re-weighed within 24 hours and recorded on the permanent weight record. When the significant variance was actual after the re-weigh, the staff would document in the resident's record, revise the Care Plan (CP), refer the resident to the Nutrition Hydration Skin Committee (NHSC), notify the physician and responsible party, and document this data. <Resident 1> Review of the quarterly Minimum Data Set (MDS, an assessment tool), dated 02/07/2024, showed Resident 1 admitted to the facility on [DATE], had severe impairments to their decision making, highly impaired vision, and behaviors of rejecting care. The MDS showed Resident 1 had medically complex conditions including fracture, dementia, and muscle weakness. The MDS showed Resident 1 had a weight loss of five percent or more in the last month, was not on a prescribed weight loss program, had no swallowing issues, and was on a therapeutic diet. The MDS showed Resident 1 had an unhealed stage 3 PU that required PU care. Review of Resident 1's baseline CP, dated 11/20/2023, showed Resident 1 required staff supervision for meals and staff assistance to the dining room for all meals. Review of a Nutrition Risk CP, dated 09/05/2023, showed Resident 1 was at increased nutritional risk related to being prescribed a therapeutic diet, decreased body mass index (a measure of body fat based on height and weight), variable food intake by mouth, assistance needed with meals, medical conditions, and PU's. The CP directed staff to refer Resident 1 to the facility RD as appropriate and weights per the facility policy. Review of an actual alteration in skin integrity CP, dated 02/08/2024, showed Resident 1 had a stage 3 PU to their mid back and a Deep Tissue Injury (DTI, deep red or maroon areas of skin caused by underlying damage to skin tissue and extent of injury is not visible) to their right heel. Review of Resident 1's Physician Orders (PO) dated from 08/11/2023 through 03/26/2024, showed no PO to weigh Resident 1. Review of Resident 1's weight record showed no weight was obtained on 08/11/2023, the day of admission. On 08/12/2023 Resident 1 weighed 90 pounds. Resident 1 re-admitted to the facility on [DATE] no weight was documented on the weight record until the next day on 08/22/2023 when Resident 1 weighed 92 pounds. Review of the weight record showed on 08/29/2023 Resident 1 weighed 90.9 pounds, and no weights were found for the following three weeks after re-admission to the facility. Review of Resident 1's weight record showed on 09/20/2023 Resident 1 weighed 82.9 pounds, a weight loss of eight pounds, from the previous weight of 90.9 pounds on 08/29/2023. The weight record showed no re-weigh were obtained within 24 hours but one weight was obtained two days later on 09/22/2023 that showed Resident 1 weighed 82.5 pounds demonstrating additional weight loss. Review of a Nutritional Evaluation, dated 09/05/2023, showed Resident 1 had no PU's, was on a no added salt diet, with regular textured foods, thin liquids, and a supplemental shake ordered three times daily. The evaluation showed Resident 1 required assistance with eating, and dined in their room. The evaluation showed the goal was for Resident 1 to have no unplanned weight loss or gain and directed staff to monitor Resident 1's weight, intake by mouth, and nutrition related labs as needed. Review of a NHSC review form, dated 09/20/2023, showed Resident 1 was being reviewed due to a PU. The form showed Resident 1's most recent weights of 90 pounds on 08/12/2023, 90.9 pounds on 08/29/2023. Staff documented there were no weight changes. The form did not include Resident 1's most recent weight on the same day of the NHSC review on 09/20/2023 at 82.9 pounds. The NHSC review form showed Resident 1 had four PU's, one to the mid-back, a DTI to the sacrum (tailbone) and both heels. The form included recommendations to continue current interventions as Resident 1's wounds and meal intake were improving and did not identify Resident 1's eight pound weight loss. Review of Nursing Progress Notes (NPN), dated 09/20/2023-09/28/2023 showed no documentation that staff informed the physician or the resident representative of Resident 1's weight loss. A NPN, dated 09/29/2024, nine days later, showed Resident 1's representative was informed of a significant weight loss of 12.3% in one month and 11.4% in three months. The NPN showed that Resident 1 had complained of pain upon readmission to the facility, meal intake was reduced, and pain was now well managed and the resident's intake by mouth had improved. The NPN showed the physician was informed and a new PO was received for a second nutritional supplement three times a day with meals. Review of a NPN, dated 10/06/2024, showed staff informed Resident 1's representative that the resident's weight continued to decrease. Review of Resident 1's weight record showed on 11/15/2023, Resident 1 weighed 76.6 pounds and on 11/23/2023 weighed 72.6 pounds, an additional four pounds weight loss. The weight record showed on 12/06/2023 Resident 1 weighed 73.5 pounds and on 12/13/2023 weighed 71.7 pounds, an additional 1.8 pounds. Review of the weight record showed no weights were documented between 01/16/2024-02/27/2024. Review of the weight record showed on 03/06/2024 Resident weighed 71 pounds, a loss of 4.1 pounds. Review of a NPN, dated 11/27/2024, showed staff documented that Resident 1 had a significant weight loss of 6.2% in one month and 20.1% in three months. Staff documented that Resident 1's oral intake varied. Review of a wound provider note, dated 01/10/2024, showed Resident 1's mid-back PU re-opened, required wound care and follow up from the wound provider. A wound provider note, dated 01/17/2024 showed Resident 1 was found with a re-opened wound to their tailbone and on 01/24/2024 a wound provider note showed Resident 1's tailbone was now healed. Additional wound provider notes dated 01/31/2024 through 03/24/2024, date of discharge Resident 1 still had the PU to their mid-back. Review of a Nutritional Note, dated 02/21/2024, showed the facility RD recommended Resident 1 be started on an appetite stimulant. Review of NHSC documentation in Resident 1's record showed no documentation that Resident 1 was reviewed in the committee between 12/20/2023 through 03/20/2024, although Resident 1 had current PU's, continued weight loss, and was identified by the RD with continued weight loss. Review of NPN's, dated 02/21/2024-03/26/2024, showed no documentation to support that facility staff implemented the RD's recommendations, or informed the physician or the resident representative about the RD's recommendation. In an interview of 04/26/2024 at 10:20 AM Resident 1's Collateral Contact (CC) stated they visited Resident 1 daily during the week. the CC stated the resident needed supervision and encouragement with meals, but staff would just bring the meal tray in, leave, and they would not try to assist Resident 1. The CC stated Resident 1 lost twenty pounds in six months, a female staff member talked to them about Resident 1's weight loss and stated the resident might need a feeding tube (a flexible tube placed into the stomach and used to administer artificial nutrition). The CC stated when they asked about the feeding tube they were told by a staff member that Resident 1 had not lost enough weight, after four more pounds lost another staff member told the CC a doctor has to give the order for a feeding tube. The CC stated they wanted Resident 1 to have a feeding tube, expected them to get one, and was asked by facility staff to review Resident 1's POLST (Physicians Orders for Life-Sustaining Treatment) form and think about changing Resident 1 to a DNR (Do not resuscitate), which would include no feeding tube. The CC stated the facility mentioned something about an appetite stimulant but never started one which is when they moved Resident 1 to another care facility. During an interview on 04/29/2024 at 3:35 PM Staff B (Director of Nursing) stated the NHSC meet weekly. Staff B stated, resident's with PU's were reviewed weekly and the RD created the list of residents to be reviewed. Staff B stated the resident's weight records were used to ensure the correct weights were reviewed in the NHSC meeting. Staff B stated they were not sure why Resident 1's 09/20/2023 weight was not used as part of the assessment during the 09/20/2023 NHSC meeting and during that meeting Resident 1's eight pound weight loss was not identified. Staff B sated when a resident admitted to the facility staff were expected to weigh the resident weekly for one month and weekly when a resident had a PU. Staff B stated they would have to look to see if additional weights were obtained after Resident 1 re-admitted to the facility. Staff B provided no additional information. Staff B stated they were not sure why weekly weights were not completed between 01/16/2024 through 02/27/2024 and stated if the resident had a PU, they should be weighed weekly. Staff B stated they were not sure why Resident 1 was dropped from the weekly NHSC meetings, had no nutrition notes from 12/20/2024-03/2024, and would have to ask the RD. Again, no additional information as provided. REFERENCE: WAC 388-97-1060(3)(h). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to obtain informed consent for residents who were assessed to require a decision maker due to cognitive impairments before performing Covid-19 testing for 5 (Residents 6, 7, 2, 8, 9) of 5 residents reviewed for resident's rights. These failures placed all residents with decision makers unable to exercise their right to be fully informed in a language they could understand and removed their ability to refuse Covid-19 testing. Findings included . Review of the facility, Notice of Resident Rights under Federal Law policy, updated 10/2016 showed the resident had the right to formulate an advanced directive (included a durable power of attorney (DPOA) and health care directives the resident chooses) and to have rights exercised by a representative, whether the resident was judged incompetent or not, to the extent allowed by law. <Resident 6> Review of a Significant Change Minimum Data Set (MDS, an assessment tool), dated 01/19/2024, showed Resident 6 had a significant change in status. The MDS showed Resident 6 had severe cognitive impairments (not able to recognize people, use language, or execute purposeful movements), no speech, impaired vision, and was usually understood by others, and usually could understand others. The MDS showed Resident 6 was not able to respond to ethnicity, their preferred language was Khmer (mostly spoken in Cambodia). Staff was unable to determine if Resident 6 needed or wanted an interpreter to communicate with facility staff. The MDS showed Resident 6 had medically complex conditions including end stage kidney disease and dementia. The MDS showed it was very important for Resident 6 to have family or close friends involved in discussions about their care and Resident 6 did not participate but their family did in the assessment and goal planning with the facility. Review of Resident 6's baseline care plan (CP), revised 01/23/2024, showed Resident 6 was forgetful and spoke Cambodian. Review of an alteration in communication CP, revised 01/23/32024, showed Resident 6 had a language barrier due to speaking Cambodian. The CP directed staff to anticipate the resident's needs and provide translator as necessary to communicate with Resident 6 with a language line. Review of a hospital history and physical (H & P), dated 01/16/2024, showed hospital staff documented that Resident 6 was not able to communicate and hospital staff communicated with Resident 6's collateral contact (CC). The CC was related to the power of attorney (POA) for Resident 6 and was the spokesperson for the family in making decisions for Resident 6. The H & P showed hospital staff documented that Resident 6 was unable to provide any medical history via the interpreter and the patient was nonverbal at baseline but more lethargic and not following commands. Review of Resident 6's physician order (PO), dated 01/17/2024, showed staff should administer a Covid-19 test as needed and directed staff to document the type of test performed, obtain consent, and notify the representative or CC, and document results. Review of an admission assessment, dated 01/17/2024, showed Resident 6 re-admitted to the facility. Staff G (Resident Care Manager (RCM)/Licensed Practical Nurse (LPN)) documented Resident 6's level of consciousness was obtunded (diminished responsiveness and slept more than normal). Resident 6 was not alert or oriented, and only responded to voice or touch. Review of a nursing progress notes (NPN), dated 01/17/2024, showed Staff G documented that Resident 6 was re-admitted with a hospice (end of life care) evaluation pending and Resident 6 was unable to verbalize needs thus far. Review of a multi-vaccine consent, dated 01/17/2024, showed Staff G communicated with Resident 6's CC who declined all vaccines over the phone when asked for consent to administer vaccines. Review of a pain evaluation, dated 01/17/2024, showed Staff G documented Resident 6 was not interviewable and was not able to verbalize pain. Review of a hospice provider note, dated 01/18/2024, showed Resident 6 was admitted to hospice and the hospice provider collaborated with the Resident 6's CC. Review of a NPN, dated 01/18/2024, showed Staff C (Infection Preventionist, LPN) documented that they offered to do a Covid-19 test on Resident 6, they agreed, tests results were negative, and Staff C discussed the current outbreak status with the resident including infection prevention measures. There was no documentation that Resident 6's decision maker was contacted for consent to perform Covid testing after Resident 6 had a significant change in condition. In an interview on 02/02/2024 at 11:43 AM, Staff G stated they called Resident 6's CC for consent for vaccines and Resident 6's CC made decisions due to Resident 6's condition after re-admission to the facility. Staff G stated they were not sure if resident 6 was fluent in English. During an interview on 02/02/2024 at 1:10 PM, when asked if Resident 6 was able to understand and make an informed decision for Covid-19 testing in their current condition of being non-verbal and non-responsive, Staff C stated, yes, when I went in Resident 6's room they were up in the wheelchair and alert. I asked simple yes or no questions and Resident 6 nodded their head, indicating yes, proceed with the test. Staff C was asked why other facility staff and the hospice providers communicated with the CC/decision maker for consent, and Staff C stated that they did not see Resident 6 the day before so can't speak to how they were on 01/17/2024 but on 01/18/2024 they were alert and, on this day, they were able to consent. Staff A (Administrator) stated Resident 6 was able to understand some English and this was their pattern before their change in condition. Staff B (Director of Nursing) stated Staff C acted as they would expect when consent was obtained from Resident 6. <Resident 7> Review of an Annual MDS, dated [DATE], showed Resident 7 had severe cognitive impairments, had highly impaired hearing (deaf), and highly impaired vision (eyesight cannot be corrected to a normal level). The MDS showed Resident 7 had unclear speech, could sometimes understand, and could sometimes be understood by others. The MDS showed Resident 7's preferred language was American Sign Language (ALS), required an interpreter to communicate with the facility staff, and it was very important to Resident 7 to have family or close friends involved in discussion about their care. Resident 7 had medically complex conditions including alzheimers dementia, seizure disorder, schizophrenia, deafness, and non-speaking. Section Q, participation in assessment and goal setting, showed the resident did not participate but a legal guardian did participate in the assessment and goal planning with the facility. Review of Resident 7's base line CP, revised on 02/01/2024, directed staff that Resident 7 was unable to talk because of deafness, had difficulties making themselves understood, and the resident communicated with pen and paper. The CP directed staff to use a language line interpreter for professional sign language assistance. Review of court documents, dated 08/26/2019, showed an order appointing full guardianship of Resident 7, and the alleged incapacitated person (Resident 7) was incapable of managing their personal and medical affairs and is need of a full guardianship over their person. The document showed Resident 7 showed no evidence of understanding the nature of the proceedings, or of being able to participate meaningfully in the hearing. The document showed the guardian had the authority and was responsible for to consent and arrange for, or refuse to consent to, medical, dental, psychological or psychiatric treatment and care including any and all medications, diagnostic testing . Review of Resident 7's admission record showed under contacts the guardian was listed as the responsible party, guardian, and emergency contact. Review of Resident 7's physician order (PO), dated 11/09/2023, showed staff should administer a Covid-19 test as needed and directed staff to document the type of test performed, obtain consent and notify the representative, and document results. Review of NPN's, dated 12/20/2023, 12/23/2023, 12/25/2023, 12/27/2023, 12/29/2023, 01/03/2024, 01/05/2023, 01/09/2024, 01/12/2024, showed, routine Covid tests was completed with negative results, and the resident was informed. A NPN, dated 01/28/2024, showed a Covid test was done at 9:00 PM because Resident 7 vomited three times, and test result were negative for Covid. There was no documentation that consent was obtained by the guardian to perform Covid-19 testing on Resident 7. During an interview on 02/02/2024 at 1:10 PM, Staff A (Administrator) stated Resident 7 was non-verbal but could make certain decisions. When asked how would staff know what decisions they could or could not make, Staff C stated that Resident 7 would make gestures, point at objects, and could let us know. Staff A stated Resident 7 needed a guardian to assist with bigger decisions and Staff B (Director of Nursing) stated Resident 7 could make their own decisions. When asked if any staff members used sign language, Staff A stated there was a few staff members that could use sign language. Staff did not indicate if the staff members were used to communicate with Resident 7 when obtaining consent. Staff A stated consent was not obtained or documented as obtained, and they would have to look into it. No further documentation was provided. <Resident 2> Review of a Quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairments, had clear speech, was sometimes understood and could sometimes understand. Resident 2 had medically complex conditions including, high blood pressure, renal failure, malnutrition, and failure to thrive. The MDS showed it was very important to Resident 2 to have family or close friends involved in discussions about their care. Review of Resident 2's baseline CP, revised 01/08/2024, showed Resident 2 was confused, forgetful, and their primary language was English. Review of court documents, dated 10/13/2023, showed a petition for guardianship because Resident 2 lacks the ability to meet essential requirements for physical health, safety, or self-care because the respondent (Resident 2) is unable to receive and evaluate information, or make, or communicate decisions. Review of Resident 2's admission record showed under contacts the guardian was listed. Review of Resident 2's POs showed a 10/30/2023 PO for a Covid-19 test as needed and directed staff to document the type of test performed, obtain consent, notify the representative, and document results. Review of NPN, dated 12/20/2023, 12/23/2023, 12/25/2023, 12/27/2023, 01/03/2024, and 01/05/2024, showed routine Covid tests completed, results were negative, and the resident was informed. There was no documentation that consent was obtained from the guardian to perform Covid-19 testing on Resident 2. In an interview on 02/02/2024 at 1:30 PM Staff C stated that Resident 2 could make their own decisions but it depended on how alert they were at the time. When asked why consent was not obtained or documented before testing, Staff C replied they were on vacation and would have to look. No additional documents were provided. <Resident 8> Review of a Significant Change MDS, dated [DATE], showed Resident 8 had a significant change in status, that showed Resident 8 had : severe cognitive impairment, unclear speech, severely impaired vision, was rarely or never able to make self-understood, and rarely or never able to understand others. Resident 8 had medically complex conditions including dementia, depression, and altered mental status. The MDS showed it was very important to Resident 2 to have family or close friends involved in discussion about their care and Resident 8 did not participate but their family did in goal setting with the facility. Review of Resident 8's baseline CP, revised 01/16/2024, showed Resident 8's primary language was English. Review of a communication problem CP, revised 01/16/2024, showed Resident 8 had communication problems related to hearing deficits in their right ear. Review of DPOA for Resident 8, dated 02/01/2018, showed the DPOA was chosen by Resident 8 to act on their behalf effective immediately. Review of Resident 8's admission record showed under contacts the DPOA was Resident 8's responsible party for finances and care. Review of Resident 8's POs showed no active PO's for Covid-19 testing. Review of NPN, dated 12/20/2023, 12/23/2023, 12/25/2023, 12/27/2023, 12/29/2023, 01/03/2024, 01/05/2024, 01/09/2024, and 01/12/2024, showed a routine Covid test was completed, the results were negative and the resident was informed. There was no documentation that consent was obtained from the DPOA to perform Covid-19 testing on Resident 8. During an interview on 02/02/2024 at 1:35 PM Staff A stated Resident 8 had impaired cognition and a DPOA for care decisions. Staff A stated Resident 8 could answer simple questions, but it depended on the day. Staff A stated they would expect staff to obtain consent from the DPOA and document in the resident's record. <Resident 9> Review of the Quarterly MDS, dated [DATE], showed Resident 9 had : severe cognitive impairment, unclear speech, was sometimes able to understand and was sometimes able to be understood by others. Resident 8 had medically complex conditions including history of a brain bleed with right sided weakness, aphasia (a language disorder that affects the person's ability to communicate), dementia, and psychotic disorder. The MDS showed it was very important to Resident 2 to have family or close friends involved in discussion about their care and Resident 9 did not participate but their legal guardian did in goal setting with the facility. Review of communication problem CP, revised 07/12/2023, directed staff to ask clarifying questions to ensure answer accuracy, speak on an adult level, clearly and slowly, and use short simple phrases when speaking to Resident 9. Review of court documents, dated 03/19/2020, showed an order appointing full guardianship of Resident 9, and the alleged incapacitated person (Resident 9) was incapable of managing their personal and medical affairs and is need of a full guardianship over their person. The document showed Resident 9 showed no evidence of understanding the nature of the proceedings, or of being able to participate meaningfully in the hearing. The document showed the guardian had the authority and was responsible to consent and arrange for, or refuse to consent to, medical, dental, psychological or psychiatric treatment and care including any and all medications, diagnostic testing . Review of Resident 9's POs showed a 02/07/2023 PO for a Covid test as needed and directed staff to document the type of test performed, obtain consent, notify the representative, and document results. Review of NPN, dated 12/20/2023, 12/23/2023, 12/25/2023, 12/27/2023, 12/29/2023, 01/03/2024, 01/05/2024, 01/09/2024, and 01/12/2024, showed routine Covid test completed, results negative and resident informed. There was no documentation that consent was obtained from the guardian to perform Covid testing on Resident 9. In an interview on 02/02/2024 at 1:39 PM Staff A stated Resident 9 had a hard time communicating with aphasia and did have a guardian. Staff A stated they would expect to see documentation of the guardian's consent in the resident's record and acknowledged it was not in the record. Staff A stated the purpose of a guardian or DPOA is to assist the resident with decision making. REFERENCE: WAC 388-97-0180(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered Care Plan (CP), and the resident's choices for 1 resident (Resident 36) of 7 residents reviewed for pain, non-pressure skin, and oxygen management. The failure to assess, care plan, monitor, and follow Physician Orders (PO) placed Resident 36 at risk for overdose of opioid medication, untreated skin issues, worsening medical conditions, and diminished quality of life. Findings included . The 05/25/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 36 participated in the assessment, was cognitively intact, able to make self-understood, understand others, had no behaviors, and no refusals of care. Resident 36 had multiple complex diagnoses including intervertebral disc degeneration (breakdown of the spaces between the bones of the back) and opioid dependence. Resident 36 was assessed with pain in their back that required opioid medication administered routinely and as needed (PRN) for seven days of the assessment period. Resident 36 had a diagnosis of chronic respiratory failure with low oxygen and breathing problems, and environmental allergy respiratory symptoms. Resident 36 required oxygen supplementation for shortness of breath and poor oxygenation. Resident 36 was assessed at risk for developing pressure ulcers and required medication treatments applied to their skin. <Pain Pump Management> The 06/2016 Pain Management policy showed residents were evaluated at admission by a Licensed Nurse (LN) using a pain evaluation tool, a medication review, and record review. The information collected in the evaluation was used to develop and individualized care plan. The policy showed when a PRN (as needed) medication was administered the LN should document and reevaluate effectiveness of the PRN medication. The 01/2020 facility policy Standing Order for Emergency Use of [opioid antagonist] (a medication to reverse an opioid overdose) showed the standing order was created to reduce the risk of fatal opioid overdose. The policy described the opioid antagonist was indicated for the reversal of an opioid overdose with rapid administration to prevent death. The policy authorized trained staff to administer the opioid antagonist to a resident in the event of an overdose. In an interview on 08/06/2023 at 10:14 AM, Resident 36 stated they were at the facility for rehab because of back pain and immobility. Resident 36 stated they were administered oral pain medication from the staff routinely and when they requested pain medications. Review of the 05/11/2023 hospital history and physical, provided to the facility by fax, date stamped 05/18/2023, showed Resident 36 had a pain pump that administered an opioid medication and a muscle relaxant medication on a continuous basis. The hospital record showed the pain pump was refilled 10 days prior to hospitalization. The document showed Resident 36 had an identification card for the pain pump with device manufacturer and serial number, both identified in the hospital document. Review of the 05/18/2023 nursing admission pain evaluation showed Resident 36 was interview able, had back pain, and had an opioid pain medication pump. Review of Resident 36's 05/18/2023 admission POs showed an order that showed Resident 36 had a continuous pain pump that administered opioid and muscle relaxant medications, with the ability for Resident 36 to self-administer a PRN bolus (a larger dose of medication administered on-demand). Resident 36 had additional 05/18/2023 POs for oral a second oral opioid medication with a routine schedule and a PRN option. The PO record showed Resident 36 had a 05/18/2023 order for an oral muscle relaxant medication on a routine schedule and a PRN option. The non-formulary order for the pain pump was not applied to the Medication Administration Records (MAR, a working document for nurses to give resident medications) that Resident 36 had an internal opioid pain pump in addition to the oral opioid medications administered. Review of the 05/25/2023 Minimum Data Set (MDS- an assessment tool) showed Resident 36 was admitted on [DATE] with diagnoses including spinal disc degeneration (compression in spine), back pain, and opioid dependence. Resident 36 was assessed for pain, had a PO for routine and PRN oral pain medications. The MDS showed Resident 36 was administered opioid medications for seven days during the assessment period. The 05/25/2025 MDS care area assessment (CAA- a care plan development tool) showed the assessor did not address Resident 36's pain on the initial comprehensive care plan. A 05/31/2023 (14 days after admission) Pain Care Plan (CP) showed Resident 36 had chronic pain and directed staff to administer medication per PO, monitor and document for side effects of medication, monitor and record pain characteristics and report to nurse and physician any resident complaints of pain. The CP did not show any information regarding Resident 36's pain pump. There was no information to inform staff of the type of pump, function of the pump, medication used, instructions to monitor or manage the functions or refill of the pain pump. There were no protocols for emergency actions for possible opioid overdose. Review of a 06/19/2023 Patient Session Report from the provider was scanned into Resident 36's medical record. The report showed Resident 36 had an implantable device which delivered opioid and muscle relaxant medication by continuous infusion and bolus delivery of medication by resident on-demand. The report showed a refill of the device was completed on 06/19/2023 in the facility. The remaining medication before fill was 4.6 milliliters (ml) and after the fill the device held 40 ml. The report showed Resident 36 had self-administered 30 on-demand doses since the last refill. The document was not signed as reviewed by the facility staff or the facility practitioner. Review of 23 facility practitioner visit encounter notes from 05/19/2023 to 07/22/2023 showed no documentation to acknowledge Resident 36 had a pain pump with infusion or on-demand administration of opioid medications. In an interview on 08/09/2023 at 8:36 AM, Resident 36 stated they had the pain pump for years and it contained opioid and muscle relaxant medication for their back pain. Resident 36 stated the pump was continuous infusion and they were able to do on-demand doses up to three times per day as needed. Resident 36 stated they used the on-demand function a few times while staying at the facility. Resident 36 stated they had not talked to the practitioner or the nurse in detail about how the pump worked. Resident 36 stated I figured they knew about it and how it worked. Resident 36 stated they did not know what to do if they had an overdose of the pain medication and the nurses should know what to do. In an interview on 08/09/2023 at 8:40 AM, Staff H (Physician Assistant- Certified) stated Resident 36 had an internal pain pump that was used while residing in the facility. Staff H was not sure if it was being used anymore. Staff H stated each resident prescribed opioid medications should have an order for an opioid antagonist nasal spray for staff to administer for symptoms of an overdose. In an interview on 08/09/2023 at 8:45 AM, Staff B (Director of Nursing) was asked to provide a policy or procedure on how nursing staff manages resident pain pumps. Staff B stated, We do not do pain pump management. In an interview on 08/09/2023 at 8:46 AM, Staff I (Licensed Practical Nurse assigned to Resident 36) stated they knew Resident 36 had a medication pump, but Staff I did not provide any care to the pain pump. Staff I stated they did not know the pump administered opioid and muscle relaxant medication or that Resident 36 could self-administer bolus doses from the pain pump. Staff I stated there was no directions on the MAR to monitor the continuous or PRN medication administered from the pain pump. In an interview on 08/09/2023 at 8:49 AM, Staff J (Nurse Manager) stated Resident 36 had an internal pain pump. Staff J reviewed the electronic medical record and did not find information on the type of pump, settings or how the pump worked, type of medication and dosage delivered by the pump, how to monitor or have pump refilled, and there were no emergency protocols or medication for potential overdose of opioid medication. Staff J stated they would have to find out how to monitor and manage the pain pump. Staff J stated they do not have access to any policy or procedures and would have to ask the Director of Nursing. Staff J stated it was important for the nursing staff to have the information on the pain pump, medication used and PRN doses administered by the resident on-demand. Staff J stated nurses needed to monitor Resident 36 for symptoms of a potential opioid overdose. Staff J stated the PO, MAR, and CP needed updating and Resident 36 required an order for an opioid antagonist for response to an emergency overdose. <Non-Pressure Skin Management> Review of the 05/18/2023 admission skin assessment showed Resident 36 had scattered red patches on both legs, back from psoriasis (a skin condition causing itchy, flaky skin). Resident 36 also had three areas of a red rash, between their legs, abdomen folds and groin. Review of the May 2023, June 2023, July 2023, and August 2023 Treatment Administration Records (TAR) showed Resident 36 had no PO for skin treatments to the areas of psoriasis or the three rashes. Review of the 05/18/2023 CP showed no identification of Resident 36's psoriasis or skin rashes. Review of the weekly skin observation tools completed on 05/30/2023, 06/08/2023, 06/13/2023, 06/21/2023, 06/27/2023, 07/05/2023, 07/11/2023, 07/18/2023, and 07/25/2023 all showed no new skin impairment. Review of the 05/18/2023 to 08/06/2023 progress notes showed no assessment or treatment documentation of Resident 36's psoriasis or three rashes. In an interview on 08/06/2023 at 10:21 AM, Resident 36 stated I have had a yeast infection since I go here, The staff has not done anything about it, There were no ointments or powders applied to my skin. In an interview and observation on 08/08/2023 at 11:43 AM, Resident 36 stated Look at my arm (pointed to posterior left forearm) I don't dare touch it or it will start to itch and I will scratch my skin off. Resident 36's forearm was bright red with raised bumps and flaking skin. Resident 36's right arm also had patches of red flaky skin. Resident 36 stated no nursing staff or practitioners had looked at their arms or discussed any treatment to help with the itching. Resident 36 agreed to talk with the nurse about their skin. In a follow-up interview and observation on 08/09/2023 at 9:33 AM Resident 36 stated the nurses did not look at the rashes and there were no treatments applied. Staff I (Licensed Practical Nurse) and Staff M (Licensed Practical Nurse) went to Resident 36's room and observed both arms, both legs, buttocks, groin, and feet of Resident 36. Staff I completed a skin check and noted the posterior left forearm with a red area from wrist to elbow. Resident 36 stated their arm was itchy and it was that way since admission. Staff I noted patches of red, flaky spots on both upper thighs. Resident 36 stated I had those when I got here. Resident 36 reported a yeast infection to Staff I who observed the area and stated it was red. Resident 36 stated there was a painful area when touched and felt like a blister. Staff I observed a dark purple-red spot 1.5 cm round with dry/flaky skin on left buttock. Staff I stated the left buttock area was blanchable and need to get some cream on that. Resident 36 stated the area was tender when touched by Staff I. Staff I looked at Resident 36's heels, observed thick dry, peeling skin on both heels with underlying redness. Staff I stated skin treatments were needed for all areas observed on the arms, legs, heels, and groin/buttocks. In an interview on 08/09/20203 at 9:40 AM, Staff M reviewed Resident 36's 05/18/2023 admission skin assessment and confirmed Resident 36 had scattered red patches on both legs and back and red rashes, between their legs, abdomen folds and groin on admission. Staff M reviewed the 07/25/2023 weekly skin observation tool and stated there were no new skin impairments identified. Staff M reviewed Resident 36's POs and stated there was no treatments ordered for the skin impairments observed on Resident 36. In an interview on 08/09/2023 with Staff J (Nurse Manager) reviewed Resident 36's admission skin assessments, the PO, the CP and stated the skin impairments were not identified on the CP, there was no monitoring or treatments for Resident 36's skin impairments. Staff J stated it was important to identify, monitor and treat Resident 36's skin issues or they could worsen and could get infected. <Oxygen (O2) Management> In an observation and interview on 08/06/2023 at 10:28 AM, Resident 36 was lying in bed with O2 tubing in their nose, connected to an O2 concentrator (a machine that supplies O2) on the floor. There was no date on the tubing and the concentrator setting was set at 3 liters per minute (LPM). Resident 36 stated they had a chronic respiratory condition and used supplemental O2 prior to coming to the facility. Resident 36 stated they did not know what the setting should be. Resident 36 checked their O2 level with a device on their finger and stated it was 93%. Review of a 05/18/2023 PO showed Resident 36 was ordered O2 by nasal tubing at 2 LPM to keep O2 level greater than 92% and check O2 level every shift. Review of the 08/2023 MAR showed staff was monitoring the O2 level every shift and the average O2 level was 94-98%. The MAR showed no documentation from the staff of the O2 concentrator setting. The MAR showed no directions when to change the tubing. Review of the 05/18/2023 CP showed no information that Resident 36 used supplemental O2 or directions to staff on monitoring or managing O2 delivery systems. In an interview on 08/09/2023 at 8:49 AM, Staff J (Nurse Manager) stated O2 tubing was changed weekly by the night shift staff and the tubing should be dated. Staff J looked at the MAR and TAR and stated there should be, but there were no directions to staff to change the O2 tubing. Staff J reviewed Resident 36's CP and stated O2 use was expected on the CP but no O2 information was found on Resident 36's CP. Staff J stated there was also no documentation of monitoring Resident 36's O2 LPM setting documented on the MAR or TAR every shift. Staff J stated nurses were expected to look at the O2 concentrator setting every shift to ensure the POs were followed. Staff J stated it was important to change the tubing for infection control and to prevent respiratory infections. Staff J stated the CP, MAR and TAR needed revision for O2 management for Resident 36. In an observation and interview on 08/09/2023 at 9:33 AM, Staff I observed the setting on Resident 36's O2 concentrator and stated it was set at 3 LPM. Staff M reviewed the PO and stated the O2 setting was prescribed for 2 LPM and the PO was not being followed. REFERENCE: WAC 388-97-1060(1), (3)(b), (j)(vi), (4). .

