What is NORTH AUBURN REHAB & HEALTH CENTER's CMS rating?

NORTH AUBURN REHAB & HEALTH CENTER has a three-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does NORTH AUBURN REHAB & HEALTH CENTER have any serious inspection findings?

Yes, NORTH AUBURN REHAB & HEALTH CENTER has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 100 total deficiencies from recent inspections.

What are the staffing levels at NORTH AUBURN REHAB & HEALTH CENTER?

NORTH AUBURN REHAB & HEALTH CENTER has a four-star staffing rating from CMS with 0.81 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is NORTH AUBURN REHAB & HEALTH CENTER located?

NORTH AUBURN REHAB & HEALTH CENTER is located in AUBURN, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does NORTH AUBURN REHAB & HEALTH CENTER have?

NORTH AUBURN REHAB & HEALTH CENTER has 125 certified beds.

Who owns NORTH AUBURN REHAB & HEALTH CENTER?

NORTH AUBURN REHAB & HEALTH CENTER is a for profit - limited liability company facility and is part of the CALDERA CARE chain.

Is NORTH AUBURN REHAB & HEALTH CENTER safe?

NORTH AUBURN REHAB & HEALTH CENTER has documented safety concerns including 3 immediate jeopardy citations. Families should ask about corrective actions taken.

Do nurses at NORTH AUBURN REHAB & HEALTH CENTER stick around?

NORTH AUBURN REHAB & HEALTH CENTER has average staff turnover at 43%, which is typical for the nursing home industry.

Was NORTH AUBURN REHAB & HEALTH CENTER ever fined?

Yes, NORTH AUBURN REHAB & HEALTH CENTER has been fined $182,936 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is NORTH AUBURN REHAB & HEALTH CENTER on any federal watch list?

No, NORTH AUBURN REHAB & HEALTH CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at NORTH AUBURN REHAB & HEALTH CENTER?

Medicare inspectors have found 100 deficiencies at NORTH AUBURN REHAB & HEALTH CENTER: 3 critical, 2 serious, 95 moderate. Each deficiency represents a violation of federal nursing home requirements.

How does NORTH AUBURN REHAB & HEALTH CENTER compare to other nursing homes?

NORTH AUBURN REHAB & HEALTH CENTER has a 3-star overall rating, which is average compared to other nursing homes in WA. Consider visiting multiple facilities before making a decision.

NORTH AUBURN REHAB & HEALTH CENTER

Name: NORTH AUBURN REHAB & HEALTH CENTER
Address: 2830 I STREET NORTHEAST, AUBURN, WA, 98002, US
Telephone: (253) 561-8100
Rating: 3.0

2830 I STREET NORTHEAST, AUBURN, WA 98002 · (253) 561-8100

For profit - Limited Liability company 125 Beds CALDERA CARE Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#109 of 190 in WA

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Last Inspection: April 2025

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

Overview

North Auburn Rehab & Health Center has received a Trust Grade of F, indicating significant concerns about the facility's operation and care. Ranking #109 out of 190 in Washington places it in the bottom half of nursing homes in the state, and #24 out of 46 in King County means there are only a few local options that perform better. The facility is showing signs of improvement, with issues decreasing from 28 in 2024 to 25 in 2025. Staffing is relatively strong, rated at 4 out of 5 stars with a turnover of 43%, which is slightly better than the state average. However, the facility has incurred $182,936 in fines, which raises red flags about compliance, and significant incidents include failures to respond appropriately to medical emergencies and ensure safe food preparation for residents with specific dietary needs, which poses serious health risks. While there are some strengths, these critical issues suggest that families should carefully consider their options.

Trust Score: F
In Washington: #109/190
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 43% turnover. Near Washington's 48% average. Typical for the industry.
Penalties: $182,936 in fines. Lower than most Washington facilities. Relatively clean record.
Skilled Nurses: Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
Violations: 100 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 28 issues

2025: 25 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (43%)
5 points below Washington average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

3-Star Overall Rating

Near Washington average (3.2)

Meets federal standards, typical of most facilities

Staff Turnover: 43%

Near Washington avg (46%)

Typical for the industry

Federal Fines: $182,936

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: CALDERA CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 100 deficiencies on record

3 life-threatening 2 actual harm

Apr 2025 25 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain resident consent for vaccinations for 3 of 5 sampled residents (Residents 35, 7, & 24) and 1 supplemental resident (Resident 28) reviewed for vaccinations, obtain resident consent prior to administration of psychotropic medication for 2 of 5 residents (Resident 7 & 24) reviewed for unnecessary medications, and obtain consent prior to utilization of safety devices for 4 of 6 residents (Resident 7, 24, 28, & 35) reviewed for accident hazards. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options. Findings included . <Policy> According to a facility policy titled, Vaccinations for Residents P&P, revised 12/2022, did not discuss obtaining consent prior to vaccine administration and showed inquiries concerning the policy should be referred to the Staff A (Administrator) or Staff P (Infection Preventionist). According to a facility policy titled, Psychoactive Medication Management, revised 08/2024, the facility would review the psychoactive medication with the resident and/or representative when it was prescribed. The policy did not instruct staff to obtain consent per regulation for psychotropic medications prior to implementing and/or changing. According to a facility policy titled, Safety Device Application, revised 04/07/2023, the facility would review safety devices with the resident and/or representative. <Vaccinations> <Resident 35> Review of Resident 35's health records showed the resident received the Covid 19 (respiratory virus) and Flu vaccination on 10/03/2024. Resident 35's health records did not show consent was obtained for the 2024/2025 season Covid 19 or Flu vaccine prior to administration. Resident 35's health records showed the facility documented the resident received pneumonia vaccines historically on 11/19/2014 and 11/22/2021. Resident 35's health records did not show documentation to support the historical pneumonia vaccine administration. <Resident 7> Review of Resident 7's health records showed the resident received the Covid 19 and Flu vaccination on 10/03/2024. Resident 7's health records did not show consent was obtained for the 2024/2025 season Covid 19 or Flu vaccine prior to administration. Resident 7's health records showed the resident received pneumonia vaccines on 02/27/2020 and 11/04/2018. Resident 7's health records did not show consent was obtained prior to pneumonia vaccine administration. <Resident 24> Review of Resident 24's health records showed the resident received the Covid 19 and Flu vaccination on 11/15/2024. Resident 24's health records did not show consent was obtained for the 2024/2025 season Covid 19 or Flu vaccine prior to administration. Resident 24's health records showed the resident received pneumonia vaccines on 02/27/2020 and 11/06/2018. Resident 24's health records did not show consent was obtained prior to pneumonia vaccine administration. <Resident 28> Review of Resident 28's health records showed the resident was offered and declined the Covid 19 vaccination on 03/17/2025. Resident 28's Covid 19 consent form showed Resident 28's name typed in, not signed, and a box marked for offered and refused. Resident 28's health records showed the facility documented the resident historically received pneumonia vaccines on 05/30/2019 and 03/08/2018 and the flu vaccine on 02/24/2025. Resident 28's health records did not show documentation to support the historical pneumonia vaccines or flu vaccine administration. In an interview on 04/21/2025 at 9:39 AM Staff P stated they expected staff to obtain residents or resident representatives signed consents for vaccinations or a witness signature if a resident or representative was unable to sign. Staff P stated when a resident stated they received a vaccination historically, the expectation was to obtain a copy of the residents immunization report and scan into the residents health records to show confirmed documentation of the vaccination being administered. Staff P stated Resident 35, 7, 24, and 28 did not have a signed consent for their immunizations but should. Staff P stated Residents 35 and 28's health records did not include documentation from the department of health supporting the historical immunization administration. <Psychotropic Medications> <Resident 7> According to a 11/08/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 7 readmitted to the facility on [DATE]. The MDS showed Resident 7 had diagnoses of, but not limited to, depression, traumatic brain injury (sudden injury that causes damage to the brain), and psychotic disorder (severe mental illness characterized by a disconnection from reality), seizure disorder (a neurological disease.) The MDS showed Resident 7 received antipsychotic, antidepressant, and anticonvulsant medications during the assessment period. Review of Resident 7's health records showed a physician ordered dose change for an antipsychotic medication on 04/18/2025 and an antidepressant medication dose change on 02/25/2025. Resident 7's records showed consent was not obtained for the antipsychotic or antidepressant medication dose changes. <Resident 24> According to a 01/05/2025 Annual MDS Resident 24 readmitted to the facility on [DATE]. The MDS showed Resident 24 had diagnoses of, but not limited to, depression, non-Alzheimer's dementia, and schizophrenia. The MDS showed Resident 24 received antipsychotic and antidepressant medications during the assessment period. Review of Resident 24's health records showed physician order dose changes for an antipsychotic medication on 03/21/2023 and an antidepressant medication dose change on 02/25/2025. Resident 24's records showed consent was not obtained at time of dosage changes for the antipsychotic or antidepressant medications. Resident 24's records showed a Psychopharmacological Medication Informed Consent form dated 04/18/2023 for the antipsychotic medication dosage change with .son via email typed in the box name of person receiving informed consent. The form was completed 26 days after Resident 24 received an increased dose of antipsychotic medication. In an interview on 04/18/2025 at 9:20 AM Staff O (Resident Care Manager) stated they were unable to provide a copy of an email notification to Resident 24's son and Resident 7's guardian for the antipsychotic and antidepressant medication dose changes. In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) stated consent was not obtained for Resident 7's and 24's dosage changes for their antipsychotic or antidepressant medications. Staff E stated they expected staff to obtain signed consent from the resident or resident representative prior to administration. Staff E stated they expected staff to obtain a signature from the resident or resident representative on the informed consent form and if staff received verbal consent over the phone, they expected staff to have another staff member sign the form as a witness. <Safety Devices> <Resident 7> Observation on 04/15/2025 at 9:56 AM showed bilateral bed rails and a bolstered air mattress (a mattress filled with air that includes bolsters on either side) to Resident 7's bed. Observation at this time showed a tilt in space wheelchair for Resident 7. Review of Resident 7's health records showed a 01/02/2019 physician order for the tilt in space wheelchair (a wheelchair that reclines back), a 08/28/2024 physician order for the bolstered air mattress, and a 06/10/2022 physician order for the bilateral bed rails. Review of Resident 7's health records showed no evidence of consent for the bilateral bed rails, bolstered air mattress, or tilt in space wheelchair from the resident or their guardian. In an interview on 4/18/2025 at 9:20 AM Staff O stated they were unable to provide email notifications for Resident 7's bilateral bed rails or bolstered air mattress. Staff O showed a quarterly update email notification on 03/25/2025 for the tilt in space wheelchair but the notification did not include whether the guardian consented or not. Staff O stated the form they used as a consent form did not include documentation of consent but should. <Resident 24> Observation on 04/15/2025 at 10:52 AM showed bilateral bed rails to Resident 24's bed. Review of Resident 24's health records showed a 02/28/2023 physician order for the bilateral bed rails. Review of Resident 24's health records showed no evidence of consent for the bilateral bed rails from the resident. <Resident 28> Observation and interview on 04/14/2025 at 12:25 PM showed bilateral bed rails to Resident 28's bed. Resident 28 stated they did not use the bed rails because they did not want to depend on them. Resident 28 stated staff did not discuss the bed rail usage with them. Review of Resident 28's health records showed a 03/18/2025 physician order for the bilateral bed rails. Review of Resident 28's health records showed no evidence of consent for the bilateral bed rails from the resident or the resident representative <Resident 35> Observation on 04/15/2025 at 12:57 PM showed a bed rail to Resident 35's right side of bed. Review of Resident 35's health records showed a 03/25/2025 physician order for the right-side bed rail. Review of Resident 35's health records showed no evidence of consent for the bilateral bed rails from the resident or the resident representative. Resident 35's health records showed a 03/25/2025 safety device evaluation form for the right-side bed rail with resident typed in the information provided to box, no signature for consent. Resident 35's health records showed they had severe cognitive impairment and had a Power of Attorney (POA) for their healthcare decision making. In an interview on 04/17/2025 at 9:00 AM Staff O stated they expected staff to obtain consent prior to implementation of safety devices. Staff O stated they were informed by corporate that by providing a copy of the device safety assessment was obtaining consent from the resident or resident representative. Staff O stated the form does not include documentation whether the resident or resident representative consented to the bed rails or not so they were unable to provide consents for Residents 7, 24, 28, or 35's devices. Staff O stated they were unaware Resident 35 was unable to consent at the time and during this interview observed Resident 35 had a POA in place. Staff O stated Resident 35's POA was not notified of the bed rail and they did not obtain a signature from the resident consenting to the bed rail. REFERENCE: WAC 388-97-0260, -0200(2), -0300(3)(a). .

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to have a system in place which ensured grievances were thoroughly investigated and resolved in response to residents' concerns for two (Residents 52 &17) of three residents reviewed for grievances. Failure to ensure accurate resident inventories detracted from staff's ability to thoroughly investigate reported complaints of missing items and failure to follow up with residents about the grievances placed residents at risk of feeling frustration and diminished quality of life. Findings included . <Policy> According to the 02/2024 Grievances Policy, employee responsibilities in the grievance process included: (1) initiating the Resident Grievance Report for all concerns brought forth by residents, and (2) immediately providing the completed report to the Grievance Officer or designee. The policy showed the Grievance Officer or designee would follow-up with the resident/resident representative about the grievance to ascertain satisfaction with the resolution of the reported concern. <Resident 52> According to the 02/24/2025 Quarterly Minimum Data Set (MDS- an assessment tool) Resident 52 was cognitively intact and able to understand and be understood in conversation. In an interview on 04/14/2025 at 2:27 PM Resident 52 indicated they had multiple missing personal items including an Amazon Tablet stating, I reported it to the administrator, two or three administrators ago. Review of the grievance log showed on 11/22/2024 the resident reported missing an Amazon tablet. According to the grievance form dated 11/22/2024 staff documented the concern was resolved because, Resident was not certain (they) had an Amazon Tablet. Tablet not on the inventory. Review of the resident's record and grievance documents showed no indication staff attempted to determine if the resident ever had the Amazon Tablet or if the inventory was correct. In an interview on 04/18/2025 at 8:17 AM Staff E (Assistant Director of Nursing) indicated that resident inventories are done on the day of admission and kept in a 3-ring binder at the nurse's station. Review of the binder at the nurses' station showed no inventory for Resident 52. Staff E at this time confirmed the absence of an inventory and stated it should be in the book. Staff E contacted Staff G (Social Service Director - SSD) who provided multiple pieces of paper, undated, with no resident name or identifiers but included a partial list of personal items. Observation on 04/18/2025 at 8:28 AM showed Resident 52 had multiple items in their possession including an Amazon Fire Tablet, a cellular phone, three pairs of glasses and a cane. Review of the undated personal inventory for Resident 52 showed that these items were not on the inventory list. In an interview on 04/18/2025 at 8:31 AM Staff E confirmed Resident 52's inventory should, but did not, include the resident's name, room number and date and the identified electronics, glasses and cane. Staff E stated if a resident reported missing items, staff should not rely solely on the inventory sheets as they were not always correct. <Resident 17> According to the 01/31/2025 Quarterly MDS Resident 17 was assessed as cognitively intact and able to understand and be understood in conversation. In an interview on 04/14/2025 at 10:58 AM Resident 17 stated they had a missing iPhone, which the facility would not replace stating, I had to buy an android, I couldn't afford an iPhone. I really liked that phone. The resident at this time indicated she would prefer an iPhone. Observation at that time showed Resident 17 had an android cell phone. According to the grievance log Resident 17 reported the phone was missing on 01/20/2025. According to the grievance notes facility staff documented SSD followed up with admin and (they) notified SSD to see if resident (family) would like for phone to be replaced and (they) declined stating,I already purchased another phone for (the resident). In an interview on 04/21/2025 at 8:30 AM Staff G reviewed the grievance form and confirmed staff did not follow up with Resident 17 regarding the missing phone. REFERENCE: WAC 388-97-0460. .

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information and provide required written notices at the time of transfer/discharge to the residents and/or their representatives for 3 (Residents 54, 31, & 7) of 4 residents reviewed for hospitalization. Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights. Findings included . <Resident 54> According to the 09/02/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 54 was discharged to the hospital with their return anticipated. Review of Resident 54's medical records did not show documentation indicating the LTCO was notified of the resident's hospital transfers for the 09/02/2024 discharge as required. In an interview on 04/17/2025 at 12:13 PM, Staff G (Social Services Director) stated they sent transfer/discharge notice to LTCO at the end of every month. Staff G reviewed September 2024 hospital transfers/discharges list and stated they missed notifying LTCO about Resident 54's hospital transfer on 09/02/2024. <Resident 31> According to the 03/25/2025 Discharge MDS showed Resident 31 discharged to the hospital with their return anticipated. Review of Resident 31's 03/25/2025 Transfer or Discharge Notice document explained the resident was being discharged for acute treatment needs that could not be met at the facility. Under the section Notice provided to: indicated staff were to provide the notice to the resident or their representative. This section showed the nurse signed the form and the form was not provided to Resident 31 or their representative as required. In an interview on 04/18/2025 at 8:58 AM, Staff E (Assistant Director of Nursing) confirmed the Transfer or Discharge Notice document was not signed by the resident. Staff E stated it was their expectation the document be provided to and signed by the resident/resident representative.<Resident 7> According to a 02/16/2025 Discharge Return Anticipated MDS Resident 7 was transferred to an acute care hospital on [DATE] with their return anticipated. Review of Resident 7's 02/16/2025 Transfer or Discharge Notice document explained the resident was being discharged for acute treatment needs that could not be met at the facility. Under the section Notice provided to: indicated staff were to provide the notice to the resident or their representative. This section showed the nurse typed the name of the guardianship company. In an interview on 04/18/2025 at 8:55 AM Staff G stated they notify LTCO monthly. Staff G stated they were instructed they did not have to notify the LTCO with the reason for transfer to hospital so they only sent the residents name, date of transfer, and where the resident was sent. Staff G stated they were unable to provide documentation for the LTCO notification for Resident 7's transfer on 02/16/2025. In an interview on 04/21/2025 at 10:38 AM Staff R (Business Office Manager) stated Resident 7 .wouldn't do anything with paperwork if it was provided to them and they're on Medicaid. Staff R confirmed the Transfer or Discharge Notice document was not signed by the resident and they were responsible for providing written transfer notifications to the residents and/or resident representatives. Staff R stated Staff C (Corporate Nurse) completed the written transfer notice for Resident 7's 02/16/2025 transfer to hospital and says it was sent via email to Resident 7's guardian. In an interview on 04/21/2025 at 12:56 PM Staff D (Chief Nursing Officer) stated they talked to Staff C and they were unable to provide a copy of the emailed written transfer notification to the guardian for Resident 7's transfer to the hospital on [DATE]. REFERENCE: WAC 388-97-0120 (2)(a-d). .

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours for 3 (Resident 54, 31, & 7) of 4 residents reviewed for hospitalization. This failure placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Facility Policy> According to a facility policy titled, Bed Hold Notification Notice of Bed Hold Policy and Return, dated 09/2022, the facility would provide written notice to the resident/representative when a resident was transferred to a hospital with the residents bed hold rights and the centers bed hold policy. <Resident 54> According to the 09/02/2024 and 01/27/2025 Discharge Minimum Data Set (MDS - an assessment tool), Resident 54 was discharged to the hospital twice with their return anticipated. Review of Resident 54's medical records did not show bed hold documentation to indicate Resident 54 or their representative accepted or declined a bed hold for both occurrences during their hospitalization. Review of Resident 54's 09/02/2024 and 01/27/2025 Bed Hold Notification form showed the form was not signed by the resident or their representative indicating they were made aware of their rights to hold the bed or whether the resident wished to accept or decline the bed hold. Review of Resident 54's 09/02/2024 Bed Hold Notification form was signed by the facility staff on 09/12/2024 ten days after Resident 54 was sent to the hospital. In an interview on 04/18/2025 at 8:58 AM, Staff E (Assistant Director of Nursing) confirmed the Bed Hold Notification document was not signed by the resident. Staff E stated it was their expectation the document be provided to and signed by the resident/resident representative.<Resident 31> According to the 03/25/2025 Discharge MDS showed Resident 31 discharged to the hospital with their return anticipated. Review of Resident 31's 03/25/2025 Bed Hold Notification form showed the form was not signed by the resident or their representative indicating they were made aware of their rights to hold the bed or whether or not the resident wished to enter into a bed hold agreement. In an interview on 04/18/2025 at 8:58 AM, Staff E confirmed the Bed Hold Notification document was not signed by the resident. Staff E stated it was their expectation the document be provided to and signed by the resident/resident representative. <Resident 7> According to a 02/16/2025 Discharge Return Anticipated MDS Resident 7 was transferred to an acute care hospital on [DATE] with their return anticipated. Review of Resident 7's 02/16/2025 Transfer or Discharge Notice/Notice of Voluntary Transfer (Bed Hold) document explained the resident was being discharged for acute treatment needs that could not be met at the facility. Under the section Bed Hold Notification Duration of Transfer/Discharge showed TBD with no documentation of the guardianships decision on whether to hold the bed or not. The form does not show the cost of holding the bed, have a place for the resident/representative to sign to consent the bed hold, or decline the bed hold. In an interview on 04/21/2025 at 10:38 AM Staff R (Business Office Manager) stated Resident 7 .wouldn't do anything with paperwork if it was provided to them and they're on Medicaid so the facility did not need to offer a bed hold because they couldn't afford it anyway. Staff R confirmed the Bed Hold document was not signed by the resident or their representative. Staff R stated they were responsible for providing Bed Holds to the residents and/or resident representatives and when another staff member completed the form, they (Staff R) were responsible to follow up to ensure a copy was provided and documentation was in the residents health record to show the form was provided and whether or not they agreed to a bed hold. Staff R stated Staff C (Corporate Nurse) completed the Bed Hold form for Resident 7's 02/16/2025 transfer to hospital and stated it was sent via email to Resident 7's guardian, but Staff R was unable to provide documentation of the residents/representatives wishes for the bed hold. Staff R stated they expected the forms to be emailed to representatives for evidence of notification. In an interview on 04/21/2025 at 12:56 PM Staff D (Chief Nursing Officer) stated they talked to Staff C and they were unable to provide a copy of the emailed written transfer notification/bed hold to the guardian for Resident 7's transfer to the hospital on [DATE]. REFERENCE: WAC 388-97-0120(4). .

CONCERN (D)

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a safe discharge including documenting the reason for leaving or explaining the risks of discharging for 1 of 1 (Resident 67) resident who chose to leave the facility Against Medical Advice (AMA). This failure placed the resident at increased risk of hospital readmission and diminished quality of life. Findings included . <Facility Policy> According to a facility policy titled, Against Medical Advice Discharge, revised 05/2023, the facility would complete an AMA form, read the information with the resident, and carefully explain the information before witnessing the resident sign the form before the resident left the facility AMA. The facility would treat the situation similarly to a refusal of care, discuss the reasons for leaving AMA with the resident/their representative. Staff were to document the risks of discharging AMA, the resident's reason for leaving AMA, the condition of the resident at discharge, the transportation method used, and items the resident removed from the facility. <Resident 67> According to the 03/13/2025 Discharge Minimum Data Set (MDS - an assessment tool), Resident 67 was admitted to the facility on [DATE] and was discharged with return not anticipated. The MDS showed Resident 67 had impaired memory and required two-person assistance with personal hygiene, transferring, and toileting needs. Review of a 03/13/2025 nursing progress note showed Resident 67 was taken out of the facility AMA by family and AMA paperwork was signed. Review of Resident 67's record showed an AMA form was signed by Resident 67's family on 03/13/2025. This AMA form showed the medical risks and benefits were not explained to the resident/representative by staff members and none of the medical risks listed on the form were marked by staff. Review of the nursing progress notes from 03/10/2025 through 03/13/2025 showed no documentation Resident 67's primary care provider was notified of Resident 67's AMA discharge. There was no documentation staff discussed with Resident 67's representative the care, medications, or equipment the resident needed at home. In an interview on 04/21/2025 at 11:00 AM, Staff D (Clinical Nursing Officer) reviewed Resident 67's record and stated the facility did not follow the AMA discharge policy. Staff D stated staff should discuss with the resident/representative the reason for leaving AMA, explain the risks and benefits of leaving AMA, notify the provider, arrange medications as ordered, and document all these efforts in Resident 67's record, but they did not. REFERENCE: (WAC) 388-97-0080 (5)(6). .

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 03/05/2025 Significant Change MDS, the r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 03/05/2025 Significant Change MDS, the resident was cognitively intact and required care related to fractures and other multiple traumas. Resident 30 was assessed with multiple skin issues including pressure ulcers, functional limitations in range of motion to both lower extremities, and was dependant on staff for toileting, bathing, and dressing the lower extremities. Observations on 04/14/2025 at 1:27 PM revealed Resident 30 lying in bed and was noted with a moderate amount of crusty, reddish debris on the medial (inside) left great toe nail bed. The resident stated, I get ingrown toenails, I have to see a diabetic doctor to get my nails trimmed .No, I haven't seen a podiatrist since I've been here. During observations on 04/18/2025 at 10:19 AM, Staff B (Director of Nursing) confirmed the resident had brownish rust colored discharge to both the left and right great toes and the resident appeared to have, ingrown toenails. Staff B stated nursing staff should have noted these skin issues during the daily treatments to the feet and notified the provider to ensure treatment. Review of April 2025 Treatment Administration Records (TARs) showed staff provided daily treatments to both feet. According to the 04/16/2025 Total Body Skin evaluation weekly form, there was a treatment to the right heel, an open area left lower leg, and a pressure ulcer to their tailbone. <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/24/2025 Quarterly MDS, Resident 52 had heart disease, and was dependant on staff for toileting, bathing, and was assessed as not able to walk due to medical condition or safety concerns. Review of the Cardiovascular Care Plan (CP) dated 04/30/2024 staff were directed to observe edema daily. A CP dated 10/22/2024 showed the resident had, edema and lymphedema (a condition causing swelling due to a buildup of lymph fluid in the body's tissues). This CP directed staff to Monitor/document for excessive edema and encourage resident to elevate legs. Review of 12/18/2024 Physician Orders directed staff to apply compression stockings to Resident 52's bilateral lower extremities on in the morning and remove them on night shift, and to assess edema every morning. According to staff, the resident had edema assessed as 1 (Immediate rebound of skin tissue with 2-millimeter (mm) pit.) Observations on 04/14/2025 at 2:12 PM showed Resident 52 lying in bed with lower extremities exposed. No compression stockings were applied. The resident's lower legs were enlarged and puffy. The lower extremities were not elevated on pillows. The resident stated at this time that they did experience some edema but staff did not offer to elevate their legs. Similar observations of the resident having enlarged lower extremities without benefit of compression stockings were made on 04/15/2025 at 12:41 PM, 04/16/2025 at 11:44 AM, and 04/18/2025 at 12:30 PM. During observations on 04/18/2025 at 12:30 PM Staff C (Corporate Nurse) confirmed the resident had what was described as 3+ (Tissue rebound greater than 15 seconds but less than 60 seconds with 5 to 6 mm pit pitting edema in the bilateral lower extremities. At that time, Staff C confirmed the treatment records that reflected edema levels of 1+ were not reflective of the resident's lower extremity edema. Based on observation, interview, and record review the facility failed to: ensure residents received follow up appointments as recommended for wound treatment for 1 (Resident 23) of 1 resident reviewed for referral follow up, ensure residents' skin was assessed, monitored, and treated as required for 2 (Resident 30 & 52) of 5 residents reviewed for non-pressure skin, and ensure blood work was obtained for 1 (Resident 7) reviewed. These failures placed all residents at risk for delay in treatment, worsening of conditions, unmet care needs, and a decreased quality of life. Findings included . <Resident 23> Review of the 02/08/2025 Minimum Data Set (MDS - an assessment tool) showed Resident 23 had diagnoses including heart failure, end-stage kidney failure, and diabetes (inability to control their blood sugar levels). The MDS showed Resident 23 had a diabetic foot ulcer. Review of Resident 23's physician orders showed an 11/20/2024 order directing staff to refer the resident to infectious disease for a bone infection to their right, second toe. Review of an 11/22/2024 consulting wound provider progress notes showed Resident 23 was being treated for a diabetic foot ulcer. This note showed Resident 23 had a bone infection to the ulcer area. The wound provider referred Resident 23 for an infectious disease consult. Review of a 01/08/2025 staff progress note showed Resident 23 had an appointment with infectious disease scheduled for that day but the appointment was rescheduled to 01/22/2025. Observation on 04/14/2025 at 10:27 AM showed Resident 23 lying in bed. Resident 23 had a small, open, scabbed area to their second toe on their right foot. Review of Resident 23's comprehensive records on 04/18/2025 showed no further progress notes indicating Resident 23 went to their appointment with infectious disease on 01/22/2025 as scheduled. There were no scanned documents or appointment recommendations in the resident's record. In an interview on 04/18/2025 at 9:09 AM, Staff E (Assistant Director of Nursing) reviewed Resident 23's records and confirmed the resident did not attend their appointment on 01/22/2025. Staff E stated it was important for staff to ensure Resident 23 attended their infectious disease appointment to ensure the resident did not have an underlying infection. <Resident 7> According to an 11/08/2024 Annual MDS, Resident 7 had a diagnosis of, but not limited to, Vitamin D Deficiency. Review of Resident 7's health records showed a physician order for a high dose Vitamin D supplement. Resident 7's records showed no blood work was obtained to check their Vitamin D level. In an interview on 04/17/2025 at 9:26 AM, Staff O (Resident Care Manager) stated they would expect a Vitamin D to be obtained prior to implementing a high dose Vitamin D Supplement, but a Vitamin D level was not completed for Resident 7. In an interview on 04/18/2025 at 12:05 PM Staff E reviewed Resident 7's health records and stated they did not see a Vitamin D level was ever obtained for Resident 7, but it should be, prior to starting the high dose Vitamin D supplement. Staff E stated it was important to obtain the Vitamin D level to ensure they were not administering unnecessary medications. REFERENCE: WAC 388-97-1060 (1). .

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities for 1 (Resident 30) of 2 residents reviewed for vision services. Failure to ensure Resident 30 received assistance in obtaining vision devices placed this resident at risk for decline in Activities of Daily Living (ADLs) related to vision. Findings included . <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 09/13/2024 admission Minimum Data Set (an assessment tool) had adequate vision and did not require the use of corrective lenses. Observation on 04/14/2025 at 1:20 PM showed Resident 30 lying in bed, a pair of eyeglasses were noted on the overbed table. In an interview at this time, Resident 30 indicated they needed an eye exam stating, I put in for an eye exam a few months ago, but it didn't happen, nobody's gotten back to me. In an interview on 04/16/2025 at 8:19 AM, Resident 30 stated. I can't read and when attempting to read a written document stated, it's a blur. The resident clarified at this time, I got glasses over two years ago . I need new glasses. Record review showed a progress note dated 11/01/2024 which indicated, Resident scheduled to be seen by [NAME] Vision on 11/01/2024, (resident) has declined due to feeling ill. Next F/U (follow up) will be December 2024. Record review showed no evidence Resident 30 received vision services. In an interview on 04/21/2025 at 9:16 AM, Staff G (Social Service Director) stated the facility has an eye service that comes in and sees residents when requested. Staff G confirmed staff should have, but did not, reschedule the resident until survey staff brought it to their attention on 04/17/25 with the next available appointment being in June. Staff G indicated they forgot about Resident 30. Refer to F641 Accuracy of MDS REFERENCE: WAC 388-97-1060(3)(a). .

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure 2 of 3 sampled residents (Residents 6 & 7) reviewed for Pressure Ulcers (PUs), received appropriate pressure reducing measures and repositioning on a consistent basis. This failure placed all residents at risk for PU development, and a diminished quality of life. Findings included . <Facility Policy> According to a facility policy titled, Safety Device Application, revised 04/07/2023, showed the facility would apply the safety device as directed. The policy showed staff would follow the safety device Care Plan (CP) and interventions. According to a facility policy titled, Wound Prevention and Treatment, revised 02/03/2023, the facility would reduce the occurrence of pressure over bony prominence to minimize injury, manage risk factors, and provide preventive interventions. The policy showed the staff would ensure residents received continuous preventative interventions to promote healing and prevent skin issues. <Resident 6> According to a 01/04/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 6 had no memory impairment. The MDS showed Resident 6 was at risk of developing PUs and had three PUs. Review of Resident 6's health records showed a 04/22/2023 physician order for air mattress settings to be at alternate level 5 and staff would check for correct settings every shift. Residents 6's records showed a 10/24/2023 air mattress CP with an intervention for staff to monitor appropriate functioning of air mattress every shift. Resident 6's records showed a 03/05/2025 right heel PU CP with an intervention for staff to frequently reposition the resident to prevent new PU's or worsening of active PUs. In an observation and interview on 04/14/2025 at 9:25 AM showed Resident 6's air mattress settings at float level 8. Staff S (Registered Nurse) stated Residents 6's air mattress should be at alternate level 5. Staff S stated nursing staff were responsible for checking the air mattress settings every shift to ensure they were set per physician orders to prevent skin breakdown. In an interview on 04/14/2025 at 12:51 PM Resident 6 stated they depended on staff to reposition them in their bed with the air mattress. Resident 6 stated the staff were supposed to reposition them every two to three hours but often did not. In a continuous observation on 04/17/2025 from 7:56 AM until 12:06 PM Resident 6 was lying in bed flat on their back. In an interview on 04/17/2025 at 11:46 AM Staff V (Certified Nursing Assistant) stated they were expected to reposition Resident 6 per their CP instructions. Staff V stated they repositioned Resident 6 off their left side and onto their back just before breakfast came out and were just about to get them up in their wheelchair. Staff V stated this was not per Resident 6's CP instructions for repositioning. In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) stated they expected staff to reposition residents at a minimum of every two hours while in bed or up in a chair. <Resident 7> According to the 11/08/2024 Annual MDS Resident 7 had no memory impairment. The MDS showed Resident 7 was at risk for PUs. The MDS showed Resident 7 had a pressure a reduction device to their bed. Review of Resident 7's health records showed a safety device air mattress with bolsters CP with an intervention to keep the air mattress set at 180 pounds and 30-minute cycle time/alternating. Resident 7's records showed a physician order to set the air mattress at 165 pounds and cycle time/alternating with the staff to check for correct settings every shift. In an interview on 04/18/2025 at 8:28 AM Staff L (Resident Care Manager) stated Resident 7's bed was set incorrectly and should not be set at 340 pounds. Staff L stated the nursing staff are to monitor air mattress settings every shift to ensure they are set according to the physician order to prevent skin breakdown. REFERENCE WAC: 388-97-1060 (3)(b). .

CONCERN (D)

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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide necessary foot care and treatment in accordance with professional standards, including provision of nail care and Podiatry Services. Deficient practice was identified for 3 (Residents 30, 17, & 23) of four residents reviewed for nail care. Failure to provide timely toenail care placed the residents at risk for negative health outcomes. Findings included . <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 03/05/2025 Significant Change Minimum Data Set (MDS - an assessment tool) the resident was cognitively intact and had multiple diagnoses including diabetes. Resident 30 was assessed with functional limitations in range of motion to both lower extremities and was dependant on staff for dressing the lower extremities. Record review showed no evidence Resident 30 received Podiatry services since admission. Observations on 04/14/2025 at 1:27 PM revealed Resident 30 lying in bed and was noted with a moderate amount of crusty reddish debris on the inside of their left great toe nail bed. The resident stated, I get ingrown toenails, I have to see a diabetic doctor to get my nails trimmed .No, I haven't seen a podiatrist since I've been here. In an interview on 04/16/2025 at 7:24 AM Staff G (Social Service Director) stated, Anyone who wants to be seen (by the Podiatrist -Foot doctor), anyone who has diabetes needs to be seen; I always check with nursing. Staff G elaborated, If we couldn't get an in house podiatrist, we would send them out for that service . In an interview on 04/18/2025 at 10:50 AM, when asked how long after admission should a diabetic resident be seen by podiatry, Staff C (Corporate Nurse) stated, I prefer diabetic residents are seen quarterly; so a resident admitted in September should have been seen twice by now. Staff C confirmed Resident 30 should have, but did not receive, Podiatry services. During observations on 04/18/2025 at 10:19 AM Staff B (Director of Nursing Services) stated Resident 30 appeared to have, ingrown toenails. Staff B confirmed the resident should be referred to Podiatry upon admission. <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly MDS assessment, was assessed as cognitively intact with multiple medically complex diagnoses, including diabetes. Observations on 04/16/2025 at 10:31 AM showed the resident lying in bed. In an interview at that time the resident stated, It's been awhile since seeing a podiatrist. Record review showed a 09/19/2024 Podiatry Consult that documented treatments received and recommended Follow up in 2-3 months or as needed for a more acute problem. Record review showed no documentation to support the resident had any subsequent Podiatry services. In an interview on 04/16/2025 at 7:24 AM Staff G provided a 02/26/2025 Podiatry Consult for Resident 17, which was not in the record. Staff G stated there were problems with the previous Podiatrist which caused delay in services, but they currently had a new Podiatrist service. In an interview on 04/18/2025 at 12:57 PM, Staff C stated Resident 17 should have been seen prior to the 02/26/2025 visit and staff did not ensure Podiatry follow up in 2-3 months as recommended at the 09/19/2025 visit. <Resident 23> Review of the 02/08/2025 Quarterly MDS showed Resident 23 had diagnoses including heart failure, end-stage kidney failure, and diabetes (inability to control their blood sugar levels). The MDS showed Resident 23 had a diabetic foot ulcer. Review of Resident 23's progress notes showed an 11/17/2025 consulting wound provider note recommending a Podiatry referral for management and evaluation of hammer toes as foot deformity may complicate wound healing. The consulting wound provider wrote additional notes recommending a podiatry referral for Resident 23 on 11/23/2024, 12/08/2024, 12/13/2024, 12/22/2024, 12/28/2024, 01/04/2025, 01/11/2025, 01/19/2025, and 01/24/2025. Review of Resident 23's 04/14/2025 order summary showed a 01/14/2025 physician's order instructing staff to refer the resident to a podiatrist for a right foot wound. Review of Resident 23's comprehensive records on 04/21/2025 showed no progress notes, orders, or scanned documents indicating facility staff followed the wound provider's recommendation to refer Resident 23 to a podiatrist. In an interview on 04/21/2025 at 8:11 AM, Staff G stated they were responsible for arranging the facility's podiatry services and confirmed Resident 23 was not seen by a podiatrist since the referral made in November 2024. Staff G stated the facility was having issues with podiatry services and did not currently have a date of when the podiatrist would be available to the facility. In an interview on 04/21/2025 at 9:17 AM, Staff E (Assistant Director of Nursing) confirmed Resident 23 was not seen by a podiatrist as recommended. Staff E stated staff should have followed the wound provider's recommendation for a podiatrist but they did not. Refer to: F684 REFERENCE: WAC 388-97-1060(3)(j)(viii). .

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to identify, assess, and implement interventions to prevent accidents for 1 of 1 resident (Residents 62) reviewed for smoking. These failures left the resident at risk for injury and a diminished quality of life. Findings included . <Facility Policy> Record review of the facility policy titled, Smoking, revised 06/2023, showed the facility would screen all residents for smoking via the nursing admission evaluation. Residents who wished to continue smoking would have smoking reflected in their care plan. The policy showed the facility would store all smoking materials in a locked storage cabinet in the resident's room, at the nurse's station, or another designated location in the facility. <Resident 62> According to the 01/03/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 62 had clear speech, their memory was intact, and they understood others during communication. The MDS showed Resident 62 required one person assistance with transfers, toileting, and bed mobility. The MDS showed Resident 62 used a wheelchair for mobility. In an interview on 04/14/2025 at 10:57 AM, Resident 62 stated they smoked once or twice a day and had their smoking materials in a drawer in their room. Resident 62 stated they knew the rule to not smoke on facility property and they had to go 50 feet away from the facility property. Review of Resident 62's record showed Resident 62 did not have a smoking assessment completed. Review of a Social Services evaluation completed on 03/31/2025 showed Resident 62 as a smoker. In an interview on 04/16/2025 at 7:44 AM, Resident 62 stated the facility staff knew they smoked. Resident 62 stated the facility staff provided them with a metal lock box to keep their smoking materials in their room in a drawer. Resident 62 stated they last smoked yesterday around 5:00 PM. Observation on 04/16/2025 at 7:50 AM showed Resident 62 had a curtain of cigarettes and a lighter in a metal box in a drawer in Resident 62's room. In an interview on 04/16/2025 at 8:44 AM, Staff G (Social Services Director) stated Resident 62 was not smoking currently. Staff G stated Resident 62 was found vaping outside the facility a couple of months ago and it was discussed with the resident that the facility was a non-smoking facility. Staff G stated they were not aware of Resident 62 currently smoking or of the lock box in their room. In an interview on 04/16/2025 at 9:10 AM, Staff B (Director of Nursing) stated they were a non-smoking facility and everyone had to follow the facility policy. In an interview on 04/16/2025 at 9:15 AM, Staff D (Chief Nursing Officer) stated the facility was a non-smoking facility. Staff D stated they were unaware Resident 62 smoked or that Resident 62 kept smoking materials in their room. Staff D stated the expectation was to assess residents who smoked to determine if they were safe to smoke independently or needed supervision, but they did not complete the smoking assessment. In an interview on 04/16/2025 at 9:36 AM, Staff A (Administrator) stated they were unaware Resident 62 smoked. Staff A stated the facility staff should complete the smoking assessment but they did not. REFERENCE: WAC 388-97-1060(3)(g). .