Based on observation, interview, and record review the facility failed to ensure residents were free from accidents and hazards for 1 of 1 resident (Resident 54) reviewed for smoking. The failure to assess Resident 54's smoking safety and develop a Care Plan (CP) to monitor and prevent accidents placed Resident 54 at risk for falls, burns, other injuries, and diminished quality of life. Findings included . The 06/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 54 was cognitively intact, able to make themself understood and understand others. Resident 54 was assessed with unsteady walking and turning, and used a walker. Resident 54 was assessed to require supervision when walking inside their room and the hallway and extensive assistance with locomotion off the unit. An observation on 08/06/2023 at 7:05 AM showed Resident 54 exited the locked entrance door of the facility. Resident 54 exited the building unsupervised. In an interview on 08/06/2023 at 7:50 AM, Staff A (Administrator) stated the facility was non-smoking. Staff A stated one resident would go off the property and smoke independently and identified Resident 54. In an interview on 08/06/2023 at 9:52 AM, Resident 54 stated they walked to the sidewalk to smoke a few times per day. Resident 54 stated they were able to go out and smoke independently since being cleared by physical therapy a few months ago. Resident 54 stated the nurse held their cigarettes and lighter in the medication cart. Resident 54 stated they sign out of the facility at the nurse's station and get the cigarettes then go outside to smoke on the sidewalk. Resident 54 stated no one goes with them. In an interview on 08/07/2023 at 2:03 PM, Resident 54 stated no staff had watched them light a cigarette, hold a cigarette, or evaluated them to walk to the sidewalk to smoke. In an observation and interview on 08/07/2023 at 2:10 PM Staff K (Licensed Practical Nurse) showed a package of cigarettes and a red lighter in the top drawer of the medication cart and pointed to the sign out record. Staff K stated Resident 54 comes to the nurse four to six times a day to get the cigarettes and lighter, then signs out, and goes outside to smoke. Staff K stated they did not evaluate Resident 54 for smoking safety. Staff K stated there was no monitoring of Resident 54 smoking or tracking of the cigarettes or lighter. Review of the resident sign out book showed pages dated from 08/07/2023 back to December 2022. Resident 54 started to sign out on 04/23/2023. Resident 54 signed out between four and six times a day. The page dated 07/26/2023 to 07/30/2023 showed Resident 54 signed out as early as 7:00 AM and signed back in as late as 10:25 PM. Resident 54 was signed out an average of 20 minutes per smoking event. In an interview on 08/08/2023 at 1:59 PM, Staff B (Director of Nursing) stated Resident 54 started smoking after physical therapy cleared them. Staff B stated a smoking safety assessment was not completed prior to Resident 54 starting to smoke independently. Staff B stated it was important to assess Resident 54's safety to make sure they could handle the lighter, cigarette, walk to the smoking sidewalk, and report burns. Staff B stated the CP did not contain any directions to staff to support safe smoking. In an interview on 08/09/2023 at 10:24 AM, Staff A stated there was no assessment documentation by therapy or nursing and there was no smoking CP in Resident 54's clinical record. Staff A stated the assessment and CP should have been completed before Resident 54 started smoking independently. REFERENCE: WAC 388-97-1060(3)(g). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 60> Review of the 06/30/2023 admission MDS showed, Resident 60 was cognitively intact. In an interview on 08/06/2023 at 10:00 AM, Resident 60 stated they were transferred to the hospital by the facility in June 2023. Resident 60 stated they did not remember receiving a written notification from the facility outlining the details of their discharge. Review of Resident 60 medical record revealed no documentation the resident, their RR or the LTCO was notified of Resident 60's transfer to the hospital. In an interview on 08/07/2023 at 8:45 AM Staff G (Director of Medical Records) stated they could not locate the notices of transfer for Resident 32, 33, or 60. Staff G stated the completion of the notice of transfer was the responsibility of social services. In an interview on 08/09/2023 at 9:01 AM, Staff A (Administrator) stated the resident and/or their RR and the Ombudsman should be notified in writing of transfers and discharges. Staff A stated the facility system for transfer/discharges was not intact and written notifications were not provided as required. REFERENCE: WAC 388-97-0120(1)(2) (a-d). <Resident 32> Review of 07/22/2023 Quarterly MDS showed, Resident 32 was cognitively intact. A 06/16/2023 progress note showed Resident 32 discharged to the hospital on [DATE]. Review of Resident 32's medical record showed no written transfer/discharge notice was provided to the resident or their RR. <Resident 33> Review of 07/27/2023 Quarterly MDS showed Resident 33 was cognitively intact. A 05/10/2023 progress note showed Resident 33 was discharged to the hospital on [DATE]. Review of Resident 33's medical record showed no written transfer/discharge notice was provided to the resident or their RR. Based on record review and interview the facility failed to ensure residents and/or their Resident Representative (RR) was provided a transfer or discharge notice in writing in a language or manner they understood and send a copy to the State Long-Term Care Ombudsman (SLTCO). The notice must contain the reason for transfer or discharge, location, a statement of appeal rights, and information for contacting the Ombudsman. The failure to provide written transfer/discharge notice to 4 of 4 residents (Resident #28, #32, #33, #60) upon facility-initiated transfer to the hospital prevented residents from inappropriate discharge, provide residents with access to an advocate who can inform them of their options and rights and to ensure the SLTCO is aware of facility practices and activities related to transfers and discharges. Findings included . Review of the 10/2019 facility policy Transfer and Discharge showed the facility would provide a written notice of transfer to the resident using the Resident Notice of Transfer or Discharge form which included; a date notice is given, effective date of transfer/discharge, where the resident was to be moved, contact information for the ombudsman, contact information for protection and advocacy agency for residents with disability, explanations of right to appeal the transfer/discharge, additional information required by applicable state law, and a copy of the notice is sent to the ombudsman office. <Resident 28> An interview on 08/06/2023 at 12:27 PM, Resident 28 stated they were transferred to the hospital recently. Resident 28 stated they did not remember receiving a written transfer/discharge notice. Review of the 05/22/2023 Significant Change Minimum Data Set (MDS- an assessment tool) showed Resident 28 was cognitively intact. Resident 28 was identified as their own responsible party. Review of the 05/13/2023 progress notes showed, Resident 28 was discharged from the facility on 05/13/2023 at 12:46 PM. Review of Resident 28's medical record showed no written discharge notice was provided to the resident or their RR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 60> Review of the 06/30/2023 admission MDS showed, Resident 60 was admitted to the facility on [DATE] for end-stage kidney disease, chronic lung disease, and fluid overload. Resident 60 was assessed to require limited assistance with transfers, bed mobility, dressing, and toileting. Resident 60 discharged to the hospital on [DATE] for low oxygen carrying capacity. In an interview on 08/06/2023 at 10:00 AM, Resident 60 stated they were recently transferred to the hospital by the facility. Resident 60 stated they did not remember receiving a written bed hold notice. Review of Resident 60 medical record in its entirety, no written bed hold notice was located. In an interview on 08/08/2023 at 12:20 PM, Staff E stated the business office and admission staff were responsible to provide the resident or their RR the bed-hold notice on transfer to the hospital. Staff E said they were currently notifying the private pay residents of the bed-hold process, but not the residents on State pay. In an interview on 08/09/2023 at 9:00 AM, Staff A stated they were not completing the notification of bed hold for those residents that were insured through State pay as required. REFERENCE: WAC 388-97-0120(4)(a-c). <Resident 33> Review of 07/27/2023 Quarterly MDS showed, Resident 33 was assessed as cognitively intact, could make themselves understood and able to understand others. A 05/10/2023 progress note showed Resident 33 was discharged to the hospital on [DATE]. In an interview on 08/07/2023 at 8:45 AM, Staff G (Director of Medical Records) stated they could not locate the notice of bed hold for Resident 33. Staff G stated the completion of the notice of bed hold was the responsibility of the admissions office staff. Based on observation, interview, and record review the facility failed to provide residents or the Resident's Representative (RR) with a bed-hold notice upon transfer to the hospital for 3 of 4 residents (Resident 28, 33, and 60) reviewed for hospitalization. The failure to provide a copy of the written bed-hold notice and reserve bed payment policy upon transfer to the hospital, regardless of payment source, prevented residents from exercising their rights and choice to return to the facility upon hospital discharge. Findings included . The 10/2019 Bed-hold policy showed the nursing staff would provide the resident and/or their RR a copy of the Notice of Bed Hold Policy upon transfer or discharge to the hospital. The policy showed the resident or responsible party would complete the bed-hold notice and sign to hold or refuse the bed-hold. <Resident 28> Review of the 05/22/2023 Significant Change Minimum Data Set (MDS- an assessment tool) showed Resident 28 was cognitively intact and could make themselves understood and able to understand others. Resident 28 was also identified as their own responsible party. Review of the 05/13/2023 progress note showed, Resident 28 was transferred to the hospital on [DATE] at 12:46 PM. In an interview on 08/06/2023 at 12:27 PM, Resident 28 stated they were recently transferred by the facility to the hospital. Resident 28 stated they did not remember receiving a written copy of a bed-hold notice. A review of Resident 28's medical record in its entirety found no copy of a bed-hold notice. In an interview on 08/08/2023 at 12:20 PM, Staff E (Business Office Manager) stated they were not able to locate a written bed-hold notice for Resident 28. Staff E stated the facility did not provide Resident 28 a copy of the bed-hold notice. In an interview on 08/09/2023 at 9:01 AM, Staff A (Administrator) stated only residents with shared cost are provided a written bed-hold notice and residents on State paid services were not provided a bed-hold notice. Staff A stated neither Resident 28 nor their RR were provided a written bed hold notice when they transferred to the hospital. Staff A stated the bed-hold notice process was not as complete as it should be and bed-hold notices were not being completed by the facility as required.

Based on observation, interview, and record review the facility failed to ensure medications and vaccinations were stored at the appropriate temperature and failed to dispose of expired medications in a timely manner in 2 of 2 medication rooms (East and [NAME] Medication Room) and 1 of 3 medication carts (East Medication Cart) reviewed for medication storage. The failure to dispose of expired medications placed residents at risk for narcotic drug diversion and at risk of administration of expired or discontinued medication. The failure to monitor and document refrigerator temperatures twice daily when storing vaccinations placed residents at risk for administered vaccinations that were no longer useful. Findings included . <Facility Policy> The undated facility policy Discontinued Medications directed staff to remove discontinued medication from the medication cart immediately upon receipt of an order to discontinue the medication to avoid continued administration. The undated facility policy Controlled Substances showed controlled substances had a potential for abuse and had special handling for storage, disposal, and record keeping according to federal and state laws. The policy showed controlled medications that were discontinued or expired had restricted access until destroyed by two licensed clinicians as directed by state regulation. The undated facility policy Medication Destruction directed staff to destroy medications that were discontinued, left at the facility after a resident discharged or when medications were expired. < Medication Cart> Observation and interview on 08/07/2023 at 10:56 AM with Staff K (Licensed Practical Nurse) showed one diabetic injectable medication with an open date of 05/11/2023. Staff K stated the medication was to be used for 56 days then expired. The injectable medication was expired on 07/06/2023. Staff K stated the medication should have been removed from the medication cart since it was expired. Staff K stated the pharmacy staff audited the medication cart on 08/04/2023 and discussed with Staff K the diabetic medication was past the acceptable date, but they were not going to dispose of the medication because it was expensive. Observation and interview on 08/07/2023 at 11:06 AM with Staff K showed four narcotic cards in the locked drawer of the medication cart. The four cards were labeled either discontinued or discharged . Staff K stated the narcotic medications were either discontinued and the resident was still in the facility or the resident discharged . Staff K stated two registered nurses were required to dispose the narcotics and the four cards should have been removed and destroyed when the medication was no longer prescribed. In an interview on 08/08/2023 at 1:59 PM, Staff B (Director of Nursing) stated two nurses were required to dispose of narcotic medications when discontinued or when a resident discharged . Staff B stated the four cards of narcotic medication should have been disposed. Staff B stated nurses were expected to remove expired medications from the medication cart and dispose of the medication in the destruction container. <Medication Rooms> Observation and interview in the East Medication room on 08/07/2023 at 10:32 AM with Staff M (Licensed Practical Nurse) showed the refrigerator contained multiple vaccination vials for pneumonia, influenza, COVID, and tuberculosis testing. Observation of the refrigerator temperature log showed the facility recorded the refrigerator temperature daily. Staff M stated the temperature of the refrigerator was only documented once daily. Staff M verified there was no temperatures recorded for 08/03/2023, 08/04/2023 or 08/05/2023. Observation and interview in the [NAME] Medication room on 08/08/2023 at 11:50 AM with Staff L (Registered Nurse) showed the refrigerator contained two vials of tuberculosis testing. Observation of the refrigerator temperature log showed the facility recorded the refrigerator temperature daily. Staff L stated the night shift documented the refrigerator temperature once daily. Staff L confirmed there was only one refrigerator check recorded on the log and no freezer temperature recorded. Review of the August 2023 Temperature Log in the [NAME] Medication room directed staff to Check the temperatures in both the freezer and refrigerator compartments of the vaccine storage units at least twice each working day. In an interview on 08/08/2023 at 9:49 AM, Staff O (Infection Control Preventionist) stated refrigerators storing vaccinations should have temperature monitoring twice daily. REFERENCE: WAC 388-97-1300(2)(3)(a). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure 3 of 4 nurses (Staff P- Licensed Practical Nurse/LPN, Staff K- LPN, Staff N- LPN) followed hand hygiene procedures when in direct contact with residents. The failure to complete hand hygiene during medication administration placed residents at risk for illness, infections, and diminished quality of life. Findings included . <Hand Hygiene> Observation of Medication Pass on 08/07/2023 at 9:09 AM showed Staff P (Licensed Practical Nurse - LPN) wearing gloves and prepared to administer a syringe of diabetic medication to a resident in room [ROOM NUMBER]. Staff P stated to the resident they would be right back, removed gloves and left the room. Staff P went to the medication cart, helped another nurse find something in the cart, grabbed a new pair of gloves and returned to room [ROOM NUMBER]. Staff P did not use hand gel (alcohol-based hand sanitizer) when entering room [ROOM NUMBER] and did not use hand gel before putting on the gloves. Staff P administered the syringe of diabetic medication, removed gloves, and returned to the medication cart to use the hand gel. Staff P missed two opportunities for hand hygiene before direct contact to administer medication to the resident. Observation of Medication Pass on 08/08/2023 at 1:10 PM showed Staff K (Licensed Practical Nurse) administering intravenous (IV) medication to a resident in room [ROOM NUMBER]. Staff K was observed removing their gloves after entering the settings on the IV pump, then put on new gloves and touched the IV access on the resident's right upper arm to inspect the site and the dressing. Staff K missed one opportunity for hand hygiene before direct contact with the resident's IV site and dressing. Observation of Medication Pass on 08/08/2023 at 12:06 PM showed Staff N (Licensed Practical Nurse) enter room [ROOM NUMBER] to administer medication and did not use hand gel prior to direct contact with the resident. Staff N then returned to the medication cart, used hand gel, and prepared medication for the resident in room [ROOM NUMBER]. Staff N closed and locked the medication cart, entered room [ROOM NUMBER], did not use hand gel, and administered medications to the resident in room [ROOM NUMBER]. Staff N returned to the medication cart and used the hand gel on the cart. Staff N missed four opportunities for hand hygiene while administering medications to two residents. <Syringe> Observation of Medication Pass on 08/08/2023 at 12:46 PM showed Staff N administer the syringe of diabetic medication to the resident in room [ROOM NUMBER]. Staff N did not use hand gel when entering the room, put on gloves and injected the needle of the syringe into the residents left upper arm, removed their gloves, and carried the used syringe with the dirty needle down the hallway to the medication cart at the nurse's station and removed the needle without wearing gloves. In an interview on 08/08/2023 at 1:59 PM, Staff B (Director of Nursing) stated the nursing staff was expected to gel in and gel out and explained the staff must use hand sanitizer before they enter a resident room and when they leave the resident room. Staff B stated nursing staff was also expected to use hand gel between glove changes and to wash their hands with soap and water when hands were visibly dirty. Staff B stated nurses should not walk down the hallway carrying an uncovered dirty needle. REFERENCE: WAC 388-97-1320(1)(a)(c). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 38 According to the 01/07/2022 Quarterly Minimum Data Set (MDS an assessment tool), Resident 38 admitted to the facility on [DATE], was assessed as cognitively intact, able to make their own decisions, and had diagnoses including diabetes, hypertension (high blood pressure), and arthritis. The MDS assessed the resident's preference as very important for them to be able to have a private phone calls, take care of their personal belongings, and have a safe place to lock up their personal belongings. Review of a 05/06/2021 Personal Inventory List showed the resident admitted with a brown wallet, $13.00 in cash, a bank debit card, a drivers license, one cell phone, and multiple other clothing and personal items. Review of a 01/28/2022 Grievance Form showed Resident 38 submitted a grievance for missing a phone charger, wallet with identification card, pictures in wallet, $13.00 cash, credit card, four pairs of tweezers , six reading glasses, scissors, tape measurer, string, white tape, needle and thread, storage basket, and multiple clothing items. The Grievance form showed the grievance was confirmed and resolved by 02/02/2022 During an interview on 02/03/2022 at 9:21 AM Resident 38 stated they were missing their wallet, phone charger and some other personal items after moving rooms because they were Covid positive. The resident requested their phone charger but didn't get an answer on that, eventually their cell phone's battery died and they were not able to communicate with their friends or family. Resident 38 stated they informed the Social Worker, the nurses, and the Certified Nurses Assistant (CNA) and they said they would bring me a new charger. The new charger didn't work for my phone, it never charged it, but there was one male nurse who let me borrow their phone charger and it worked with my cell phone but it was their personal one so I had to give it back to them. My phone's battery is still dead and I can't communicate with anyone. They told me yesterday I would have a new charger but didn't receive one. On 02/08/2022 at 9:10 AM Resident 38 was observed sitting in their wheelchair, a bedside table next to them with their cell phone siting on the table. Resident 38 stated that their cell phone's battery is still dead and have not received a phone charger from the facility. In an interview on 02/08/2022 at 10:50 AM Staff L (Social Services Assistant) stated Resident 38 lost their phone charger when they moved rooms and they brought the resident a phone charger but the resident told them it didn't work because the red light wasn't on. A friend sent the resident a phone charger but that one did not work for their phone. During an interview on 02/10/2022 at 11:03 AM Staff K (Social Services Director) stated the resident's phone charger will be delivered on 02/14/2021 but the resident's wallet has not been located. Social services will assist the resident with a new identification card, obtaining a new debit card, and the ED told us [Social Services Department] that we will reimburse the resident's missing $13.00 Staff K stated when the resident moved to the covid unit staff observed their wallet in the drawer and was not sure where it went. The facility does not normally call the police unless the resident states it was stolen. Additionally, Staff K added that residents are offered a lock box to secure belongings but was not sure if Resident 38 had a lock box and key. Observations on 02/10/2022 at 11:11 AM showed Staff L bring the same charger they tried before to the resident's room and plugged in the resident's cell phone. Resident 38 stated that the phone wasn't flashing the red light which indicates it is charging. Staff L stated to the resident to give it some time to see if it is charging. At 11:29 AM Resident 38 stated the charger was not working, their phone was observed to not be charged. In an interview on 02/10/2022 at 11:32 AM Staff A (Administrator) stated the missing cell phone charger was part of a large grievance for Resident 38. We [the facility] are working on replacing the items,the wallet was never found, and they did not know if the debit card was still active. Staff A confirmed with Social services that the resident's bank was not contacted to verify any activity on the missing debit card, Staff A stated they did not do a internal investigation but did a grievance because the resident did not identify the item was stolen and they base it off what the resident says. Staff A stated all rooms have a lock box and key so residents can keep personal items safe. Observations on 02/10/2022 at 12:19 PM Resident 38 stated that the charger was not charging their cell phone. A dresser was observed next to the resident's bed, the bottom drawer with a lock. Resident 38 stated they didn't have a key for the drawer with a lock. REFERENCE: WAC 388-97-0460. Based on observation, interview, and record review, the facility failed to timely resolve grievances, and identify, log, and/or resolve issues raised at Resident Council as grievances for 5 (Residents 40, 50, 48, 31, & 11) of 10 residents council participants. The facility failed to resolve a missing items grievance for 1 (Resident 38) of 10 residents reviewed for grievances. Failure to identify, log, and timely resolve grievances left residents at risk for unresolved grievances, frustration and missing property. Findings included . Facility Policy According to the Facility's Resident Rights Under Federal Law policy, updated on November 2016, residents had the right to voice grievances to the Center or other agency or entity that hears grievances, without discrimination or reprisal, and without fear of discrimination or reprisal. The policy also stated residents had the right to prompt efforts by the Center to resolve grievances. Resident Council During a Resident Council meeting on 02/08/2022, Resident 40 and Resident 50 stated they did not know how to file a grievance. Resident 48, Resident Council President, stated they [the resident's] would fill out a piece of paper and put it in the garbage can. Review of three month's of Resident Council minutes from November 2021 through January 2022 revealed the following: The 11/17/2021 Resident Council Meeting minutes showed residents brought up concerns regarding the timeliness and manner of care provided by Nursing Aides on evening shifts, meal trays not being delivered on time, and meal tickets not being read. A review of the November 2021 Grievance Log revealed none of these concerns were logged on the Grievance Log, or reviewed on a Grievance Form. The 12/15/2021 Resident Council Meeting minutes showed Resident 40 brought up the concern they were not getting their concerns addressed from the Social Services Department. This concern was not added to the Grievance Log and no Grievance Form was created to address the issue. The minutes also contained a Discussion of Old Business section where Resident 30 was noted to express concern about menu selections not matching the actual food provided. The 01/27/2022 Resident Council Meeting Minutes minutes showed: Resident 31 had a grievance about a housekeeping assistant for which a Grievance form was complete but which was not logged; Resident 11 stated they have problems gagging on their food sometimes and on the form (soft texture) was noted. A review of Resident 11's chart showed a 10/20/2021 Physician's Order for soft, bite-sized textured food for the resident. Resident 11's concern about texture was not logged and a Grievance Form not completed. In an interview on 02/10/2022 at 12:32 PM, Staff A (Executive Director and Grievance Officer) stated that grievances should be resolved and logged. Staff A stated sometimes, when they are able to resolve things immediately, they don't always then complete a Grievance Form, or log the grievance, and that this could account for the inconsistencies in the logging and completion of the grievance forms for grievances brought up at Resident Council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a fall with significant injury to the State Agency Hotline as required for 1 (Resident 206) of 11 residents reviewed for accidents. Failure to report to the State Agency placed residents at the potential risk for further unidentified safety risks and neglect. Findings included . A 01/27/2022 admission Minimum Data Set (MDS- An assessment tool) showed Resident 206 was admitted to the facility on [DATE] with the diagnoses of irregular heart rate, heart failure, seizure disorder, and dementia. A 01/21/2022 admission fall assessment showed Resident 206 was a high fall risk. A 01/22/2022 progress note showed at 3:30 AM Resident 206 was noted lying on the floor on the left side in the hallway by the entry door to the resident's room. Resident 206 had a large bump on the left forehead from hitting their head on the floor. A review of the January 2022 facility accident log showed Resident 206 had a fall on 01/22/2022 at 3:30 AM. The log showed the incident was not reported to the State Agency. In an interview on 02/09/2022 at 1:00 PM, Staff B (Director of Nursing) stated a phone or online report to the State Agency was not completed as required, and it should have been reported. Refer to F689 Free of Accident Hazards/Supervision/Devices. REFERENCE: WAC 388-97-0640(5)(a), (6)(a)(c). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately and thoroughly investigate an allegation of abuse/neglect for 1 (Resident 42) of 11 residents reviewed. The facility failed to: establish a timeline of events (who knew what when); and identify if care and services were provided. These failures detracted from the facility's ability to accurately determine the root cause of the events and from staff's ability to determine whether abuse/neglect occurred. Findings included . Resident 42 According to the 01/12/2022 Quarterly Minimum Data Set (MDS an assessment tool) Resident 42 readmitted to the facility on [DATE] and had multiple medically complex diagnoses including hemiplegia (paralysis) with right side weakness, vascular dementia with behavioral disturbance, and hypertension. The resident was assessed as moderately cognitively impaired, had a history of falls in the facility, used a wheelchair (w/c), and self-propelled in the w/c using their left hand. Review of a 01/24/2022 nursing progress note showed Resident 42 informed staff that their right hand was swollen and bruised on the back and palm. The resident denied any pain, and was able to move their hand and fingers. Resident 42 stated their right hand got caught in their w/c. The Provider was notified and x-rays were completed on 01/24/2022 showed no fracture. According to the 01/29/2022 facility investigation, Staff B (Director of Nursing) interviewed Resident 42 on 01/25/2022 and the resident stated they bumped their right palm and hand on their bedside table, they were trying to move the bedside table away. The resident denied any abuse or neglect. Interventions included padding bedside table to prevent further injury, a treatment and monitoring orders for the right-hand swelling, and OT (Occupational Therapy) evaluation and treatment. Observations on 02/02/2022 at 9:20 AM, 02/03/2022 at 10:16 AM, 02/07/2022 at 1:13 PM and 02/08/2022 at 8:18 AM revealed the resident had a faded bruise on the back of their right hand . Observation of Resident 42's room on 02/03/2022 at 10:16 AM showed their bed side table's corners were padded. Record review showed no Care Plan (CP) was initiated to address the resident's hand/skin issues related to this incident. In an interview on 02/08/2022 at 11:00 AM, Staff N (Resident Care Manager) stated the resident hit their hand with something but did not know what exactly happened. Review of Resident 42's OT (Occupational Therapy) records after 01/24/2022 revealed no indication the resident's hand incident was addressed by OT. In an interview on 02/09/2022 at 1:28 PM Staff B stated Resident 42 was very forgetful, and the resident stated they hit their hand on the bedside table, and that the bedside table corners were padded. Staff B acknowledged they should have, but did not, complete a thorough investigation which should have included a wheelchair evaluation as part of the investigation. REFERENCE: WAC 388-97-0640 (6)(a)(b) .