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheters (device that drains urine from the bladder to an external bag) had a valid medical justification for the use of or a plan for discontinuation for one (Resident 36) of two residents reviewed for catheter use. These failures placed residents at risk for urinary tract infections and decline of normal bladder function. Findings included . According to the facility policy on indwelling catheters dated 12/2024, all residents with an indwelling catheter required a medical justification for the initiation and continuing need for catheter use. A comprehensive assessment included underlying factors supporting medical justification, determination of which factors could be reversed and development of a plan for appropriate indications for continuing use of an indwelling catheter beyond 14 days which may include: urinary retention that could not be treated or corrected medically or surgically, and characterized by documented post void residual volumes in a range over 200 mls (milliliters), inability to mange the retention/incontinence with intermittent catheterization, and persistent overflow incontinence (a type of urinary incontinence where the bladder doesn't empty completely, causing urine to leak out when it becomes too full), symptomatic infections, and/or renal (kidney) dysfunction, contamination of . pressure ulcer wounds <Resident 36> Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 admission Minimum Data Set (MDS - an assessment tool) had diagnoses including renal insufficiency but no obstructive uropathy (a condition where the normal flow of urine through the urinary tract is blocked, potentially leading to kidney damage) and no neurogenic bladder (a condition where damage to the brain, spinal cord, or nerves affected bladder control, leading to issues like urinary retention, incontinence, or both) . This MDS showed the resident had an indwelling urinary catheter. The 03/12/2025 Quarterly MDS showed a new diagnosis of obstructive uropathy. Observation on 04/14/2025 at 10:31 AM revealed Resident 36 lying in bed, a catheter bag was attached to the bed frame. In an interview at that time, the resident could not recall how long they had the catheter or why they had it stating, I have a shoddy memory. In an interview on 04/16/2025 at 7:31 AM, Resident 36's family member stated Resident 36 did not have the catheter until they were hospitalized prior to (the resident's) admission to the facility. The family member stated the resident had, No previous need for the catheter, never had urinary problems. According to progress notes dated 12/06/2024 staff documented, Patient to start voiding trial (procedure to determine if a patient could empty their bladder adequately without the need for a catheter. The process typically involves removing a catheter, encouraging the patient to void into a measuring cup or container, and then measuring the amount of urine voided and the amount of urine left in the bladder after voiding.) on the 9th. Staff documented on 12/09/2024 at 2:33 PM, Foley catheter [discontinued] per provider order. Will monitor for ability to urinate. At 11:28 PM on 12/09/2024 staff documented, Foley catheter [discontinued]. Resident can go bedside commode to urine out several times. There was no indication facility staff documented the number of times the resident urinated, the volume of urine output, or attempted post void residuals (catheterizing the resident after urination to determine if urine remained in the bladder). There was no further assessment of the resident's urinary status until a note on 12/10/2024 at 1:51 PM when staff documented, Resident noted with urinary retention Foley catheter placed with 1000 cc (cubic centimeters) of urine return noted. Foley catheter left in place. Provider aware. According to the Urinary Elimination Care Plan dated 12/06/2024, interventions included, Urology consult as needed but the record revealed staff did not consider a urology consult to confirm the resident's urinary retention could not be treated or corrected medically. Record review showed no documentation to support the resident had untreatable urinary blockage or any history of being unable to void prior to the most recent hospitalization. There was no indication in the record facility staff considered prolonged use of the indwelling urinary catheter could lead to a decrease in bladder tone and function, or what interventions might be done to mitigate those effects. In an interview on 04/18/2025 at 9:23 AM Staff C (Corporate Nurse) confirmed no post void residuals were obtained and there was no attempt at bladder retraining stating, We could have done better. Staff C confirmed staff failed to follow the facility policy to ensure the catheter was necessary. REFERENCE: WAC 388-97-1060(3)(c). .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident 17) reviewed for nutrition and staff offered and provided hydration services to 2 of 2 residents (Resident 7 & 35) reviewed for hydration. Failure to ensure consistent, timely weights, and act on the Registered Dietician (RD) recommendations, including reweighs, placed the residents at risk for delayed identification of interventions, and continued weight loss. Failure to offer and provide hydration services to residents placed all residents at risk for dehydration and decreased quality of life. Findings included . <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the 07/31/2024 admission Minimum Data Set (MDS - an assessment tool) the resident had diagnoses which included a brain injury causing the loss of muscle function, either complete or partial, in part of the body, and diabetes (unstable blood sugar levels), and weighed 260 lbs (pounds). The 01/31/2025 Quarterly MDS assessed the resident at 233 lbs and identified a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, but was on a prescribed weight loss regimen. Observation on 04/16/2025 at 10:30 AM revealed Resident 17 lying in bed. At this time the resident stated they had lost a lot of weight within the last year. Review of Resident 17's weights showed large weight fluctuations without reweighs or assessments. On 08/28/2024 the resident was assessed to weigh 232.4 lbs with the next weight documented as 254 lbs on 09/03/2025, a weight gain of 21.6 lbs in less than a week. There was no reweigh until three weeks later on 09/28/2024 (at 251 lbs) and no assessment of the almost 22 lb weight gain. Resident 17's record showed no subsequent weight until 11/06/2024 when the resident was noted to weigh 242 lbs, a loss of 9 lbs. Staff documented monthly weights for Resident 17 until 02/04/2025 with the next subsequent weight obtained over six weeks later on 03/21/2025. Weight records showed the resident weighed 227.2 lbs on 03/21/2025 and on 04/03/2025 weighed 203 lbs. Four days later, on 04/07/2025 staff documented the 04/03/2025 weight was incorrect and reweighed the resident at 213 lbs, which was a 14.2 lb (6.25%) weight loss in less than three weeks. Review of the Therapeutic nutritional risk Care Plan (CP) dated 08/01/2024, showed Resident 17's goal was No significant changes [related to] inadequate oral intake, although gradual weight loss as able maybe beneficial. Resident 17's goal weight was 175 lbs. The CP for Resident 17 showed staff would monitor weight per protocol and weight loss desired by the resident and the RD would review/confirm appropriate goal weight. There were no interventions that directed staff when to weigh or reweigh the resident, when or what weight deviations to report, or what an objective, measurable safe weight loss goal was for any given period of time for Resident 17. In an interview on 04/17/2025 at 1:39 PM, when asked how staff knew when to weigh or reweigh residents, Staff C (Nurse Consultant) stated it should be on the CP. After reviewing Resident 17's record, Staff C confirmed staff were not reweighing the resident with noted weight changes and there should be, but were not, documented assessments of those weight changes. In an interview on 04/17/2025 at 1:48 PM Staff D (Corporate Nurse) stated, I expect reweighs for +/- 5 lbs on the same day or the following day. Staff D stated, The resident should be reweighed and there should be a measurable goal for safe weight loss for example one to two pounds per week. In an interview on 04/17/2025 at 2:00 PM when asked what an objective, measurable safe weight loss would be for Resident 17, Staff Q (RD) replied, I would say within 5% (weight loss) for a month; 2% in a week. Staff Q confirmed for Resident 17, Yes we identified it (weight loss) was 6%. Staff Q was asked how staff were to ensure a weight loss does not exceed 5% in a month, when the weight loss of 6% was not identified until after it occurred. No further information was provided. <Resident 7> Review of the 11/08/2024 Annual MDS showed Resident 7 had no memory impairment. The MDS showed Resident 7 did not have swallowing difficulties. Review of Resident 7's health records showed an 11/14/2024 at risk for dehydration CP indicating staff would encourage fluids with each care. Resident 7's health records showed a 04/03/2025 diet order with no restrictions on fluids. In an interview on 04/15/2025 at 9:21 AM, Resident 7 stated staff do not bring them water. Resident 7 stated they were always thirsty. Resident 7 stated they had to ask staff to bring them a water pitcher and sometimes they would get one, but sometimes they would not come back with one. Observation on 04/16/2025 at 8:56 AM showed staff did not offer Resident 7 hydration services. Resident 7 asked staff to bring them a water pitcher with fresh water. <Resident 35> According to a 06/29/2024 admission MDS, Resident 35's ability to make daily decisions was severely impaired. The MDS showed a dehydration/fluid maintenance care area was triggered for Resident 35 and staff would assess and manage their fluid needs. Review of Resident 35's health records showed a 06/22/2024 peripheral vascular disease related to diabetes CP with an intervention for staff to encourage good hydration. Observations on 04/15/2025 at 12:05 PM showed no water pitcher or fluids available in Resident 35's room. In an interview on 04/18/2025 at 12:05 PM, Staff E (Assistant Director of Nursing) stated they expected staff to offer and provide water pitchers to all residents every shift and as needed. Staff E stated they expected staff to automatically provide hydration services, and the residents should not have to ask to get them. REFERENCE: WAC 388-97-1060(3)(h). .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with current accepted professional standards in 2 of 2 medication carts and 1 medication room reviewed. Additionally, the facility failed to ensure medications were stored in a secure manner for 1 (Resident 52) of 1 residents with medications at bedside. These failures placed residents at risk to receive expired and/or improperly administered medications and biologicals. Findings included . <MEDICATION CART A> Observation of Medication Cart A on [DATE] at 7:44 AM revealed a topical skin treatment that suppresses the immune system for Resident 22 which was discontinued on [DATE] and a topical cream used to treat fungal or yeast infections for which there was no current order. In an interview at this time, Staff S (Registered Nurse) indicated the resident no longer received either of the treatments stating, they should be discarded. A topical treatment to decrease inflammation was noted for Resident 49. Staff S stated, (The resident) doesn't have an order for that anymore, it should be removed. <MEDICATION CART B> Observation of Medication Cart B showed a bottle of heart medication used to treat chest pain for Resident 220 who discharged from the facility on [DATE], over six months ago, and for Resident 221 who discharged from the facility on [DATE], 10 months ago. Another bottle of this medication was noted and was not labeled with a resident name, prescribing physician, or directions for use. A Hemoccult test fluid (a chemical used to test stool samples) was stored in with the oral medications. The medication cart contained: a topical treatment to treat dry or scaly skin for Resident 222 who discharged from the facility on [DATE]. A medicated topical treatment to treat infected skin lesions was observed for Resident 23 which was discontinued on [DATE]. An ointment used to treat fungus infections for Resident 23 which was ordered [DATE] and discontinued on [DATE]. A second treatment to treat fungal infections for Resident 23 was dispensed on [DATE]. According to Staff J (Licensed Practical Nurse) the resident, doesn't use that anymore and, we should get rid of it. An open bottle of irrigation solution (used to clean wounds) was observed and dated [DATE] but did not have a resident name on the bottle. In an interview on [DATE] at 10:11 AM, Staff J stated medications and treatments should be removed from the medication cart when the treatments were discontinued or if the resident discharged from the facility. Staff J confirmed staff should have, but did not, remove the medications and treatments. <Medication Room> Observation of the Medication Room refrigerator on [DATE] at 8:35 AM revealed an open, undated bottle of an injectable medication used to test for Tuberculosis (a communicable respiratory disease) and a vaccine for shingles (a painful, blistering rash caused by a virus) syringe for Resident 39 that was dispensed on [DATE] but not administered. In an interview at this time, Staff L (Licensed Practical Nurse) stated the Tuberculosis testing solution should be dated when opened and the vaccine medication should be administered or destroyed. Observation at this time showed 15 bags of Intravenous antibiotics were identified in the refrigerator for Resident 28. While the order for the antibiotic was discontinued on [DATE], additional bags of antibiotics were dispensed by the pharmacy on [DATE] and [DATE]. In an interview on [DATE] at 10:33 AM, Staff C (Corporate Nurse) stated staff should have contacted the pharmacy after the medication was received on [DATE] and destroyed the medication when there was no longer an order for it. In an interview on [DATE] at 10:35 AM Staff C stated staff should dispose of discontinued medications, as soon as possible, we try to do it once a week. When asked at what time, after a resident is discharged , their medications should be destroyed/removed from the medication cart, Staff C stated, I would take it out within 24 hours of discharge. <Medications at Bedside> Observations on [DATE] at 12:41 PM showed Resident 52 had a bottle of vision supplements for eye health and one bottle of multivitamins on their overbed table. Similar observations were noted on [DATE] at 7:38 AM and [DATE] at 8:31 AM. In an interview on [DATE] at 12:14 PM Staff E (Assistant Director of Nursing), confirmed the presence of the unsecured medications at the bedside and stated the resident should have their medications in a lockbox. Staff E stated staff should, but did not, report when they found medications at the bedside. REFERENCE: WAC 388-97-1300(1)(B)(II), (c)(ii-iv)(2). .

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate records for 10 (Residents 17, 52, 61, 40, 47, 6, 7, 36, 62, & 35) of 20 current sampled residents reviewed and 15 supplemental residents (9, 2, 51, 19, 27, 32, 4, 5, 18, 15, 29, 49, 24, 33, & 21) reviewed. The facility failed to ensure: physician orders were clear/accurate, assessment documents accurately reflected resident condition, behaviors were monitored, personal inventories were accurate/updated/available, informed consents were signed/dated, and resident inventory lists were complete. Failure to ensure clinical records were complete and accurate placed residents at risk of not having their needs met. Findings included . <Podiatry Consults> <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly Minimum Data Set (MDS - an assessment tool) was assessed as cognitively intact with multiple medically complex diagnoses, including diabetes. Record review showed a Podiatry Consult dated 09/19/2024 that was not scanned into the resident's record until 02/11/2025. Record review showed no subsequent Podiatry Consults. In an interview on 04/16/2025 at 7:24 AM Staff G (Social Service Director) provided a 02/26/2025 Podiatry Consult for Resident 17, which was not in the residents records. Staff G stated the consults were provided to Medical Records, who should scan the consults into the record. Staff G stated they kept a notebook with the visits as backup but confirmed it was important for medical consults to be scanned into resident records. <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 04/04/2025 Quarterly MDS had multiple medically complex diagnoses, including diabetes. Record review on 04/21/2025 showed no documented Podiatry Consults in Resident 61's health records. In an interview on 04/16/2025 at 7:24 AM Staff G provided a 02/26/2025 Podiatry Consult for Resident 61, which was not in the record. Record review for Residents 52, 40, 47, 6, 7, 36, 62, and 35 showed evidence these sample residents received Podiatry services on 02/26/2025. Record review performed on 04/21/2025 for supplemental residents 9, 2, 51, 19, 27, 33, 32, 4, 5, 18, 15, 29, 49, 24, & 21 showed they received Podiatry services on 02/26/2025 had no documentation in the record to support the visits occurred. In an interview on 04/16/2025 at 7:24 AM, Staff G confirmed documentation to support these services occurred were not in the resident's records. Refer to F585 - Grievances. Refer to F658 - Services Provided Meet Professional Standards. Refer to F687 - Foot Care. Refer to F641 - Accuracy of Assessments. Refer to F758 - Free From Unnecessary Psychotropic Medications. REFERENCE: WAC 388-97-1720 (1)(a)(i-iv); (2)(a-m). .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to: ensure staff performed hand hygiene before and after resident care for 3 of 3 staff observed, ensure proper labeling and containment of resident's personal care items observed in 2 resident rooms, administer medications while maintaining infection control measures, and wear facility required face masks appropriately to prevent the spread of infection. These failures placed residents at risk for the development of infectious diseases and living in an unclean environment. Findings included . <Facility Policy> According to the facility's October 2023 revised Handwashing/Hand Hygiene policy, all personnel were trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. This policy showed staff were expected to perform hand hygiene before applying non-sterile gloves and before touching a resident. <Environment> <room [ROOM NUMBER]> Observations during initial rounds showed: on 04/14/2025 at 9:14 AM the bathroom for room [ROOM NUMBER] had a blue basin on the floor that was not bagged or labeled, two unlabeled urinals with no lids on the back of the toilet and a bag of garbage on the floor. Similar observations of the unbagged basin on the floor and unlabeled urinals on the toilet were made on 04/16/2025 at 5:52 AM and 04/17/2025 at 2:17 PM. <room [ROOM NUMBER]> Observation of the bathroom for room [ROOM NUMBER] on 04/14/2025 at 9:14 AM showed a lidless urinal on the back of the toilet not labeled or bagged; a blue basin in a bag on floor which was not labeled, one graduate cylinder (a plastic container used to collect or measure bodily fluids) on the back of the toilet labeled for 32-2 but not bagged, and a denture cup at the sink which was not labeled. Similar observations of the urinal, basin, graduate cylinder were noted on 04/16/2025 at 6:06 AM. In an interview on 04/21/25 12:15 PM Staff E (Assistant Director of Nursing) stated that personal care items in bathrooms should be labeled with resident names, anything stored on the floor should be bagged. and urinals should have lids and be stored in a bag. <Medication Administration> <Resident 2> Observation on 04/14/2025 at 8:35 AM showed Staff J (Licensed Practical Nurse) administer medications to Resident 2. Staff J was observed to place three bottles of eye drops, two inhalers, and a nasal spray on the resident's bed without a barrier, then proceeded to administer each medication. Staff J placed the now cross contaminated medication containers on top of the medication cart without cleaning medication bottles or using a barrier. Observation on 04/15/2025 at 8:18 AM showed Staff J remove a hand held inhaler from their pocket and place into Medication Cart B. In an interview on 04/16/2025 at 9:23 AM, Staff B (Director of Nursing) stated staff should use barriers to prevent cross contamination during medication pass. <Mask Use> <C Hall> Observations on 04/14/2025 at 11:43 AM showed unidentified therapy staff walking a resident in C Hall wearing their face mask below their nose. <A Hall> Observation and interview on 04/16/2025 at 5:31 AM showed Staff Y (Restorative Aide) sitting in a chair on A hall without a mask on. Staff Y stated the facility required staff to wear a surgical mask while in care areas of residents. Staff Y stated they should always wear a surgical mask in the resident hallways but forgot to put one on. <Hand Hygiene> <Resident 36> Observation of personal care provided to Resident 36 on 04/17/2025 at 9:33 AM showed Staff K (Certified Nursing Assistant - CNA) and Staff U (Lead CNA) initiate catheter care for Resident 36. Observation showed Staff K don gloves, then empty urine from the catheter into an unlabeled urinal touching the bathroom door with the now contaminated right hand used to clamp the urinal tubing. Staff K then changed gloves without performing hand hygiene. Staff U directed Staff K to remove their gloves and perform hand hygiene. As there was no hand sanitizer in the room, Staff K left the room to use the hand sanitizer in the hall before returning to the room. At this time the resident stated, That's not helpful, (they) touched the doorknob then touched it again on the way back in. Staff K received a soiled washcloth from Staff U to place in a bag retrieved from the overbed table which was then moved to the foot of the bed. With contaminated hands, Staff K then dried the resident as Staff U performed catheter care. <Resident 64> Review of Resident 64's 04/16/2025 physician orders showed a 03/12/2025 order directing staff to provide nutrition by enteral feeding (method of delivering nutrition directly into the gastrointestinal tract through a tube). A 03/04/2025 order directed staff to use enhanced barrier precautions related to the resident's enteral feeding tube. Observations on 04/18/2025 at 11:37 AM showed Staff W (Licensed Practical Nurse) preparing to stop Resident 64's enteral feeding for the day. Staff W put on a gown prior and entered Resident 64's room without performing hand hygiene and was observed talking with the resident. Staff W had their surgical mask below their nose and proceeded to use their bare hand to reposition the mask. Staff W grabbed pair of gloves and did not complete hand hygiene prior to putting on the gloves. Staff W removed a new syringe and placed it in a graduate cylinder used for Resident 64's enteral feeding. Staff W instructed Resident 64 to lift their gown, Staff W stopped the feeding and removed the external portion of the enteral feeding tube from the resident. Staff W placed a plug in the resident's enteral tube and repositioned their gown. Staff W removed their gloves, completed hand hygiene, and exited the room. <Resident 6> Observation on 04/17/2025 at 12:06 PM showed Staff V (CNA) providing incontinent cares to Resident 6 for an incontinent episode of loose stool in their brief. Staff V was observed to clean Resident 6's loose stool off their catheter (tube inserted into the bladder to drain urine) tubing. Staff V changed their gloves between dirty and clean cares without performing hand hygiene. 04/17/2025 at 1:45 PM Staff V stated they should have performed hand hygiene between dirty and clean care glove changes, but they did not. In an interview on 04/21/2025 at 9:40 AM Staff P (Infection Preventionist) stated they expected staff to wear surgical masks in resident areas. Staff P stated they expected staff to perform hand hygiene upon entering a resident room, prior to providing resident care, between clean and dirty cares, and between glove changes. REFERENCE: WAC 388-97-1320 (1)(c)(2)(a). .

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately assess 5 (Resident 30, 36, 61, 62, & 69) of 20 residents' Minimum Data Sets (MDS - an assessment tool) reviewed. Failure to ensure accurate assessments regarding cognitive patterns (Resident 36) language (Resident 61), oral status ( Resident 61), vision status (Resident 30), behaviors (Resident 36), dental status (Resident 62), and discharge status (Resident 69) placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 30> According to the 09/13/2024 Admission, the 12/14/2024 Quarterly, and the 03/05/2025 Significant Change MDSs, staff assessed Resident 30 with adequate vision and no corrective lenses. Observations on 04/14/2025 at 1:20 PM revealed a pair of glasses on Resident 30's overbed table. Resident 30 stated they required eyeglasses, and their current prescription was old. In an interview on 04/17/2025 at 8:29 AM Staff B (Director of Nursing) stated the MDS was coded incorrectly and should reflect the resident's altered vision and use of glasses. According to the 03/05/2025 Significant Change MDS, staff assessed the resident with three pressure ulcers but no vascular ulcers (sores on the skin caused by impaired blood circulation, either in arteries or veins). According to a 03/05/2025 contracted wound company's progress note, Resident 30 was treated for a Chronic Ulcer that was not reflected on the 03/05/2025 MDS. In an interview on 04/21/2025 at 9:05 AM Staff D (Corporate Nurse) confirmed staff should, but did not, correctly code the wound in question. <Resident 36> According to the 03/12/2025 Quarterly MDS staff were able to interview Resident 36 for activity preferences, but did not complete the Cognitive Patterns interview with the resident because the resident was rarely/never understood. Staff coded this MDS to indicate Resident 36 demonstrated delusions (a false belief or judgment about external reality despite evidence to the contrary) during the assessment period. Observations on 04/16/2025 at 7:36 AM showed Resident 36 lying in bed conversing with a family member at the bedside. The resident was able to participate in conversation, answering questions when asked. Observations on 04/14/2025 at 9:02 AM, 10:31 AM, and 12:19 PM, 04/16/2025 at 5:35 AM, 7:36 AM, and 11:20 AM, and on 4/17/2025 at 9:33 AM and 2:48 PM, revealed no indication the resident demonstrated delusional behavior. In an interview on 04/16/2025 at 7:47 AM Staff G (Social Service Director) stated I don't know why the Social Worker coded (the resident) as not interviewable, that's wrong, (the resident) is interviewable. Staff F stated the MDS was coded incorrectly as there was no indication Resident 36 demonstrated delusional behavior during the assessment period. <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 01/02/2025 admission MDS had diagnoses including a brain injury which caused the loss of muscle function and aphasia (a disorder that affected a person's ability to communicate). According to the dental section of the MDS, staff were unable to examine Resident 61's dental status. Observation on 04/18/2025 at 10:44 AM showed Resident 61 lying in bed. At this time, Staff B did a cursory oral exam and stated, I would say the MDS was wrong, I cannot think of a reason staff would document unable to examine on the MDS. According to Section B of the 01/02/2025 admission MDS, Resident 61 had no speech and was rarely/never understood. Review of Section F showed staff indicated Resident 61 was able to be interviewed for preferences for activities and Section Q showed the resident, but no family, participated in the assessment. In an interview on 04/21/2025 at 8:42 AM Staff D was unable to answer how staff were able to interview the resident regarding activity preferences, but not mental status. The 01/02/2025 admission MDS indicated Resident 61's primary language was Samoan but staff documented unable to determine the need or want for an interpreter. In an interview on 04/21/2025 at 8:09 AM Staff G stated they contacted the resident's family and confirmed that while the resident communicated in both Samoan and English, Samoan was the primary and preferred language. Staff E confirmed the resident involved family members and the facility should indicate the resident would benefit from an interpreter. <Resident 62> Review of a 01/03/2025 admission MDS showed Resident 62 had no natural teeth and no loose natural teeth. Review of a 01/02/2025 admission evaluation showed Resident 62 had two teeth and no dentures. Review of a 12/31/2024 Oral/dental Care Plan (CP) showed Resident 62 had two natural teeth and instructed staff to report to the dietitian for any chewing issues. Review of a 04/01/2025 Oral/dental health related to broken natural teeth CP instructed staff to coordinate arrangements for dental care. Observation and interview on 04/14/2025 at 10:50 AM showed Resident 62 had only two natural upper teeth and no lower teeth or dentures. Resident 62 stated they had only two teeth left, and they were very loose. Resident 62 stated they had a hard time chewing some of the foods. In an interview on 04/18/2025 at 10:04 AM Staff N (MDS Specialist) confirmed Resident 62's MDS showed they had no natural or broken teeth. Staff N stated the MDS was inaccurate. Staff N stated it was important for the MDS to be accurate to plan residents' care appropriately. <Resident 69> According to Resident 69's 02/24/2025 Discharge MDS, Resident 69 discharged from the facility on 02/24/2025 to a short-term general hospital. Review of a 02/24/2025 Resident Discharge Summary/Instructions evaluation form showed Resident 69 discharged to their private home. In an interview on 04/16/2025 at 11:39 AM, Staff N reviewed Resident 69's 02/24/2025 MDS and discharge summary. Staff N confirmed the MDS was coded incorrectly. REFERENCE: WAC 388-97-1000 (1)(b). .

CONCERN (E)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the completion of a required Pre-admission Screening and Resident Review (PASRR) Level 2 evaluation (a person-centered evaluation that is completed for anyone identified as having or suspected of having a Serious Mental Illness (SMI), intellectual disability, developmental disability, or related condition) prior to admission for 3 of 5 sampled residents (Residents 17, 52, & 62), and 2 supplemental residents (30 & 36) reviewed for PASRRs. These failures placed the residents at risk for unmet mental health care needs. Findings included . <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the 07/31/2024 admission Minimum Data Set (MDS-an assessment tool) had diagnoses which included anxiety disorder and depression. Review of Resident 17's health records showed a 07/17/2024 Level I PASRR reflected SMIs and recommended a Level 2 PASRR. Resident 17's records showed a second Level I PASRR was completed by the facility on 12/05/2024 and also indicated Resident 17 required a Level 2 PASRR. Review of Resident 17's records showed no indication facility staff attempted to coordinate a Level 2 PASRR until staff documented on 04/08/2025, SS (Social Services) sent an email to the WA PASRR (office who performs the Level 2 PASRR) regarding any updates on an evaluation for the resident's updated PASRR. Currently pending an evaluation at this time. SS to follow up with any updates. In an interview on 04/16/2025 at 7:51 AM, Staff G (Social Services Director) confirmed there was a delay in seeking Level 2 PASRRs. When asked why there were significant delays in referring residents for Level 2 evaluations, Staff G indicated they got behind because they had no assistant. <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/22/2024 admission MDS had diagnoses which included anxiety disorder and depression. Review of Resident 52's health records showed a Level 1 PASRR dated 02/12/2024 accurately reflected the resident's anxiety and depressive disorders but indicated Resident 52 did not require a Level 2 evaluation. Resident 52's records showed a PASRR level I completed by the facility on 12/05/2024 indicated the resident required a Level 2 evaluation. Review of Rsident 52's progress notes showed no efforts to obtain a Level 2 evaluation until progress notes on 04/08/2025 showed, SS sent an email to the WA PASRR regarding any updates on an evaluation for the resident's updated PASRR. Currently pending an evaluation at this time. SS to follow up with any updates. Staff documented on 04/17/2025, On 4/14/25, SS received email from WAPASRR ., stating that they need supporting documents . Staff G, in an interview on 04/16/2025 at 7:51 AM, confirmed there was a systemic delay in coordinating Level 2 PASRRs stating, I should have contacted them earlier. <Resident 62> According to the 01/03/2025 admission MDS, Resident 62 admitted to the facility on [DATE] and had diagnosis of depression. Resident 62 received antidepressant medication seven of seven days during the assessment period. Review of the 12/31/2024 Level I PASRR showed Resident 62 had SMI depression and required a level II PASRR. Review of Resident 62's records showed no indication the facility staff attempted to coordinate a Level II PASRR until Staff G documented on 04/08/2025 they sent an email to WA PASRR authority regarding updates on an evaluation for PASRR Level II. In an interview on 04/16/2025 at 11:02 AM, Staff G stated there was a delay in following up Level II PASRR. Staff G stated they should follow up with PASRR evaluator within 30 days from PASRR I updated, but they did not. <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 09/13/2024 admission MDS had diagnoses which included anxiety disorder and depression. According to the Level I PASRR dated 09/04/2024, Resident 30 had no SMIs. Facility staff completed a second Level I PASRR on 12/05/2024 which reflected Resident 30 had anxiety disorder and mood disorder and recommended a Level II PASRR. In an interview on 04/16/2025 at 7:24 AM, Staff G stated the Level II request was sent to the evaluator on 02/06/2025; but it should have been sent prior to that. Staff G indicated there should be follow up after a few weeks if no response was received from the agency performing the Level II PASRRs. Staff G confirmed at this time there was a delay in coordinating a Level II PASRR for Resident 30. <Resident 36 > Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 admission MDS had diagnoses which included depression and bipolar disorder. According to the 12/04/2024 PASRR level I, Resident 36 had SMI but did not trigger for a Level 2 PASRR. Facility staff completed a second Level I on 12/09/2024 which reflected the resident required a Level II evaluation. In an interview on 04/16/2025 at 7:24 AM, Staff G stated the request for coordinating a Level II evaluation for Resident 36 was not faxed until 02/07/2025, two months after it was determined a Level II was required. There was no further follow up for coordination until a progress note on 04/08/2025 when SS staff reached out to the agency responsible for Level II evaluations. In an interview on 04/16/2025 at 11:28 AM Staff G stated, We should have contacted the PASRR folk earlier . every few weeks. REFERENCE: WAC 388-97-1915(4). .

CONCERN (E)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission to the facility for 3 of 5 (Residents 52, 24 & 35) and 1 supplemental resident (Resident 30) reviewed for PASRR's . This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/22/2024 admission Minimum Data Set (MDS- an assessment tool) had diagnoses which included Anxiety Disorder (a mental health disorder with an excessive, irrational dread of everyday situations) and Depression (mental health disorder characterized by persistent feelings of sadness and/or lack of interest in daily activities). The Level 1 PASRR dated 02/12/2024 accurately reflected the resident's anxiety and depressive disorders but indicated the resident did not require a Level II evaluation. Review of a 12/05/2024 PASRR I Resident 52 had Serious Mental Illness (SMI) and required a Level II PASRR. In an interview on 04/16/2025 at 7:54 AM, Staff G (Social Service Director) indicated the PASRR rules changed in July 2024 and the 12/05/2024 PASRR requesting a Level II was late and should have been completed in July of 2024. <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 09/13/2024 admission MDS Resident 30 had diagnoses which included anxiety disorder and depression. According to the Level I PASRR dated 09/04/2024, Resident 30 had no SMI's. Facility staff completed a second Level I PASRR on 12/05/2024 which reflected Resident 30's anxiety and mood disorder In an interview on 04/16/2025 at 7:24 AM, Staff G confirmed Resident 30's admission PASRR was incorrect. Staff G explained incorrect PASRRs should be corrected within the first 72 hours of admission. When asked why it took three months to correct the PASRR Staff G stated, It should have been done but we got behind and we did an audit in December. In an interview on 04/16/2025 at 8:20 AM when asked why PASRRs were not corrected timely, Staff G replied, It fell through the roof (like through the cracks) I didn't have a stable assistant. <Resident 24> According to a 10/07/2024 Quarterly MDS Resident 24 had diagnoses of, but not limited to, Depression and Schizophrenia (mental health disorder often characterized by hallucinations, delusions, and/or disorganized thoughts). Review of Resident 24's health records showed a 12/05/2024 PASSR I which indicated a PASSR II referral was made. Resident 24's records did not include a PASRR II. In an interview on 04/18/2025 at 8:55 AM Staff G stated they communicated with the state PASRR coordinator since questions came up during survey about PASRR's and the coordinator had informed them they had not received a PASRR II referral for Resident 24. Staff G stated they were responsible to follow up on PASRR's within 3 weeks after a referral was made but they did not follow up on Resident 24's because they were running behind. <Resident 35> According to a 06/29/2024 admission MDS Resident 35 had diagnoses of, but not limited to, Depression and Anxiety Disorder. Review of Resident 35's health records showed a 06/22/2024 PASSR I with no SMI's documented and no level II referral necessary. Resident 35's records showed a 12/18/2024 updated PASRR I that included SMI's, documented a level II PASRR was indicated, and the PASRR II referral was made. In an interview on 04/18/2025 at 8:55 AM Staff G stated they were expected to review the PASRR I's after the resident admitted to the facility to ensure they were correct. Staff G stated Resident 35's PASRR I review was missed. Staff G stated they completed an updated PASRR I on 12/18/2024 to reflect the SMI's and that a PASRR II referral was indicated. Staff G stated they communicated with the state PASRR coordinator since questions came up during survey about PASRR's and the coordinator had informed them they had not received a PASRR II referral for Resident 35. Staff G stated they were responsible to follow up on PASRR's within 3 weeks after a referral was made but they did not follow up on Resident 35's because they were running behind. REFERENCE: WAC 388-97-1915(1)(2)(a-c). .

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure Care Plans (CP) were updated and/or revised as needed to reflect person-centered care for 4 (Residents 17, 61, 36 & 62) of 20 sample residents whose CPs were reviewed, and failed to provide CP meetings for 4 (Residents 62, 23, 66, & 28) of 7 sample residents reviewed for CP meetings. The failure to update and/or revise CPs or provide CP meetings left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's Care Planning Process policy revised 05/2023 showed the comprehensive CP was an interdisciplinary tool that must have measurable objectives with time frames and described the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The CP must be reviewed and revised at a minimum on admission, quarterly, and with a significant change in condition. Review of the facility's Care Conferences policy revised 05/2023 showed the facility would ensure the resident/resident representative were part of the interdisciplinary team and participate in the development and ongoing review of the plan of care. The facility would schedule care conferences for residents upon admission, quarterly, with significant changes in condition, and per residents/representatives request and document the outcome of the care conference meeting and attendees in resident's record. <Failure to Review/Revise CPs> <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly Minimum Data Set (MDS- an assessment tool) dated 01/31/2025 was assessed with a brain injury which caused the loss of muscle function and required partial to moderate assistance with rolling from lying on the back to left and right side. This MDS also reflected the resident experienced a weight loss and was on a prescribed weight-loss program. Observations on 04/14/2025 12:01 PM showed loose rails/enabler bars on both the left side and right side of the bed. Review of the Safety Device - bed mobility bar/rail CP documents dated 07/26/2024, staff were directed to evaluate safety device use monthly and as needed. A second intervention directed staff to, Evaluate safety device quarterly. In an interview on 04/16/2025 at 12:06 PM Staff C (Corporate Nurse) stated nursing evaluates the rails quarterly, not monthly, and the CP should be clarified. The Therapeutic nutritional risk CP dated 08/01/2024 identified a goal of, No significant changes r/t (related to) inadequate oral intake, although gradual weight loss as able may be beneficial. Resident's goal weight is 175 lbs. Interventions included, Monitor weight per protocol. The CP did not define acceptable parameters of a gradual weight loss or how much weight could be lost safely in a certain period of time. The CP did not direct staff when to weigh the resident. Progress notes dated 04/11/2025 identified Resident 17 had a 14.2 pound (or 6.2%) weight loss in one month. In an interview on 04/17/25 at 1:39 PM when asked how staff knew when to weigh a resident, Staff C (Corporate Nurse) stated, It should be on the CP. In an interview on 04/17/2025 at 1:54 PM Staff D (Clinical Nursing Officer) stated, There should be a measurable goal for safe wt loss, for example 1-2 pounds per week. Staff D confirmed this information should be included in the CP. <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 04/04/2025 Quarterly MDS was assessed with multiple complex diagnoses, including aphasia (a disorder that affects a person's ability to communicate), that the resident's preferred language was one other than English and was dependent on tube feeding (a method of delivering nutrients through a tube into the stomach of individuals who cannot or will not eat or drink enough food to meet their nutritional needs). Review of Resident 61's CP showed no indication of alteration in communication related to the resident's preferred language nor were there interventions to improve communication related to a potential language barrier. Failure to ensure clear means of communication in a language the resident prefers and detracts from the resident to understand their healthcare status and the care being provided. According to the Nutrition risk CP dated 04/02/2025, interventions directed staff to Monitor/document circumstances surrounding mealtimes/refusals to eat. Attempt to determine pattern or cause. Where possible alter or remove the cause. A Potential for pain CP dated 12/26/2024 directed staff to Observe during eating for indications of dental, mouth and/or facial pain. A 04/01/2025 Bladder Incontinence CP directs staff to monitor and report change in eating pattern. A separate CP for Inadequate oral intake related to NPO (nothing by mouth) . dated 02/04/2025 was in direct conflict with CPs which indicated the resident could eat. The Inadequate oral intake CP also specified the resident received a brand of nutritional supplement tube feeding not specifically formulated to residents with diabetes at 65 cc (cubic centimeters) an hour for 20 hours a day. Review of the April 2025 MARs showed staff were instructed to administer a specific nutritional supplement for diabetics at 75 cc an hour. In an interview on 04/17/2025 at 9:24 AM Staff C confirmed staff should, but did not update the CP to reflect the tube feeding type and rate. Staff C also confirmed the CP was not individualized as it directed staff to monitor issues related to eating when the resident took nothing by mouth. <Resident 36> Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 admission MDS had diagnoses that included bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, ranging from periods of abnormally elevated mood and energy to periods of depression), demonstrated no indicators of psychosis which required the use of antipsychotic medication daily and utilized an indwelling urinary catheter. Review of MARs for April 2025 showed Resident 36 received an antipsychotic medication for Bipolar disorder with Psychotic Features. Review of Target Behaviors showed staff were monitoring for Angry Outbursts and Verbal Aggression. According to a Psychiatric Practitioner note dated 02/06/2025 staff were directed to, Continue to monitor for any increase in frequency or severity of auditory hallucinations . Review of the Uses antipsychotic medication (related to) Bipolar Disorder dated 12/09/2024 indicated that target behaviors included mood swings and angry outbursts. In an interview on 04/18/2025 at 9:16 AM Staff C confirmed the CP should, but did not, include the psychotic behavior (hallucinations) which required the antipsychotic medication and questioned the inclusion of the mood swings on the CP as they were not monitored. According to Resident 36's Alteration in Urinary elimination CP dated 12/06/25 the resident had a diagnosis of neurogenic bladder (a condition where nerve damage disrupts communication between the brain and bladder, leading to a loss of bladder control). In an interview on 04/18/25 at 9:23 AM Staff C confirmed the CP should indicate obstructive uropathy (a condition where a blockage in the urinary tract prevents the normal flow of urine from the kidneys to the bladder and then out of the body) not neurogenic bladder. <Resident 62> According to the 01/03/2025 admission MDS, Resident 62 admitted to the facility on [DATE] and had diagnosis of complex medical conditions including one side of body weakness. This assessment showed Resident 62 required one person assistance with transferring and toileting. Review of a revised 01/08/2025 Activities of Daily Living (ADL) Care Plan (CP) showed Resident 62 required a mechanical Hoyer lift machine with two-person assistance for transfers and one person assistance with toileting. Observation on 04/14/2025 at 10:57 AM showed Resident 62 transferred independently from bed, on 04/15/2025 at 11:01 AM, and at 2:32 PM, and on 04/16/2025 at 10:55 AM, showed Resident 62 was walking in hallway with a walker. In an interview on 04/16/2025 at 11:00 AM, Staff M (Certified Nursing Assistant) stated Resident 62 did not need help with transfers, they transferred themselves and walked in their room and in hallways independently with their walker. In an interview on 04/18/2025 at 8:44 AM, Staff C (Corporate Resource Nurse) stated the facility updated resident's care plans with change in condition and change in medications and staff had to follow the care plans to provide safe care to residents. Staff C stated Resident 62 was independently transferring and ambulating everywhere with a walker. Staff C reviewed Resident 62's care plans and stated care plans were not updated according to Resident 62's status. Staff C stated care plans should, but were not, revised and updated. <CP Meetings> <Resident 62> According to the 01/03/2025 admission MDS, Resident 62 admitted to the facility on [DATE], had clear speech, and no memory impairment. The assessment showed Resident 62 had complex medical conditions including hemiplegia (a condition characterized by paralysis or weakness on one side of the body) and depression. In an interview on 04/14/2025 at 10:48 AM, Resident 62 stated they did not have a CP meeting since they were admitted to the facility. Review of Resident 62's record did not show documentation Resident 62 had a CP meeting since their admission. In an interview on 04/18/2025 at 8:28 AM, Staff G (Social Service Director) reviewed Resident 62's record and confirmed there was no documentation regarding a CP meeting. Staff G stated the facility staff should have a CP meeting with Resident 62 and their representative, but they did not. <Resident 23> According to the 05/09/2024 admission MDS, Resident 23 admitted to the facility on [DATE] and had diagnoses including kidney failure requiring dialysis (procedure that filtered waste from the blood), an autoimmune disease affecting the brain and spinal cord, and depression. The MDS showed Resident 23 was cognitively impaired, had clear speech, was sometimes understood, and could sometimes understand others. In an interview on 04/14/2025 at 10:32 AM, Resident 23 stated they were not aware of having any care conferences. Review of Resident 23's records on 04/21/2025 at 8:10 AM showed the resident did not have documentation of a care conference until 11/11/2024, over six months after they admitted to the facility. In an interview at that time, Staff G stated residents were supposed to have a care conference with the first 72 hours after admission and quarterly thereafter. Staff G confirmed Resident 23 did not have an admission or quarterly care conference until 11/11/2024. <Resident 66> According to the 03/21/2025 admission MDS, Resident 66 had clear speech, was usually understood and could usually understand others. The MDS showed Resident 66 had diagnoses including an amputation, wound infection, and diabetes (inability to regulate blood sugar levels). In an interview on 04/14/2025 at 8:48 AM, Resident 66 stated they did not have a care conference since their admission to the facility. Review of Resident 66's records on 04/21/2025 at 8:07 AM showed no documentation the resident was offered or provided a care conference. In an interview at that time, Staff G confirmed the resident did not have a care conference as required. <Resident 28> According to a 02/28/2025 admission MDS Resident 28 admitted to the facility on [DATE]. The MDS showed Resident 28 had no memory impairment. Review of Resident 28's health records showed a 03/14/2025 initial care conference evaluation. The evaluation showed only the daughter was in attendance. In an interview on 04/18/2025 at 8:55 AM Staff G stated expectations for offering/conducting care conferences were within 72 hours after admission to the facility, quarterly, and as needed. Staff G stated social services, rehab director, nurse manager, dietary, and activities attend resident care conferences. Staff G stated only the daughter and Staff G attended Resident 28's care conference on 03/14/2025. Staff G stated there was no documentation in Resident 28's health records as to why they were not invited to their own care conference and could not recall any reason for this. Staff G stated Resident 28 and other interdisciplinary team members did not, but should have, participated in Resident 28's care conference. REFERENCE: WAC 388-97-1020(2)(c-d)(f), (4)(b). REFER TO: F692-Nutrition/Hydration Status Maintenance. F700- Bedrails .