**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) Level II evaluation recommendations were implemented and incorporated into the care plan (CP) for 1 (Resident 53) of 3 residents reviewed for Level II PASRRs. The failure to incorporate/implement Resident 53's treatment plan into their comprehensive CP placed the resident at risk for not receiving necessary mental health and counseling services and unmet psychosocial needs. Findings included . Resident 53 Resident 53 admitted to the facility on [DATE]. According to the 01/20/2022 Quarterly Minimum Data Set (MDS an assessment tool), the resident had moderate cognitive impairment, diagnoses of non-Alzheimer's dementia, bipolar disorder and psychotic disorder, and received antipsychotic and antidepressant medication on seven of seven days during the assessment period. According to the 05/05/2012 Level II Psychiatric Evaluation Summary Information, [PESI], the resident was referred for a Level II evaluation secondary to indicators of serious mental illness (SMI). The symptoms of SMI were identified as: depression, hallucinations. psychosis, agitation, and excessive worry. The resident's psychosis culminated in placement in an inpatient Geropysch (a field of psychiatry focused on older persons) Unit from 03/16/2012-03/28/2012 secondary to Resident 53's delusions and hallucinations that staff were attempting to kill the resident. The Level II evaluator indicated that Resident 53's record contained many contradictory psychiatric diagnoses and inadequate information to support any of them with the exception of: Cognitive disorder (Any disorder that significantly impairs the cognitive function of an individual to the point where normal functioning in society is impossible without treatment).; Psychotic disorder (A mental disorder characterized by a disconnection from reality); and questionable Personality disorder (enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment.) The following Recommendations for Service were made: Obtain the discharge summary from Resident 53's inpatient Geropysch stay for accurate diagnoses and treatment of psychotic features; provide services from a Mental Health Professional (MHP) or agency to; a) perform a full assessment/evaluation b) for psychiatric medication evaluation and management; would benefit from continued psychiatric support such as a referral to a community mental health center or any counseling available in the nursing home; and indicated the resident had always been nocturnal and stated, This should not be viewed as a problem for the patient, even if it interferes with the SNF [Skilled Nursing Facility] way of doing things. Record review showed no CP was developed that identified the resident had a positive Level II PASRR or that incorporated Level II treatment plan recommendations. During an interview on 02/11/2022 at 8:54 AM, Staff K (Director of Social Work) stated staff were unaware that Resident 53 had a positive Level II PASRR and indicated that was why the resident's Level II treatment plan had not been incorporated into the plan of care. REFERENCE: WAC 388-97-1915(4). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and/or ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 3 (Residents 14, 42 & 44) of 5 residents reviewed for unnecessary medications. These failures placed residents at risk for inappropriate placement, not receiving timely and necessary mental health services, and unmet psychosocial care needs. Findings included . Resident 14 Resident 14 admitted to the facility on [DATE]. According to the 12/02/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of depression, and received antidepressant medication on seven of seven days during the assessment period. Review of the resident's Physicians's Orders (PO) showed a 11/01/2021 order for Citalopram (an antidepressant) daily for depression. According to Resident 14's 07/06/2021 Level I PASRR, the resident had no serious mental illness (SMI) indicators. The box for depressive disorder was blank. During an interview on 02/11/2021 at 08:54 AM, Staff K (Director of Social Work) indicated the resident's Level I PASRR was inaccurate and needed to be updated. Resident 42 Resident 42 admitted to the facility on [DATE]. According to the 01/12/2022 Quarterly MDS, the resident had moderate cognitive impairment, diagnoses of psychotic disorder, anxiety disorder, depression, and received antipsychotic and antidepressant medication on seven of seven days during the assessment period. Record review showed Resident 42 had the following POs: a 01/14/2022 order for Seroquel (an antipsychotic) twice daily for psychotic disorder; and a 06/28/2021 order for Duloxetine (an antidepressant) daily for depression. According to Resident 42's 02/22/2019 Level I PASRR, the resident had a SMI indicator of anxiety disorder, but not depressive or psychotic disorder. During an interview on 2/8/2022 at 07:25 AM, Staff K stated that Resident 42's Level I PASRR was inaccurate and needed to be updated. Resident 44 Resident 44 admitted to the facility on [DATE]. According to the 12/16/2021 Quarterly MDS, the resident had moderately impaired cognition, was able to make their own decisions, and had diagnoses of medically complex conditions including depression. The resident received antidepressant medication on seven days during the assessment period. Review of the resident's record showed a 08/24/2021 PO for Mirtazapine (anti-depressant) daily for major depressive disorder. Review of the resident's record showed no indication the facility obtained a PASRR. In an interview on 02/08/2022 at 10:50 AM Staff K confirmed Resident 44 did not have a PASRR in their record, and when the resident admitted to the facility there was a waiver in place that allowed the facility 30 days to obtain the PASRR. Staff K stated they did not have a process in place to follow up on the PASRR that needed to be obtained within the 30 days. Staff K stated the resident's PASRR should have been obtained 30 days after admission. REFERENCE: WAC 388-97-1915(1), -1975(1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement the baseline care plan (CP) within 48 hours of admission that included instructions needed to provide effective and person-centered care that met professional standards or quality of care for 2 (Residents 213 & 208) of 7 residents reviewed for new admissions. The failure to include the minimum healthcare information necessary to properly care for residents, such as a developmental delay diagnosis, a fluid restriction, and the use of oxygen (O2), placed residents at risk for unmet needs and created the potential for a diminished quality of life. Findings included . Resident 213 A review of the 01/31/2022 Hospital Discharge Summary for Resident 213 showed a principal diagnosis of developmental delay (DD). Review of a 02/01/2022 Baseline CP showed no documentation of the resident's diagnosis of DD. In an interview on 02/07/2022 at 11:45 AM, Staff J (Resident Care Manager) reviewed the baseline CP for Resident 213 and confirmed the diagnosis and behavior interventions for the DD diagnosis were not listed. Staff B (Director of Nursing) interviewed at 11:46 AM on 02/02/2022 stated staff should follow the CP for a resident with DD. Staff B stated the DD diagnosis and interventions were not listed on the baseline CP for Resident 213 because the diagnosis was missed during the hospital record review at admission. Resident 208 A review of the 02/02/2022 admission Minimum Data Set (MDS- an assessment tool) showed resident 208 was admitted on [DATE] with diagnoses including urinary tract infection with sepsis (an infection of the blood stream) and chronic obstructive pulmonary (lung) disease and used O2 therapy prior to and during the stay at the facility. Resident 208 was assessed as cognitively intact and able to make themselves understood and understand others. A review of the 01/28/2022 baseline CP showed no information about Resident 208's oxygen use. A review of the 01/2022 physician orders (PO) showed no order for Resident 208 to use O2. In an observation and interview on 02/01/2022 at 2:20 PM, Resident 208 stated they used O2 for many years, and had used O2 for about a week since admission to the facility. Resident 208 was wearing a nasal cannula connected to an O2 concentrator set at 2 liters per minute. In an interview on 02/07/2022 at 11:11 AM, Staff J reviewed the baseline CP and the physician orders for Resident 208 and confirmed O2 therapy was not on the care plan and there was not a PO to administer O2. Staff J stated there should be a PO and O2 should be listed on the baseline CP. REFERENCE: WAC 388-97-1020(3). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 7 (Residents 12, 13, 27, 21, 15, 38 & 256) of 25 residents reviewed. The failure to obtain, follow, and clarify Physician's Orders (PO) when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . Resident 12 Record review showed the resident had a 06/04/2021 order for Metoprolol (an antihypertensive medication) twice daily, with orders to hold the medication if the resident's systolic blood pressure (SBP) was less than 100, and to notify the doctor if the SBP was less than 100 or greater than 180. Review of Resident 12's vital sign flowsheet showed from 01/01/2022- 01/15/2022 showed only one blood pressure (BP) was recorded for the following days: 01/01/2022; 01/03/2022; 01/04/2022; 01/6/2022; 01/07/2022; 01/08/2022; 01/10/2022; 01/11/2022; 01/12/2022 and 01/13/2022. Review of the January 2022 Medication Administration Record (MAR) showed no place was provided for nursing to record what the resident's SBP was prior to administration of the Metoprolol. In an interview on 02/07/2022 at 11:34 AM, Staff N (Resident Care Manager- RCM) reviewed the resident's record and confirmed there was no documentation to support facility nurses obtained the resident's SBP prior to administration as ordered. Staff N stated nursing should have identified the order was input incorrectly and corrected/clarified the order. Record review showed Resident 12 had 05/25/2021 bowel care orders for: Milk of Magnesia (MOM) as needed (PRN) for constipation, if no bowel movement (BM) for three days, administer MOM on day four; Dulcolax suppository PRN, if no results from MOM, administer on the next shift during waking hours; and Fleets enema PRN, if no results from Dulcolax, administer on the next shift during waking hours. The resident had a 01/27/2022 order for Senna (a stool softener) daily PRN for constipation. The order did provide objective criteria indicating when the Senna would/should be administered in lieu of the above bowel care orders. In an interview on 02/07/2022 at 11:54 AM, Staff N stated that the senna order needed to be clarified. Review of the resident's current Physicians Orders (POs) showed the following 09/29/2021 orders: Referral to neurology for tremors; and Referral for sleep study. Record review on 02/07/2022, showed no documentation or indication the resident was seen by neurology or the sleep clinic, or that the appointments were scheduled. In an interview on 02/07/2022 at 11:43 AM, Resident 13 indicated they were not seen by neurology or the sleep clinic and stated they were not aware they had been referred. During an interview on 02/10/2022 at 02:41 PM, Staff N explained nurses were responsible for scheduling appointments when referrals to specialists were made. Staff N stated the nurse receiving the order could schedule the appointment or the referral could be forwarded to the RCM to make the referral. Staff N acknowledged neither occurred. Resident 13 Review of the resident's 09/16/2021 hospital Discharge Summary showed the resident had one trial discontinuance of the urinary catheter but had a 1-liter post void residual (PVR - fluid remaining in the bladder after urination) and had the catheter reinserted. The Physician documented the following, Urinary retention may be secondary to prolonged immobility and possible urethral edema. Trial removal two weeks and follow-up with urology. Record review showed no documentation or indication the resident was seen by urology or that the appointment was scheduled. During an interview on 02/10/2021 at 4:58 PM, Staff B (Director of Nursing) stated upon admission nurses were expected to review the admitting resident's paperwork including the discharge summary. Staff B indicated the urology referral should have been identified and processed but was not. Resident 27 On 02/07/2022 at 9:25 AM during observations of care, Resident 27 was observed with a foam dressing covering parts of both buttocks and zinc oxide cream applied to the skin of both buttocks. Staff D (Licensed Practical Nurse -LPN) stated they applied the dressing the previous day (02/06/2022) and there was an order for zinc oxide but no order for the foam dressing. Review of Resident 27's POs revealed no order for a foam dressing. In an interview on 02/10/2022, Staff N stated there was not, but should have been, an order for the foam dressing in place prior to use. Resident 21 According to the 12/21/2021 admission Minimum Data Set (MDS an assessment tool), Resident 21 admitted to the facility on [DATE] with multiple medically complex diagnoses including dementia, kidney disease and deep vein thrombosis (a blood clot in a deep vein, usually in the legs). According to this MDS, Resident 21 had severe cognitive impairment and required extensive physical assistance from two staff for bed mobility and dressing. Observations on 02/07/2022 at 11:41 AM, showed Resident 21 had ace wraps applied to both legs from just above the knees to right below the knees. Observations on 02/08/2022 at 1:27 PM, showed Staff D applying ace wraps to both of Resident 21's knees. Staff D stated, They must have fallen off, I put them on this morning. Similar observations were noted on 02/10/2022 at 9:43 AM, that showed Resident 21 had ace wraps applied to both knees. According to the 01/20/2022 progress note by the Advanced Registered Nurse Practitioner (ARNP) the reason for the visit with Resident 21 was for bilateral lower extremities (BLE) edema. This note showed orders that directed staff to apply ace wraps to BLE once daily, 12 hours on, 12 hours off. Review of February 2022 Medication Administration Records (MARs) showed orders that directed staff to apply ace wraps to BLE once daily, 12 hours on, 12 hours off for edema. In an interview on 2/10/2022 at 9:59 AM, Staff AA (LPN) stated they would expect to see the ace wraps applied to the BLE, pointing to the ankle area, and going up to just below the knees and indicated that placement is important to help reduce edema to lower legs. Staff AA also verified there should be a time scheduled for staff to remove the ace wraps 12 hours after applying them. In an observation at this time, Staff AA confirmed the ace wraps were applied to both knees and indicated nursing staff failed to apply the ace wraps as ordered to BLE for Resident 21. Resident 15 According to the 12/03/2021 Significant Change MDS Resident 15 was assessed to be at risk of developing pressure ulcers/injuries and required extensive physical assistance of staff for bed mobility, dressing, personal hygiene, and bathing. Review of February 2022 Treatment Administration Records (TARs) showed Resident 15 had orders that directed staff to complete a weekly skin audit every week on Thursdays. This order gave directions for staff to document, YES indicates New skin impairment, NO indicates No New impairment. Resident 15 was scheduled for a skin check on 02/03/2022 that was signed off as completed by staff. Review of records on 02/04/2022 showed no indication that nursing staff documented whether Resident 15 had any skin impairments found during that skin assessment. In an interview on 02/10/2022 at 9:55 AM, Staff N stated the weekly skin check order for Resident 15 was missing the documentation that allowed staff to indicate yes or no if the resident had skin impairment. Staff N indicated staff should have but did not clarify the order to include required documentation. Resident 38 Review of the 01/07/2022 Quarterly MDS showed Resident 38 was admitted to the facility on [DATE] and was assessed as cognitively intact, able to make decisions, and had medically complex conditions, including diabetes, arthritis, and multiple sclerosis. Review of 05/06/2021 Hospital discharge orders showed a referral for Resident 38 to follow up with an orthopedic surgeon. Review of a 10/07/2021 Nursing Progress note showed the resident had a follow up appointment with the Orthopedic surgeon, the resident required right knee surgery, and it may take 2-3 months. Review of the resident's clinical record showed no consultation from the orthopedic surgeon. During an interview on 02/01/2022 at 12:01 PM Resident 38 stated they came to the facility with a bad right knee and saw the Orthopedic doctor who informed them their right knee needed to be replaced. The resident stated the surgery was supposed to be on November 1st, that they had their medical clearance for surgery, and that it still hasn't happened. In an interview on 02/11/2022 at 9:20 AM Staff B stated the resident should have been followed up in January for their surgery, but the resident was in the quarantined unit at that time. At 9:30 AM Staff N stated they called the surgeon's office but didn't document it. When asked about the resident's surgery being scheduled Staff N stated there was no date scheduled for surgery and they would have to call the surgeon's office to follow up. Staff B confirmed the consultation with the surgeon was not in the resident's record and they would expect it to be. Resident 256 A review of admitting physician orders (PO) showed a 01/24/2022 order for Wixela (a steroid inhaler) without the instructions to rinse mouth and spit after each use. A 01/24/2022 order for Miralax (a laxative) powder without the instructions to mix with a designated amount of fluid prior to administration of the medication to the Resident. In an interview on 02/10/2022 at 11:49 AM, Staff J, (Resident Care Manager) stated the orders were incomplete and would need additional instructions clarified for administration. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Eating Resident 206 A review of the 01/27/2022 admission MDS showed Resident 206 had diagnoses of Alzheimer's Dementia, severe vision loss and required an altered texture of food. Resident 206 was assessed to require extensive physical assistance from one person for eating. The 01/27/2022 CAA (Care Area Assessment- a care planning tool) showed Resident 206 had a swallowing problem, vision problems and inability to eat without assistance. The CAA showed Resident 206 had cognitive issues that could interfere with eating, including throwing food, poor memory, anxiety, difficulty making self understood and understanding others. The CAA showed CP goals to improve eating ability, slow or minimize decline, and avoid complications regarding eating difficulties. The 01/21/2021 Baseline CP showed Resident 206 needed set up and cueing for eating and was not updated with the new assessment on 01/27/2022. Staff was not informed of the amount of assistance Resident 206 required for adequate food intake. In an observation on 02/02/2022 at 08:57 AM, Resident 206 was sitting in a wheelchair at the nurse's station. A person set the breakfast tray on the counter next to Resident 206. The staff person stated here is your breakfast but did not turn the resident to the tray or orient the resident to the food on the tray. The staff did not hand them silverware or a cup to start eating or drinking. Resident 206 sat next to the food tray until they yelled out, I want to go to bed. The resident was assisted to lay down and did not eat breakfast. Resident 206 was not offered any other food or supplement. In an observation on 02/03/2022 at 09:21 AM, Resident 206 was sitting in a wheelchair in their room, with a bedside table in front of the chair. A person brought in the breakfast and set it on the table, placed sugar in the hot cereal and placed the call light in the resident's lap and left Resident 206 to eat on their own. The caregiver returned at 9:41 AM, 20 minutes later, and sat with Resident 206 to assist them to eat without re-heating the food on the plate. The caregiver was with the resident until 9:46 AM and then removed the tray. Observation of the tray showed Resident 206 had one or two bites of food and drank a glass of milk. In an observation on 02/04/2022 at 9:07 AM, Resident 206 was sitting in the wheelchair in the hallway with a bedside table in front of them, wearing a mask over their nose and mouth. A staff person brought the breakfast tray and set it on the table in front of the resident. The staff person did not set up the tray for the resident, did not help Resident 206 remove the mask and left to deliver another tray to a different resident. At 9:19 AM, 12 minutes later, a caregiver came to set up the tray for Resident 206 without reheating the food. Resident 206 asked to go to the car, the caregiver moved the resident into their room with their breakfast and left the resident to eat alone. At 9:40 a caregiver came into the room, assisted Resident 206 to drink a glass of milk and removed the tray from the resident. Observation of the tray showed Resident 206 drank a glass of orange juice, 1/3 of a glass of milk and a couple bites of oatmeal. Resident 206 was not offered any other food or supplement. In an observation on 02/07/2022 at 1:14 PM, Resident 206 was sitting in a wheelchair in the hallway with a lunch tray in front of them for 11 minutes without staff assisting or supervising or cueing to eat. Resident 206 called out Can I get water on this table? Resident 206 had 2 cups of fluids in front of him, they picked up a glass of juice to drink. Staff did not set the tray up so Resident 206 could eat; the silverware was under the rim of the plate out of view and was upside down. Resident 206 did not touch any of the meal. In an interview on 02/07/2022 at 1:25 PM, Staff I (Resident Care Manager) saw Resident 206 in the hallway not eating and there was no staff person to assist Resident 206 with eating. Staff I looked up the CP and stated Resident 206 was supposed to have set up and supervision for eating. Staff J acknowledged staff was not supervising or cueing Resident 206 and the resident did not eat any of the lunch by themselves. In an observation on 02/08/2022 at 9:01 AM, Resident 206 was in the hallway, a staff person set down a tray of breakfast on the bedside table in front of the resident. Resident 206 was wearing a mask over their nose and mouth, did not have the lid over the plate removed,, and glasses of milk and orange juice remaine covered. In an interview on 02/08/2022 at 9:08 AM, Staff Y (Certified Nursing Assistant) stated Resident 206 needed assistance with eating and said I can help them. Staff Y set up the tray and started to leave when stopped to ask if Resident 206 was able to eat with a mask on. Staff Y said no and removed the mask for Resident 206. At 9:18 AM an occupational therapist (OT) sat down with Resident 206 and assisted them to eat. The OT stated Resident 206 was assessed to require extensive assistance with eating by the therapy team. In an interview on 02/08/2022 at 9:10 AM, Staff I stated they would change the CP for Resident 206 because they needed help to eat. In an interview on 02/10/2022 at 11:49 AM, Staff J confirmed Resident 206 was assessed to require one person extensive assistance for eating, the CP was incorrect, and when Resident 206 did not eat, staff was expected to assist, offer an alternative, and tell the nurse. The nurse placed the resident on alert and assessedthe resident for the correct amount of assistance needed. Staff J stated this process did not happen for Resident 206. Personal Hygiene Resident 308 Resident 308 was admitted to the facility on [DATE]. According to the 01/29/2022 Admission/ Medicare -5 Day MDS, Resident 308 was cognitively intact with clear speech, had no rejection of care and required extensive physical assistance from staff for bed mobility, transfers, dressing and personal hygiene. Observations on 02/01/2022 at 10:01 AM showed Resident 308 had uncombed, greasy hair. On 02/02/2022 at 10:57 AM Resident 308's hair was still unbrushed. In an interview at this time, Resident 308 stated staff did not brush their hair for a while. Resident 308's toothbrush was also noted to be in the top draw of nightstand unopened in the original packaging. Observations on 02/04/2022 at 9:30 AM, showed Resident 308's toothbrush wasstill unopened in the residents top drawer. Similar observations were noted on 02/07/2022 at 9:28 AM with the toothbrush still sealed in original packaging in top drawer. Observation on 02/07/2022 at 10:48 AM, showed Resident 308 pulled their upper partial out of their mouth, showed the missing teeth and thick yellow buildup on partial, and stated I usually pull it out and clean it when I brush my teeth. Resident 308 revealed they were not been able to do that since they were admitted to the facility. On 02/07/2022 at 11:30 AM Staff B verified the toothbrush was unopened in Resident 308's top drawer. In an interview at this time, Staff B stated staff should have assisted Resident 308 with ADLs, which included assisting with brushing hair and teeth. Resident 21 Resident 21 was admitted to the facility on [DATE]. According to the 12/21/2021 admission MDS, Resident 21 had severe cognitive impairment, showed no rejection of care, and required extensive physical assistance from staff for bed mobility, dressing, personal hygiene, and bathing. Observations on 02/02/2022 at 12:59 PM showed Resident 21 with hair uncombed, and the resident was picking at their teeth with fingernails. On 02/03/2022 at 9:10 AM observations showed Resident 21 was moved to a new room without a nightstand. No toothbrush could be located for the resident. At this time Resident 21 continued to have uncombed hair. Similar findings were noted on 02/04/2022 at 11:50 AM. In an interview on 02/07/2022 at 11:35 AM, Staff B confirmed Resident 21's hair was uncombed and matted and verified no nightstand or toothbrush was available for the resident. Staff B stated their expectation is for staff to assist dependent residents with ADLs daily. Resident 21's still-unopened toothbrush was observed in the top drawer of Resident 21's in a nightstand by the resident's bed on 02/08/2022 at 2:20 PM and again on 02/09/2022 at 4:30 PM. In an interview on 02/10/2022 at 9:59 AM, Staff AA (Licensed Practical Nurse) verified the unopened toothbrush remained in nightstand and confirmed Resident 21's hair remained uncombed. REFERENCE: WAC 388-97-1060(2)(C) Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on staff to meet their Activities of Daily Living (ADLs) needs, were consistently provided such assistance for 9 (Residents 12, 13, 15, 36, 44, 54, 206, 21, & 308) of 25 sample residents reviewed for ADLs. The failure to provide assistance to residents who were dependent on staff for bathing (Residents 13, 12, 206, 15, 36, 44, & 54), nail care (Resident 21 & 13), eating (Resident 206), and personal hygiene (Residents 308 & 21) placed residents at risk for unmet needs, poor hygiene, embarrassment and diminished quality of life. Findings included . Bathing Resident 13 Resident 13 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, demonstrated no behaviors or rejection of care, choices about bathing were very important, and was dependent on staff for provision of bathing. During an observation and interview on 02/02/2022 at 1:40 PM, Resident 13 reported the facility did not provide them bathing this year and stated I can smell myself . Review of Resident 13's December 2021 and January/February 2022 bathing records showed the resident was to be bathed twice weekly on Mondays and Thursdays. According to the bathing record the resident was offered/provided bathing on the following dates: 12/02/2021; 12/14/2021 (12 days later); 12/21/2021 (7 days later); 12/23/2021; 01/05/2022 (13 days later); 01/06/2022; 01/10/2022; and 02/05/2022 (26 days later). In an interview on 02/07/2022 at 1:53 PM, Staff N (Resident Care Manager) stated, [Resident 13] should have been bathed more frequently. Resident 12 Resident 12 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact, required physical assistance with bathing, demonstrated no behaviors or rejection of care, and choices related to bathing were very important. During an interview on 02/02/2022 at 10:40 AM, Resident 12 reported they had only received one bed bath and no showers in 2022. In an interview on 02/07/22 at 01:15 PM the resident explained, When it goes too long I wash my own hair in the sink here. Review of Resident 12's January and February 2022 bathing records showed the resident was to be bathed twice weekly on Wednesdays and Saturdays. According to the bathing record the resident was offered/provided bathing on the following dates: 01/13/2021 (bed bath); and 01/26/2021 (refused). During an interview on 02/07/22 at 02:05 PM, Staff N acknowledged facility staff failed to consistently offer and provide bathing to Resident 12. Resident 206 A review of the 01/27/2022 admission MDS showed Resident 206 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's Dementia, incontinence, muscle weakness and difficulty walking. The assessment showed Resident 206 required extensive assistance with bathing, transfers and used a wheelchair for ambulation. A review of the care plan showed Resident 206 was scheduled for showers on Mondays and Thursdays. A review of the bathing records for Resident 206 showed there was a period of time when no shower or bed bath was offered or provided between 01/25/2022 and 02/03/2022, 10 days. Resident 206 was scheduled for two showers in this period that were not provided or offered and refused. In an interview on 02/10/2022 at 11:49 AM, Staff J (Resident Care Manager) stated the aide was expected to provide a shower on scheduled shower days, if refused the aide should let the nurse know, the nurse would make a progress note, put the resident on alert, and another shower would be offered to the resident at a different time or day. Staff J stated that process did not happen for Resident 206. Resident 15 Resident 15 was admitted to the facility on [DATE]. According to a 12/3/2021 Significant Change MDS, Resident 15 was cognitively intact, showed no rejection of care, and required physical assistance of staff for bathing. In an interview on 02/02/2022 at 9:28 AM, Resident 15 indicated they were not getting showers, adding they gave me a spit bath once. Resident 15 stated, I finally got one a couple of days ago. Review of Resident 15's revised 11/29/2021 Baseline Care Plan (CP) showed interventions that identified a bathing schedule for twice weekly on Monday and Thursdays. Review of December 2021 bathing records revealed Resident 15 went 13 days without any bathing and review of January 2022 bathing records showed no documentation that bathing occurred in the first 12 days of the month. In an interview on 02/11/2022 at 8:26 AM, Staff N stated it did not appear that staff provided showers as scheduled for Resident 15, and indicated residents should receive bathing per their care plan. Resident 36 Review of the 01/10/2022 Annual MDS showed the resident had severe cognitive impairment, and required extensive assistance from staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Review of Resident 36's December 2021, January and February 2022 bathing records showed the resident preferred bathing one time a week and preferred a male shower aide if the schedule allowed. According to the bathing records, Resident 36 was not offered bathing from 12/22/2021- 01/08/2022, a total of 17 days, and was not offered or documented bathing from 01/24/2022- 02/05/2022, a total of 12 days. In an interview on 02/11/2022 at 9:20 AM Staff B (Director of Nursing), reviewed bathing records for Resident 36 and confirmed that no showers were offered or documented at least weekly. Resident 44 According to the 01/31/2021 Medicare 5 Day MDS, the resident was assessed with moderately impaired cognition, able to make their own decisions, and required extensive assistance from staff with bed mobility, dressing, toilet use, personal hygiene, and bathing. Review of Resident 44's November 2021, December 2021 and January 2022 bathing records showed the resident preferred bathing twice a week on Tuesday and Friday. According to the bathing records, Resident 44 was not offered bathing from 11/16/2021- 12/07/2022. One refusal was documented for 12/08/2021, and the resident did not receive bathing until 12/28/2021, six weeks later. In an interview on 02/11/2022 at 9:20 AM Staff B acknowledged that bathing was not offered to Resident 44 at a minimum of weekly. Resident 54 According to the 01/12/2022 Quarterly MDS, the resident was assessed with severe cognitive impairment, not able to make their own decisions, and required one person assistance with bathing. Review of Resident 54's October 2021, November 2021, December 2021, and January 2022 bathing records showed the resident had one shower offered and refused in October 2021, no showers were documented for November 2021, two showers were documented for December; one refusal and one n/a or non-applicable, and January 2022 showed the resident received a shower on 01/06/2022 and a bed bath on 01/13/2022. In an interview on 02/11/2022 at 9:20 AM Staff B stated they would expect the resident to receive bathing at a minimum of once weekly, and acknowledged the resident's bathing was not being completed. Nail Care Resident 21 According to the 12/21/2021 admission MDS, Resident 21 had severe cognitive impairment, showed no rejection of care, and required extensive physical assistance from staff for bed mobility, dressing, personal hygiene, and bathing. Observations on 02/07/2022 at 11:41 AM, showed Resident 21 with toenails that were long, jagged, and extended past the toes on both feet. In an interview on 02/07/2022 at 11:41 AM, Staff D (Licensed Practical Nurse), stated staff should be providing nail care weekly for residents and confirmed Resident 21's toenails were long and had not been trimmed weekly. Resident 13 Resident 13 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS the resident was cognitively intact, and required extensive assistance with ADLs. During an observation and interview on 02/02/2022 at 1:40 PM, Resident 13 stated, My toenails are long, they haven't been cut since September [2021]. My fingers nails have not been cut either .I usually like them long but not this long, most of them have broken off now. Observation of the resident's fingernails showed the resident's thumbs, pinky fingers and index fingers on both hands were greater than an inch long, and curly inward upon themselves creating cone shaped nails, the nails on to the resident's other fingers were short and jagged. Observation of the resident's toenails showed both great toenails were thick, yellowing and a 1/2 inch in length, the toenails to the 4th digits on each foot (next to pinky toe), were long untrimmed and curling around the end of the toes. The other toenails were short but. uneven and jagged. The resident reported their toenails were brittle and would snag the bedding and break. In an interview on 02/01/2022 at 11:48 PM, Staff B stated it was the expectation that residents receive nail care weekly. A potential for impairment to skin integrity CP, revised 12/21/2021, directed staff to Keep fingernails short. During an observation interview 02/09/2022 at 05:32 PM, Resident 13 reported to Staff N that their finger and toenails had were not cut for over two months. Staff N observed Resident 13's nails and acknowledged it did not appear staff were providing weekly nail care stating No, they need to be cut.