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for 7 of 20 (Residents 36, 54, 30, 17, 7, 64, & 52) residents reviewed. Nursing staff failed to: follow or clarify physicians orders when indicated, document for only those tasks completed, monitor residents for significant medication dose changes, follow up on appointment recommendations from outside providers, and to monitor residents for side effects for the treatment received at appointments in outside clinics. These failures placed residents at risk for medication errors, delay in treatment, adverse outcomes, and diminished quality of care. Findings included . <Failure to Follow/Clarify Physician Orders> <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the most recent Quarterly Minimum Data Set (MDS-an assessment tool) received regularly scheduled and as needed pain medication. Review of March 2025 Medication Administration Records (MARs) showed a Physician's Order for a pain patch Apply to bilateral (both) knees topically one time a day for Pain Do not exceed 3 patches for up to 12 hours (hr) with 24 hr period. Wash hands after handling and remove per schedule. The order directed staff to apply the patches at 9:00 AM and remove them at 5:59 AM next morning. According to the MAR, staff applied the patches for 15 hours per day rather than the 12 hours as directed. A second order directed staff to apply a pain patch to Bilateral shoulders topically one time a day for (joint disease). Do not exceed 3 patches for up to 12 hrs with 24 hr period. Wash hands after handling and remove per schedule. This order similarly directed staff to apply the patches at 9:00 AM and remove them at 5:59 AM. According to the MAR, staff applied the patches for 15 hours per day rather than the 12 hours as directed. After reviewing the MAR, in an interview on 04/16/2025 at 10:56 AM Staff C (Nurse Consultant) stated, The patch should only be on for 12 hours, the nurse should have clarified the order since the time code indicated a time of greater than 12 hours. Staff C also confirmed that the nurses, by following the physicians orders would exceed the do not exceed 3 patches directive and should have clarified the order. Observation of the resident on 04/15/2025 at 12:07 PM showed the resident had an undated white patch applied to the right shoulder. Observations on 04/16/2025 at 10:26 AM showed the resident had an undated white patch applied to the right shoulder. During observations of the resident on 04/16/2025 at 10:56 AM, Staff C stated the nurse who applied the patch to the right shoulder should have, but did not, initial and dated it upon application. Examination of the resident's left shoulder revealed no pain patch. The resident stated at this time My left shoulder is fine, it's my neck that hurts. Further examination showed staff applied a pain patch to the resident's neck without a physician order to do so. In an interview on 04/16/2024 at 10:56 AM Staff C stated, No, there shouldn't be a patch on the neck, there is no order. Nurses should not apply medicated patches without physician's orders. Examination of the resident's knees showed pain patches to each knee dated 04/14/2025. In an interview on 04/16/2025 at 10:56 AM Staff C stated, The patches should be dated for today (04/16/2025). Review of the April 2025 MARs showed nursing staff documented the 04/14/25 knee pain patches were removed and that new patches were applied and removed on 04/15/2025. In an interview on 04/16/2025 at 10:56 AM, Staff C confirmed Resident 52 did not get medications as ordered and that nursing staff signed for tasks that were not performed. Additionally, according to April 2025 MAR staff were instructed to obtain weights on 04/01/2025 but documented, NA, rather than a weight. In an interview on 04/16/2025 at 10:44 AM, Staff C stated, We don't force residents, but the nurses should reattempt the weight and document a progress notes as to why they couldn't get the weight, then reattempt it later. <Concomitant Medications> Review of March and April 2025 MARs showed Resident 52 had as needed orders for as needed muscle relaxant and as needed pain medication at the same time on 03/06,15, 24, 29 and 30/2025 and on 04/05/2025 and 04/09/2025. In an interview on 04/16/2025 at 10:39 AM. Staff C stated that nursing staff should give the muscle relaxant medications first to relieve the muscle spasms which might be causing the pain, then the pain medication if it was still needed. Staff C stated the medications should not be given together unless the order directs to do so. <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the admission MDS dated [DATE] had diagnoses which included anxiety disorder which required the use of antianxiety medication. Record review showed Resident 17's antianxiety medication dose was doubled on 09/16/2024. Resident 17's records showed a 09/16/2024 progress note, Patient received new order antianxiety medication TID (three times a day) for Anxiety. There was no alert charting to monitor Resident 17 for any changes or effects of the significant increase in dosage. In an interview on 04/18/2025 at 9:41 AM Staff C stated Yes, there should be alert charting for doubling the antianxiety medication, but no there wasn't. Review of April 2025 MARs showed a physician order for (Medication used to treat heartburn) Give 1 tablet by mouth one time a day for GERD for 14 Days 30 minutes before other (medications). According to the MAR, this medication along with six other oral medications were scheduled for 0600. In an interview on 04/16/2025 at 10:39 AM. Staff C stated the nurse should have clarified the orders to ensure the heartburn medication was given on an empty stomach. <Resident 36> Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 admission MDS had multiple medically complex diagnoses, including Vitamin D deficiency. Review of Resident 36's hospital discharge records showed orders for staff to administer Vitamin D supplement tablet once a week. Nursing staff transcribed this order for Resident 36 as daily and continued to administer it for nine days until 12/18/2024. Pharmacy review identified the vitamin D error for Resident 36. In an interview on 04/17/2025 at 1:07 PM Staff C acknowledged failure of the nurse to transcribe the physician orders correctly resulted in a medication error for Resident 36 and did not meet professional standards of practice. <Resident 30> Observation of medication pass on 04/14/2025 at 12:50 PM showed Staff J (Licensed Practical Nurse) obtain a blood sugar level of 230 from Resident 30, after the resident had started consuming their meal. Staff J then administered three units of an injectable medication based on the sliding scale order. In an interview on 04/16/2025 at 9:23 AM, Staff B (Director of Nursing) and Staff C confirmed the physician's order for blood sugar check and the injectable medication was scheduled at 11:30 AM, which was before lunch and obtaining blood sugars after Resident 30 initiated a meal placed the resident at risk for elevated blood sugars which would require higher doses of the injectable medication. <Resident 54> According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility on [DATE] and had diagnoses including rectal cancer, malnutrition, and chronic pain. The MDS showed Resident 54 was independent with daily activities and ambulation. In an interview on 04/14/2025 at 1:34 PM, Resident 54 was awake, sitting on the edge of their bed in their room, stating they were tired. Resident 54 stated they had cancer and had appointments with cancer doctors at least 4 days a week. Resident 54 stated they were going to be out of the facility for appointments on 04/15/2025, 04/16/2025, 04/17/2025, and 04/18/2025 and then had no appointments for two weeks. Observation on 04/17/2025 8:45 AM showed Resident 54 was walking in their room, stating their appointment was longer yesterday. Observation showed an Intravenous (IV) catheter on Resident 54's right chest, covered with a dressing. Resident 54 had a pump in their hand with tubing attached to their IV catheter and stated their cancer doctor provided them this pump for cancer medications. Review of Resident 54's health record showed nursing progress notes on 04/15/2025 and 04/16/2025 indicating Resident 54 was out of the facility for appointments. No documentation showed Resident 54 came back from the appointments with any new medication orders or recommendations. Review of Resident 54's April 2025 physician orders showed no order for the IV catheter, dressing change, to monitor the IV site for any symptoms of infection, and to monitor the resident for any side effects of chemotherapy medications Resident 54 received at the cancer clinic during the appointments. In an interview on 04/17/2025 at 1:03 PM, Staff E (Assistant Director of Nursing) stated they were not aware Resident 54 had an IV catheter on their right chest area or a pump for medication. Staff E reviewed Resident 54's record and stated there was no order for an IV line or pump. Staff E stated staff should check with the resident for any new orders from oncologist when Resident 54 returned from appointments and document in their record, but they did not. <Resident 64> According to the 03/11/2025 admission MDS, Resident 64 had unclear speech, was usually understood, and was able to understand others. The MDS showed Resident 64 had diagnoses including stroke, malnutrition, and a swallowing disorder due to the stroke. The assessment showed Resident 64 received nutrition via a tube surgically placed in their stomach. Review of Resident 64's 04/16/2025 order summary report showed the resident had a 03/04/2025 order directing staff the resident was to have nothing by mouth. Review of Resident 64's April 2025 MAR showed an order directing staff to offer the resident a snack at bedtime and document the percentage of the snack consumed by Resident 64. The MAR showed from 04/01/2025 to 04/17/2025, staff documented Resident 64 ate 100% of the snack offered on 11 of 17 opportunities. Staff documented not applicable on one occasion and a dash or 0 on 4 occasions. In an interview on 04/18/2025 at 10:21 AM, Resident 64 stated staff did not bring them or offer snacks at bedtime because they were unable to swallow. In an interview on 04/21/2025 at 10:20 AM, Staff E confirmed Resident 64 had a nothing by mouth order. Staff E stated staff should not be documenting tasks that were not done and staff should have clarified the order to provide Resident 64 with a snack at bedtime. <Resident 7> According to a 11/08/2024 Annual MDS Resident 7 experienced frequent 6/10 pain on a pain scale of 1-10 with 10 being the worst pain they've experienced. The MDS showed Resident 7 received scheduled pain medication during the assessment period. Review of Resident 7's health records showed a 02/24/2025 physician order for an as needed pain medication without parameters. In an interview on 04/17/2025 at 9:24 AM Staff O (Resident Care Manager) stated Resident 7 had no pain level or maximum dose in 24 hours parameter in place for their as needed pain medication. Staff O stated Resident 7's pain medication should not exceed 3000 milligrams in 24 hours and the order should include this. REFERENCE: WAC 388-97-1620(2)(b)(ii). .

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 5 of 12 (Residents 61, 22, 62, 54, & 31) who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance including bathing, oral care, and nail care as required, left residents at risk for poor hygiene, soiled long nails, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 04/04/2025 Quarterly Minimum Data Set (MDS - an assessment tool) was assessed with a brain injury which caused the loss of muscle function and aphasia (a disorder that affects a person's ability to communicate), and was dependent on tube feeding (a method of delivering nutrients to individuals who cannot or will not eat or drink enough food to meet their nutritional needs). This MDS assessed the resident as dependant on staff for all care, including personal hygiene. According to the resident's 01/22/2025 Care Plan (CP) for ADLs staff should provide oral care every shift with a toothette or glycerin sponge. Observations on 04/14/2025 at 12:13 PM revealed Resident 61 had long fingernails to both hands and dried debris along the left side of their mouth. A partial view of the resident's mouth showed yellow film/debris on their teeth and along the gum line. Similar observations were made on 04/16/2025 at 1:02 PM and 04/17/2025 at 1:22 PM. During an observation on 04/18/2025 at 10:44 AM, Staff B (Director of Nursing) stated, (The resident) has really bad breath, the teeth look brown and do not look clean. Staff B confirmed it appeared no oral care was done stating, It does not look like oral care has been happening <Resident 22> According to the 03/13/2025 Quarterly MDS, Resident 22 had intact memory and had a diagnosis of depression and edema (swelling caused by fluid build up in body tissues) on both legs. The MDS showed Resident 22 was dependent on staff for showers, toileting hygiene, and lower body dressing. Resident 22 required one-person assistance with personal hygiene and transfers. The MDS showed Resident 22 did not refuse care during the assessment period. The 10/21/2024 revised ADL Self Care deficit CP showed Resident 22 was totally dependent on staff for bathing and Resident 22 preferred showers twice a week. The CP showed Resident 22 required extensive assistance from staff for personal hygiene. Observations on 04/14/2025 at 11:55 AM, 04/15/2025 at 9:21 AM, and 04/17/2025 at 12:08 PM, showed Resident 22's fingernails were long and dirty, their toenails were thick, and there was dry flaky skin on both feet. Their lower legs were wrapped with elastic bandages. In an interview on 04/14/2025 at 11:55 AM, Resident 22 stated they wanted to have showers twice a week, but staff provided only bed baths because of the bandages wrapped on Resident 22's legs. Resident 22 stated staff did not wash their feet for a few weeks. Review of the Certified Nursing Assistant (CNA) documentation from 03/25/2025 through 04/19/2025 showed Resident 22 received four bed baths in 30 days and no shower was provided. This documentation showed no nail care was documented as provided. There were no documented refusals of nail care assistance. In an interview on 04/17/2025 at 12:52 PM, Staff E (Assistant Director of Nursing) reviewed Resident 22's CP and stated Resident 22 should receive showers twice a week but staff provided bed baths. Staff E stated staff should remove Resident 22's bandages from their legs and provide showers but they did not. Staff E stated nail care was important for dependent residents. Staff E stated shower aides and nurses were educated to clip resident's nails weekly and as needed, but staff did not follow the instructions. <Resident 62> According to the 01/03/2025 admission MDS, Resident 62 required one person assistance from staff with personal hygiene, toileting needs, and bathing. The MDS showed no refusal of care behaviors during the assessment period. The 01/08/2025 revised ADL Self Care deficit CP showed Resident 62 required extensive assistance from staff with personal hygiene needs. Observations on 04/14/2025 at 10:46 AM, 04/16/2025 at 7:38 AM, and on 04/17/2025 at 10:41 AM showed Resident 62 had long fingernails and had black debris under their nails. Resident 62 stated they need assistance from staff to clip their fingernails. In an interview on 04/17/2025 at 12:55 PM, Staff E stated staff should provide nail care to all residents weekly on their shower days and as needed. Staff E stated any refusals should be documented in resident's records and notify the supervisor. <Resident 54> According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility with rectal cancer and chronic pain, and required one person assistance from staff for bathing. The MDS showed no refusal of care during the assessment period. Observation on 04/14/2025 at 11:22 AM and 04/15/2025 at 12:40 PM showed Resident 54 had long, sharp, and broken fingernails and had black debris under their fingernails. Resident 54 stated they need help to cut their fingernails. Review of April 2025 CNA documentation showed no nail care was documented to be provided. There were no documented refusals of nail care assistance. In an interview on 04/17/2025 at 1:00 PM, Staff E stated staff should provide nail care to all residents weekly on their shower days and as needed. Staff E stated any refusals should be documented in resident's records and notify the supervisor. <Resident 31> According to the 02/25/2025 admission MDS, Resident 31 was cognitively impaired, had clear speech, was usually understood, and could usually understand others. The assessment showed Resident 31 required supervision or touching assistance with personal hygiene. Observation on 04/17/2025 at 11:27 AM showed Resident 31 lying in bed, with their right foot exposed. The toenails were long, extending past the toes. At that time, Staff X (CNA) observed and confirmed Resident 31's toenails were long. Staff X removed Resident 31's sock on the left foot revealing long toenails to the resident's left foot. Review of Resident 31's April 2025 CNA task documentation showed staff were to document every day shift if staff provided nail care to the resident. This documentation showed staff documented Y for yes-nail care was provided to the resident on 04/15/2025. This documentation did not specify if the nail care provided was to the resident's finger or toe nails. Review of Resident 31's 04/16/2025 physician orders and 03/31/2025 Activities of Daily Living CP showed no orders or directions to staff regarding what assistance the resident required for finger or toe nail care, or who was to provide the care and when. In an interview on 04/21/2025 at 9:28 AM, Staff E stated nail care should be done as needed. Staff E stated they expected CNAs to report to the nurse if they noted long toe nails on a resident. Staff E stated they expected nurses to note long toe nails on weekly skin checks and provide trimming as needed. REFERENCE: WAC 388-97-1060(2)(c). .

CONCERN (E)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly MDS dated [DATE] w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly MDS dated [DATE] was assessed with a brain injury which caused the loss of muscle function and required partial to moderate assistance with rolling from lying on the back to left and right side. Observations on 04/14/2025 at 12:01 PM showed Resident 17 had loose bed rails on both the left and right side of the bed. These rails were noted perpendicular to the bed rather than parallel to the bed with the rails extending up over the mattress. In an interview at this time Resident 17 stated they used the rails for bed mobility but they were, loose. Similar observations of Resident 17's bed rails were noted on 04/16/2025 at 7:40 and 10:27 AM. During an observation on 04/16/2025 at 12:06 PM Staff C (Nurse Consultant) confirmed Resident 17's bed rails were loose and they should be checked on a regular basis and tightened as needed. When asked if the rails were properly installed (perpendicular rather than parallel to the bed) Staff C referred to Staff H. In an interview on 04/16/2025 at 1:02 PM Staff H confirmed the rails on resident 17's bed should not be installed perpendicular stating I put them (the rails) on there right, the aides keep changing it .I changed it back. Staff H confirmed the aides should not alter the application of the bed rails. <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the Significant Change MDS dated [DATE] the resident was cognitively intact and was assessed with functional limitations in range of motion to both lower extremities and required partial/moderate assistance with bed mobility. Observations on 04/14/2025 at 1:22 PM showed bed rails were installed on both the right and left sides of Resident 30's bed. When the left rail was noted as loose, Resident 30 wiggled the right rail stating, Check this other one, it's loose too. Similar observations of Resident 30's loose rails were noted on 04/16/2025 at 8:17 AM and 12:56 PM. <Resident 22> According to the 03/13/2025 Quarterly MDS Resident 22 admitted to the facility on [DATE], and had chronic pain in their knees. Resident 22 was cognitively intact, was assessed with functional limitations in range of motion to both lower extremities, and required extensive assistance with bed mobility. Review of Resident 22's record showed the 09/23/2024 physician order under safety device for the bilateral bed rails for mobility. The 09/03/2024 physician order under nonpharmacological interventions to reduce pain for the resident was repositioning in bed. Review of the 09/23/2024 Safety devise CP showed Resident 22 had bed mobility bars related to muscle weakness and instructed staff to observe the safety device for changes regarding effectiveness of the safety device and report changes to the charge nurse. Observation and interview on 04/14/2025 at 12:04 PM showed Resident 22 lying in their bed on their back. The observation showed side rails were installed on both the right and left sides of Resident 22's bed. The rail on the right side bed rail was up and the rail on the left side of the bed was down. Resident 22 stated they reposition themselves with side rails in bed, but the left side of the bed rail was broken for a few days, and they could not reposition themselves in bed. Resident 22 stated staff knew about the left side rail was broken and maintenance director was supposed to fix it, but it was not done yet. Similar observations of the left, non-functional side rail were noted on 04/15/2025 at 10:12 AM, 04/16/2025 at 9:03 AM and 2:24 PM, on 04/17/2025 at 12:25 PM. In an interview on 04/17/2025 at 10:08 AM, Staff H stated they were not aware of the broken left side rail for Resident 22's bed. Staff H stated there was no record of Resident 22's left bed rail being broken on the maintenance log. In an interview on 04/17/2025 at 12:55 PM, Staff E stated they were not aware of the broken side rail on Resident 22's bed. Staff E stated they expected staff to notify the maintenance department about the broken side rail so maintenance could fix it, but staff did not. REFERENCE: WAC 388-97-1060(3)(g), -2100 (1). Based on observation, interview, and record review the facility failed to provide risks and benefits of bed rail use prior to installation, ensure proper installation of bed rails, and provide ongoing maintenance of bed rails for 5 of 5 residents (Resident 7, 24, 28, 35, & 17) reviewed for bed rails and 2 supplemental residents (Residents 30 & 22) reviewed. These failures placed residents at risk for injury, entrapment, and other negative health outcomes. Findings included . <Policy> According to a facility policy titled, Safety Device Application, revised 04/07/2023, the facility would review safety devices with the resident and/or representative. The policy showed the facility would ensure proper installation as directed for the bed rails. <Resident 7> According to a 11/08/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 7 had no memory impairment. Review of Resident 7's health records showed a 06/10/2022 physician order for the bilateral bed rails. Resident 7's records showed an 11/13/2024 safety device assessment form for the bed rails with the resident's guardian name typed in the information provided to box on the form. Observation and interview on 04/15/2025 at 9:56 AM showed bilateral bed rails to Resident 7's bed. Resident 7 stated staff had not discussed the bed rail use with them. <Resident 24> According to a 01/05/2025 Annual MDS Resident 24 had short term and long-term memory impairment. The MDS showed Resident 24's daily decision ability was moderately impaired. The MDS showed Resident 24's primary language was not English. The assessment showed Resident 24's family participated in the assessment. Review of Resident 24's health records showed a 02/28/2023 physician order for the bilateral bed rails. Resident 24's records showed a 01/18/2025 safety device assessment form for the bed rails with son typed in the information provided to box on the form. In an interview on 04/14/2025 at 9:25 AM Staff S (Registered Nurse) stated the maintenance department was responsible for proper safety device maintenance and installation. Observation on 04/15/2025 at 10:52 AM showed bilateral bed rails to Resident 24's bed. Resident 24's right bed rail completely folded inward onto the bed when grabbed and the left bed rail was very loose, making them both unsafe for the resident to use for positioning in bed. <Resident 28> According to a 02/28/2025 admission MDS Resident 28 had no memory impairment. Review of Resident 28's health records showed a 03/18/2025 physician order for the bilateral bed rails. Observation and interview on 04/14/2025 at 12:25 PM showed bilateral bed rails to Resident 28's bed. Resident 28 stated they did not use the bed rails because they did not want to depend on them. Resident 28 stated staff did not discuss the bed rail usage with them. <Resident 35> According to a 04/01/2025 Quarterly MDS Resident 35 had short term and long-term memory impairment. The MDS showed Resident 35's daily decision ability was moderately impaired. Review of Resident 35's health records showed a 03/25/2025 physician order for the right-side bed rail. Resident 35's health records showed a 03/25/2025 safety device evaluation form for the right-side bed rail with resident typed in the information provided to box, no signature for consent. Resident 35's health records showed they had severe cognitive impairment and had a Power of Attorney (POA - designee to make decisions on part for the resident) for their healthcare decision making. Observation on 04/15/2025 at 12:57 PM showed a bed rail to Resident 35's right side of bed. In an interview on 04/17/2025 at 9:00 AM Staff O stated they were unaware Resident 35 was unable to consent at the time and during this interview observed Resident 35 had severe cognitive impairment and had a POA in place. Staff O stated Resident 35's POA was not notified of the risks and benefits of the bed rail use. In an interview on 04/18/2025 at 9:20 AM Staff O stated they were unable to provide a copy of the notification signed by the resident/representative or a confirmation email notification of risks and benefits for Resident's 7, 24, or 28's bed rail use. In an interview on 04/18/2025 at 9:26 AM Staff H (Maintenance) assessed Resident 35's bed rails to be loose. Staff H stated maintenance was responsible for installing the bed rails, and the nursing staff were trained on how to tighten them when they become loose. Staff H stated the bed rails never stayed put and always became loose. Staff H stated maintenance was not responsible for monitoring the ongoing proper installation of the bed rails and nursing staff were supposed to fix them when they noticed the rails were loose.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 3 of 5 residents (Residents 52, 17, & 35) reviewed for unnecessary medications and 2 (Resident 36 & 54) supplemental residents were free from unnecessary psychotropic drugs related to the failure to: ensure clinical justification for dose increases, adequately monitor, and attempt Gradual Dose Reductions (GDR). These failures placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings include: <Policy> According to a facility policy titled, Psychoactive Medication Management, revised 08/2024, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. The policy showed after the first year, a GDR must be attempted annually, unless clinically contraindicated. <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/22/2024 admission Minimum Data Set (MDS - an assessment tool) had multiple diagnoses including anxiety disorder (mental health conditions characterized by persistent and excessive worry or fear that can interfere with daily life and cause significant distress) and depression. This MDS showed staff assessed the resident demonstrated no indicators of psychosis (a term used to describe a set of symptoms, including hallucinations and delusions, that can indicate a significant disconnection from reality) and no behavioral symptoms. Observations on 04/16/2025 at 12:21 showed the resident lying in bed and appeared well groomed. The resident was pleasant and congenial, participating actively in conversation. Record review showed the resident admitted to the facility with orders for an as needed an antihistamine (medication used to relieve allergy symptoms) for anxiety. While the as needed antihistamine was given only four times in April and three times in May 2024, the resident was started on regularly scheduled antianxiety medication twice a day on 05/11/2024. Review of Treatment Administration Records (TARs) showed staff monitored behaviors of anxiety on 5 of 62 shifts in May 2024. Medication Administration Records (MARs) for June 2024 showed the resident's dose was increased on 06/19/2024. Record review showed Resident 52 demonstrated anxiety on 4 of 36 shifts prior to the dose increase and no episodes of anxiety in the week prior to tripling the dose. A physician order note dated 06/18/2024 triggered a drug-to-drug interaction warning but review of progress notes showed no increase in resident behaviors or distress, no clinical justification of the significant increase in the antianxiety medications, and no alert charting related to either behaviors or the increase of anxiety medication. In an interview on 04/18/2025 at 9:50 AM, Staff C (Corporate Nurse) stated, We do not have documentation to support that, referring to clinical justification for tripling Resident 52's antianxiety medication. <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the 7/31/2024 admission MDS, had diagnoses which included anxiety disorder and required the use of antianxiety medication. Observations throughout the day on 04/14/2025, 04/15/2025 and 04/16/2025 showed Resident 17 in bed and up in their wheelchair working on art projects or watching TV. In an interview on 04/17/2025 at 1:10 PM, Resident 17 stated that they did occasionally experience anxiety but it was not currently an issue. Record review showed Resident 17 admitted to the facility with Physician orders for antianxiety medication to be administered three times a day. Target behavior records showed no anxiety was demonstrated in July, August, or September of 2024 but review of the MARs showed the antianxiety medication was doubled and was to be administered three times a day on 09/16/2024. A 09/16/2024 progress note showed, Patient received new orders antianxiety medication three times a day for Anxiety. Patient consented to the medication. There was no documented increase in behaviors or distress to justify an increase in dosage. In an interview on 04/18/2025 at 9:41 AM, Staff C stated after reviewing the record there was no clinical justification to increase Resident 17's antianxiety medication. <Resident 36> Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 admission MDS, had diagnoses including bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, ranging from periods of abnormally elevated mood and energy to periods of depression). The MDS showed Resident 36 required the use of antipsychotic medication daily and demonstrated no indicators of psychosis. Review of MARs for April 2025 showed Resident 36 received antipsychotic medication twice a day for Bipolar disorder with psychotic features. Review of April 2025 Target Behaviors showed staff were monitoring for Angry Outbursts and Verbal Aggression but no psychotic behaviors were identified that required treatment. According to a 02/06/2025 Psychiatric Practitioner note, staff were directed to, Continue to monitor for any increase in frequency or severity of auditory hallucinations . In an interview on 04/18/2025 at 9:16 AM Staff C confirmed staff did not, but should, monitor the identified auditory hallucinations.<Resident 54> According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility with diagnoses of cancer and chronic pain. The MDS showed Resident 54 received antipsychotic medication on seven of seven days during the assessment period and was assessed with no behavior or rejection of care during the assessment period. Review of Resident 54's April 2025 order summary showed a 02/06/2025 physician order for an antipsychotic medication to be taken daily for cancer. Review of the 12/13/2024 antipsychotic medication CP included the instructions for staff to discuss with provider regarding ongoing need for use of medication. Review of Resident 54's record showed a 03/31/2025 interdisciplinary team nursing progress note that Resident 54 received antipsychotic medication related to depression from cancer and the provider agreed to discontinue the antipsychotic medication and to start on an antidepressant medication daily. Review of Resident 54's record on 04/17/2025 including physician orders and MARs showed no documentation Resident 54's antipsychotic medication was discontinued, and an antidepressant medication was started. In an interview on 04/17/2025 at 1:09 PM, Staff C stated they reviewed Resident 54's medications in a psych meeting and the provider ordered to discontinue the antipsychotic medication. Staff C reviewed Resident 54's record and stated staff should have followed the provider's recommendations and discontinue the antipsychotic medication, but they did not. <Resident 35> According to a 06/29/2024 admission MDS, Resident 35 admitted to the facility on [DATE]. The MDS showed Resident 35 had a diagnosis of, but not limited to, depression. The MDS showed Resident 35 received antidepressant medications during the assessment period. Review of Resident 35's records showed a 03/27/2025 antidepressant medication use care plan with an intervention to attempt a GDR per pharmacist recommendations. Resident 35's records showed a 06/22/2024 physician order for an antidepressant medication. In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) reviewed Resident 35's health records and stated they did not attempt a GDR for Resident 35's antidepressant medication since admission to the facility. Staff E stated it was important to attempt GDRs for psychotropic medications to ensure they were not over medicating the resident or administering and unnecessary medication to the resident. REFERENCE: WAC 388-97-1060(3)(k)(i). .

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5%. Failure to properly administer 5 of 25 medications for 3 of 4 residents (Residents 2, 30, & 19) observed during medication pass resulted in a medication error rate of 20%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications. Findings included . <Policy> According to the facility policy on ophthalmic (eye) drops, dated 11/15/2024, when administering multiple medications to the same eye, staff would wait 3-5 minutes between drops and staff would apply gentle pressure to the tear duct after administration or instruct the resident to close their eye. Waiting between eye drops was important to maximize their effectiveness and prevent potential side effects. It allows each drop to be absorbed by the eye before the next one is administered, preventing dilution and ensuring the medication stays in contact with the eye longer. Failure to follow Physician Ordered time parameters between eye drops decreases effectiveness of the respective medication and constitutes a medication error. Pressing gently on the tear duct, the small opening in the inner corner of the eye, after applying eye drops helps prevent the medication from draining into the nose and throat and ensures adequate dosage. This technique helps keep the medication in the eye longer, allowing it to be absorbed more effectively and potentially reducing systemic side effects. The facility procedure for oral metered dose inhalers instructed staff to wait 20-30 seconds between administration of doses for the same medication, and 2-5 minutes if medications were different. <Resident 2> Observation on 04/16/2025 at 8:21 AM showed Staff J (Licensed Practical Nurse) bring multiple medications into Resident 2's room, administering them in quick succession. Staff J was observed to administer two drops of an eye drop into each of Resident 2's eyes at 8:26 AM. Staff J then administered a nasal spray according to physician orders at 8:26 AM. Staff J administered one drop of another medicated eye drop to the left eye at 8:26 AM and proceeded to give a tissue to the resident who then wiped their eye. Staff J did not instruct Resident 2 to apply gentle pressure to the tear duct after eye drop administration or instruct the resident to close their eye per facility policy. These medications for Resident 2 were scheduled on the Medication Administration Record (MAR) to be given at 7:00 AM. Staff J administered another medicated inhaler at 8:26 AM to Resident 2. Staff J then administered a different medicated eye drop at 8:27 AM to Resident 2's left eye. The resident blinked and wiped their eye with a tissue. Staff J did not instruct Resident 2 to depress the tear duct or close their eye as directed in the facility policy. According to the manufacturer insert for this eye drop, there should be a 5-minute wait between eye drop administrations but the MAR instructed staff to wait only three to ten minutes between administration from other eye drops. Staff J then administered two puffs of another inhaler at 8:27 AM. In an interview on 04/16/2025 at 8:29 Staff J stated, I know I gotta wait like 5 minutes between eye drops and they want you to wait a couple of minutes between the inhaler. In an interview on 04/16/2025 at 9:23 AM Staff B (Director of Nursing) and Staff C (Nurse Consultant) stated the spacing between the inhalers, should be at least five minutes. In an interview on 04/16/2025 at 1:50 PM, Staff B and Staff C confirmed this was an error and the medicated eye drops should be given before 8:00 AM and not within 3 minutes of other eye drops. <Resident 30> Observation of medication pass on 04/14/2025 at 12:50 PM showed Staff J obtain a blood sugar level of 230 from Resident 30, after the resident had started consuming their meal. Staff J then administered an injectable medication to Resident 30 based on blood sugar parameters in the physician order. According to the April 2025 MAR, the blood sugar check and injectable medication coverage for the blood sugar results was ordered for 11:30 AM but completed at 12:52 PM. In an interview on 04/16/2025 at 9:23 AM, Staff B and Staff C confirmed if the physician's order for blood sugar check and the injectable medication were scheduled at 11:30 AM, they should be done within 30 minutes of that scheduled time. Staff B and Staff C stated if the injectable medication was done late, You need to call the doctor .yes that would be an error.<Resident 19> Observation of medication pass on 04/16/2025 at 7:00 AM showed Staff W (Licensed Practical Nurse) administer Resident 19 nine medications. Review of Resident 19's physician orders on 04/16/2025 showed one of the nine medications administered to the resident was not ordered for Resident 19. Resident 19's records showed a single stool softener ordered for the residents that Staff W did not administer and instead Staff W administered a medication that had two stool softeners in one tablet. In an interview on 04/16/2025 at 9:38 AM, Staff W stated they administered the wrong stool softener to Resident 19. Staff W stated they should have administered the single stool softener and not the medication with two stool softeners in it. In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) stated they expected staff to follow physician orders when administering residents their medications. Staff E stated it was important to follow physician orders to ensure administration of correct medications. REFERENCE: WAC 388-97-1060(3)(k)(ii). .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure food was served under sanitary conditions. Facility staff failed to: monitor and ensure adequate sanitation for the dishwasher and ensure staff reported when sanitation levels were inadequate. These failures placed residents at risk for food-borne illness. Findings included . Observation of the kitchen during rounds, on 04/17/2025 at 9:47 AM, showed Staff I (Dishwasher) running dishes from breakfast service through the dishwasher. Staff F (Dietary Manger) explained the facility used a low temperature dishwasher which required chemical sanitation (Chlorine used to kill viruses, bacteria, and other microorganisms to prevent foodborne illness) to clean dishes and kitchen utensils stating, I try to keep it (test strips which registered chlorine) at 200 Parts Per Million. During this observation, Staff F, tested the dishwasher for proper sanitizing solution. The chlorine test strip was dipped into the dishwasher water and was noted to be white, indicating an absence of chlorine. Staff F tested for adequate levels of sanitizer two additional times with the same results of a white strip (no/low levels chlorine/sanitizer in the solution). In an interview at 9:54 AM, Staff F stated the dishwasher checks for sanitizer three times a day with each meal but was unable to locate the log that staff used to documented testing of the dishwasher function. Staff I, in an interview on 04/17/2025 at 9:47 AM stated the sanitizer test was really low when it was checked before breakfast. Staff I acknowledged that if the test strip remained white it meant, there was no chemical. When asked to whom this issue was reported, Staff I replied, No one. In an interview at this time, Staff F stated Staff I should have reported there was no sanitizer and that the log on which staff documented the sanitation levels was missing. Staff F proceeded to contact the company that services the dishwasher, and was instructed to Prime the sanitizer bucket by toggling a switch on the side of the dishwasher. Observations on 04/17/2025 at 10:52 AM, showed that after replacing the sanitizer bucket and priming the machine two times, chlorine levels were noted to meet required sanitizing levels. Further interview revealed Staff F replaced the sanitizer bucket the previous day at 3:00 PM but was not aware of the need to prime the new sanitizer bucket. Staff F said it was reasonable to conclude the sanitizer was not functioned since then. Staff F was requested to provide documentation to support staff were educated / trained on how to replace the sanitizer bucket and what to do if inadequate amounts of sanitizer were noted. No information was provided. REFERENCE: WAC 388-97-1100(3) & -2980. .

Mar 2024 28 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 276> Review of a 03/12/2024 emergency department provider note showed Resident 276 arrived to the emergency depa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 276> Review of a 03/12/2024 emergency department provider note showed Resident 276 arrived to the emergency department after a fall resulting in a fractured pelvis. This note showed Resident 276 denied bladder or bowel dysfunction. The provider note showed prior to the fall, Resident 276 was independent with Activities of Daily Living (ADL). Review of a 03/13/2024 hospital Occupational Therapy (OT) evaluation showed OT recommended Resident 276 use a bedside commode for toileting. Review of a 03/15/2024 facility OT evaluation and plan of treatment document showed Resident 276 admitted to the facility on [DATE]. The evaluation showed prior to admission to the facility, Resident 27 was independent with toileting needs. The functional skills portion of this assessment showed Resident 276 was dependent on staff for toileting hygiene and transferring to the toilet. Review of the 03/15/2024 ADL CP showed Resident 276 was not toileted due to having incontinence of their bowel and bladder. This CP directed staff to provide total assistance to Resident 276 for all their incontinent care and hygiene needs. In an interview on 03/17/2024 at 12:06 PM, Resident 276 stated they were up all night, no one checked on me. Resident 276 stated they had to lie in their dirty underwear all night. Resident 276 stated staff told the resident to go pee and number two in my diaper. Resident 276 stated they knew when they had to go to the bathroom, and they were not incontinent of bowel or bladder. In an interview on 03/19/2024 at 6:58 AM, Resident 276 stated they were still using their diaper as a bathroom. In an interview on 03/22/2024 at 8:39 AM, Staff C stated staff referred to hospital documents to assist with initial CP development and assessment of toileting needs. Staff C stated staff should never encourage a resident to use their brief instead of a toilet and stated if a resident wanted to use the toilet, they had the right to do so. Staff C stated if there were barriers to using the toilet, the staff should seek alternative methods to meet the resident's needs. REFERENCE: WAC 388-97-0180. Based on observation, interview, and record review the facility failed to provide care and services that ensured privacy in a manner that maintained and promoted resident rights and resident dignity for 2 of 3 sampled residents (Residents 46 & 276) reviewed for dignity concerns. Failure to dress residents, provide privacy, and assist with toileting placed residents at risk for diminished resident rights, feelings of institutionalization, embarrassment, frustration, disrespect, and diminished self-worth. Findings included . <Resident 46> According to the 09/11/2023 Significant Change Minimum Data Set (an assessment tool), Resident 46 admitted to the facility on [DATE], had multiple medical conditions and impaired memory. Resident 46 was assessed to require one to two-person extensive assistance with transfers, dressing, toileting, and oral hygiene. Observations on 03/17/2024 at 11:23 AM and 2:02 PM, 03/18/2024 at 9:00 AM, and 03/19/2024 at 9:16 AM showed Resident 46 was lying in their bed wearing only a brief. The door and privacy curtain were open allowing staff, other residents, and visitors to see Resident 46 lying in their brief from the hallway. In an interview on 03/19/2024 at 9:35 AM, Resident 46 stated they did not want to wear clothes. Review of Resident 46's comprehensive Care Plan (CP) showed staff did not include Resident 46's refusals to wear clothes or preferred to lay in bed with no clothes on. In an interview on 03/20/2024 at 1:18 PM, Staff P (Social Services Assistant) stated they were aware of Resident 46 refused to wear clothes in bed, but they did not document the refusals in Resident 46's record. In an interview on 03/20/2024 at 1:25 PM, Staff O (Social Services Director) stated staff should have documented Resident 46's preferences/refusals in the CP to direct staff to provide privacy to Resident 46. In an interview on 03/20/2024 at 1:42 PM, Staff C (Assistant Director of Nursing) stated staff should have offered Resident 46 assistance to get dressed and document the refusals in Resident 46's record. Staff C stated staff should have provided privacy by pulling the privacy curtain and closing the door per Resident 46's preferences, but they did not.

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC - a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) as required for 1 of 3 residents (Resident 68) reviewed for beneficiary notification. This failure placed Resident 68 and other residents at risk for not being fully informed and losing their right to an appeals process. Findings included . <Facility Policy> According to the facility policy titled, SNF Beneficiary Notices Under Medicare Part A, revised 11/14/2022, the facility would inform Medicare A beneficiaries when they no longer met the skilled coverage criteria. The policy showed a NOMNC was given by the facility to all Medicare beneficiaries at least two days before the end of their Medicare covered Part A stay because the notice contained information regarding the beneficiary's right to an expedited appeals process review by a Quality Improvement Organization. <Resident 68> The 02/21/2024 admission Minimum Data Set (MDS - an assessment tool) showed Resident 68 admitted to the facility under their skilled Medicare A benefits with a start of care date of 02/14/2024. The Discharge MDS showed Resident 68's Medicare A benefits ended on 02/29/2024. Review of the facility census showed Resident 68 discharged to the community on 02/29/2024. A 02/26/2024 physician progress note showed Resident 68 verbalized they were ready for discharge on [DATE] in the afternoon once their antibiotic therapy was completed. The 02/29/2024 nursing progress note showed Resident 68 was discharged to their home accompanied by their family member. Review of Resident 68's medical records did not show a NOMNC was not provided at least two days prior to the last covered day. In an interview of 03/19/2024 at 8:51 AM, Staff O (Social Services Director) stated it was important to provide beneficiary notices to residents whose skilled services were ending so residents could prepare themselves for a safe discharge or they could exercise their right to an appeals process if/when residents felt they needed more services. Staff O stated they should have, but did not provide Resident 68 a NOMNC as required. REFERENCE: WAC 388-97-0300(1)(e), (5), (6). .

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to initiate and complete a thorough grievance investigation for 2 of 2 residents (Residents 42 & 71) who were reviewed for grievances. The facility failed to ensure there was a resolution for lost property (Resident 42) and how the environmental noise affected their quality of life (Resident 71). These failures placed residents at risk for frustration and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Grievances, revised 02/2024, employee responsibilities in the grievance process included: (1) initiating the Resident Grievance Report for all concerns brought forth by residents, and (2) immediately providing the completed report to the Grievance Officer or designee. The policy showed the responsible department for the grievance identified would communicate with the resident/representative and would attempt to resolve the issue within five days. The policy showed the Grievance Officer or designee would follow-up with the resident/resident representative about the grievance to ascertain satisfaction with the resolution of the reported concern. <Resident 42> Review of the 01/05/2024 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 42 had clear speech, understands, and understood others during communication. On 03/18/2024 at 9:26 AM, Resident 42 stated their white blouse/shirt, which had their name on it, went missing last week and was not found, or given any update by staff. Resident 42 stated they recall telling Staff S (Certified Nursing Assistant), . [Staff S] filled out a form for me. Review of the facility Grievance Logs from 09/15/2023 until 03/18/2024 showed no listed grievance from Resident 42. In an interview on 03/21/2024 at 9:11 AM, Staff S stated when residents tell them personal property was missing, they would initiate the grievance form and would hand it to social services. When asked if they recall Resident 42 telling them their clothes were missing and filling out a grievance form for the resident, Staff S stated, Yes, I gave the form to Staff O [Social Services Director]. In an interview on 03/21/2024 at 9:26 AM, Staff O stated they did not receive any grievance form from Staff S. Staff O reviewed the copies of grievance forms they kept for monitoring and stated there was none for Resident 42. Staff O stated it was important to complete a grievance form for residents with missing properties to ensure a resolution, either found or replaced, was achieved. <Resident 71> Review of the 02/29/2024 admission MDS showed Resident 71 admitted to the facility on [DATE], had clear speech, their memory was intact, and they understood others during communication. Review of the facility census showed Resident 71 was in room [ROOM NUMBER]-2 from 02/25/2024 until 03/14/2024, and then moved to room [ROOM NUMBER]-1 on 03/15/2024. On 03/17/2024 at 11:16 AM, Resident 71 stated they verbalized concerns to social services staff regarding the noise level (when they were still residing in room [ROOM NUMBER]-2) and losing sleep because their roommate kept yelling for help during the day and throughout the night. Resident 71 stated they were moved to the next room over, in room [ROOM NUMBER]-1, but they remained to be bothered by the resident's calling out behavior, .last night, the yelling ran for four hours and it was too difficult to get some sleep . Resident 71's current roommate (in room [ROOM NUMBER]-2) validated Resident 71's statement and stated they were bothered both by the noise level especially at night. This roommate stated they formally wrote a grievance report themselves regarding the same issue. Review of the facility provided Grievance Logs from 09/15/2023 until 03/18/2024 showed there was no grievance investigation initiated for Resident 71. The log showed the resident in room [ROOM NUMBER]-2 filed their grievance on 03/04/2024 and showed a resolution was achieved. In an interview on 03/21/2024 at 8:30 AM, Staff A (Administrator) stated it was important to have a grievance process so the residents would have a voice, their rights addressed, and gave the facility the opportunity to improve, .keeps us [staff] aware of what is going on, of any lingering issues, to be able to identify trends and help improve the facility environment . Staff A stated they expected all employees to know and complete the grievance process. In an interview on 03/21/2024 at 9:28 AM, Staff V (Life Enrichment Director) stated Resident 71 grieved about their yelling roommate during the resident council meeting but they did not think about initiating a grievance investigation or following up accordingly to ensure a resolution was achieved. REFERENCE: WAC 388-97-0460. .