Resident 7 According to the 11/16/2021 Quarterly MDS, Resident 7 had diagnoses including hemiplegia (one-sided paralysis following a brain bleed), muscle contractures and dementia, and was severely cognitively impaired. Resident 27's Decreased Physical Mobility CP, revised on 10/14/2021, included a 01/17/2019 intervention to receive restorative nursing services 5-7 times a week to have their right hand splinted. On 02/02/2022 at 11:06 AM, and at 02/07/2022 at 11:33 AM, Resident 7 was observed to be in bed with no splinting of their right hand. Review of Resident 7's Treatment Administration Record (TAR) revealed that in December 2021, there was no record of Resident 7's right hand being splinted as CP directed. The January and February 2022 TAR showed between 01/30/2022 and 02/07/2022, Resident 7's right hand was splinted on only 4 of 9 occasions. In an interview with Staff AA and Staff CC (LPN) on 02/07/2022 at 11:34 AM, Staff AA stated Resident 7 required splinting 5-7 times a week, and their right hand was only splinted on 3 occasions over the last week. Staff AA and Staff CC stated they facility has only one restorative aide who was often pulled to the floor. Refer to: F725 - Sufficient Nursing Staff REFERENCE: WAC 388-97-1060(3)(d). Based on observation, interview, and record review the facility failed to ensure 3 (Residents 12, 13, & 7) of 5 residents reviewed for limited Range of Motion (ROM) received treatment and services to increase and/or prevent a decline in ROM. The facility's failure to ensure Restorative Nursing Programs (RNPs) were provided to residents at the frequency they were assessed to require, placed residents at risk for a decline in ROM, reduction in strength and mobility, increased dependence on staff and decreased quality of life. Findings included . Resident 12 According to the 12/01/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had no functional limitation in ROM to their upper extremities (UE) or lower extremities (LE) and received an active ROM RNP on four of seven days during the assessment period. In an interview on 02/02/22 at 11:18 AM, Resident 12 stated that their goal was to discharge to an apartment but expressed concern that no one was working with them to improve their Activities of Daily Living (ADLs) or activity tolerance. The resident reported someone only came twice or maybe three times a week to exercise their shoulders but the resident felt this was insufficient. According to a Impaired mobility related to weakness care plan (CP), revised 01/07/2022, Resident 12's goals were to: maintain present muscle strength, current functional level and endurance; and maintain the ability to ambulate 50 feet with supervision, and the use of four wheeled walker. Interventions included the provision of an active ROM RNP 4-6 times a week, to the resident's bilateral (Both) UEs and LEs, to all joints and all planes, two sets of 8 repetitions, using a yellow theraband (Rubber or elastic bands that provide resistance and strengthen muscles). During an interview on 02/10/22 at 11:19 AM, Staff AA (Licensed Practical Nurse - LPN/ Restorative Nurse) explained that when a program was written for 4-6 times a week, the frequency was determined by the resident's tolerance. Per Staff AA the program should be offered 6 times a week and if the resident could not tolerate that frequency, staff should document the intolerance. According to Resident 12's Restorative flowsheet, which directed staff to provide an active ROM program 4-6 times a week, Resident 12 was only offered the active ROM program 6 times in December 2021 and 15 times in January 2022. During an interview on 02/10/2022 at 12:43 PM, Staff AA reviewed Resident 12's Restorative flowsheets and acknowledged the resident was not offered/provided their RNP at the frequency they were assessed to require. Resident 13 According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact, had no functional limitations in ROM to either UE or LE, and received no RNPs during the assessment period. In an interview on 02/02/2022 at 2:23 PM, Resident 13 indicated they had limited ROM to bilateral shoulders and stated, I can't even turn my [overbed] light on because I can't reach above and behind my head. The resident stated that they were unsure if they were on a RNP, but acknowledged sometimes a staff member did come and do ROM exercises. According to an Impaired mobility related to weakness CP, revised 12/21/2021, staff were directed to provide an active ROM program to bilateral UEs and LEs 3-6 times a week. According to Resident 13's Restorative flowsheets, staff were to provide an active ROM program 3-6 times a week. Review of the flowsheets showed the resident was offered: the active ROM program 5 times in December 2021 and 16 times in January 2022. During an interview on 02/10/2022 at 12:43 PM, Staff AA reviewed Resident 13's Restorative flowsheets and acknowledged the resident was not offered/provided their RNP at the frequency they were assessed to require.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1 (Resident 256) of 2 residents reviewed for urinary incontinence and 1 (Resident 13) of 3 residents reviewed for urinary catheters received the necessary care and services to achieve their optimal level of urinary function. Failure to comprehensively assess the causes of incontinence and provide treatment and services to restore bladder function, and failure to: accurately identify the reason for a resident's urinary catheter use; provide documentation to support why an indwelling catheter required to be re-inserted after discontinuance; and to ensure residents without a history of requiring an urinary catheter were timely evaluated by urology, placed residents at risk for urinary tract infections, loss of bladder tone continued decline in urinary function, skin issues, and embarrassment. Findings included . Resident 256 A review of the 01/31/2022 admission MDS showed Resident 256 admitted to the facility on [DATE] and required two-person physical assistance for bed mobility, transfers, and toileting assistance. Resident 256 was assessed as cognitively intact, able to make self understood and to understand others. Resident 256 was assessed as frequently incontinent bladder, occasionally incontinent bowel and was not placed on a trial toileting program. The 01/31/2022 Care Area Assessment (CAA) assessed Resident 256's incontinence to be related to urinary urgency and restricted mobility and included goals to minimize decline, avoid complications and minimize risks of incontinence. The 02/05/2022 care plan (CP) showed Resident 256 was incontinent of bladder with no bladder retraining program or routine toileting schedule. The CP stated resident should use incontinent products for incontinence and did not instruct staff to take Resident 256 to the toilet. In an interview on 02/01/2022 at 2:37 PM, Resident 256 stated they had some bladder incontinence before coming to the facility, but the incontinence is now much worse. In an interview on 02/10/2022 at 12:41 PM, Resident 256 stated they used the call light to get help to the bathroom, but it takes staff a long time to respond and by that time the resident was incontinent. Resident 256 stated they were not working with therapy to improve bladder incontinence. In an interview on 02/11/2022 at 11:19 AM, Staff JJ (Director of Rehab) stated a referral was not received from nursing for a bladder retraining program. Staff JJ stated there was a therapy protocol for toileting programs and bladder retraining, but the facility did not implemented the protocol. In an interview on 02/11/2022 at 10:49 AM, Staff I (Resident Care Manager) reviewed the 01/24/2022 admission Bladder Evaluation and confirmed the treatment options selected for Resident 256 included bladder retraining and routine toileting program with a referral to therapy. Staff I reviewed the CP and stated there was no toileting program or a retraining program for Resident 256 and that there should be a toileting schedule. Staff I stated a referral was not and should be made to therapy regarding Resident 256's incontinence. Resident 13 Resident 13 admitted to the facility on [DATE]. According to the 09/23/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had a diagnosis of unspecified urinary retention and had an indwelling urinary catheter. During an interview on 02/02/2022 at 2:11 PM, the resident reported they did not require a urinary catheter prior to hospitalization and indicated staff attempted to remove the catheter twice but they were unable to void. The resident was not sure if both attempts at removal of the catheter were at the facility or if one was at the hospital and one at the facility. Resident 13 stated, It [Indwelling Urinary Catheter] should come out I think. Review of the resident's comprehensive CP showed a Potential for infection related to indwelling catheter revised on 01/12/2021, that showed, Resident demonstrates the following indications to support indwelling catheter use: Neurogenic bladder (a bladder that does not function because of nerve damage). Record review, showed no indication the resident was assessed for, or diagnosed with a neurogenic bladder. The facility's 09/21/2021 Physician History and Physical showed the resident had an indwelling catheter due to urinary retention. The facility Physician documented urinary retention probably [due to] neurogenic bladder. Review of the resident's 09/16/2021 hospital Discharge Summary showed the resident had one trial discontinuance of the urinary catheter but had a 1-liter post void residual (PVR - fluid remaining in the bladder after urination) and had the catheter reinserted. The Physician documented the following, Urinary retention may be secondary to prolonged immobility and possible urethral edema. Trial removal two weeks and follow-up with urology. Record review showed a trial discontinuation of the resident's urinary catheter was attempted 10/05/2021 as noted by staff's initial on the resident's Treatment Administration Record (TAR). The catheter was reinserted 10/07/2021. Other than the 10/05/2021 initial on the TAR, indicating the catheter was discontinued, there was no other documentation in the resident's record indicating what time the catheter was discontinued, how the catheter removal was tolerated by the resident, when the resident first voided, if a PVR was performed and if so, what the result was. There was no documentation or indication when or why the indwelling catheter needed to be reinserted Record review on 02/06/2022 showed Resident 13 still was not seen by a physician specializing in the bladder (urology) as recommended in the 09/16/2021 discharge summary. Review of the Physician's Orders (PO) showed on 01/06/2022 the resident was again referred to urology by a facility practitioner. During an interview on 02/10/2021 at 4:58 PM, Staff N (Resident Care Manager) and Staff B (Director of Nursing), acknowledged the resident's CP was inaccurate and Resident 13 did not have a supporting diagnosis for the use of an indwelling urinary catheter (e.g. neurogenic bladder, urinary retention with obstruction). Staff B and Staff N indicated Resident 13 the urology referral was not made nearly five months after it was recommended. Staff B then acknowledged there was no documentation in the resident's record to support why the staff re-inserted the indwelling catheter after the trial discontinuation on 10/05/2021. REFERENCE: WAC 388-97-1060(3)(c). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 27 According to the 1/31/2022 Significant Change MDS, Resident 27 originally admitted to the facility on [DATE], and received hospice services. Review of the 1/20/2022 Hospice Election Form, showed Resident 27 began receiving hospice services on 1/20/2022. According to the an Authorizations and Designations Form, signed on 2/16/2021, Resident 27's responsible party, the facility was authorized to make funeral arrangements. The form included an area to document the name and address of the resident's preferred Funeral Home that was not completed. Record review revealed a document scanned into Resident 27's Electronic Health Record on 10/07/2021 titled Contact Information Card for National Crematorium. The scan was of a business card with the phone number for the National Crematorium Society attached to a note from the Resident 27's responsible party. The note instructed Staff K to keep on file for use when Resident 27 passed. In an interview on 02/11/2022 at 8:45 AM, Staff K stated they had a note explaining Resident 27's decision maker paid for a cremation and the note included contact information for the crematorium. Staff K stated the Authorization and Designations Form should be, but were not updated to reflect Resident 27's funeral wishes, and that this was the responsibility of the Social Services Department. REFERENCE: WAC 388-97-0960(1). Based on interview and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 (Residents 12 & 13) of 3 residents reviewed who demonstrated a pattern of refusals, and failed to provide medically-related social services related to end-of-life arrangements for 1 supplemental resident (Resident 27). The facility's failure to identify, communicate, and attempt to determine the reasons for resident refusals, precluded staff from developing and implementing resident specific approaches and interventions to mitigate causative factors and increase acceptance of care. These failures placed the resident at risk for unmet or unidentified care needs and unfulfilled end-of-life arrangements. Findings Included . Resident 13 Resident 13 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, and demonstrated no behaviors or rejection of care. Review of Resident 13's comprehensive Care Plan (CP) showed the resident was suppose to receive an active Range of Motion (ROM) Restorative Nursing Program (RNP) 4-6 times a week and a walking RNP 3-6 times a week. Review of Resident 13's January 2022 Restorative flowsheets showed of the 16 times the ROM program was offered, the resident refused 8 times and of the 6 times the walking program was offered, the resident refused 5. Record review showed no indication facility staff identified or communicated Resident 13's trendable pattern of refusals, attempted to determine the reasons behind the refusals, or considered alternative interventions or methods of treatment to increase resident acceptance of care. In an interview on 02/11/2022 at 8:58 AM, Staff K (Director of Social Services) stated when a resident was consistently refusing something (e.g. medications, care etc) social services (SS) should be notified. Staff K explained the SS role in resident refusals as talking with residents to find out why the residents are refusing, (is it due to preference, pain, a particular staff member etc.) once identified a new CP was developed to address resident concerns with a goal of improving the acceptance of care. During an interview on 02/11/2022 at 8:54 AM, Staff K stated SS did not address Resident 13's refusals because they were not informed of them. Resident 12 Resident 12 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact, and demonstrated no behaviors or rejection of care. Record review showed the resident had a 06/21/2021 order for Mirtazapine (an antidepressant) daily, and a 09/13/2021 order for Cal Dense (a nutritional supplement) twice daily. According to Resident 12's December 2021 Medication Administration Records (MARs) from 12/01/2021 -12/13/2021 the resident refused the Mirtazapine on 12 of 13 days. Review of Resident 12's MARs also showed the resident refused the evening dose of Cal Dense on 22 of 31 days in December 2021, and on 24 of 31 days in January 2022. Record review showed no indication facility staff identified or communicated Resident 12's trendable pattern of refusals, attempted to determine the reasons behind the refusals, or considered alternative interventions or methods of treatment to increase resident acceptance of care. During an interview on 02/11/2022 at 8:54 AM, Staff K indicated SS hadn't addressed Resident 12's refusals because they weren't communicated to them.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). One (Staff D) of 3 Licensed Nurses made 3 errors during 27 opportunities, for 2 residents (Resident 7 and 42) of 4 residents observed for medication pass. This resulted in an error rate of 11.11%. This failure placed residents at risk for not receiving the intended therapeutic effects of physician ordered medications. Finding included . Resident 42 Observations on 02/09/2022 at 8:00 AM showed Staff D (Licensed Practical Nurse- LPN) prepared and administered the following medications to Resident 42: Cholecalciferol 1 tablet of 1000 IU (International Units) and Potassium Chloride liquid, 20 ml (milliliters) in a medication cup. A Review of February 2022 Medication Administration Records (MARs) showed the Physician Orders (POs) for: Cholecalciferol Tablet 1000 I UNIT Give 2000 IU by mouth one time a day and Potassium Chloride Liquid 20 MEQ (milliequivalents)/15 ML, Give 20 MEQ by mouth one time a day and to mix/dilute with 120 cc (cubic centimeters) cold water or juice. In an interview on 2/10/2022 at 11:10 AM Staff N (Resident Care Manager) indicated that staff should read and follow the PO to give 2 tabs of Cholecalciferol and to give 20 mls of the Potassium Chloride, that should be diluted. Resident 7 Observation on 02/07/2022 at 8:25 AM showed Staff D prepared and administered Lispro (Insulin) 10 units while the resident was eating their breakfast. According to February 2022 MARs, Resident 7 had a PO for Lispro (Insulin) 10 units SQ (subcutaneously) to be given before meals. In an interview on 02/10/2022 at 11:10 AM Staff N indicated that staff should read and follow the PO. Staff N acknowledged the Insulin should be administered prior to meals. REFERENCE: WAC 388-97-1060(3)(k)(ii) .

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured, labeled with required resident identifying information, dated when opened, and expired medications and biologicals were disposed of timely in accordance with professional standards in 4 of 5 medication carts, 2 of 2 medication rooms, and 2 of 2 central supply storage rooms reviewed. This failure placed residents at risk for receiving expired medications and at risk for other medication errors. Findings included . Southeast Medication Cart An observation and interview on 02/01/2022 at 1:27 PM showed the southeast medication cart contained an insulin pen without an open date, a bottle of cranberry tablets 450 milligrams (mg) with an expiration date of 11/2021, a bottle of Aspirin 81 mg with an expiration date of 12/2021, a bottle of liquid Iodine that expired 06/2021. Staff H (Licensed Practical Nurse - LPN) verified the expiration dates and stated the medications should be discarded when expired and insulin pens should be dated upon the first time used. Observation and interview on 02/01/2021 at 1:27 PM with Staff H showed the southeast medication cart contained four tubes of prescribed ointments for four different discharged residents and one bottle of anesthetic spray for a fifth discharged resident. Staff H stated the treatments should be removed from the cart when a resident discharges. A 02/01/2022 1:27 PM observation of the southeast medication cart showed a bottle of Ammonium Lactate (a skin lotion) for a resident located in another part of the facility and a tube of Clotrimazole-Betamethasone (a skin ointment) without a label or marked with a resident name. Staff H interviewed on 02/01/2022 at 1:27 PM stated these items should be removed from the cart. East Medication Cart Observation of the East Hall medication cart on 02/01/2022 at 12:55 PM with Staff R (LPN), showed the following expired medications: bottle of Rena Vite tablets that expired 01/2022; bottle of Vitamin C that expired 12/2021; bottle of Aspirin that expired 11/2021; bottle of Vitamin B Complex that expired 1/2022; and two bottles of Co Q-10 (a dietary supplement) that expired in 11/2021. In an interview on 02/01/2022 at 12:55 PM, Staff R confirmed the medications were expired and stated they should be removed from the medication cart. Observations made on 02/01/2022 at 1:00 PM, with Staff R showed a container of Latanoprost and Brimonidine (eye drops used to treat glaucoma) were both open and undated for Resident 306. A bottle of Tubersol (a solution used for tuberculosis testing which required refrigeration) was found in the top drawer of the medication cart. In an interview on 02/01/2022 at 1:00 PM Staff R confirmed the eye drops were open and undated, and indicated staff should date these medications when they were opened. Staff R indicated the Tubersol solution should be kept in the refrigerator. West Medication Cart Observation of the [NAME] Medication cart on 02/01/2022 at 11:45 AM, with Staff D (LPN), showed an OTC (Over the counter) medication, Thiamin Vitamin B-1, expired on 01/2022, a Cranberry supplement 450 mg expired on 11/2021, a Currad Hydrocortisone 1% cream expired on 12/2021, a Systane lubricant eye drop bottle opened on 11/27/2021 with no resident's name and expired on 12/27/2021, an Iodosorb cream tube was opened with no date and no resident name on it, an open Hemorrhoidal suppository box expired on 03/2021, and an open, undated Ketotifen Fumarate eye drop bottle for a resident who discharged the prior month. In an interview on 02/01/2022 at 12:20 PM, Staff D confirmed the above listed medications were expired, undated and unlabeled. On 02/10/2022 from 07:28 AM to 7:55 AM, Staff D was observed administering medications to Resident 55, who required all nutrition and medication to be administered through a feeding tube (a medical device to deliver nutrition, hydration and/or medications for residents unable to take food and medication orally). At 7:58 AM, while Staff D was still in Resident 55's room, the [NAME] medication cart was observed unlocked, with the drawers containing resident medications easily opened. No residents were observed in the area. Staff D then left Resident 55's room and returned to the cart. Staff D was asked if the cart was secure. While staff D pressed/engaged the lock from the unlocked position to the locked position with their right palm, Staff D stated that the cart was now locked and then pulled a drawer to demonstrate the cart was now locked cart would no longer open. Southwest Medication Cart Observation of the Southwest Medication Cart on 02/01/2022 at 12:28 PM, with Staff S (LPN), showed the following expired, undated when opened, or unlabeled medications: a bottle of Thiamine Vitamin B-1, expired 01/2022; a bottle of Acidophilus, expired 01/2022; A bottle of Cranberry tabs, expired 11/2021; a Epinephrine autoinjector (epi-pen), expired 01/2022; Resident 5's Ellipta Breo tray (which directed staff to date the tray when opened, and discard after 6 weeks) was opened and undated; an unlabeled (No resident name) Ellipta Breo tray was observed to be open and undated; Resident 30's Spiriva Respimat, which directed staff to date when opened, and discard after 3 months, was open and undated. During an interview on 02/01/2022 at 12:48 PM, Staff S confirmed the presence of the above expired, undated, and unlabeled medications. Southeast Medication Room Observations of the Southeast medication room on 02/01/2022 at 12:07 PM with Staff H, showed several large bags full of Normal Saline 0.9% syringes for Resident 259, who discharged from facility on 01/01/2022, and Resident 261 who discharged from the facility on 01/07/2022. Observations at this time also showed a bottle of Omeprazole powder for oral suspension, (used to treat or prevent gastrointestinal ulcers), for Resident 260 that expired on 01/16/2022. In an interview on 02/01/2022 at 12:10 PM, Staff H indicated medications should be sent back to pharmacy or destroyed if a resident was discharged and stated, we return medications every week to the pharmacy. Staff H indicated that staff should discard the expired medications. Southwest Medication Room During observation of the Southwest medication room on 02/03/2022 at 10:39 AM, a bag of intravenous Vancomycin for Resident 285, was observed in the medication refrigerator with an expiration date of 01/20/2022. In an interview on 02/03/2022 at 10:43 AM, Staff D acknowledged the Vancomycin was expired and should be discarded. Central Supply Rooms An observation and interview on 02/01/2022 at 11:51 AM with Staff T (Central Supply) in the main central supply room showed nine bottles of Pink Bismuth (for upset stomach) expired 10/2021, three bottles of calcium carbonate liquid (for heartburn) expired 11/2021, three bottles Magnesium citrate liquid (for constipation) expired 10/2021, and one tube of Terbinafine Hydrochloride (a skin treatment) expired 08/2021. Staff T stated expired medications should be removed and thrown away, and these items were not discarded. An observation and interview on 02/01/2022 at 12:28 PM with Staff T in the small supply room by the therapy gym, showed three bottles of Fexofenadine (for heartburn) expired on 10/2021, four bottles of artificial tears expired on 09/2021, two bottles mineral oil expired on 9/2021, four bottles of Loperamide (for diarrhea) expired on 12/2021, two bottles of Calcium Carbonate liquid (for heartburn) expired 11/2021, four bottles of Fluticasone nasal spray (for allergies) expired 08/2021, four bottles of sunscreen expired 04/2021, two boxes of hemorrhoid suppositories expired 03/2021, and a box of single use antibiotic ointment packets expired 12/2021 mixed with non-expired packets. Expired medical supplies were also observed, including a box of nasal aspirators expired in 2018 and 2021, two boxes of urine test strips expired 11/2021, two boxes of hemoccult containers and two boxes of hemoccult cards with test solution expired 03/2021 In an interview on 02/01/2022 at 12:28 PM Staff T stated the expired items should be thrown away. Medications at the Bedside Observations on 02/01/2022 at 9:54 AM showed Resident 307 had a large bottle of Vitamin C sitting on their nightstand. Multiple observations of the unsecured Vitamin C bottle at bedside were also noted on 02/02/2022 at 2:04 PM, 02/03/2022 at 8:12 AM, 02/04/2022 at 8:37 AM, and on 02/04/2022 at 1:26 PM. In an interview on 02/04/2022 at 1:33 PM, Staff Z (LPN), confirmed the bottle of Vitamin C on Resident 307's nightstand and stated medications should not be left unsecured at the bedside. REFERENCE: WAC 3988-97-1300(2), -2340. .