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify the need for and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) for 1 of 21 sample residents (Resident 15). The failure to identify and complete a SCSA MDS left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, (RAI, a manual directing staff on requirements for completion of a Minimum Data Set- MDS) dated [DATE] showed a SCSA must be completed within 14 calendar days after the facility determined or should have determined there was a significant change in the resident's physical or mental condition. An SCSA was appropriate if there were consistent patterns of changes, with either two or more areas of decline. <Resident 15> According to the 02/25/2024 Quarterly MDS Resident 15 usually understood and was understood by others in conversation and had severe memory impairment. The MDS showed Resident 15 had an acute onset change in mental status with inattention and disorganized thinking. The MDS showed Resident 15 had hallucinations and behaviors including intruding on others' privacy. The MDS showed Resident 15 required supervision/touching assistance for eating and oral hygiene, and partial/moderate assistance with lower body dressing and putting on/taking off footwear. Prior to the 02/25/2024 Quarterly MDS, the facility last completed an MDS assessment on 11/25/2023. The 11/25/2023 Quarterly MDS showed Resident 15 understood and was understood by others. This MDS did not indicate the presence of an acute onset mental status change. The MDS did not show Resident 15 had hallucinations. The MDS showed Resident 15 showed no behaviors during the assessment period. The MDS showed Resident 15 required set up/clean up assistance for eating and oral hygiene, and supervision/touching assistance for lower body dressing and putting on/taking off footwear. A 02/03/2024 nursing to therapy communication progress note showed Resident 15 was experiencing a possible change in condition in the following areas: Transfers, Positioning/Bed mobility, Falls, Safety/Judgment. A 02/13/2024 alert progress note showed Resident 15 hallucinated that two snakes were on their bed. In an interview on 03/22/2024 at 9:12 AM, Staff D (MDS Coordinator) stated a resident required a SCSA MDS when facility staff identified a resident had a significant decline in two or more areas. When asked if the facility should have identified Resident 15 required a SCSA MDS, Staff D stated they realized after completion of the 02/27/2024 Quarterly MDS they may have missed the opportunity to complete a SCSA MDS, That was a problem. For some reason, I did not do one. Staff D stated they emailed their regional nurse who asked Staff D if they wanted to start a SCSA MDS for Resident 15. Staff D stated they declined but should have said yes. REFERENCE: WAC 388-97 -1000 (3)(b). .

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

<Resident 44> According to the 02/19/2024 Annual MDS, Resident 44 had diagnoses including brain cancer, dementia (loss of brain function which affects thinking and behavior), and psychotic disor...

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<Resident 44> According to the 02/19/2024 Annual MDS, Resident 44 had diagnoses including brain cancer, dementia (loss of brain function which affects thinking and behavior), and psychotic disorder with delusions. The assessment showed Resident 44 received antipsychotic medication on a routine basis during the assessment period. This assessment showed Resident 44 had behaviors including threatening and cursing at others that put others at significant risk for physical injury. The assessment showed Resident 44's behavior worsened and affected Resident 44's participation in activities. Review of the 01/03/2023 Level I PASRR showed Resident 44 was identified with an SMI indicator for depression and no dementia diagnosis, and Level II PASRR evaluation was not required. Review of a 03/06/2024 psychiatrist's progress note showed Resident 44 was easily irritable, with intermittent anxiety during exam. The note showed Resident 44 declined medications for anxiety and stated, I do not want any more medications. The psychiatrist recommended staff continue monitoring Resident 44's behaviors for psychotic features. Review of the March 2024 Medication Administration Record showed Resident 44 received an antipsychotic medication every day for psychosis due to their diagnosis. In an interview on 03/20/2024 at 1:05 PM, Staff O stated Resident 44's Level I PASRR was updated on 01/03/2024 and a Level II PASRR was not indicated. Staff O stated Resident 44's behaviors worsened and the resident received antipsychotic medications twice daily. Staff O reviewed Resident 44's Level I PASRR and stated the form was inaccurate and required revision to refer to Level II evaluation in accordance with to Resident 44's current mental status. REFERENCE: WAC 388-97-1915 (1)(2)(a-c). Based on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 2 of 5 residents (Residents 7 & 44) reviewed for PASRRs. This failure left residents at risk for risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> According to the facility's April 2023 PASRR Requirements policy, if at any time the facility found a previous Level 1 PASRR was incomplete, erroneous, or no longer accurate the facility would immediately complete a new Level 1 PASSR screening. The policy showed as applicable the facility would submit the new level 1 to the state agency for consideration of Level 2 services. <Resident 7> According to the 02/08/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 7 had moderate memory impairment and verbal behaviors four-to-six times a week that interfered with activities, created a risk for injury, and disrupted care or the environment. The MDS showed Resident 7 had diagnoses including traumatic brain dysfunction, depression, and psychotic disorder. Record review showed the facility completed a Level 1 PASRR for Resident 7 on 06/23/2022. The 06/23/2022 Level 1 PASRR showed Resident 7 had depression, anxiety, and a psychotic disorder. The Level 1 PASRR showed Resident 7 was more resistant to care and verbally [and] physically aggressive . when staff provided care and indicated a Level 2 evaluation (a process to assess a resident's need for specialized mental health/behavioral services) was required. The revised 08/01/2023 new Level 1 PASRR completed . Care Plan (CP) included a goal for a Level 2 PASRR evaluation to be completed and recommendations implemented by 08/31/2022 for Resident 7. This CP included a 06/24/2022 intervention showing the facility's social services department would refer Resident 7 for a Level 2 PASRR evaluation. Record review showed no Level 2 PASRR was included in Resident 7's record. In an interview on 03/19/2024 at 10:35 AM, Staff O (Social Services Director) stated the purpose of a Level 1 PASRR screening was to assess residents for Serious Mental Illness (SMI) and intellectual disabilities. Staff O stated PASRR screenings were to be completed prior to admission, and when significant changes occurred such as increased behaviors, and if an initial screening was identified as incorrect. Staff O reviewed Resident 7's record and stated they did not see any follow up to the 06/23/2022 Level 1 PASRR. Staff O stated either a Level 2 evaluation or level 2 denial letter should be Resident 7's chart but was not. Staff O stated they would provide any additional documentation if located. No additional information was provided.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

<Resident 52> According to the 02/17/2024 Annual MDS, Resident 52 had clear speech, their memory was intact, and had medical conditions including heart failure, high blood pressure, and irregula...

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<Resident 52> According to the 02/17/2024 Annual MDS, Resident 52 had clear speech, their memory was intact, and had medical conditions including heart failure, high blood pressure, and irregular heart rate/rhythm. In an observation and interview on 03/17/2024 at 08:10 AM, Resident 52 was observed sitting in their wheelchair. Both their legs were wrapped with compression stockings. Resident 52 stated they took a diuretic (a medication that helped reduce fluid build-up in the body) daily to manage the swelling on their legs and their high blood pressure. Review of Resident 52's POs showed a 02/27/2024 order for a diuretic daily. The order came with parameters instructing the nurse to hold the diuretic if Resident 52's heart rate was less than 60 beats per minute (BPM) and to notify the physician. The March 2024 Medication Administration Record (MAR) showed, on 03/01/2024, Resident 52's heart rate was 55 BPM; the diuretic was administered to Resident 52 and was not held by the nurse as ordered. Review of Resident 52's progress notes from 03/01/2024 until 03/18/2024 did not show the nurse notified the physician as instructed. In an interview on 03/20/2024 at 10:46 AM, Staff C confirmed the diuretic was administered outside the parameters by the nurse as shown in the MAR and stated there was no physician notification documented in Resident 52's medical records. Staff C stated they expected the nurses to follow medication parameters as ordered for resident safety. 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 (POs) were clarified for 2 (Residents 6 & 30) of 21 sample residents; blood pressure was measured as ordered for 2 (Residents 15 & 7) of 21 sample residents; and POs were followed for 2 (Residents 55 & 52) sample residents. These failures placed residents at risk for unmet care needs, inappropriate care, falling, weight loss, and other negative health outcomes. Findings included . <Clarifying Orders> <Resident 6> According to the 01/04/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 6 had medically complex diagnoses including insomnia, muscle spasms and three Stage 4 Pressure Ulcers (open areas of skin caused by pressure over bony prominences; Stage 4 indicating full thickness tissue loss with exposed bone, tendon, or muscle). The MDS showed Resident 6 received as-needed pain medications, and experienced pain that occasionally affected their sleep and day-to-day activities. Record review showed Resident 6 had two as-needed pain POs: a 01/08/2024 PO for a non-narcotic pain medication, give 500 Milligram (MG) by mouth every six hours as needed for pain or fever; a 02/21/2024 PO for a narcotic pain medication, give 10 MG every eight hours as needed for chronic pain. Neither order had parameters to show nurses under what circumstances each medication should be administered. Review of the March 2024 Medication Administration Record (MAR) showed Resident 6 was not provided their as-needed non-narcotic pain medication from 03/01/2024 through 03/18/2024. The March 2024 MAR showed Resident 6 was provided the narcotic pain medication six times from 03/01/2024 through 03/18/2024: once for a pain of 3 out of 10, once for a pain of 4 out of 10, three times for 5 out of 10 pain, and once for a pain of 7 out of 10. In an interview on 03/22/2024 11:08 AM Staff B (Director of Nursing) stated the narcotic pain medication should be administered for moderate to severe pain, and the non-narcotic pain medication should be used for mild pain. Staff B stated the orders did not specify when to administer which medication, and nurses should offer the non-narcotic medication first. <Resident 30> According to the 02/29/2024 Quarterly MDS, Resident 30 had clear speech and medical conditions including memory impairment, anxiety, and mood disorder. The MDS showed Resident 30 exhibited wandering behavior that occurred daily. An 11/24/2023 behavior CP showed Resident 30 was an elopement risk because of their exit-seeking behavior and the resident wore a wander guard alarm (a safety device that sounded when near an exit) provided by the facility. A 02/21/2024 CP intervention directed the staff to monitor the resident's wander guard alarm. Observation on 03/17/2024 at 8:31 AM showed a wander guard alarm for Resident 30's wandering behavior was placed around the resident's left leg/ankle. Review of the March 2023 Treatment Administration Record (TAR) showed a 11/24/2023 order to check the wander guard alarm placement and the skin underneath the device on Resident 30's right ankle. The TAR order was signed off as completed by nurses on all three shifts (day, evening, and night) from 03/01/2024 until 03/19/2024. In an interview on 03/21/2024 at 12:46 PM, Staff C (Assistant Director of Nursing) confirmed the wander guard alarm was located on the left ankle of Resident 30 and not the right ankle as written in the TAR order. Staff C stated nurses should not be signing off on the TAR that the wander guard alarm placement and the skin integrity were checked because the order was incorrect. <Orthostatic Blood Pressure Measurement> <Resident 15> According to the 02/25/2024 Quarterly MDS Resident 15 had diagnoses including debility (physical weakness), seizures, psychotic disorder, bipolar disorder, and a history of falling. The MDS showed Resident 15 had two or more falls since the prior MDS assessment, and took antipsychotic and diuretic, opioid, and antidepressant medications. Resident 15's POs included 03/01/2023 POs to measure their orthostatic blood pressure (a safety measure where a resident's blood pressure is measured when lying, then sitting, and if practical, standing to monitor for changes in blood pressure with changes in elevation that could cause dizziness and falls). Review of the December 2023 MAR showed on 12/21/2023 Resident 15's blood pressure was measured at 118/72 when lying, 118/72 when sitting, and 118/72 when standing, indicating no change in blood pressure with change in elevation. Review of the January 2024 MAR showed on 01/20/2023 Resident 15's blood pressure was measured at 114/83 when lying, 114/83 when sitting, and 114/83 when standing, indicating no change in blood pressure with change in elevation. Review of the February 2024 MAR showed on 02/19/2023 Resident 15's blood pressure was measured at 122/66 when lying, 122/66 when sitting, and 122/66 when standing, indicating no change in blood pressure with change in elevation. In an interview on 03/22/2024 at 9:45 AM Staff B stated orthostatic blood pressure were measured to monitor changes in blood pressure with elevation. Staff B stated it was unusual for blood pressure to stay the same when moving from lying to sitting, or from sitting to standing. Staff B reviewed the December 2023 through February 2024 MARs and stated it might be that staff documented incorrectly when Resident 15 refused or was unable to participate at the time to move from lying to sitting to standing. Staff B stated if that was the case the nurse should have documented as such on the MAR. <Resident 7> According to the 02/08/2024 Quarterly MDS Resident 7 had diagnoses including traumatic brain dysfunction, a seizure disorder, depression, and a mental health diagnosis. The MDS showed Resident 7 received antipsychotic, antidepressant, and narcotic pain medications. Review of Resident 7's POs showed 07/28/2022 POs to measure their orthostatic blood pressure lying and sitting every 30 days. Staff were not required to measure Resident 7's standing blood pressure as Resident 7 was not assessed to be safe to stand. Review of the January 2024 MAR showed on 03/21/2024 Resident 7's lying blood pressure was 112/65, and their sitting blood pressure was also 112/65. Review of the February 2024 MAR showed on 03/19/2024 Resident 7's lying blood pressure was 110/59, and their sitting blood pressure was also 110/59. In an interview on 03/22/2024 at 9:45 AM Staff B stated it was unlikely that Resident 7's blood pressure would not change with the change in elevation from lying to sitting. Staff C stated it was important to follow the PO and accurately document Resident 7's orthostatic blood pressure. <Following Orders> <Resident 55> According to the 02/03/2024 Annual MDS Resident 27 had severe memory impairment, and diagnoses including non-traumatic brain dysfunction, difficulty swallowing, dementia, and the presence of a feeding tube hole. The MDS showed Resident 55 received nutrition through a feeding tube. Review of Resident 55's POs showed a 07/11/2023 PO to provide 1200 ML of artificial nutrition via feeding tube at @ 60 ML/hour for 20 hours. The PO showed staff should start the pump at 12PM daily and finish the feeding at 8AM or until the total volume of 1200 ml was infused. The PO showed staff should document the total amount provided in ML. A 07/18/2023 order showed Resident 55 should not receive food or medications by mouth. The 03/05/2023 tube feeding Care Plan (CP) showed Resident 55's daily feeding should start at 12 PM and end at 8 AM or when 1200 ML was infused. Review of Resident 55's weight records showed no significant weight loss between 09/27/2023 and 03/15/2024. Observation on 03/18/2024 at 12:41 PM showed the bottle of artificial nutrition was started on 03/18/2024 at 05:00 AM, rather than at 12 PM as ordered. The bottle had 875 ML of the artificial nutrition left, indicating the bottle was not started per the PO. Observation on 03/19/2024 at 10:31 AM showed Resident 55's feeding pump was off. The artificial nutrition bag was not labeled to indicate when the feeding started but the tubing from the bottle was labeled at 3:20 PM. There was 800 ML of artificial nutrition left in the bottle, indicating the bottle was not started per the PO. Observation on 03/21/2024 at 9:51 AM showed Resident 55's feeding pump was off. The bottle of artificial nutrition was labeled 03/21/2024 but the time it was started was not added. The bottle had 775 ML of the artificial nutrition remaining. Observation on 03/22/2024 at 7:58 AM showed the artificial nutrition bottle labeled 03/22/2024 and did not include a time. In an interview on 03/22/2024 at 8:23 AM Staff C (assistant Director of Nursing) stated nurses should provide Resident 55's artificial nutrition as ordered. Staff C stated the feeding should start at 12 PM and finish at 8 AM. Staff C stated nurses should label the artificial nutrition and tubing with a date and time.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

<Resident 30> The 02/29/2024 Quarterly MDS showed Resident 30 had clear speech and medical conditions including memory impairment, mental health diagnoses, and malnutrition. The MDS showed Resid...

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<Resident 30> The 02/29/2024 Quarterly MDS showed Resident 30 had clear speech and medical conditions including memory impairment, mental health diagnoses, and malnutrition. The MDS showed Resident 30 did not have skin issues during the assessment period. Observation and interview on 03/17/2024 at 8:36 AM showed Resident 30 had very thin, fragile skin. An adhesive dressing was on the resident's right forearm. Resident 30 stated they were unsure of what was underneath the dressing at the time, but believed it had something to do with them scratching their arm. The same observations where Resident 30 had an adhesive dressing were made on 03/18/2024 at 12:42 PM, on 03/19/2024 at 10:07 AM, on 03/20/2024 at 1:14 PM, and on 03/21/2024 at 8:45 AM. Review of a 03/08/2024 facility incident report showed Resident 30 had a skin impairment of unknown origin on the right forearm. The report showed the provider was notified and Resident 30 was diagnosed with dermatitis (a skin condition characterized by swelling and irritation) and was prescribed a medicated cream to be applied for five days. A 03/08/2024 skin CP showed Resident 30's right forearm dermatitis was identified and a CP intervention showed a skin treatment was to be done daily until the condition was healed. Review of the POs showed a 03/08/2024 order directing staff to cleanse the resident's right forearm irritation with normal saline, pat dry, apply a non-adhesive (non-stick) dressing, and wrap the right forearm with a cloth mesh (net-like) dressing. Review of the March 2024 Treatment Administration Record (TAR) showed the nurses signed off on the right forearm treatment as completed from 03/17/2024 until 03/20/2024 without using the dressing materials as ordered. During the skin/wound care observation on 03/21/2024 at 2:40 PM with Staff JJ (Licensed Practical Nurse), the skin on Resident 30's right forearm was observed dry and healing; the areas where the old adhesive dressing was attached was bright red. In an interview on 03/21/2024 at 2:23 PM, Staff C (Assistant Director of Nursing) confirmed the adhesive dressing applied by the nurses on Resident 30's right forearm from 03/17/2024 until 03/20/2024 as observed was not the treatment ordered for the resident. Staff C stated they expected the nurses to follow the PO/TAR as ordered for resident safety. <Resident 52> According to the 02/17/2024 Annual MDS, Resident 52 had clear speech, their memory was intact, and had medical conditions including diabetes. The MDS showed Resident 52 was administered insulin (injectable diabetes medication) daily during the assessment period. The 03/05/2024 diabetes CP showed Resident 52 was monitored by staff for diabetic medication effectiveness and side effects. Review of Resident 52's POs showed a 03/06/2024 order for insulin administration twice a day for the resident's diabetes. Review of the March 2024 Medication Administration Record (MAR) showed, from 03/07/2024 until 03/18/2024, Resident 52's injection site was not being rotated. The MAR report showed Resident 52's insulin was injected on their left abdominal area in 13 out of 23 opportunities of the medication being administered. On 03/19/2024 at 11:31 AM, Resident 52 stated they injected their own insulin, .they [nurses] give me my insulin pen and I inject it in my abdomen myself . Review of Resident 52's medical records did not show a self-administration of medication assessment was completed for the resident. In an interview on 03/20/2024 at 10:46 AM, Staff C confirmed Resident 52 was not assessed or evaluated for self-administration of their insulin. Staff C stated the nurses should be administering Resident 52's injectable medication themselves, .[nurses] need to perform the assessment first if [Resident 52] chooses to administer [insulin] on their own . Staff C stated they expected the nurses to rotate the insulin injection sites to decrease the risks of increased skin bruising and tissue damage. In an interview on 03/22/2024 at 8:27 AM, Staff L (Chief Nursing Officer) stated they expected the nurses to complete a self-medication administration assessment first before letting a resident do it themselves for resident safety. REFERENCE: WAC 388-97-1060(1). Based on observation, interview, and record review, the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of skin care/treatment and self-medication administration for 3 of 21 residents (Resident 15, 30, & 52) reviewed for quality of care. These failures placed residents at risk for undiagnosed condition of the skin and soft tissues, skin breakdown, unsafe medication administration, and a decreased quality of life. Findings included . <Resident 15> According to the 02/25/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 15 had highly impaired memory and medical diagnoses including heart failure, diabetes (unstable blood sugar in the body), mental health diagnoses, and heart failure. The MDS showed Resident 15 was assessed with no skin impairments. In an interview on 03/17/2024 at 8:31 AM, Resident 15 stated they were supposed to get a growth on the right side of their neck treated. Resident 15 stated nothing was done yet. Resident 15 showed a small lump under the skin on the right side of their neck. Review of the Physician's Orders (POs) showed a 02/29/2024 PO to complete a total body skin check each week. Review of Resident 15's comprehensive Care Plan (CP) showed no CP addressing the assessment or treatment of the lump on Resident 15's neck. A 10/24/2023 progress note showed an order was made for an ultrasound of Resident 15's neck and sent to the medical records department. Progress notes on 12/15/2023 and 03/05/2024 showed repeated orders for an ultrasound for Resident 15's neck In an interview on 03/21/2024 at 10:07 AM, Staff W (Medical Records) stated when an order was created for a resident, the nurse manager reviewed the order and send it to medical records. Once medical records processed the order requiring an appointment, the information was sent to the transportation coordinator, who would schedule the appointment. Staff W stated if they received the 10/24/2023 order, they would have processed it and notified the transportation coordinator of the resident's need for an appointment and transportation. In an interview on 03/21/2024 at 10:10 AM, Staff X (Transportation Coordinator) stated they did not receive notification from Staff W regarding Resident 15's 10/24/2023 PO for an ultrasound. In an interview on 03/21/2024 at 10:48 AM, Staff B (Director of Nursing) provided documentation showing Resident 15 had an ultrasound of their neck on 03/06/2024, four months and 14 days after the original PO. The ultrasound showed a 1.9 x 1.0 x 1.7 centimeter mass. Staff B stated Resident 15 was referred to an Ear-Nose-Throat specialist after the ultrasound. Staff B stated the ultrasound should have, but was not provided timely.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure residents with vision deficits were assessed and provided Assistive Devices (ADs) to maintain vision abilities for 1 of 1 residents (Resident 42) reviewed for vision needs. These failures placed Resident 42 and other residents at risk for unmet care needs and a decreased quality of life. Findings included . <Facility Policy> Review of the facility's policy titled, Vision and Hearing, revised 05/2023, the facility would assist residents in obtaining routine and prompt vision/hearing care. The policy showed the social services department would identify residents who needed eye examinations and would coordinate routine services. <Resident 42> According to the 01/05/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 42 had clear speech, understands and understood others during communication, and had a diagnosis of diabetes (unstable blood sugar levels in the body). The MDS showed it was very important for Resident 42 to have reading materials. The MDS showed Resident 42 had adequate vision and used a pair of eyeglasses as an AD. The 11/02/2023 vision care plan showed Resident 42 had altered sensory function related to their visual disturbance and listed vision consults as an intervention. On 03/18/2024 at 9:17 AM, Resident 42 was in bed wearing their eyeglasses and was observed squinting while reading their electronic device. Resident 42 stated their eyes were bad and their eyeglasses were no longer appropriate. Resident 42 stated it was a while since they last saw an eye doctor. Resident 42 stated they needed assistance to have their eyes checked so they could get a new pair of eyeglasses. Review of Resident 42's medical records showed a 05/23/2023 physician note indicating the resident had a diagnosis of diabetic eye disease (eye complication characterized by poor vision). A 06/05/2023 physician note showed Resident 42 complained of seeing double and was referred to see a specialist to rule out stroke (brain damage). The facility was not able to provide any documentation to support Resident 42 was provided an eye consultation to address their need for new prescription eyeglasses. In an interview on 03/21/2024 at 10:02 AM, Staff O (Social Services Director) stated they were not aware Resident 42 needed vision care services. Staff O confirmed Resident 42 was not in the list of residents to be seen for routine vision services. In an interview on 03/22/2024 at 8:31 AM, Staff A (Administrator) stated it was important to ensure vision care and services were provided to residents for better quality of life. Staff A stated adequate vision enabled resident's independence in performing their activities of daily living including their reading enjoyment. In an interview on 03/22/2024 at 8:42 AM, Staff L (Chief Nursing Officer) stated Resident 42's vision deficit should have, but was not properly assessed during the MDS completion. Refer to F641- Accuracy of Assessments. REFERENCE: WAC 388-97-1060(3)(a). .