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 10 residents (Residents 309, 308, 13, 207, 40, 12, 14, 38, 44, & 15) revealed concerns about the taste, temperature, and overall palatability of food served by the facility. Observations of the entrée prepared for residents who required a pureed diet on 02/09/2022, showed staff failed to use written recipes for the preparation of pureed food. The failure to use a recipe did not ensure that the proper consistency, flavor, and/or nutritional value of the food was maintained. This placed four of (Residents 306, 21, 44 & 262) four residents who required pureed food at risk for improper texture and a lack of palatability. Findings included . Resident Interviews Resident 309 In an interview on 02/01/2022 at 11:52 AM, Resident 309 stated the food was, unmentionable, I don't eat that much, only a couple bites. The meat is dry with no taste, the veggies are soggy, and overcooked with no taste. Observations on 02/02/2022 at 3:00 PM, showed Resident 309 opening a bag of snacks at bedside and stated, we don't talk about the food, it's deplorable, that's why I have this bag down here from my daughter. Observations on 02/09/2022 at 1:44 PM, showed Resident 309 did not touch the food on their meal tray. In an interview at this time, Resident 309 indicated they spoke with staff about the food quality and stated nothing changed. Resident 308 In an interview on 02/01/2022 at 10:01 AM, Resident 308 stated the food was, lousy and indicated it, could be cooked better. In an interview on 02/02/2022 at 10:51 AM, Resident 308 frowned and gave a thumbs down gesture, when discussing how breakfast tasted. Resident 308 stated, I didn't eat much of it, did you see what it looked like? Resident 308 reported the timing for meals was, all over the place, and the meals get here about 9 AM, then about 2 PM and then dinner usually comes at 6 or 7 PM. Resident 308 indicated the food was sometimes cold. Observations on 02/04/2022 at 9:30 AM, showed Resident 308 with a mostly untouched breakfast tray sitting in front of them. Resident 308 stated, it was yucky, the toast has been sitting there for a while. Resident 13 On 02/02/2022 at 2:06 PM, Resident 13 stated, They have a problem here on the [NAME] [Unit], we are served first, and my pork loin was cold when I got it .no it's not isolated it's the norm. Resident 207 On 02/02/2022 at 2:17 PM, Resident 207 stated their biggest complaint is food in the morning, dry biscuit, eggs dry, jalapeno's too spicy, I have talked with them .but nothing, I gave up on breakfast. Resident 40 On 02/02/2022 at 12:48 PM, Resident 40 indicated they disliked the food. Resident 12 On 02/02/2022 at 10:46 AM, Resident 12 stated the food was not very good because it was served cold, what was supposed to be a turkey sandwich was made with ham and no condiments like mayonnaise were provided making the sandwich too dry to eat. Resident 14 On 02/02/2022 at 1:31 PM, Resident 14 reported that the food did not taste good and was cold most of the time, .even the soup was cold most of the time when they bring it. Resident 38 On 02/03/22 at 9:30 AM, Resident 38 laughed when asked about food concerns. Taste is fine, there is not a lot of food. I am a little overweight. I am sure I have lost weight at least over 20 lbs. Resident 44 On 02/02/22 at 10:26 AM, the resident stated, The food doesn't taste good. Resident 15 In an interview on 02/02/2022 at 9:25 AM, Resident 15 stated breakfast was terrible and indicated they felt the same thing was served every day. Resident 15 stated breakfast used to come at 8:00 AM but now, it sits until 9 AM, and reports their food is cold every day. Resident 15 indicated they usually get hungry waiting for their lunch to come and reports it does not get delivered until about 2:30 PM. Observations at this time showed Resident 15 left the breakfast eggs and ham on plate untouched. Meal Preparation/Service Observation of the noon meal service on 02/09/2022, occurred between 11:15 AM and 12:58 PM. At 11:25 AM Staff EE (Cook) dumped an unmeasured amount of chopped chicken breast into a blender and blended it for approximately 15 seconds. Staff EE then added an unmeasured amount of chicken broth to the blender and blended for an additional 5 seconds. Staff EE grabbed a tulip desert bowl and dipped it into the large bin of thickener to fill it. The unmeasured amount of thickener was then dumped into the blender and blended for 10-15 more seconds. Staff EE visually observed the mixture, and dipped the tulip desert bowl into the bin of thickener and dumped the unmeasured amount into the blender. After blending the mixture for another 10 seconds, Staff EE emptied the contents of the blender into a pan, covered it with plastic wrap and placed it in the warmer. At 11:41 AM Staff EE used a spatula to push an unmeasured amount of orzo (rice-shaped pasta) out of a metal container into the blender. Staff EE twice added an unmeasured amount of chicken broth and on three occasions added unmeasured amounts of thickener, while alternating blending the mixture, before they emptied the blender into a metal bin, covered it with plastic wrap, and placed it into the warmer. At 11:45 AM Staff EE explained they knew how much thickener and broth to add to the pureed pesto chicken by looking at it. Cold Food/Warm Fluid According to the facility's Food Storage policy, updated October 2017, cold foods are maintained at a temperature of 41 degrees Fahrenheit (F) or less and hot foods leave the kitchen or steam table at 140 F or above. Review of holding temperatures taken by dietary staff prior to meal service at 12:08 PM, showed the fish was 125 F, the beef patties were 115 F, and the rest of the hot menu items ranged from 140 to 188 F. The pre-poured cups of milk and water were measured at 39 F and 40.6 F. Meal service began at 12:11 PM. At 12:58 PM, approximately halfway through meal service, a test tray was requested on the last cart leaving the kitchen. Test Tray Data On 02/09/2022 between 1:28 PM food temperatures and other data pertinent to food palatability was obtained from a test tray containing pesto chicken, herbed orzo vegetables, milk, pureed pesto chicken, and pureed orzo. Temperatures and other data obtained were as follows: There regular pesto chicken measured 129 F. When tasted, the meat was lukewarm, but tender with good flavor. The herbed orzo was 127 F. When tasted, this dish had no real flavor, was mushy and overcooked. The pureed chicken was 129 F, had very little taste and was a paste-like texture. The pureed herbed orzo was 131 F and when tasted, had a paste-like texture and was unpalatable. The milk on the tray was 49 degrees. During an interview on 2/09/2022 at 2:49 PM, Staff FF (Dietary Service Manager) stated they worked at the facility for two years. When asked about the use of recipes when making pureed food, Staff FF expressed they had never seen a recipe for pureed food and did not believe their vendor provided recipes for pureed diets. On 02/09/2022 at 4:03 PM, Staff FF returned and stated, I was wrong, we do have recipes for pureed diets. REFERENCE: WAC 388-97-1100(1)(2). .

Based on observation and interview, the facility failed to ensure multiple food items in the dietary department were properly stored, labeled, resealed after use, and that out-of-date foods were identified and discarded. The failure to properly store and label foods, including potentially hazardous foods, placed residents at risk for consuming expired/spoiled foods and exposure to food borne illness. Findings included . According to the facility's October 2017 Food Storage policy, staff were directed to do the following: store dry bulk foods (flour, sugar, thickener, spices) in seamless metal or plastic containers with tight fitting covers; label open items with use by dates; label spices with a use by date 1 year after the open date; label prepared gelatin with a use by date 7 days after preparation; and bulk non-potentially hazardous food (such as mustard, ketchup, soup base etc.) should be labeled with a use by date 6 months after opening. According to the facility's Leftover Foods Usage and Storage Inservice Training, published December 2009, leftovers should be covered, labeled with the food name, use by date, and be used within 72 hours of the original preparation/cooking date. During initial observations of the dietary department on 02/01/2022 between 9:10 and 9:47 AM the following was observed. Dry Storage: two packages of cream soup base were torn open, the contents were visible as the container not resealed; a package of brown gravy mix with the top corner cut off and was not resealed; the lid to a large bulk bin of thickener was wide open; two bottles of yellow mustard had Best-By dates of 12/30/2021; and two seasoning containers with open dates of 01/27/2021. In an interview on 02/01/2022 at 9:38 AM, Staff FF (Dietary Service Manager) confirmed the above observations of unsealed, and/or out of date products and acknowledged seasonings should be disposed of 1 year after their open date. Refrigerator/Freezer observations: two small plastic containers of Italian dressing dated 01/25/2022; an open and undated package of tortillas; an uncovered metal pan of prepared gelatin; an undated Ziploc bag containing a peanut butter jelly sandwich; a small undated metal tin of browning tuna mixture; meatballs stored over the top of vegetables; and boiled eggs stored over the top of apples. In an interview on 02/01/2022 at 9:47 AM, Staff FF acknowledged potentially hazardous foods were improperly stored, and indicated all items should be covered and labeled with a use by date, but were not. REFERENCE: WAC 388-97-1100(3). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care in a manner that promoted resident respect and dignity for 3 (Residents 13, 12 & 27) of 3 sample residents and 2 (Residents 14 &44) supplemental residents reviewed for dignity concerns. Facility staff failed to assist and ensure: residents were bathed, clean and free from odor prior to scheduled visitations and/or appointments; failed to ensure resident light cords were unencumbered; failed to ensure residents were dressed in a dignified fashion or had access to clothing. The failures placed residents at risk for feelings of embarrassment, helplessness, and diminished self-worth. Findings included . Resident 13 Resident 13 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, demonstrated no behaviors or rejection of care, indicated choices about bathing were very important, and was dependent on staff for provision of bathing. During an observation and interview on 02/02/2022 at 1:40 PM, the resident was observed to be unkempt, with moist unbrushed hair. Resident 13 stated, It's not wet that's grease. I haven't been bathed this year. I can smell myself and had to go out to appointments that way. That's not dignified. I had a neurology appointment and started asking to be bathed two days before my appointment, but it did not happen. The resident shared they were also sent unclean to their vascular surgery and rehabilitation specialist appointments stating, They (specialists) are lucky they had to wear masks, so they didn't have to smell me. Review of Resident 13's December 2021 and January/February 2022 bathing records showed the resident was to be bathed twice weekly on Mondays and Thursdays. According to the bathing record the resident was offered/provided bathing on the following dates: 12/02/2021; 12/14/2021 (12 days later); 12/21/2021 (7 days later); 12/23/2021; 01/05/2022 (13 days later); 01/06/2022; 01/10/2022; and 02/05/2022 (26 days later). In an interview on 02/07/2022 at 1:53 PM, Staff N (Resident Care Manager) stated, [Resident 13] should have been bathed more frequently and acknowledged the resident should not have had to go to appointments un-bathed. Resident 12 Similar findings were noted for Resident 12, who admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact, required physical assistance with bathing, demonstrated no behaviors or rejection of care, and choices related to bathing were very important. During an interview on 02/02/2022 at 10:40 AM, Resident 12 stated, Shower huh, I haven't had a shower [since]well into last year. I've had one bed bath and no showers this year .I did refuse once, because they showed up at seven AM with no warning and wanted me to go right then. The resident then stated, I stink all the time .I keep putting deodorant on, but it doesn't always help . try having someone visit when you look like that. Review of Resident 12's January and February 2022 bathing records showed the resident was to be bathed twice weekly on Wednesdays and Saturdays. According to the bathing record the resident was offered/provided bathing on the following dates: 01/13/2021 (bed bath); and 01/26/2021 (refused). The facility's documentation was consistent with the resident's report of only receiving one bed bath in 33 days. During an interview on 02/07/22 at 02:05 PM, Staff N acknowledged the provision of bathing did not promote a dignified existence. Staff N then indicated they wanted to look further into the resident's bathing record. No further documentation or information was provided. Resident 27 According to the 1/31/2022 Significant Change MDS, Resident 27 was assessed to be severely cognitively impaired, and totally dependent on staff for assistance with dressing. The MDS showed choices about clothing were very important to Resident 27. On 02/02/2022 at 12:12 PM, Resident 27 was observed in bed wearing a polo shirt, and no pants. Resident 27's privacy curtain was open and Resident 27's incontinence brief was visible from the hallway. On 02/04/2022 at 09:07 AM, Resident # 27 was observed in bed, dressed in a gown. The gown was tied at the neck and Resident 27 removed both their arms from the sleeves, exposing their arms, shoulders, and parts of their chest. On 02/04/2022 at 11:40 AM, Resident 27 was observed to be wearing the same gown, with their right shoulder and right chest exposed. Resident 27 was noted to be pushing their bedding down away from their body towards the foot of the bed. A pair of pants and a plaid shirt were noted on hangars on the handle of the dresser. On 02/08/2022 at 07:53 AM, Resident 27 was observed in bed, with the privacy curtain not in use. Resident 27 was dressed in a gown which was fastened around the neck and did not cover their shoulders or legs. Resident 27 was visible from the hallway. On 02/09/2022 at 10:53 AM, Resident 27 was observed in bed dressed in a robe fastened at the neck and not covering their shoulders or arms, wearing a brief and no pants, with their legs over their bedding. A pair of pants and plaid shirt were observed still hanging from the door handle of Resident 27's closet. On 02/10/2022 at 06:51 AM, Resident 27 was observed in bed with their door open, the light on and the privacy curtain not in use. Resident 27's incontinence brief was visible from the hallway. A plaid shirt and pair of pants were noted to still be hanging on the handle of the closet. In an interview on 02/08/2022 at 09:53 AM, Staff O (Certified Nursing Assistant - CNA) stated that Resident 27 frequently disrobes and that it is necessary for staff to make sure the privacy curtain is closed. Staff O stated they put a shirt on [Resident 27] once and it worked pretty good. In an interview on 02/08/2022 at 09:59 AM, Staff P (CNA) stated that Resident tries to undress all the time and that they were unsure of the reason why the resident tried to undress. In an interview on 02/08/2022 at 11:24 AM, Staff N (Resident Care Manager) stated there was no reason for staff not to assist Resident 27 to get dressed. Resident 14 Observations on 02/09/2022 at 10:54 AM Resident 14 had plastic bag tied to the string to turn the light on in their room. In an interview on 02/09/2022 at 11:00 AM Resident 14 stated they were using the bag to lengthen the cord to turn the light on at night, but they did not like this plastic bag. In an interview on 02/09/2022 at 11:07 AM Staff X stated they never noticed the plastic bag with the string. In an interview on 02/09/2022 at 11:15 Am Staff Q (Maintenance Assistant) stated the resident wanted the plastic bag that way and but Resident 14 told the Staff Q that they never liked the plastic bag. During an interview on 02/09/2022 at 11:49 AM Staff N (RCM) stated they should have added on an extension to the string, should not have used the plastic bag. Resident 44 According to a 01/12/2022 Significant Change MDS, the resident had moderate cognitive impairment and was able to make their own decisions. Resident 44 required extensive assistance with bed mobility, dressing, and personal hygiene. The MDS showed choices about clothing were very important to Resident 44. On 02/02/2022 at 10:20 AM Resident 44 was observed lying in bed in a hospital gown. Similar observations were made of the resident in a hospital gown on 02/04/2022 at 11:55 AM, 02/07/2022 at 10:35 AM, and 1:02 PM, 02/08/2022 at 12:50 PM, 02/09/2022 at 10:31 AM and 1:16 PM, and 02/10/2022 at 9:20 AM and 2:18 PM. In an interview on 02/07/2022 at 1:31 PM Resident 44 stated that they don't get out of bed because they are cold. Observations of the resident's closet revealed the resident had no clothes. Review of a 06/14/2022 Personal Belonging Inventory form signed by the resident and facility staff showed the resident admitted with 1 pair of shoes, 1 cell phone and upper dentures. During an interview on 02/08/2022 at 10:50 AM Staff K (Director of Social Services) stated it was not determined why Resident 44 won't get out of bed. Staff K stated they were not aware the resident had no clothing. REFERENCE: WAC 388-97-0180(1-4). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 27 According to a 01/31/2022 Significant Change MDS, Resident 27 admitted to the facility on [DATE]. Record review showed no indication Resident 27 had an AD or was provided written information about ADs and the right to formulate one. Resident 27's 02/22/2021 ADF stated Resident 27 did not provide the facility with a copy of an AD, and did not clarify if the facility provided additional information about the right to formulate one. Resident 40 According to a 01/10/2022 Quarterly MDS, Resident 40 admitted to the facility on [DATE]. Record review showed no indication Resident 40 had an AD or was provided written information about ADs and the right to formulate one. Resident 40's 02/24/2021 ADF stated the resident did not provide the facility a copy of an AD, and did not clarify if the facility provided additional information about the right to formulate one. Resident 55 According to a 01/24/2022 Quarterly MDS, Resident 55 admitted to the facility on [DATE]. Record review showed no indication Resident 27 had an AD or was provided written information about ADs and the right to formulate one. Resident 55's 02/22/2021 medical records did not include an ADF or any other documentation indicating whether or not the resident had an AD, provided a copy to the facility, or was informed of their rights to formulate one by the facility. REFERENCE: WAC 388-97-0280(3)(c)(i-ii), -0300(1)(b), (3)(a-c). Based on interview and record review, the facility failed to obtain Advanced Directives (AD) from residents who had them and/or failed to notify residents of their right to formulate one for 9 (Residents 12, 13, 14, 42, 15, 21, 27, 40 & 55) of 13 residents reviewed for ADs. This failure detracted from the resident's ability to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their preferences and choices honored regarding emergent and end-of-life care. Findings included . Resident 12 Resident 12 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 and able to understand and be understood in conversation. Record review showed no indication Resident 12 had an AD or whether the resident was provided written information about ADs or the right to formulate one. In an interview on 02/02/2022 at 11:13 AM, Resident 12 expressed they were uncertain what an AD was and didn't know if they had one. During an interview on 02/08/2022 at 10:41, Staff BB (Admissions) stated upon admission residents were asked if they had an AD, and if not, informed of their right to formulate one. Per staff BB this documentation could be found on the admissions Authorizations and Designations Form [ADF]. Review of Resident 12's 06/01//2021 ADF showed the document had the following two checkboxes provided: Provided a/an AD and Not provided. The form did not delineate between a resident who had an advanced directive but was unable to provide a copy at the time of admission, from a resident who did not have an AD. In both instances the Not Provided box was checked. The document failed to notify residents without an AD of their right to formulate one. In an interview on 02/08/2022 at 12:58 PM Staff BB acknowledged Resident 12's ADF failed to clearly determine if the resident had an AD, and failed to inform the resident of their right to formulate one. Resident 13 Resident 13 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact and able to understand and be understood in conversation. Record review showed no indication Resident 13 had an AD or was provided written information about ADs or the right to formulate one. In an interview on 02/02/2022 at 1:40 PM, Resident 13 stated they were unsure if they had an AD. Review of the residents 06/01/2021 ADF showed the box Not Provided was checked, but gave no indication whether the resident had an AD or not. On Resident 13's ADF a third check box was added that stated, If the resident has not Provided an Advance Directive, resident has been informed in writing of his/her right to make his/her own healthcare decisions including the right to accept or refuse medical treatments, to prepare an Advance Directive, and to complain about the Center's Advance Directive policy to the state survey agency. This box was left unchecked. During an interview on 02/08/2022 at 12:58 PM, Staff BB explained the facility's ADF was changed over time, and now included a section informing residents of their right to formulate an AD. Staff BB acknowledged the box indicating Resident 13 was informed of their right to formulate an AD, remained unchecked. Resident 14 Resident 14 admitted to the facility on [DATE]. According to the 12/02/2021 Quarterly MDS, the resident was cognitively intact and able to understand and be understood in conversation. Record review showed no indication Resident 14 had an AD or was provided written information about ADs or the right to formulate one. According to the resident's 07/13/2021 ADF a copy of an AD was Not Provided. The form did not indicate whether the resident had an AD or not. The document did not include information about AD and the resident's right to formulate one. During an interview on 02/08/2022 at 12:58 PM, Staff BB agreed Resident 14's ADF failed to inform the resident of their right to formulate an AD. Resident 42 Similar findings were noted for Resident 42, who admitted to the facility on [DATE]. Record review showed no indication Resident 42 had an AD or was provided written information about ADs or the right to formulate one. A review of the resident's 02/28/2019 ADF showed it did not include information informing the resident of their right to formulate an advanced and indicated the resident had an AD. During an interview on 02/08/2022 at 12:58 PM, when asked to see a copy of Resident 42's AD, Staff BB provided guardianship paperwork for the resident. Upon being informed that guardianship was not the same as AD, Staff BB indicated the ADF was inaccurate and acknowledged the ADF failed to inform the resident or representative of the right to formulate one. Resident 15 Resident 15 was admitted to the facility on [DATE] and according to a 12/3/2021 Significant Change MDS, was assessed as cognitively intact with multiple medically complex diagnoses including cancer. Review of the facility's Soft Chart binder, kept at the nurse's station, on 02/02/2022 at 12:13 PM revealed no AD paperwork for Resident 15. Record review showed Resident 15 did not have a current ADF and records showed no indication Resident 15 had an AD or was provided written information about ADs and the right to formulate one for this admission. Resident 21 Resident 21 was admitted to the facility on [DATE]. According to the 12/21/2021 admission MDS, Resident 21 was assessed with severe cognitive impairment, having clear speech, able to make self-understood, and sometimes able to understand others. Review of the facility's Soft Chart binder, kept at the nurse's station, on 02/04/2022 at 10:07 AM revealed no AD paperwork for Resident 21. In a phone interview on 02/09/2022 at 12:05 PM, Resident 21's spouse indicated they were the Power Of Attorney (POA) for healthcare for Resident 21 and stated facility staff had not requested a copy of the POA paperwork. In an interview on 02/11/2022 at 8:08 AM, Staff N (Resident Care Manager - RCM), stated if a resident had an AD they should be in the resident's record and readily available to staff to know what their wishes are.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately assess 7 (Residents 208, 256, 14, 53, 27, 307, & 308) of 25 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 208 A review of the 02/02/2022 admission 5-day Minimum Data Set (MDS an assessment tool) showed Resident 208 was admitted on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a lung disease). A review of the 01/26/2022 hospital discharge records showed Resident 208 was diagnosed in the hospital with a complicated urinary tract infection (UTI) with sepsis (a blood infection) and acute kidney failure. A review of the certified nursing assistant (CNA) documentation during the assessment period of 01/27/2022 thru 02/02/2022 showed Resident 208 received one episode of total dependence/one person physical assistance, three episodes of extensive assistance/one person physical assistance, and 3 episodes of independence/no assistance in bed mobility. There were many shifts during this timeframe where documentation was blank. The 02/02/2022 MDS coding showed bed mobility required supervision and one person physical assistance. A review of the CNA documentation during the assessment period of 01/27/2022 thru 02/02/2022 showed Resident 208 received one episode of total dependence/one person assistance, two episodes of extensive assistance/one person physical assistance, and one episode of independence/no assistance in dressing. There were many shifts during this timeframe where documentation was blank. The 02/02/2022 MDS coding showed dressing of supervision and one person physical assistance. A review of the CNA documentation during the assessment period of 01/27/2022 thru 02/02/2022 showed Resident 208 received two episodes of extensive assistance/one person physical assistance, two episodes of supervision with one person physical assist and one episode of independence/no assistance in walking. There were many shifts during this timeframe where documentation was blank. The 02/02/2022 MDS coding showed walking of supervision and one person physical assistance. In an interview on 02/09/2022 at 11:59 AM, Staff M (MDS Coordinator- Registered Nurse) who reviewed the MDS coding for bed mobility, walking and dressing and compared it to the CNA documentation during the assessment period, stated the coding was incorrect. Staff M acknowledged many of the shifts in the assessment period were not documented and stated CNA's are expected to document care provided on every shift and were not doing the documentation which made the MDS coding difficult. Staff M reviewed the hospital primary diagnosis and compared this to the MDS primary diagnosis and stated it was incorrect and should have been UTI with sepsis and not COPD. Staff M stated the MDS coding is expected to follow the rule of three and a MDS modification would be completed to show the correct coding and diagnosis. Resident 256 Similar findings for Resident 256 showed incorrect MDS coding in dressing, eating, hygiene and locomotion on the MDS compared to the assessment period CNA documentation. Staff M reviewed, acknowledged errors and initiated a MDS modification. Resident 307 According to the 02/02/2022 admission MDS, Resident 307 was assessed with adequate vision and no corrective lenses. In an interview on 02/01/2022 at 1:31 PM, Resident 307 stated they had glasses for reading but was unsure where they were. Review of Resident 307's 01/26/2022 Baseline Care Plan (CP) showed interventions for VISION: Glasses reading. In an interview on 02/11/2022 at 8:47 AM, Staff N (Resident Care Manager) indicated the corrective lenses that Resident 307 required should be reflected on the MDS. Resident 308 According to the 01/29/2022 Admission/ Medicare -5 Day MDS, Resident 308 was assessed as cognitively intact with adequate vision, no corrective lenses, and no dental concerns. Observations on 02/04/2022 at 9:30 AM, showed Resident 308 was missing teeth on their upper partial (dentures). Resident 308 stated they had missing and broken teeth to the back sides of their lower jaw. The resident reported having difficulty chewing food with their partial denture broken. Resident 308 stated they usually wore glasses, but they were at home. Observations on 02/07/2022 at 11:28 AM showed, Staff B (Director of Nursing) verified the missing teeth on Resident 308's upper partial. Review of 01/27/2022 Baseline CP for Resident 308, identified interventions that the resident had glasses, but did not bring with them. Observations on 02/11/2022 at 8:00 AM showed, Resident 308 was lying in bed wearing a black pair of glasses. In an interview at this time, the resident smiled, and stated, my brother brought them to me yesterday. In an interview on 02/11/2022 at 8:33 AM, Staff N stated staff should have identified the broken partial, and the use of corrective lenses on the MDS and indicated they would refer Resident 308 to dental for repair. REFERENCE: WAC 388-97-1000(1)(b). Resident 27 According to section §483.20(b)(2)(ii) of the Code of Federal Regulations, facilities must complete a Significant Change MDS within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. According to the 01/31/2022 Significant Change MDS, Resident 27 readmitted to the facility from an acute hospital on [DATE], and had diagnoses including Alzheimer's and non-Alzheimer's dementia, a urinary tract infection, and muscle weakness. According to a 01/12/2022 progress note, Resident 27 was sent out to an acute hospital on [DATE] following an observed decline related to a urinary tract infection and COVID-19 infection. According to a 01/19/2022 progress note, Resident 27 returned from the hospital with [a] decline in functional and mental status, [requiring] extensive assist with transfers, bed mobility, toileting/changing. [Resident 27 is] now incontinent of both B[owel] & B[ladder], very confused and restless in bed, has open areas to bilateral buttocks . According to the 01/20/2022 Hospice Election Form, Resident 27 was approved for hospice services on 01/20/2022. Record review of the Electronic Health Record on 02/09/2022 revealed the 01/31/2022 Significant Change MDS was incomplete, 20 days after Resident 27 was approved for hospice. In an interview on 02/09/2022 at 09:44 AM, Staff M stated that the Significant Change MDS should have been, but was not completed within 14 days of Resident 27's approval fro hospice services, as this indicated a permanent significant change. Resident 14 Resident 14 admitted to the facility on [DATE]. According to the 07/13/2021 admission MDS the resident had a Stage IV pressure ulcer (PU) (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) , which was present upon admission. Record review revealed a 07/01/2021 hospital history and physical that showed Resident 14 was identified with a Deep Stage IV [sacral] wound with apparent visible bone during hospitalization. Review of the facility's weekly wound care notes, between 07/16/2021 - 02/03/2022, showed staff consistently assessed the resident's sacral wound to be a Stage IV PU. According to Resident 14's 12/02/2021 Quarterly MDS, the resident had one unstageable PU and no Stage IV PUs. In an interview on 2/10/2021 at 07:25 AM, Staff M stated the 12/02/2021 MDS was inaccurate and should have coded the resident's PU as a Stage IV. Resident 53 Resident 53 admitted to the facility on [DATE]. Record review showed on 05/05/2012 the resident was determined to be positive for a Level II Pre-admission Screening and Resident Review (PASRR). This required the provision of specialized services. According to Resident 53's 10/29/2021 Annual, 11/27/2020 Significant Change and 05/27/2020 Annual MDS, the resident was not considered to be a Level II PASRR. During an interview on 02/11/2022 at 09:08 AM, Staff M stated the above referenced MDSs were incorrectly coded and should have reflected the resident was a Level II PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 42 Resident 42 was admitted to the facility on [DATE]. According to the 01/12/2022 Quarterly MDS, the resident had moderate cognitive impairment, could sometimes understand and be understood in conversation, had one non-injury fall since the prior assessment, and received antipsychotic and antidepressant medication on seven of seven days during the assessment period. Record review showed a high risk for falls CP, revised on 10/15/2021, that directed staff not to leave the resident in the bathroom unattended. A actual fall CP, revised 01/12/2022, directed staff to offer toileting every two hours and to assist the resident to the bathroom. On 02/01/2022 at 12:32 PM, 02/02/2022 at 09:20 AM, and 02/07/2022 at 09:55 AM, Resident 42 was observed ambulating to the bathroom independently, without an assistive device. During an interview on 02/08/2022 at 11:10 AM, Staff N stated that Resident 42 had been cleared to toilet independently and indicated the CPs were inaccurate and needed to be updated. According to a antipsychotic medication CP, revised on 01/14/2022, Resident 42 received the antipsychotic medication Olanzapine. Record review showed the resident's Olanzapine was discontinued on 01/14/2022, the same day it was ordered. During an interview on 02/08/2022 at 11:10 AM, Staff N stated the CP was inaccurate and needed to be updated. Resident 14 Resident 14 admitted to the facility on [DATE]. According to 12/02/2021 Quarterly MDS, the resident was cognitively intact, at risk for pressure ulcer development, and had one Stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) pressure ulcer. According to alteration in skin integrity CP, revised 12/03/2021, staff were directed to use a draw sheet or lifting device to move the resident and to pad the right side of the bed frame. Observations on 02/02/2022 at 09:08 AM, 02/03/2021 at 10:27 AM, 02/04/2022 at 08:04 AM and 02/07/2021 at 07:18 AM, showed the right side of Resident 14's bed frame was not padded. During an interview on 02/08/2022 at 11:00 AM, Staff N stated the CP was inaccurate and needed to be updated. Refer to: F689 - Accidents Refer to: F690 - Bowel/Bladder Incontinence, Catheter, UTI. REFERENCE: WAC 388-97-1020(2)(c)(d), (5)(b). Based on observation, interview, and record review, the facility failed to ensure resident's person-centered Care Plans (CP) were reviewed, revised, and implemented as required for 14 (Residents 213, 256, 13, 12, 53, 39, 15, 21, 308, 309, 36, 54, 42, & 14) of 25 residents reviewed. The failure to ensure resident's CP were reviewed and revised to accurately reflect resident care needs, placed residents at risk for unsafe or inadequate care, unmet care needs and potential negative outcomes. Findings included . Resident 213 A review of the 01/2019 facility Behavior Management policy showed residents identified as trauma survivors are reviewed for individual care needs to support culturally competent trauma informed care. The CP is developed to account for individual experiences and preferences to mitigate triggers that may cause re-traumatization to the extent possible. Resident 213 was admitted to the facility on [DATE]. A review of a 02/01/2022 Trauma Informed Care Assessment showed Resident 213 experienced physical and verbal violence directed at them in a past personal relationship which caused the resident to have physical reactions such as heart pounding, trouble breathing, and sweating when reminded of the stressful experience. A review of the 01/31/2021 CP showed no identification of Resident 213's past trauma. The CP did not provide interventions to instruct staff how to mitigate triggers that may cause re-traumatization or provide culturally competent trauma informed care to Resident 213. In an interview on 02/11/2022 at 8:42 AM, Staff L (Social Work Assistant) stated they did not update Resident 213's CP to identify and include interventions for trauma informed care. Staff L stated the CP should be updated when the assessment gets completed. Staff L acknowledged the missing information on the CP prohibited the staff to provide care to Resident 213 with awareness of the resident's trauma history. Resident 256 A review of the 01/31/2022 admission Minimum Data Set (MDS an assessment tool) showed Resident 256 was assessed as cognitively intact, able to make self understood and understand others. Resident 256 was assessed as frequently incontinent of urine and occasionally incontinent of bowels. The MDS showed a toileting program was currently not being used to manage Resident 256's incontinence. A review of the 02/03/2022 Care Area Assessment (CAA- a care planning tool) for incontinence of Resident 256 showed contributing factors to incontinence were mobility impairment, urgency of urination, and need for assistance with toileting. The CAA did not assess or identify the type of incontinence Resident 256 experienced. The CAA identified the overall goal was to slow or minimize decline, avoid complications, and minimize risks of incontinence. A review of the 01/31/2022 CP showed Resident 256 was incontinent and required extensive 2 person assist toileting. There was no schedule or plan for staff to follow to assist Resident 256 with the frequency of toileting to prevent incontinence or prevent worsening of incontinence. In an interview on 02/02/2022 at 2:37 PM, Resident 256 stated they were more incontinent of urine now than before they were admitted to the facility. On 02/10/2022 at 12:41 PM, Resident 256 stated they did not have a schedule for toileting help and had to use the call light each time they required assistance to the bathroom to prevent incontinence. Resident 256 stated I need help to go to the bathroom, when I call for help it takes them a long time to answer and I am incontinent by the time they get here. In an interview on 02/11/2022 at 10:42 AM, Staff I (Resident Care Manager) reviewed the CP and stated Resident 256 should have a toileting schedule on the CP to direct staff to assist the resident with planned toileting every two hours. Resident 36 According to the 01/10/2022 Annual MDS, the resident had severe cognitive impairment, was not able to make their own decisions, and had multiple medically complex conditions, including dementia, diabetes, and depression. The resident required extensive assistance from staff for bed mobility, transfers, dressing, and toileting. The MDS showed for walking in room or walking in corridor the activity did not occur during the assessment period. Review of a 05/13/2019 Limited Mobility CP showed for ambulation the resident was independent after set-up with a walker. On 02/03/2022 at 10:13 AM Resident 36 was observed self-propelling in their wheelchair (w/c) throughout the facility. Observations on 02/04/2022 at 9:49 AM, 02/07/2022 at 10:23 AM, and 02/08/2022 at 9:04 AM supported Resident 36 self-propelled their w/c. In an interview on 02/11/2022 at 9:20 AM Staff B stated the resident did not ambulate and the CP needed to be updated. Resident 54 According to the 01/12/2022 Quarterly MDS, the resident had severe cognitive impairment, was not able to make their own decisions, and had medically complex conditions, including dementia, and depression. The resident was assessed with delusions and behaviors of rejecting care and wandering. Record review showed no CP developed for the resident's depression and rejection of care. On 02/04/2022 at 12:10 PM Resident 54 was observed wandering in w/c down the hallway, a staff member was observed assisting the resident with coffee and walking the resident back to their room. In an interview on 02/11/2022 at 8:11 AM Staff K (Social Services Director) stated they would expect a resident who had a diagnosis and was being treated for depression to have a CP in place. Staff K stated the resident's wandering behavior should be included in a CP. Resident 15 According to the 12/03/2021 Significant Change MDS Resident 15 had multiple medically complex diagnoses including fractures and cancer. This MDS assessed Resident 15 to require extensive physical assistance of staff for bed mobility, dressing, personal hygiene, and bathing. According to a 10/23/2021 CP for left humerus fracture, interventions included Keep arm sling to the left arm at all times, and to support injured area with pillows and immobilize part as appropriate. According to a revised 12/02/2021 Actual Fall CP, interventions included Medical monitoring for possible change in condition - twice weekly H&H [hemoglobin & Hematocrit blood tests] testing- monitored by provider. In an interview on 02/11/2022 at 8:26 AM, Staff N stated the interventions for arm sling, immobilization and twice weekly blood tests were no longer applicable, and confirmed the CP should have, but was not revised and updated to reflect Resident 15's current condition. Resident 21 Resident 21 was admitted to the facility on [DATE]. According to the 12/21/2021 admission MDS, Resident 21 was assessed with severe cognitive impairment, minimal difficulty hearing, having clear speech, able to make self-understood, and sometimes able to understand others. According to a 12/22/2021 Communication CAA, staff documented that Resident 21 .has hearing loss in [their] Lt [left] ear and can hear others statements if the speaker speaks into [their] right ear. On this CAA staff documented communication would be addressed in the CP. Review of Resident 21's medical record on 02/03/2022 revealed no CP was initiated for communication regarding hearing loss. Observations on 02/02/2022 at 12:56 PM showed staff entered Resident 21's room and started writing information on paper to communicate with the resident. Observations on 02/04/2022 at 12:58 PM showed staff entered Resident 21's room and stated, are you finished eating? Resident 21 just looked at staff and did not respond. In an interview on 02/07/2022 at 11:41 AM, Staff P (Certified Nurses Assistant) indicated this was their first day working with Resident 21 and stated they were unsure if the resident had any hearing issues. Observations on 02/08/2022 at 12:55 PM, showed Staff E (Certified Nurses Assistant) was observed talking softly to Resident 21 while leaning over next to the resident's left ear. In an interview at this time, Staff E stated they were unsure if Resident 21 had any hearing concerns and stated, [they] only say a few words. In an interview on 02/10/2022 at 1:55 PM, Staff N stated staff should have added interventions for communication with the resident on the CP and verified the CP should have, but did not reflect Resident 15's current conditions. Resident 308 According to a 01/29/2022 Admission/ Medicare -5 Day MDS, Resident 308 had multiple medically complex diagnoses including Schizophrenia and required the use of antipsychotic (a medication used to manage psychosis) medications. Review of Resident 308's CP on 02/03/2022 revealed no CP in place regarding the use of an antipsychotic medication. In an interview on 02/11/2022 at 8:33 AM, Staff N confirmed the CP should have, but was not revised and updated by staff to reflect Resident 32's use of antipsychotic medications. Resident 309 Resident 309's 12/10/2019 baseline CP had interventions that did not specify resident's bathing schedule, fluid restriction status, or use of dentures and glasses. In an interview on 02/11/2022 at 8:55 AM, Staff N confirmed the CP should have, but was not revised and updated by staff to reflect Resident 309's current conditions.Resident 39 According to the 1/6/2022 Quarterly MDS, Resident 39 had diagnoses including right side hemiplegia (one-sided paralysis after a brain bleed), coronary artery disease, heart failure, muscle weakness, and arthritis. Resident 39's 10/18/2021 Actual Fall With Minor Injury CP included interventions for the bed to be in its lowest position. Resident 39's 10/18/2021 Refusals CP stated Resident 39 preferred to have their bed in a high position, and that the risks and benefits were explained. In an interview on 02/09/2022 at 12:34 PM, Staff N (Resident Care Manager) stated Resident 39's CP was not clear regarding the positioning of the bed and needed to be updated. Resident 13 Resident 13 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact, and required one person extensive assistance with activities of daily living (ADLs) with the exception of eating and bathing According to the baseline CP, with a goal date of 03/16/2022, the resident required: two person extensive assistance with transfers; was dependent for transfers; required a hoyer lift and/or a sit to stand for transfers; was dependent for dressing; required extensive assistance for dressing; was dependent for meals; and required limited assistance for meals. During an interview on 02/11/2022 at 10:58 AM, Staff B (Director of Nursing), acknowledged the CP was contradictory, inaccurate and needed revision. Observation and interview on 02/02/22 at 02:22 PM, showed Resident 13 lying on an alternating low air loss mattress. The resident stated it was due to a wound on the hip. Record review showed a 12/13/2021 order directing staff to check the function of the alternating low air loss mattress air [loss] mattress every shift and notify the Director of Nursing if it was not functioning correctly. Review of the Potential for alteration in skin integrity CP, revised 12/21/2021, showed no indication the resident had an alternating low air loss mattress. During an interview on 02/11/2022 at 10:58 AM, Staff B stated that the CP needed to be updated. Review of the Chronic pain CP, revised 12/21/2021, directed staff to Administer analgesia (Tramadol) as per orders. Give 1/2 hour before treatments or care. Record review showed the resident's Tramadol order was discontinued on 10/11/2021. During an interview on 02/11/2022 at 10:58 AM, Staff B acknowledged the CP was inaccurate and needed to be updated. Review of the activity CP, revised 12/21/2021, listed an intervention of The resident prefers to socialize with: (SPECIFY), but failed to specify with whom the resident preferred to socialize. During an interview on 02/11/2022 at 10:58 AM, Staff B conceded the CP was not personalized/resident specific and needed to be updated. Review of the Nutrition /Hydration CP, revised 12/27/2021, directed staff to complete a meal monitor, if intake was less than 50%, staff should offer a substitute or supplement. Review of Resident 13's January 2021 meal monitor showed of the 93 meals provided, staff failed to document the percent the resident consumed 41 times, precluding staff from identifying if the resident ate less than 50% and from offering a alternative or supplement as directed on the CP. During an interview on 02/11/2022 at 10:58 AM, Staff B acknowledged staff could not implement the above intervention without first identifying what percentage the resident ate. Resident 12 Resident 12 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact, and independent with ADL's including walking in the room and corridor. Review of the baseline CP, with target date of 02/23/2021, showed the resident required: One person assistance with walking; extensive one person assistance with transfers; and supervision and cueing with transfers. During an interview on 02/10/2022 at 4:17 PM, Staff B acknowledged Resident 12 was independent with ADL's and indicated the CP was inaccurate and needed to be updated. According to the Post discharge plan CP, revised 01/07/2022, staff identified the resident's anticipated discharge location as SPECIFY with follow up care needs of SPECIFYand an established goal of SPECIFY. During an interview on 02/10/2022 at 4:17 PM, Staff B stated the CP was incomplete, not personalized, and needed to be updated to reflect Resident 12's discharge plans and goals. Review of the Actual fall CP, revised 01/07/2022, showed interventions included: Continue with Physical therapy (PT) and Occupational therapy (OT) for strengthening and ambulation training; and Continue with OT. Record review showed Resident 12 was not receiving PT or OT services. During an interview on 02/10/2022 at 4:17 PM, Staff B indicated the the CP was inaccurate and needed to be updated. Review of the Risk for respiratory infection CP, revised 01/07/2021, showed an intervention of Daily activities per activity calendar (adjusted for in room). Special Needs: (SPECIFY). The CP failed to identify what the Special Needs were. During an interview on 02/10/2022 at 4:17 PM, Staff B acknowledged the CP failed to identify what special needs, if any, the resident required and indicated the CP needed to be updated. According to the Altered respiratory status CP, revised 01/07/2021, staff were directed to: Administer medication/puffers (inhalers) as ordered; encourage use of Incentive Spirometer (IS - a handheld medical device used to help improve the functioning of lungs); and to provide an overbed table for positioning comfort while sleeping. Review of Resident 12's Physician's orders showed the resident had no order for inhalers or nebulizers. During an observation and interview on 02/08/2022 at 9:43 AM, Resident 12 indicated they had an IS at one time but hadn't seen it for quite some time. Resident 12 also denied the need for or use of an overbed table for positioning while sleeping and stated, Where the hell did that come from. During an interview on 02/10/2022 at 4:17 PM, Staff B indicated the CP was inaccurate and needed to be updated. Resident 53 According to the Resident Mood . CP, revised 01/19/2022, Resident 53 had a Diagnosis of: Being short-tempered or easily annoyed. During an interview on 02/11/2022 at 12:17 AM, Staff B indicated the CP was inaccurate, acknowledging Being short-tempered or easily annoyed were not diagnoses. Review of the Dementia with Psychosis CP, revised 01/19/2022, showed an intervention of INCREASED SEROQUEL. During an interview on 02/11/2022 at 12:17 AM, Staff B acknowledged the intervention provided no objective direction to staff and had no objective meaning. Staff B indicated the CP needed to be revised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Edema Resident 213 A 02/07/2022 admission MDS showed resident 213 was admitted on [DATE] for congestive heart failure (CHF), cardiomyopathy (Heart failure), and edema (swelling from fluid collecting in legs and feet). Observations on 2/1/2022 at 9:43 AM, 2/2/2022 at 12:58 PM, 2/3/2022 at 2:45 PM, 2/4/2022 at 1:19 PM, showed Resident 213 in their room sitting on bed or lying in bed with feet and legs uncovered. On all observations, Resident 213's feet, ankles, and lower legs had edema, were red and shiny and had dry skin patches on feet. A review of Resident 213's MAR showed staff were monitoring for edema starting on 02/03/2022 with +1 (when pressure applied to edema the skin rebounds in 1 second), 02/04/2022 with +1, 02/05/2022 with +4 and 02/06/2022 with +4. The edema monitor showed on 02/04/2022 the Nurse Practitioner (NP) was notified of the worsening of edema. A 02/01/2022 skilled progress note showed Resident 213 did not have edema in feet, ankles, or legs on admission. Review of the nurse progress notes from 02/03/2022 to 02/07/2022 showed no assessment of the increased edema or of the possible worsening of CHF related to the edema monitoring log. A skilled nursing progress note on 02/05/2022 showed Resident 213 did not have any edema, which conflicted with the edema monitoring log. Review of the 02/07/2022 NP visit note showed Primary nurse reports no acute concern. Recent progress note reviewed. No recent acute change of condition. The NP was not told about the edema on the monitoring log from 02/05/2022 or 02/06/2022. In an interview on 02/10/2022 at 11:49 AM, Staff J reviewed Resident 256's record and stated the nursing staff did not identify or assess the weight gain and did not notify the NP. Staff J was not notified of the weight gain or status of the edema for Resident 256. Staff J stated the nurses are expected to review the resident's weight and report to the NP and dietician. Staff J stated the skilled nursing notes directed nurses to assess edema and if present, the nurses were expected to notify NP and put the resident on alert. Resident 42 Resident 42 readmitted to the facility on [DATE]. According to 01/12/2022 quarterly MDS, the resident was moderately cognitively impaired, had diagnoses of constipation, atrial fibrillation and cardiac murmur, and received diuretic medication on seven of seven days during the assessment period. On 02/02/2022 at 09:20 AM, resident was observed with 2+ edema to their bi-lateral lower extremities (BLEs). Observations on 02/03/2022 at 10:16 AM, showed 1+ edema to Right lower extremity and 2+ to Left lower extremity on 02/07/2022 at 10:45 AM. Review of the resident's POs showed a 06/28/2021 showed an order for Furosemide (a diuretic medication) twice daily for edema. A 08/05/2021 PO directed staff to Monitor the resident's edema daily and document the amount present as follows- 0, T=Trace, 1+, 2+, 3+, 4+, P=Pitting, N=Non pitting. Document condition: B=better, W=worse, M=maintained. Location: P=pedal, A= Ankle, C= calf. MD contacted: Y=Yes and N=No. Review of the January 2022 MAR showed Resident 42 had edema every day from 01/04/2022 - 02/02/2022. The documentation did not indicate if the edema was observed to the right LE, left LE or both LEs. A review of the CP, revised on 01/29/2020, showed the resident received Furosemide for edema. The CP did not identify what the resident's baseline edema was, direct staff on measures to take when/if edema was noted, such as elevating the resident lower extremities, or indicate whether staff should assess and monitor the resident's edema at all. In an interview on 02/08/2022 at 11:52 AM Staff N stated edema should be monitored and documented daily and indicated each LE should have its own documentation identifying the amount and extent of edema present, but acknowledged for Resident 42 this didn't occur. Resident 14 According to the 12/02/2021 Quarterly MDS, Resident 14 was admitted to the facility on [DATE]. Resident 14 was assessed to be cognitively intact and had diagnoses including medically complex conditions including pressure ulcer, Hypertension and Osteomyelitis. Observations on 02/02/2022 at 9:08 AM and 02/04/2022 at 8:42 AM showed the resident had 2+ edema on bilateral lower extremities (BLE). Observation on 02/07/2022 at 09:17 AM showed Resident 14 had edema 3+ on their right foot and 1+ on their left LE and was observed wearing ted hose while in their w/c. During an interview on 02/07/2022 at 09:17 AM, Resident 14 stated they preferred to get up 7:30 AM every morning and stay in their w/c until 8:00 PM. Resident 14's POs included a 12/02/2021 PO for Lasix 20 mg twice daily for Congestive Heart Failure, and a 07/08/2021 PO directing staff to monitor edema on Resident 14's BLE every morning. A Review of the January 2022 MAR showed facility nurses documented Resident 14 had edema 1+ every day without specifying which leg. A Review of Resident 14's CPs showed no CP related to Lasix or monitoring edema. In an interview on 02/08/2022 at 11:52 AM, Staff N stated the PO needed to be clarified so nurses would know to specify which leg(s) was observed with edema. Staff N also acknowledged staff should measure the edema and document accurately for each leg but did not. Resident 256 Review of the 01/31/2022 MDS showed Resident 256 was admitted with the diagnoses of deep vein thrombosis (a blood clot in the leg). Resident 256 was assessed to require extensive physical assistance with all mobility. In an observation and interview on 2/10/2022 at 12:40 PM, Resident 256 stated my legs are so swollen, they did not used to be like this. They are throbbing. I can't even put my shoes on. Resident 256 was sitting in a w/c with both feet on footrests. The skin on both legs was tight, shiny and had dry flakes. A review of Resident 256's weight log showed an admission weight on 01/25/2022 of 205.8 pounds (lb). The following weights were recorded: 02/01/2022 was 217.3 lb, 02/02/2022 was 218.0 lb, and 02/08/2022 was 224.2 lb, a total weight gain of 18.4 lb in two weeks. There were no progress notes on 02/01/2022, 02/03/2022 or 02/08/2022 identifying or assessing the weight gain for Resident 256. A 02/05/2022 nurse skilled progress note showed Resident 256 had edema observed as 4++ in right lower leg and 2++ in left lower leg. The note did not show the NP was notified of edema. Review of the 02/07/2022 initial dietician evaluation showed Significant weight gain of 5.9% within one month per weight report. And Resident is at nutrition/hydration risk r/t: Significant weight gain. The dietician's intervention was to notify provider and responsible party of significant weight gain. Review of the 02/07/2022 and 02/08/2022 NP visit notes showed no documentation the 18.4 lb or 5.9% weight gain was reported by nursing. The NP notes showed no documentation of the 4++ edema was reported by nursing for Resident 256. In an interview on 02/10/2022 at 11:49 AM, Staff J reviewed Resident 256's record and stated the nursing staff did not identify or assess the weight gain and did not notify the NP. Record review revealed no evidence the Registered Dietician (RD) was notified of the weight gain or status of the edema for Resident 256. Staff J stated the nurses were expected to review the resident's weight and report to the NP and dietician. Staff J stated the skilled nursing notes direct nurses to assess edema and if present, the nurses are expected to notify NP and put the resident on alert. REFERENCE: WAC 388-97-1060(1). Resident 36 According to the 01/10/2022 Annual MDS, the resident had severe cognitive impairment, was not able to make their own decisions, and had medically complex conditions including dementia, diabetes, and depression. The resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS showed the resident had no pressure ulcers (PU) but was at risk for PUs. Review of a Risk for PU CP (revised on 04/01/2021) directed staff to encourage and assist with repositioning frequently, when the resident was in the wheelchair (w/c). Review of a 12/13/2021 Braden Scale (used to predict pressure sore risk) showed the resident was assessed as at risk for PUs. On 02/03/2022 at 10:13 AM the resident was observed self-propelling in w/c, had no cushion, and was sliding down in their w/c. The resident was able to reposition themselves by scooting back in the w/c. On 02/04/2022 at 9:49 AM Resident 36 was observed sitting in their w/c without a cushion. The resident stated my bottom hurts. Similar observations were made on 02/07/2022 at 10:13 AM. On 02/07/2022 at 10:23 AM Resident 36 was observed having their brief changed by Staff S (Licensed Practical Nurse) and their buttocks were observed without redness or open areas. In an interview on 02/11/2022 at 9:20 AM Staff B (Director of Nursing) stated they would expect the resident to have a cushion in their w/c and are not aware of why the resident was sliding down in their w/c. Resident 14 On 02/07/2022 at 09:17 AM Resident 14 was observed with a bluish colored bruise, measuring 4.2 x 6.3 cm, on their right lower leg and a dry scab on their right calf. Observation on 02/08/2022 at 08:17 AM, showed Resident 14 with the same bruise and dry scab on their RLE (Right Lower Extremity). A Review of the January and February 2022 nursing progress notes and weekly skin assessments showed no documentation of the bruise or the scab. A Review of the current POs revealed no order to monitor the bruise or the dry scab on Resident 14's leg. In an interview on 02/07/2022 at 09:07 AM, Resident 14 stated they must have hit their leg on something. In an interview on 02/08/2022 at 11:52 AM, Staff N confirmed there was no documentation or assessment of the skin issues to Resident 14's RLE in the resident's record. Staff N acknowledged if the scab/ bruise to the resident's RLE were observable by visitors, staff should have identified the injuries as well, but failed to do so. Non-Pressure skin Facility Policy According to the Facility's Skin Integrity Policy, updated 2019, for skin impairment identified with admission, including abrasions, a nurse should document skin impairment that includes measurements of size, color, presence of odor, exudates, and presence of pain on the weekly skin evaluation. Resident 27 According to the 01/31/2022 Significant Change MDS, Resident 27 readmitted to the facility on [DATE] from an acute hospital and was assessed with skin impairments including a skin tear. On 02/02/2022 at 12:12 PM, Resident 27 was observed with a large abrasion on their scalp. Review of Resident 27's Electronic Health Record (EHR) showed an 01/18/2022 weekly skin evaluation that described this abrasion as covered with a scab, oval in shape, with no odor or drainage, and measuring 8 x 10.5 centimeters (CM). Resident 27's next weekly skin evaluation on 01/25/2022 stated there was no new skin impairment identified. Staff did not measure or describe in any way the state of the abrasion. In an interview on 02/09/22 at 12:48 PM, Staff N indicated complete and accurate skin assessments, including describing and measuring skin impairments, are essential to monitor the healing or worsening of impaired skin. Staff N stated the 01/25/2022 weekly skin assessment did not, and should have included measurements and a thorough description of Resident 27's abrasion. Based on observation, interview, and record review, the facility failed to ensure 9 (Residents 12,13, 206, 42, 27, 36, 14 213 and 256) of 25 residents reviewed, received the necessary care and services in accordance with professional standards of practice, and their comprehensive person-centered care plan. The facility's failure to ensure 4 (Residents 12, 13, 206 and 42) of 8 residents reviewed for bowel management, 3 (Residents 27, 36 and 14) of 6 residents reviewed for non-pressure skin issues, and 3 (Residents 213, 42, 14 and 256) of 5 reviewed for edema (fluid retention), received the care and services they were assessed to require, placed residents at risk unidentified and unmet care needs, delays in treatment and potential negative outcomes. Findings included . Bowel Management Resident 12 During an interview on 02/02/2022 at 10:43, Resident 12 expressed that occasionally they experienced bouts of constipation. Record review showed Resident 12 had 05/25/2021 bowel care orders for: Milk of Magnesia (MOM) as needed (PRN) for constipation, if no bowel movement (BM) for three days, administer MOM on day four; Dulcolax suppository PRN, if no results from MOM administer on the next shift during waking hours; and Fleets enema PRN, if no results from Dulcolax, administer on the next shift during waking hours. In an interview on 02/11/2022 at 11:33 AM, Staff N (Resident Care Manager) clarified that when a resident goes three days without a BM, nursing administers the MOM on day shift of the fourth day. Review of Resident 12's bowel flowsheets showed the resident went greater than 3 days with no BM on the following occasions: 12/06/2021-12/09/201 (4 days); 01/07/2022- 01/10/2022 (4 days); and 01/12/2022-01/17/2022 (6 days). Review of the resident's December 2021 and January 2022 Medication Administration Records (MAR)s showed Resident 12 was not administered an MOM in either month. During an interview on 02/11/2022 at 11:34 AM, Staff N indicated that administration of MOM was required to be given on 12/09/2021, 01/10/2022 and 01/15/2022, but acknowledged facility nurses failed to do so. Record review showed Resident 12 had a 05/25/2021 order for a right arm sling and a 09/29/2021 order for Sleep study. In an interview on 02/07/2022 at 1:27 PM, Resident 12 indicated they were never provided a arm sling or referred for a sleep study and stated, When I got here I was having pain in my right shoulder, a sling would have been nice, but I never got one. In relation to a sleep study, I didn't even know one was ordered, no one ever spoke with me about it and I certainly have not gone. Record review showed no indication the resident was provided with or had worn a right arm sling. There was no documentation or indication facility acted on the resident's referral for a sleep study. In an interview on 02/10/2022 at 2:41 PM, Staff N stated that they could not find any documentation to support staff had scheduled or attempted to schedule Resident 12's sleep study. Staff N indicated they were still looking into the the order for a right arm sling and would check with therapy. No further information was provided. Resident 13 During an interview on 02/02/2022 at 2:20 PM, Resident 13 reported they had issues with constipation stating, Oh yeah, when I first got here I went several days without a [BM], it's not as bad now, they [staff] give me stuff that helps but I still get constipated sometimes. Review of December 2021 MAR showed Resident 13 had 09/16/2021 bowel care orders for: Milk of Magnesia (MOM) as needed (PRN) for constipation, if no BM for three days, administer MOM on day four; Dulcolax suppository PRN, if no results from MOM administer on the next shift during waking hours; and Fleets enema PRN, if no results from Dulcolax, administer on the next shift during waking hours. Review of Resident 13's bowel flowsheets showed the resident went greater than 3 days with no BM on the following occasions: 12/02/2021- 12/06/2021 (5 days); and 12/26/2022-12/29/2022 (4 days). Review of the resident's December 2021 MAR showed on 12/06/2021 and 12/29/2021, facility nurses failed to administer MOM as ordered. During an interview on 02/11/2022 at 11:34 AM, Staff N acknowledged the MOM was required on 12/06/2021 and 12/29/2021, but was not administered. Resident 206 A 1/27/2022 admission 5-day MDS showed Resident 206 was admitted on [DATE] with the diagnoses of Alzheimer's Disease, constipation, and difficulty walking. On review of the 1/28/2022 Care Area Assessment, Resident 206 was determined to have severely impaired decision making and impaired cognition impacting their communication skills. Resident 206 needed extensive assistance with toileting and was incontinent of bowels and bladder requiring assistance from staff. The 03/2018 facility policy titled Bowel Protocol showed the licensed nurse was expected to review the bowel monitor record daily and if the resident did not have a bowel BM for three days, the nurse was to administer the physician ordered bowel program. A 01/21/2022 Physician Order (PO) showed Resident 206 had POs for the facility bowel protocol including Milk of Magnesia (laxative), Bisacodyl Suppository (laxative) and Fleet Enema (laxative) as needed. A review of the 01/2022 bowel record for Resident 206 showed no BM documented on 01/26/2022, 01/27/2022, 01/27/2022 or 01/28/2022, 4 days with no BM. A review of the 02/2022 bowel record for Resident 206 showed no BM documented on 02/04/2022, 02/05/2022 or 02/06/2022, 3 days with no BM. A review of the 01/2022 and 02/2022 MAR showed staff did not administer a laxative to Resident 206 on any of the days during the facility stay according to POs. In an interview on 02/10/2022 at 11:49 AM, Staff J (Resident Care Manager) reviewed the bowel monitor log for Resident 206 and confirmed the dates with no recorded BM. Staff J reviewed the MAR and verified no bowel medications were given from the bowel protocol. Staff J stated the resident should receive a laxative on day three without a BM and it was not administered. Resident 42 Review of resident 42's POs showed the resident had the following bowel management orders: Milk of Magnesia (MOM) 30 ml by mouth as needed (PRN) if resident had no BM for three days, administer MOM on day 4; Administer Bisacodyl suppository PRN next shift during working hours if no results from MOM; Fleet enema PRN next shift during working hours if no results from suppository and notify MD. Review of Resident 42's bowel records showed the resident went more than 3 days without a BM on the following occasions: 1/19/22-1/22/2022 (4 days), and 1/25/2022-1/28/2022 (4 days). Review of Resident 42's MARs showed facility nurses did not administer MOM as ordered on any of the above occasions, did not follow the protocol. During an interview 02/08/2022 at 12:04 PM, staff N (Resident Care Manager) acknowledged on 01/22/2022 and 01/28/2022 nurses should have administered MOM as ordered, but they did not.

Based on observation, interview, and record review the facility failed to provide sufficient staff to ensure supervision and provision of care, in accordance with established clinical standards, resident care plans, and identified preferences as evidenced by the responses of 6 (Residents 13, 206, 208, 12, 14 and 15) of 25 residents interviewed and 5 staff interviews. The failure to have sufficient staff detracted from the facility's ability to ensure residents consistently received assistance with Activities of Daily Living (ADLs) including restorative services and showers. These failures placed residents at risk for a decline in range of motion, mobility, accidents, injuries, poor hygiene, and diminished self-worth. Findings included . RN Services Review of the facility nurse staff schedule for 01/02/2022 thru 1/31/2022 showed two days, Saturday 01/08/2022 and Sunday 01/09/2022, when a Registered Nurse (RN) was not scheduled to provide nursing services to residents for eight consecutive hours a day. The nurse staff schedule showed only Licensed Practical Nurses (LPNs) were scheduled for all three shifts. In an interview on 02/10/2022 at 11:40 AM, Staff A (Administrator) confirmed the two days, Saturday 01/08/2022 and Sunday 01/09/2022, did not include an RN was scheduled to provide care to residents for eight consecutive hours a day. When asked if timecards or other documents were available to confirm an RN worked 8 hours on those days, no documents were provided. Resident Interviews Resident 13 In an interview on 02/02/2022 at 02:01 PM, Resident 13 stated the facility had staffing difficulties, that at one point on the East Unit only, managers answered the call lights, and that showers were not provided as frequently as they should be. Resident 206 In an interview on 02/03/2022 at 10:52 AM, Resident 206's representative stated at times they felt the facility was short-staffed. Resident 208 In an interview on 02/03/2022 at 10:14 AM, Resident 208 stated they had to wait a long time when asking for assistance at night sing their call light. Resident 12 In an interview on 02/02/2022 at 10:43 AM, Resident 12 stated the facility did not have enough nursing staff and identified the time between lunch to dinner as particularly difficult to get assistance, adding this is when I try to get things done. Resident 14 In an interview on 02/02/2022 at 01:23 PM, Resident 14 indicated it was hard to get staff assistance on sometimes, and stated it could take more than an hour for the call light to be answered on evening shift and occasionally night shift. The resident expressed concern that insufficient staff contributed to staffs' inability to provide two showers a week and reported they had only received on shower in three months. Resident 15 In an interview on 02/02/2022 at 09:28 AM, Resident 15 stated for the first month and a half at the facility, they didn't get a shower, adding they gave me a spit bath once. Restorative Programs-Staff Interviews In an interview on 02/01/2022 at 11:48 AM, Staff B (Director of Nursing) indicated the nurse in charge of the Restorative Nursing Programs (RNPs) was transitioning from Staff CC (Licensed Practical Nurse) to Staff AA (Resident Care Manager). Staff B also stated the facility usually had two full time Restorative Aides (RAs), but currently only had one. In an interview on 02/07/2022 at 11:19 AM, Staff AA identified staffing as the primary reason residents were not provided their RNPs at the frequency they were assessed to require. Per Staff AA the RA was often pulled from restorative services to provide direct patient care, and indicated when Staff KK (RA) is pulled to provide direct resident care, there was no one available to provide the RNPs. In an interview on 02/20/2022 at 11:46 AM, Staff CC (Licensed Practical Nurse, former Restorative Nurse) also identified Staffing as the primary barrier to completing resident's RNPs at the directed frequency. Staff CC, stated the facility usually employed two full time and one part time RA, but were down to just one. Staff CC indicated on occasion the RA was pulled from restorative services to provide direct resident care, which resulted in the RNPs being completed on those days. During an interview on 02/10/2022 at 11:55 AM, Staff KK (RA) stated in December 2021 the facility hired a second full time RA to ensure resident's received their RNPs, but reported the new RA was pulled to provide direct care Nearly everyday and that in December 2021, they were also pulled on average twice a week. Bathing Services-Staff Interviews During an interview on 02/09/2021 at 1:12 PM, Staff LL (Registered Nurse) and Staff D (Licensed Practical Nurse) both stated that the facility used to have two Shower Aides, but both had left and hadn't been replaced yet. Staff LL reported that the nursing aides were now tasked with providing showers to the residents on their set and acknowledged not all the scheduled showers were completed. Refer to: F677 ADL Care Provided for Dependent Residents F688 Increase/Prevent Decrease in ROM/Mobility REFERENCE: WAC 388-97-1080 (1), -1090 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents remained free of unnecessary psychotropic medications for 4 (Residents 206, 256, 42, & 36) of 5 residents reviewed for unnecessary medications and 2 (Residents 308 & 309) supplemental residents. Failure to identify the adequate indications for use, identify triggers, and document behaviors, implement non-pharmaceutical interventions before administering medication and failed to obtain informed consent prior to administration of anti-psychotic medications placed residents at risk of receiving unnecessary psychotropic medications, experiencing medication-related adverse side effects, and diminished quality of life. Findings included . A review of the facility Psychotropic Drugs policy dated 01/2019 showed staff should utilize behavioral interventions and identify behavior triggers prior to initiating psychotropic medication. This policy directed staff to validate the appropriate diagnosis and behavioral symptoms treated by the psychotropic medications. The facility's Informed Consent for Psychotropic Medications policy, dated 09/2017, directed staff to obtain informed consent from the resident or Resident Representative (RR) prior to the administration of psychotropic medication. The policy directed the nurse to review the drug, dosage, frequency, risk factors, and content (of the informed consent form) and obtain a signature if agreement to take the drug was received. The policy showed if the resident representative was unable to come to the facility, the nurse would call for telephone consent and document when consent was received. A review of the 01/2019 facility policy titled Behavior Monitoring showed a resident admitted with orders for psychotropic medications a completed consent was completed before starting the medication. The policy showed if a resident had an order for psychotropic medications, the side effects were monitored and documented as indicated. This policy showed the resident with behaviors would have the behaviors, triggers, interventions, and outcomes monitored and documented on a flow sheet when the behaviors are exhibited. Resident 206 The 01/27/2022 admission Minimum Data Set (MDS - an assessment tool) showed Resident 206 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's Dementia, Anxiety and Depression. Resident 206 was assessed with severe cognitive impairment and impaired decision making capacity. The MDS showed Resident 206 demonstrated behaviors on 4-6 days of the assessment period which placed Resident 206 at risk for injury, affected the privacy and living environment of others and interfered with resident care. A review of the 01/27/2022 Psychotropic Medication Care Area Assessment (CAA) showed Resident 206 demonstrated behaviors of yelling out and disrobing and required a psychiatrist consult. This CAA showed Resident 206 used an anti-anxiety medication PRN (as needed) and an antidepressant medication daily. Review of a PO dated 01/21/2022 directed staff to administer Lorazepam (an anti-anxiety medication) 0.5 mg by mouth every six hours PRN (as needed) for 14 days, ending on 02/04/2022. The 01/24/2022 consent form for Lorazepam showed a signature by Staff J (Resident Care Manager - RCM) and reflected the RR gave verbal consent on 01/24/2022. A review of the 01/2022 Medication Administration Records (MAR) showed Lorazepam was given to Resident 206 on 01/22/2022 at 3:51 AM and 01/24/2022 at 1:13 AM, prior to receipt of the informed consent from the RR. Review of MARs showed Lorazepam was administered eight times in 01/2022 and four times in 02/2022. Review of Resident 206's 01/2022 and 02/2022 behavior monitors showed staff documented no behaviors, triggers, non-pharmacological interventions or outcomes during this time period. The MAR showed staff failed to monitor for Lorazepam's adverse side effects as required by the facility policy. In an interview on 02/09/2022 at 1:00 PM, Staff B (Director of Nursing) stated verbal consent should be obtained prior to the administration of a psychotropic medication. Staff B stated nurse staff was expected to identify the triggers of behavior, document demonstrated behaviors and non-pharmacological interventions, and outcomes on the behavior monitor before administering a PRN psychotropic medication. Staff B reviewed Resident 206's record and confirmed there was no behavior monitoring/interventions documented before administration of the PRN Lorazepam, and no monitoring of side effects as required by the facility policies. Staff B confirmed the facility policy on the timing and documentation of informed consent was not followed for Resident 206. Resident 256 According to the 01/31/2022 admission MDS Resident 256 had diagnoses of anxiety disorder and depression. Resident 256 was assessed as cognitively intact and able to understand others and be understood. A review of the 01/24/2021 admission POs showed Resident 256 was prescribed Quetiapine (an anti-psychotic medication) and Escitalopram (an antidepressant). Resident 256 was prescribed Clonazepam (an anti-anxiety medication) 1 mg every eight hours PRN for 14 days, ending on 02/03/2022. The diagnosis used for all three medications was anxiety. A 02/03/2022 PO showed Resident 256 was also prescribed Melatonin (a sleep aid). A review of the 01/2022 MAR showed Resident 256 was administered the first dose of: Escitalopram on 01/24/2022, Clonazepam on 01/25/2022, Quetiapine on 01/25/2022 and Melatonin on 02/03/2022. Record review showed informed consent forms for Escitalopram and Clonazepam were signed by Staff J on 01/28/2022, but not signed by Resident 256. The consent forms showed verbal consent was discussed on 01/26/2022 with Resident 256, two days after the medications were initiated. Record review showed no informed consents for Quetiapine or Melatonin. A review of the 01/2022 MAR showed no behavior monitoring for depression related to the use of Escitalopram. There was no side effect monitoring for Escitalopram. There was no sleep monitor the effectiveness of Melatonin. There was no target behavior monitoring or documentation for the use of Quetiapine. Review of MARs showed Clonazepam was administered 13 times in 01/2022 and five times in 02/2022. The 01/2022 and 02/2022 MARs showed no indication the resident demonstrated anxious behaviors or that non-medication interventions were used prior to administering Clonazepam. A 02/03/2022 PO showed a change to the order, Clonazepam 1 mg by mouth twice per day, to a routine administration and no longer PRN. There was not a consent form in the record for the change in medication schedule. In an interview on 02/08/2022 at 11:05 AM, Staff J stated the consent form for Quetiapine was missed and there was not a consent form completed for the Clonazepam when the order changed to routine, and there should have been signed consent obtained. In an interview on 02/09/2022 at 1:00 PM, Staff B reviewed Resident 256's record and stated the consent forms for psychotropic medications should have been electronically signed by the resident before administration. Staff B stated all psychotropic medications should have the appropriate diagnosis for the intended use, and that Resident 256 did not have the appropriate diagnosis for Quetiapine or Escitalopram. Staff B stated the nurses are expected to document associated behaviors and non-medication intervention prior to giving PRN psychotropic medications. Staff B stated Resident 256 did not have behaviors or interventions recorded on the behavior monitor or the progress notes prior to the nurse administering 18 doses of Clonazepam. Resident 308 According to the 01/29/2022 Admission/ Medicare -5 Day MDS, Resident 308 admitted to the facility on [DATE] with medically complex diagnoses including schizophrenia, depression and anxiety disorder which required the use of psychotropic medications. Review of February 2022 MARs showed Resident 308 received Risperdal (for psychosis), Celexa (for depression), and Buspirone (for anxiety) daily. According to a 01/31/2022 anti-anxiety medication Care Plan (CP) for Resident 308, interventions directed staff to Monitor/record occurrence of target behavior symptoms (pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Record review on 02/04/2022 revealed no evidence staff monitored or documented the target behaviors (TBs) identified on Resident 308's CP or that these TB were individualized for Resident 308. Record review on 02/04/2022 revealed no CP that addressed Resident 308's use of an anti-psychotic medication or that any TBs were monitored in regard to their psychosis. In an interview on 02/11/2022 at 8:33 AM, Staff N (RCM), stated staff should have, but did not monitor the listed TBs on Resident 308's CP for anxiety and verified there was no CP or TB monitoring for the use of Risperdal for Resident 308. Staff N indicated that TBs should be individualized and monitored daily for psychotropic medications. Resident 309 Similar findings were noted for Resident 309, who was prescribed psychotropic medications without individualized TBs for depression monitored daily by staff. Resident 36 According to the 01/10/2022 Annual MDS, Resident 36 had severe cognitive impairment, was cognitively impaired, and had diagnoses including dementia and depression, demonstrated behaviors of wandering, which was assessed to occur daily, and the resident did not reject care. A 04/01/2021 Anti-psychotic medication use CP directed staff to review behaviors and interventions, and alternate therapies attempted and their effectiveness per the facility policy. The CP showed staff should consult with the Pharmacists and Doctors to consider dose reductions of anti-psychotics when clinically appropriate and at least quarterly. Review of a Impaired Safety Awareness CP (revised 10/15/2021) showed the resident wandered and was at risk for elopement. The CP directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. A 12/15/2021 PO directed staff to monitor and document the resident's behaviors of constant wandering, crying or needy behaviors, and aggression. A 08/19/2020 PO showed Risperdal (an anti-psychotic medication) 0.5 milligrams (mgs) was ordered twice daily for psychotic delusions. Review of the resident's clinical record showed the resident was on Risperdal 0.5 mg from 08/19/2020 to 05/13/2021, nine months without a Gradual Dose Reduction (GDR). Review of Psychiatry notes showed the resident was seen by the Psychiatrist on 10/02/2020, 12/11/2020, 04/15/2021 and documented the resident was tolerating Risperdal, had no side effects and to continue the current management and supportive measures. The Psychiatrist noted on 05/07/2021, if behaviors continue to worsen, or impacted safety, or care, or caused significant distress increase Risperdal to 0.5 mg q am (every morning) and 0.75 mg hs (every night). Review of 05/2021 TBs showed Resident 36 demonstrated no behaviors through 05/13/2021. A 05/13/2021 PO showed Risperdal was increased to 0.5 mg in the morning and 0.75 mg at night in the absence of any documented behaviors which would require this increase. Review of the resident's record showed no indication or documentation the resident was on alert charting or the POA (Power of Attorney) was notified of the increase in Risperdal. This order remained active until 09/19/2021 when the Risperdal was decreased to 0.5 mg twice daily. From 08/19/2020 to 09/19/2021 the resident had no GDR attempts with Risperdal. A 05/13/2021 Provider note showed the resident was recently evaluated by the Psychiatrist on 05/07/2021 with recommendations to increase the Risperdal evening dose if behaviors worsen, behaviors have continued but it could be in the setting of a UTI (urinary tract infection). Review of Resident 36's Behavior Monitoring showed for December 2021 and February 2022 showed 1 episode each month of wandering behaviors. Observations of Resident 36 wandering were made on 02/03/2022 at 8:30 AM, 02/04/2022 at 9:49 AM and 12:12 PM, 02/07/2022 at 10:32 AM and 1:35 PM, 02/08/2022 at 9:53 AM, and 02/09/2022 at 10:51 AM and 1:40 PM. In an interview on 02/11/2022 at 9:20 AM Staff B stated the process for anti-psychotic medications is the resident is placed on alert charting, notify the POA, and monitor for behaviors. Staff B stated GDR attempts are done at a minimum of quarterly and acknowledged the resident's Risperdal was not reduced but should have been. Staff B stated Resident 36 wandered daily and their behaviors should be captured accurately on the behavior monitoring. Resident 42 According to the 03/06/2019 admission MDS Resident 42 admitted to the facility on [DATE] with diagnoses of anxiety disorder, was not assessed with any psychotic disorder, and did not require anti-psychotic medications. According to the 05/05/2020 Quarterly MDS, Resident 42 was assessed with anxiety disorder and depression which required antidepressant medication but had no psychotic disorder. According to 10/09/2019 MARs, the resident received Duloxetine (antidepressant) daily for Major Depression with no TB monitoring. On 01/15/2020 POs directed staff to monitor and document the resident's identified TBs which required the use of antidepressants as: Crime, Tearfulness, Withdrawn, Isolated. Physician Orders dated 05/26/2020 directed staff to initiate Quetiapine (anti-psychotic) 12.5 mg twice daily for psychotic disorder with delusions. Review of the May 2020 MARs showed staff failed to identify any individualized TBs which required the use of the anti-psychotic medication. Observations of Resident 42 on 02/01/2022 at 12:25 PM, 02/02/2022 at 09:20 AM, 02/03/2022 at 10:16 AM, 02/07/2022 at 1:13 PM showed no delusional behaviors. Observations on 02/08/2022 at 9:18 AM showed the resident refused their medications, stating they were not needed. A 08/27/2020 Progress note indicated IDT (Interdisciplinary Team) team met for psychotropic review .no changes at this time. According to Psychiatry Provider notes dated 09/03/2020 the resident was assessed as, Awake oriented to self but confused not suicidal even mood disorganized speech no clear delusions or hallucinations no overt agitation and directed staff to increase the Seroquel to 25 mg twice a day. According to the August and September 2020 MARs, the resident did not demonstrate any TBs. Review of progress notes for August and September 2020 showed no indication the resident demonstrated any delusions or hallucinations. Record review showed no indication the resident demonstrated any behavior which would clinically justify a dose increase of the Seroquel. Review of the resident's clinical record showed the resident was on Seroquel 25 mg twice a day, and Duloxetine 60 mg once a day, from September 2020 through December 2021, a period of 16 months, without a consideration of a GDR . A 07/29/2021 PO directed staff to monitor and document the resident's behaviors of, Verbal aggression, exit seeking, refusals of care, and others; related to Anxiety disorder, Depression and Psychotic disorder with delusions. The TBs were not specified as to which behaviors required the use of which medication which detracted from staff's ability to determine effectiveness of medications. Record review showed the resident was seen by a psychiatrist on 06/19/2020, 07/27/2020, 09/03/2020, 12/11/2020. 10/01/2021, 12/03/2021,12/20/2021, and documented the resident had no clear delusions or hallucinations. The psychiatrist noted on 12/10/2021 stated the resident was very suspicious and paranoid and was easily irritable. Review of Resident 42's progress notes and behavior monitoring showed no such documented behaviors. Facility Policy for Psychotropic Drugs indicated, Prior to initiating any psychotropic drug, IDT Reviews the medical record, Behavior monitoring flow sheet, progress notes and evaluations related to behavior. This policy directed that if psychotropic medication was initiated within the last year, unless clinically contraindicated, staff should attempt a GDR in two separate quarters with at least one month between attempts and then a GDR should be attempted annually, unless contraindicated. In an interview on 02/08/2022 at 11:52 AM Staff N (RCM) was unable to provide documentation to support Resident 42 continued to require the Duloxetine or the Seroquel at the same dose for over a year and was unable to explain why a GDR for either medication was contraindicated. Staff N stated they should have attempted GDRs. REFERENCE: WAC 388-97-1060(3)(k)(i). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 14 Resident 14 admitted to the facility on [DATE]. According to the 12/02/2021 Quarterly MDS, the resident was cognitively intact and able to understand and be understood in conversation. During an interview on 02/02/2022 at 1:31 PM, Resident 14 stated they were unhappy with the food, and expressed frustration the facility never provided what they had ordered. The resident stated they ordered cold cereal, milk and sugar but did not get all their requests on the tray, not even coffee. Resident stated that they talked to the aides and kitchen manager, but no one is doing anything. Observations on 02/03/2022 at 08:27 AM showed during breakfast, the resident got oatmeal as written on the meal ticket because the facility was out of cold cereal. They received coffee but no sugar or creamer. Observations on 02/04/2022 at 08:42 AM showed during breakfast, the resident had oatmeal on their tray. The meal ticket showed; oatmeal, and half a banana. No banana was observed on the resident's tray. The resident stated they told staff and staff brought them cold cereal and half a banana from the kitchen. Observations on 02/07/2022 at 08:41 AM showed during breakfast, the resident had cold cereal, 2 pieces of white toast, half of a banana, 8 ounces (oz) of 2% milk, and apple sauce. The meal ticket still showed oatmeal. Observations on 02/08/2022 at 08:45 AM and 02/09/2022 at 8:27 AM, resident again got oatmeal and they had to ask the staff to bring cold cereal. During an interview on 02/09/2022 at 09:50 AM Staff X (Certified Nurses Assistant) stated they had not heard any concerns about the food. In an interview on 02/09/2022 at 10:39 AM, Staff BB (Admissions Coordinator) stated the resident told them they did not like hot cereal, and they got cold cereal from the kitchen for the resident. During an interview on 02/09/2022 at 12:30 PM Staff T (Certified Nurses Assistant) stated they had delivered food to resident at times and, Last week the resident told me that they do not like hot cereal, and I changed the menu to cold cereal and got them cold cereal and the kitchen knew it. In an interview on 02/09/2022 at 1:17 PM Staff N (Resident Care Manager) stated the resident had made their preference for cold cereal known to staff on multiple occasions liked, and it should be on their preferences. Staff N acknowledged that the resident is not getting food they preferred but whatever is written on the meal tickets. Refer to F804 Nutritive Value /Palatability REFERENCE: WAC 388-97-1160(1)(a)(b). Resident 208 A review of the 02/02/2022 admission MDS showed Resident 208 was admitted on [DATE] with a diagnosis of diabetes. Resident 208 was assessed to be cognitively intact, able to make self understood and understand others. The 02/02/2022 Care Area Assessment (CAA) showed Resident 208 had a nutrition status problem related to diabetes to be addressed in the care plan. The CAA showed Resident 208 was prescribed a consistent carbohydrate diet (CCHO) with regular texture and was tolerating well. The CAA showed the Registered Dietician (RD) was to monitor and manage diet; monitor intake and offer supplement as needed for inadequate intake. In an interview on 02/01/2022 at 2:20 PM, Resident 208 stated food is life and critical for me because I am diabetic. If I do not get the right food, I will not live. Resident 208 stated they were very careful with the foods eaten at home and planned a main protein and sides with low carbs for each meal. Resident 208 verbalized concerns over the amount of carbohydrates (carbs) and very little protein they were served in the facility. Resident 208 stated if you do not like your food, they take it away and there is no alternate; I do not get to choose my food from a menu. They serve things like biscuits and gravy, mushroom soup, a plate full of rice and I cannot eat those things, it's too many carbs. Resident 208 stated they asked the nurse to see the dietician last Friday (01/28/2022), and still has not seen the RD. An observation and interview on 02/02/2022 at 9:17 AM, Resident 208 received a breakfast tray that included two pieces of waffle, a small amount of scrambled egg and a small piece of ham. Resident 208 stated, I cannot eat all those carbs in waffles, I cannot drink the orange juice or milk because it is all sugar. An observation and interview on 02/03/2022 at 9:47 AM showed Resident 208 was served two pieces of French toast and one link of sausage, a bowl of cream of wheat, milk, and orange juice. Resident 208 stated I cannot eat most of this, it is all carbs, and I have told them already that I do not like cream of wheat, and they keep bringing it to me with this juice and milk. Resident 208 stated, They just don't listen. In an observation and interview on 02/04/2022 at 8:45 AM, Resident 208 explained there was a mushroom burger with a half plate of tater tots served for dinner the night before. Resident 208 stated they ate the meat and mushrooms and two tater tots and sent the rest back. Ten days after Resident 208 was admitted , in an interview on 02/04/2022 at 8:57 AM, Staff I (Resident Care Manager) stated residents are asked about their food preferences on admission, they are seen by the dietician just after admission, they have a weekly menu to choose food for each meal. Staff I left to talk with Resident 208 and returned to explain the resident had not yet been asked about their food preferences, seen the dietician and had not been able to choose their meals from the weekly menu. In an interview on 02/04/2022 at 9:38 AM, Staff GG (Dietary Aide) stated that usually dietary staff talks to the resident about food preferences within a day of admission, it is expected within 72 hours of admission. Staff GG stated, I just talked with Resident 208 today; 10 days after admission. In an interview on 02/04/2022 at 12:40 PM, Staff B (Director of Nursing) stated the dietician comes one to two times a week and attends the weekly nutrition at risk meetings. Staff B stated the dietician should evaluate a resident within 14 days of admission. In an interview on 02/11/2022 at 10:49 AM Staff I stated the dietician is notified when a resident admits to the facility by creating a diet slip. Staff I stated Resident 208 was seen by the dietician on 02/09/2022, 15 days after admission. Based on observation, interview and record review, the facility failed to ensure menus were followed for 11 (Residents 306, 262, 21, 44, 6, 40, 13, 37, 12, 5 & 17) of approximately 50 resident meals observed during the 02/09/2022 noon meal service. The facility also failed to make reasonable attempts to accommodate resident communicated dietary needs/preferences. Facility staffs' failure to follow the written menu related to portion size, diet type, resident preferences and failure to follow the recipe when preparing pureed diets, resulted in residents receiving less calories and/or larger/smaller portions than recommended by their diet order, placing residents at risk for unmet nutritional needs. Findings included Review of the menu for the noon meal on 02/09/2022, the facility was serving pesto chicken and herbed Orzo (type of pasta). The alternative meal was a taco salad with sour cream. According to the menu large portion diets were to receive 1.5 servings of the entree and starch, and small portion diets received a 1/2 serving of all items. Nutritionally Enhanced Meals (NEM) were not defined on the menu but per Staff FF (Dietary Service Manager) entailed receiving butter and whole milk with meals. Observations of trayline for the noon meal on 02/09/2022, were made between 12:08 PM and 12:58 PM. The observations were as follows: Failure to Follow Specific Diet Types Resident 6's tray card showed the resident was to receive a large portion, NEM diet. Staff were observed to provide one (breaded) fish fillet (per resident request) on a hamburger bun, instead of 1.5 fish fillets as directed for a large portion diet; Resident 37's tray card showed the resident was on a NEM diet, staff failed to apply butter to the resident's orzo and provided a cup of 2% milk rather than whole milk as directed; Resident 12's tray card showed the resident was on a NEM diet, staff failed to apply butter to the resident's orzo as directed. At 12:51 PM, 43 minutes after serving began, Staff FF identified that the butter for NEM diets was not present on the steam table and obtained the butter at that time. Inaccurate Portion Size Review of Resident 40's tray card showed the resident was on a large protein diet. Staff FF was observed to provide one heaping (4 ounce, oz) scoop of taco meat onto the resident's tray, instead of 1 4 oz scoop and 1 2 oz scoop as directed by the menu; Resident 13's tray card showed the resident was on a small portions, large protein diet. Staff FF placed one full (4 ounce) scoop of orzo on the resident's tray, rather than 2 oz as directed; Resident 5's tray card showed the resident was on a large protein diet. Staff FF was observed to place one heaping 4 oz scoop of pesto chicken on the resident's tray, instead of a measured 4 oz scoop and 2 oz scoop as directed; Resident 17's tray card showed the resident was on a large protein diet, staff were observed to provide one heaping 4 oz scoop of chopped meat, instead of one 4 oz scoop and one 2 oz scoop. At 12:38 PM, 30 minutes after serving began, Staff FF identified 2 oz scoops were needed (in conjunction with the 4 oz scoops) to appropriately measure serving sizes for small and large portion/protein diets, and placed them on the steam table next to the entrees and starches. During an interview on 02/09/2022 at 2:49 PM, Staff FF acknowledged for the first 30 minutes of tray service, staff failed to have the appropriate scoop sizes available (4 oz and 2 oz) to accurately measure out entree and starch portions for large and small portion and/or protein diets. Staff FF also confirmed butter should have been applied to the orzo of resident's on NEM, and acknowledged no butter was available until 12:51 PM, when staff identified no butter had been placed on the serving line. Pureed Food Preparation Preparation of Pureed orzo and pesto chicken on 02/09/2022 between 11:15 AM and 11:38 AM showed Staff EE (cook) failed to follow the pureed recipe, instead adding chicken broth and/or thickener based off the appearance of the texture. In an interview 02/09/2022 at 4:03 PM, Staff FF who initially stated the facility did not have recipes for pureed diets stated,I was wrong, we do have recipes for pureed diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident medical records were complete, accurate and readily accessible for 8 (Residents 27, 13, 12, 53, 15, 307, 309, & 206) of 25 residents whose records were reviewed. The facility failed to ensure: Activities of Daily Living (ADL) documentation was complete and accurate (Resident 27, 13, 12, 53, 15, 307, 309, & 206) and consultations from outside appointments were obtained and entered into resident records timely (Resident 309 & 13). Failure to ensure clinical records were complete and accurate placed residents at risk of for unmet care needs, weight loss and inaccurate assessments. Findings included . ADL Documentation Resident 27 On 02/07/2022 at 12:43 PM, Resident 27 was observed in bed, asleep with their lunch tray untouched and covered on their over-the-bed table. At 3:40 PM on 02/07/2022, an unidentified Certified Nursing Assistant (CNA) was observed providing eating assistance to Resident 27. Review of Resident 27's Meal Monitor on 02/08/2022 at 3:33 PM showed no documentation of any meal intake after 8:00 AM on 02/07/2022. No data was available for the lunch observed being provided at 3:40 PM on 02/07/2022, or for dinner on 02/07/2022, or breakfast or lunch on 02/08/2022. In an interview on 02/09/2022 at 12:42 PM, Staff N (Resident Care Manager) stated the purpose of a meal monitor was to track changes in nutritional intake, and that it was important for them to be accurately maintained. Staff N stated Resident 27's meal monitor was not, but should be complete and accurate. Resident 13 Review of Resident 13's January 2022 meal monitor showed, staff failed to document the resident's intake for 41 of the 93 meals. Resident 12 Review of Resident 12's January 2022 meal monitor showed, staff failed to document the resident's intake for 33 of the 93 meals. Resident 53 Review of Resident 53's January 2022 meal monitor showed, staff failed to document the resident's intake for 47 of the 93 meals. During an interview on 02/07/2022 at 11:29 AM, Staff N acknowledged Residents 13, 12 and 53's meal monitors were incomplete. Resident 15 Review of Resident 15's December 2021 meal monitor showed, the facility did not include documentation about the resident's meal intake for 41 of the 93 meals. January 2022 records showed 21 of the 93 meals were not documented and February 2022 meal intake records showed nine of the 30 meals had no documentation of Resident 15's meal intake. Resident 307 Review of Resident 307's January 2022 meal monitor showed, the facility failed to document the resident's meal intake for three of the 15 meals provided. February 2022 meal monitor records showed 14 of the 30 meals were not documented by staff. Resident 309 Review of Resident 309's December 2021 meal monitor showed, the staff failed to document the resident's meal intake for 30 of the 66 meals provided. January 2022 records showed 29 of the 93 meals were not documented and February 2022 meal intake records showed 11 of the 30 meals had no documentation of Resident 309's meal intake. In an interview on 02/11/2022 at 8:47 AM, Staff N stated meal intake documentation is important to help staff assess the overall health and nutritional status of a resident. Staff N confirmed staff failed to complete meal intake documentation accurately. Resident 206 A review of the 01/2022 and 02/2022 ADL documentation for bowel records completed for Resident 206 showed incomplete documentation for the following dates and shifts: 01/22/2022 evening shift, 01/24/2022 evening shift, 01/27/2022 night and day shifts, 01/28/2022 night and day shifts, 01/29/2022 night, day, and evening shifts, 01/30/2022 night and evening shifts, 01/31/2022 night and evening shifts, 02/01/2022 day shift, and 02/02/2022 day shift. Similar findings were noted on ADL documentation for bathing, dressing, hygiene, eating, meal intake, fluid intake, bladder monitor, bed mobility, transferring, and ambulation for Resident 206. In an interview on 02/10/2022 at 11:49 AM, Staff J (Resident Care Manager) stated all care staff are expected to document ADL care provided to residents every shift, every day. Staff J stated if a resident refuses or is not available then staff are expected to document the not available or refusal of care. Staff J stated there should be no missed documentation or blanks in the ADL documentation. Consultations Resident 309 Resident 309 was admitted to the facility on [DATE]. According to the 12/16/2021 Admission/ Medicare -5 Day MDS Resident 309 had multiple medically complex diagnoses including kidney failure and received dialysis (process of purifying the blood when kidneys are not working normally) services. Review of February 2022 Treatment Administration Records (TARs) showed Resident 309 had orders that directed staff to document three times a week the receipt of dialysis transfer forms with pre and post dialysis weights, and if not returned, to call for a dialysis center for a copy. On 01/20/2022 at 1:45 PM, staff documented in Resident 309's medical record that Resident stated [they] did not get the form prior to leaving. Similar documentation was also noted on 01/29/2022, 02/01/2022 and 02/03/2022. No Dialysis Transfer Forms were found in Resident 309's medical record after 01/15/2022. On 02/04/2022 medical records staff documented they called the dialysis center and requested the treatment records from 01/15/2022 through 01/31/2022. These summaries were obtained and subsequently added to Resident 309's medical records. In an interview on 02/11/2022 at 8:42 AM, Staff N stated obtaining the dialysis transfer forms after each session is important to see if any recommendations were made. Staff N indicated the records should be obtained and in the resident's record timely. Resident 13 Resident 13 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly Minimum Data Set (MDS, an assessment tool), Resident 13 was cognitively intact and able to understand and be understood in conversation. During an interview on 02/02/2022 at 1:40 PM, Resident 13 reported in November 2021 they were seen by their neurologist and vascular surgeon and in December 2021, by a rehabilitation specialist. According to Resident 13 these consulting Physician's made recommendations and/or referrals that were not timely carried out by facility staff. Record review showed no consults were present in the resident's medical record for vascular surgery or neurology from November 2021 or for an appointment with a rehabilitation specialist in December 2021. There was no indication the resident attended these appointments. During an interview on 02/09/2022 at 3:03 PM, Staff N and Staff B (Director of Nursing) were asked to provide a list of outside appointments Resident 13 attended in November and December 2021 as well as the consults from those appointments. During an interview with Staff N and Staff B on 02/10/2022 at 4:30 PM, the list of appointments the resident attended and the corresponding consults from those appointments were again requested, but no information was provided. Staff B indicated they were still looking into it, but acknowledged a consult/visit summary from consulting Physician appointments, should be present/readily accessible in the resident's medical record. REFERENCE: WAC 388-97-1720(1)(a)(i-iv)(b) .

**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 including COVID-19 and other infections. The facility failed 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 TBP notice posted outside of resident rooms; and maintain infection control during wound care and medication pass. These failures placed all residents and staff at risk for contracting communicable diseases, including COVID 19, during a global pandemic. Findings Included . PPE At the time of the survey, residents on the [NAME] Unit of the Facility were placed on TBPs from the date of enter 02/01/2022, through 02/03/2022. TBP signage outside resident rooms instructed staff to don (put on) a gown, gloves, face shield and an N95 mask prior to entering a resident room. Upon exit, signage directed staff to doff (remove) and dispose of the gown, N95 mask and gloves, and to disinfect their face shields prior to reuse. On 02/01/2022 at 10:21 AM, two unidentified Certified Nursing Assistants (CNA) were observed entering room [ROOM NUMBER] to provide assistance to a resident. Prior to entry, the CNAs, already wearing face shields and N95 masks, donned gowns and gloves. After providing care the CNAs doffed their gowns and gloves, and did not dispose of or replace their N95 mask or disinfect their face shields. On 02/01/2022 at 12:08 PM, an unidentified CNA was observed taking vital signs in room [ROOM NUMBER]. After collecting the vital signs, the CNA was observed to exit the room without replacing their N95 mask or disinfecting their face shield. Observations on 02/01/2022 at 12:43 PM, showed Staff V (Housekeeping) put on an isolation gown and without donning gloves, entered a room that had a sign for Quarantine Droplet Precautions posted at the door. Staff V was observed moving items around in the room and went over to pick up the Resident's ice water pitcher and handed it to the resident. Staff V then came to the doorway, removed the gown, washed their hands, and exited the room without cleaning their face shield. Observations at this time showed a sign hanging just inside the resident's room with instructions to staff on how to disinfect face shields. On 02/01/2022 at 1:14 PM, an unidentified CNA was exiting room [ROOM NUMBER], a TBP room, without replacing their N95 mask or disinfecting their face shield. On 02/02/2022 at 9:30 AM, Staff D (Registered Nurse) was observed doffing their gown and gloves in the hallway after exiting room [ROOM NUMBER]. Staff D did not replace their N95 mask or disinfect their face shield. In an interview on 02/04/2022 at 12:02 PM, Staff B stated their expectation was that if a resident was on quarantine TBPs there should be an isolation cart at the doorway, with signs posted to alert staff to wear an N95 mask, face shield, gown, gloves and to perform hand hygiene. Staff B stated if staff were working in quarantine TBP rooms their expectation was that staff should disinfect the face shield at exit of room. In an observation on 02/09/2022 at 10:19 AM, Staff H (Licensed Practical Nurse) was exiting the resident room wearing gloves, gown, mask, and a face shield. Staff H stopped at the sink, removed the gloves, washed hands, removed the gown, and exited the room to walk down the hall with contaminated hands from the soiled gown. Staff H did not clean the face shield when exiting the room. Staff H was stopped in the hall and asked if they had washed their hands. Staff H stated no, returned to the room, put on a gown and gloves then removed the gloves at the sink, washed their hands, removed the gown, and exited the room. In an interview on 02/09/2022 at 11:40 AM, Staff H stated the process to remove soiled PPE was remove gloves, wash hands, remove gown, clean face shield before leaving the resident room. Staff H was directed to the PPE sign on the wall and asked if they followed the sequence before leaving the prior resident room. After discussion, Staff H stated they did not follow the correct sequence of PPE removal. In an interview on 02/09/2022 at 1:00 PM, Staff B stated the correct way to remove PPE was posted on the wall outside of each resident room. Staff B stated all staff were expected to follow the posted method of removal of PPE. Staff B stated face shields were expected to be cleaned after resident care when leaving the resident room. Staff B stated staff was expected to change gloves and clean hands between dirty and clean tasks. Hand Hygiene Observations on 02/07/2022 at 11:41 AM, showed Staff P (CNA), performing incontinence care for Resident 21 after a bowel movement. Staff P was wearing gloves and used wipes during care provided. Staff P 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 P did not perform hand hygiene after providing incontinence care and did not remove soiled gloves until they went to exit the room to get more linen. Observations on 02/08/2022 at 12:55 PM, showed Staff E (CNA) was wearing gloves and using wipes while providing incontinence care for Resident 21. After completing incontinence care, Staff E applied moisture barrier ointment to the resident's buttock and then the perineal area, using the same soiled gloves. Staff E then picked up the remaining un-used moisture barrier ointment packets, with the soiled gloves, and placed them in the top drawer of the resident's nightstand. Staff E, wearing the same soiled gloves, then touched and contaminated the following: Resident 21's hand when assisting with positioning; lower legs and heel protectors; the window blind handles; bed controls; picked up the electronic tablet for staff charting and placed it under their arm; and then reached up under their face shield and touched their mask with the contaminated gloves. Staff E then removed the soiled gloves and left the room. Staff E proceeded down the hall, opened the soiled utility room door, and only then, used hand sanitizer in the hallway. Similar observations were noted on 02/09/2022 at 10:49 AM of Staff E not removing soiled gloves after providing incontinence care for Resident 21, touching, and contaminating items in the room with soiled gloves, and then after removing gloves, did not perform hand hygiene prior to assisting the roommate with positioning. In an interview on 02/09/2022 at 11:06 AM, Staff E stated hand hygiene should be performed before entering a room and then after everything, then wash. When asked if hand hygiene should be performed after providing incontinence care, Staff E stated, I do everything and then wash. In an observation on 02/09/2022 at 10:11 AM, Staff H was providing incontinence care to a resident and did not change gloves after wiping the buttocks. Staff H was observed to touch the clean linens and bed controls with soiled gloves. In an observation on 02/09/2022 at 11:05 AM, Staff H was exiting a resident room, removed gloves and gown and washed their hands at the sink. Staff H was observed to apply soap and rub hands together under 10 seconds, turned off the water with a towel, then dried their hands with clean towels. In an interview on 02/09/2022 at 11:11 AM, Staff N (Resident Care Manager - RCM) stated it was their expectation that hand hygiene should be performed when staff entered a resident's room, after providing incontinence care, anytime gloves were removed and upon exiting a room. On 02/09/2022 at 11:25 AM, Staff I (RCM) was observed providing wound care to Resident 44. Staff I donned a new pair of gloves, removed the soiled wound dressing from the resident's sacrum and put it in the garbage. Staff I cleaned the wound with a wound cleanser and removed their gloves. Staff I donned a new pair of gloves and placed a new dressing to the resident's sacrum. On 02/09/2022 at 11:35 AM Staff I acknowledged they did not perform hand hygiene after removing soiled gloves and before donning a new pair of gloves. In an interview on 02/09/2022 at 11:40 AM, Staff H confirmed that the gloves were not changed after incontinence care and stated they did touch clean surfaces with dirty gloves. Staff H stated hands should be rubbed together for five seconds and the handwashing task should take 15-20 seconds. Staff H did not know what the facility policy stated and said it was posted in the bathrooms. In an interview on 02/09/2022 at 1:00 PM, Staff B stated the expectation for hand washing was using warm water and soap, rubbing hands together for 20 seconds and cleaning all areas of hands, rinsing, drying with clean towels and then turn water off with a clean towel at the end of handwashing. Staff B stated all staff were trained in the expectations of handwashing. On 02/10/2022 at 7:28 AM, Staff D was observed administering medications for Resident 27, who required all medication administration to be delivered via a percutaneous endoscopic gastrostomy tube (PEG tube a device to deliver nutrition directly to the stomach). On 02/10/2022 at 7:42 AM, while assembling the materials needed, Staff D identified they were missing something needed to complete the task and stated, I forgot one more thing, and removed their gloves before exiting the resident's room. Staff D did not perform hand hygiene before returning to the room with an additional medication and a pair of gloves in hand. Staff D then put on the gloves they were holding without performing hand hygiene and administered Resident 27's medications. Uncleanable Surfaces Observation of room [ROOM NUMBER] on 02/01/2022 at 12:25 PM, showed facility staff had applied padding to the edges of Resident 42's overbed table, which they secured in place with duct tape, creating an uncleanable surface. Similar observations were made on: 02/02/2022 at 1:04 PM; and 02/07/2022 at 8:10 AM. On 02/07/2022 at 8:10 AM, the duct tape securing the padding to the edge of the overbed table, was observed to have come off one side of the table, leaving an eight-inch-long strip of tacky adhesive residue. In an interview on 02/09/2022 at 11:25 AM, Staff M (MDS Nurse) acknowledged that the utilization of duct tape had created an uncleanable surface. Food Preparation On 02/09/2022, at 11:38 AM Staff EE took a blender bowl/pitcher and other dishes to the dirty side of the dishwasher and ran them through. While the dishes were in the dishwasher Staff EE returned to the food prep area, without washing their hands and proceeded to set up to puree the herbed orzo (noodles). REFERENCE: WAC 388-97-1320(1)(a-c)(2)(a-c). .

Based on interview and record review, the facility failed to ensure 3 (Staff G, HH and II) of 7 staff reviewed, received effective training regarding recognizing, reporting and preventing resident abuse and mandated reporting. This failure placed residents at risk for unidentified abuse, a lack of intervention in response to allegations of abuse or neglect, and detracted from staff's ability to prevent abuse and or neglect of residents. Findings included . According to Washington State's Nursing Home Guidelines (The Purple Book - guidance on reporting and investigating allegations of abuse and neglect), all employees are mandated reporters, and are required to report concerns of abuse and neglect to the State Abuse/Neglect Hotline immediately. The facility's 2016 Abuse Prohibition Notification directed staff to comply with all Federal and State requirements to screen, train, prevent, identify, investigate, protect and report abuse [and] neglect . The policy also stated employees were oriented and in-serviced on facility abuse and neglect policies, processes, and reporting requirements. In an interview on 02/10/2022 at 05:45 AM, Staff G (Nursing Assistant), hired on 11/20/2021, stated they had received abuse/neglect training on hire, and ongoing, and they did not know who or what a mandated reporter was. In an interview on 02/10/2022 at 08:22 AM, Staff HH (Housekeeping staff), hired on 06/25/2021, stated they were not a mandated reporter. In an interview on 02/10/2022 at 02:23 PM, Staff II (Hospitality Aide), hired 11/10/2021, stated they did not know what abuse was, and did not receive any training on abuse or neglect. Review of attendance records for an 11/19/2021 in-service training on abuse and neglect showed Staff HH attended this in-service but showed no record Staff G or Staff II attended the training's. In an interview on 02/10/2022 at 11: 40 AM, Staff A (Administrator) stated Staff G did not receive abuse and neglect training on hire or during orientation. Staff A stated all staff are required to have abuse training and to to know how and when to report abuse to the hotline, understand what abuse is and who/what a mandated reporter is. REFERENCE: WAC 388-97-0640 (2)(a)(b), -1680. .