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure 1 of 5 residents (Resident 6) reviewed for Pressure Ulcers (PU) were provided ordered interventions they required for the prevention or worsening of PU. This failure to implement pressure reducing devices in accordance with physician's orders placed residents at risk for PU development, worsening of PU, pain, and a diminished quality of life. Findings included . <Facility Policy> The facility's revised 02/03/2023 Pressure Ulcer Prevention and Treatment policy showed all residents would be assessed for the risk of acquiring a PU, and individualized interventions would be identified and implemented. The policy identified support surfaces such as a bed or a wheelchair as possible interventions. <Resident 6> According to the 01/04/2023 Annual Minimum Data Set (MDS - an assessment tool) Resident 6 had medically complex diagnoses including Diabetes Mellitus (DM - a condition making regulation of blood sugar more difficult), Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) PU, and the presence of bacteria in their blood. The MDS showed Resident 6 had three Stage 4 PU, two present on admission. Review of the Physician's Orders showed a 02/20/2024 order for an air mattress (to help reduce pressure). The order directed staff to set the air mattress at a weight of 270 pounds (Lbs.) Record review showed Resident 6's current weight was 242 Lbs. taken on 03/15/2024. The 10/24/2023 air mattress with bolsters [related to] weakness to promote wound healing and pressure reduction . care plan had a goal for Resident 6 to be free of complications from use of an air mattress. The care plan directed staff to set the air mattress at 270 Lbs. Observation on 03/20/2024 at 12:22 PM showed Resident 6's air mattress set at 360 Lbs. rather than the 270 Lbs. ordered, which made the mattress firmer than ordered. There was a label attached to the air mattress pump directing staff to ensure the mattress was set at 270 Lbs. Resident 6's air mattress was observed to be set at 360 Lbs. on 03/21/2024 at 8:20 AM. At this time Staff T (Licensed Practical Nurse) confirmed the mattress was set at 360 Lbs. Staff T tried to adjust the mattress and struggled for several seconds before noticing and pressing the lock/unlock button. Once the mattress settings were unlocked, Staff T set the mattress to the correct setting of 270 Lbs. Staff T stated it was the responsibility of nurses to ensure the mattress was set correctly. Staff T stated they routinely checked the mattress for placement but did not realize they were required to also check the mattress pressure setting. Staff T stated they were unsure why the mattress was not set at 270 Lbs. as ordered. In an interview on 03/22/2024 at 11:02 AM Staff B (Director of Nursing) stated it was important for Resident 6's air mattress to be set correctly to prevent the development of more PU. REFERENCE: WAC 388-97-1060 (3)(b). .

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Wander Guard Alarm> <Resident 72> Review of the 02/29/2024 admission MDS showed Resident 72 had a diagnosis of a p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Wander Guard Alarm> <Resident 72> Review of the 02/29/2024 admission MDS showed Resident 72 had a diagnosis of a progressive memory loss disorder and was able to walk around their room and facility. This assessment showed Resident 72 wandered four to six days of the assessment period and used a wander guard alarm daily. Review of a 02/23/2024 Elopement CP showed Resident 72 was at risk for elopement related to attempting to exit the facility without supervision. Interventions included allowing Resident 72 to wander safely throughout the facility and Resident 72 had a wander alarm device to their right ankle. In an interview on 03/17/2024 at 8:45 AM, Resident 72 stated they were ready to go home and the resident provided most of their own care. In an observation on 03/17/2024 at 9:45 AM, Resident 72 was walking up and down the hallway looking for coffee. Review of Resident 72's March 2024 Medication Administration Record showed staff checked placement of Resident 72's wander guard alarm device twice daily. This MAR showed staff documented Resident 72 was without their wander guard alarm in place on the evening of 03/16/2024, both shifts on 03/17/2024, both shifts on 03/18/2024. Observation on 03/19/2024 at 10:30 AM showed Resident 72 without a wander guard alarm to either ankle. In an interview and observation on that day at 10:35 AM, Staff FF (Certified Nurse's Assistant) confirmed Resident 72 was missing their wander guard alarm. In an interview at that same time, Staff A (Administrator) stated Resident 72 sometimes removed their wander guard alarm and there should be a note in Resident 72's record related to self-removal of the device. In an observation and interview on 03/19/2024 at 10:51 AM, Staff HH (Licensed Practical Nurse) stated Resident 72 had a wander guard alarm. Staff HH stated they thought they saw Resident 72's wander guard alarm around 6:00 AM that morning. Staff HH checked Resident 72's right and left ankle and confirmed the wander guard alarm was missing. Review of Resident 72's Nursing Progress Notes (NPN) showed no progress notes on 03/16/2024, 03/17/2024, or 03/18/2024 related to the missing wander guard alarm. A NPN on 03/19/2024 at 11:18 AM showed Resident 72 was observed without the wander guard alarm. This note shows Resident 72 placed on increased supervised checks for monitoring at the present time. In an interview on 03/21/2024 at 1:36 PM, Staff B (Director of Nursing - DON) stated if a resident's wander guard alarm was displaced, the resident would be placed on 15-minute safety checks and additional staff would be implemented to help with monitoring the resident. Staff B stated the 15-minute checks should be documented but was unable to provide documentation at that time. In a follow up interview on 03/22/2024 at 10:10 AM, Staff B stated they expected staff to notify the DON when a wander guard alarm was noted to be missing. Staff B stated 15-minute safety checks should be implemented immediately and Resident 72 should be placed on alert on 03/16/2024 when the device was first noted to be missing. At that time, Staff B stated staff put Resident 72 on alert but Staff B stated they did not have documentation for it. REFERENCE: WAC 388-97-1060(3)(g). <Bolster Air Mattress> <Facility Policy> According to the facility policy titled, Safety Device Application, revised 04/07/2023, a resident must be thoroughly evaluated for the use of safety devices by the Interdisciplinary Team. The policy showed the least restrictive safety device would be used by the facility as indicated by the resident's condition. <Resident 71> Review of the 02/29/2024 admission MDS showed Resident 71 admitted to the facility on [DATE], had clear speech, their memory was intact, and understood others during communication. The MDS showed Resident 71 did not have any skin issues and was not a fall risk. Review of the facility census showed Resident 71 was in room [ROOM NUMBER]-2 from 02/25/2024 until 03/14/2024, and then moved to room [ROOM NUMBER]-1 on 03/15/2024. In an observation and interview on 03/17/2024 at 11:02 PM, Resident 71 was lying on a bolster air mattress in bed. Resident 71 stated the mattress and bed came that way when they were transferred in the room, .the mattress wasn't like this in the other room. Resident 71's roommate in room [ROOM NUMBER] stated the prior resident who discharged used it [bolster mattress]. Resident 71 stated they had difficulty transferring into their wheelchair freely to go to the bathroom because the raised bolsters hindered their movement. The 02/22/2024 Activities of Daily Living Care Plan (CP) showed Resident 71 required minimal staff assistance for transferring and toileting. Review of Resident 71's medical records did not show an assessment was completed regarding the resident's use of a bolster air mattress. In an interview on 03/17/2024 at 11:26 AM, Staff U (Maintenance Director) stated they were responsible for switching the bed back to a regular mattress when a resident who used one was discharged from the facility. Staff U stated it was important to ensure residents were using the appropriate mattress for safety, .we [staff] could not just give a resident any mattress . In an interview on 03/17/2024 at 11:39 AM, Staff JJ (LPN) stated the use of bolster air mattress could make residents feel trapped in their bed especially when the resident was mobile, .it would be difficult for them [residents] to self-transfer .they can also fall . In an interview on 03/17/2024 at 11:53 AM, Staff B stated an assessment must be conducted first before any device was used/put in place for residents that could compromise their safety, including a bolster air mattress. Staff B stated Resident 71 did not have a safety assessment completed because the resident did not need a bolster air mattress. Staff B stated the mattress should be removed and replaced with a regular bed. Based on observation, interview, and record review the facility failed to identify, assess, and implement interventions to prevent accidents for 3 of 6 residents (Residents 60, 71, & 72) reviewed for accidents. The facility failed to identify and assess 1 of 1 resident (Resident 60) for smoking, 1 of 1 resident (Resident 71) for a bolster air mattress (an air inflated mattress with propped up support to prevent accidental roll-outs), and 1 of 1 resident (Resident 72) for wander guard monitoring related to an elopement risk. These failures left residents at risk for injury, entrapment, and elopement. Findings included . <Facility Policy> Record review of the facility policy titled, Smoking, updated on 08/2022, showed the facility would screen all residents who smoked upon admission, quarterly, and as needed to determine any special needs and to assess their ability to smoke independently. The policy showed the facility would store all smoking materials in a locked storage cabinet in the resident's room, at the nurse's station, or another designated location in the facility. <Smoking> <Resident 60> According to the 02/21/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 60 had clear speech, their memory was intact, and they understood others during communication. The MDS showed Resident 60 required minimal assistance with transfers, toileting, and bed mobility. The MDS showed Resident 60 used a wheelchair (w/c) for mobility. In an interview on 03/17/2024 at 1:33 PM, Resident 60 stated they smoked twice a day and had their smoking materials in their jacket. Resident 60 stated they knew the rule to not to smoke on facility property. Review of Resident 60's record showed Resident 60 did not have a smoking assessment completed. In an interview on 03/19/2024 at 7:58 AM, Staff N (Licensed Practical Nurse - LPN) stated staff knew Resident 60 was smoking and kept smoking materials with them. Staff N stated Resident 60 was alert enough to know to smoke safely away from the facility property. In an interview on 03/19/2024 at 9:32 AM, Staff L (Chief Nursing Officer) stated the facility was a nonsmoking facility. Staff L stated they were unaware Resident 60 smoked or that Resident 60 kept smoking materials in their jacket. Staff L stated the expectation was to assess residents who smoked to determine if they were safe to smoke independently or needed supervision, but they did not complete the smoking assessment. In an interview on 03/19/2024 at 9:36 AM, Staff A (Administrator) stated they were unaware Resident 60 smoked. Staff A stated staff should have notified the supervisor, completed the smoking assessment to determine if Resident 60 needed to be supervised, and the smoking material locked for safety reasons but they did not.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 226> According to 02/22/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 226 had clear speec...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 226> According to 02/22/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 226 had clear speech, understood others during communication, and had medical conditions including systemic infection, pulmonary disease, and muscle weakness. Review of the 02/15/2024 respiratory Care Plan (CP) showed Resident 226 had asthma due to allergies, and directed nursing staff to monitor the resident's oxygen saturation (amount of oxygen in the blood). The CP did not show supplemental oxygen was being administered to Resident 226. On 03/17/2024 at 9:00 AM, Resident 226 was observed lying in bed and receiving three LPM of supplemental oxygen via a nasal cannula; the humidifier bottle attached to the oxygen concentrator was observed empty. Review of Resident 226's PO showed a 02/27/2024 order to administer two LPM of supplemental oxygen every 12 hours PRN (as needed basis) for shortness of breath. In an interview on 03/17/2024 at 11:43 AM, Staff JJ (LPN) stated the amount of supplemental oxygen ordered for Resident 226 was two LPM and not three LPM as observed. Staff JJ stated the humidifier bottle should be changed to avoid nasal injuries (nosebleed) and prevent Resident 226's nasal airways from drying up, but was not. Observations and interview on 03/17/2024 at 9:00 AM, 03/18/2024 at 10:17 AM, and 03/19/2024 at 12:48 showed Resident 226 was administered supplemental oxygen. Resident 226 stated they were using supplemental oxygen continuously and would take the nasal cannula off when personal care was being provided to them in bed, .only when [staff] are turning and changing me in bed. I need to have it [supplemental oxygen] on all the time even if I am just lying here so I don't get short of breath. Review of the March 2024 Medication Administration Record (MAR) did not show the PRN order was being signed off by the nurses who administered the supplemental oxygen to Resident 226. The facility was not able to provide any documentation to support the nurses did account for the PRN order administered as observed. In an interview on 03/19/2024 at 1:31 PM, Staff C stated the administration of PRN supplemental oxygen should be documented in the MAR so the physician could track Resident 226's supplemental oxygen use and determine if the order needed adjustment. Staff C stated the nurses should have, but did not notify the physician regarding Resident 226's duration of supplemental oxygen use (PRN versus continuous). REFERENCE: WAC 388-97-1060 (3)(j)(vi). Based on observation, interview, and record review the facility failed to ensure 2 of 2 sampled residents (Residents 176 & 226) reviewed for respiratory care received care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to the physician ordered flow rates (Resident 176 & 226) and to ensure correct equipment use (Resident 226) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, and a decreased quality of life. Findings included . <Facility Policy> According to the facility policy titled, Oxygen Management, revised 08/2023, the facility would require that a physician's order be obtained prior to the administration of oxygen and all orders of oxygen therapy must include duration of use. The policy showed equipment used, including the oxygen concentrator (a medical device that delivered supplemental oxygen) and the prefilled humidifier to prevent possible nasal dryness. <Resident 176> Resident 176 admitted to the facility on [DATE] with a diagnosis of asthma (a lung disease with narrowing of the airway, inflammation, and difficulty breathing) and kidney failure. Observations on 03/17/2024 at 9:36 AM and 03/18/2024 at 8:10 AM showed Resident 176 was lying in bed and receiving supplemental oxygen at two Liter Per Minute (LPM) via a nasal cannula (a device that delivered extra oxygen through a tube and into the nose). Review of Resident 176's March 2024 Physician Orders (POs) showed there was no order to administer oxygen treatment to Resident 176. In an interview on 03/18/2024 at 10:24 AM, Staff N (Licensed Practical Nurse - LPN) reviewed Resident 176's record and stated there should be a PO to administer oxygen for Resident 176, but there was none. In an interview on 03/20/2024 at 11:41 AM, Staff C (Assistant Director of Nursing) stated staff should have called the physician and received the oxygen orders for Resident 176 prior to the administration, but they did not. Staff C stated staff should not provide any treatment without a PO.

CONCERN (D)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide medically-related social service interventions that addressed refusal of care for 1 of 2 residents (Resident 226) reviewed for rehabilitation services and 1 of 5 residents (Resident 52) reviewed for unnecessary medications. Failure to have a process for resident refusals, identify, and find ways to support residents needs related to refusals placed residents at risk for early termination of skilled care benefits (Resident 226), unnecessary use of pain medications (Resident 52), unmet care needs, and a decreased quality of life. Findings included . <Skilled Services> <Facility Policy> Review of the undated facility policy titled, Therapy Policy and Procedures, showed the facility's therapy evaluations served as a care plan (CP) and should clearly indicate why therapy services was reasonable and medically necessary. The policy showed the facility would conduct Interdisciplinary Team (IDT) communication, including nursing, social services, and rehabilitative department, to discuss resident's progress to therapy. <Resident 226> According to 02/22/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 226 had clear speech, understood others during communication, and had medical conditions including systemic infection, pulmonary disease, and muscle weakness. Review of the facility census showed Resident 226 admitted to the facility on [DATE] under their managed Medicare A benefits for skilled services. The census showed Resident 226's skilled services ended on 03/03/2024, 17 days after their admission. In an observation and interview on 03/17/2024 at 1:51 PM, Resident 226 was observed lying in bed and weak to move independently. Resident 226 stated their skilled rehabilitation services ended and they needed more therapy, .I am not even walking yet . Resident 226 stated they were independent with their activities of daily living prior to them falling at home. Review of Resident 226's Physical Therapy (PT) session notes showed the resident refused PT services on 02/19/2024, 02/23/2024, and 02/26/2024. Review of Resident 226's Occupational Therapy (OT) session notes showed the resident refused OT services on 02/22/2024, 02/23/2024, 02/26/2024, and 03/06/2024. Review of the 03/07/2024 PT Discharge Summary showed discharged per Physician or Case Manager as the reason why Resident 226's skilled care ended. The summary showed the therapist's recommendation was for Resident 226 to continue with skilled services. In an interview on 03/21/2024 at 10:12 AM, Staff O (Social Services Director) stated Resident 226's skilled services ended because the resident did not meet skilled criteria due to the resident's refusals. Staff O stated they did not follow-up with Resident 226 to determine the reason behind the resident's continued refusal to therapy. Staff O stated they needed to have a process in place that addressed resident refusals with care. In an interview on 03/21/2024 at 12:57 PM, Staff AA (Director of Rehabilitation) stated skilled services end when residents achieved their therapy goals and/or attained their prior level of function. Staff AA stated they notified the nursing department regarding Resident 226's barriers to therapy participation including episodes of dizziness, pain, and physical readiness (toileted and up in the wheelchair) for therapy. Staff AA confirmed Resident 226's skilled services coverage ended because of the documented refusals in the resident's therapy notes that were reviewed by the insurance case manager. In an interview on 03/22/2024 at 9:12 AM, Staff L (Chief Nursing Officer) stated they expected collaboration between the IDT to address resident's therapy refusals. Staff LL stated the IDT should have, but did not ensure residents remained eligible of their skilled benefits and received the rehabilitation services they were assessed to require. <Pain Medication> <Resident 52> According to the 02/17/2024 Annual MDS, Resident 52 had clear speech, their memory was intact, and had medical conditions including nerve pain, neck pain, chronic (long-standing) pain, and muscle spasms. The MDS showed Resident 52's pain occasionally interfered with their sleep and rarely affected their day-to-day activities during the assessment period. Review of Resident 52's 03/05/2024 pain CP showed a 02/09/2023 CP intervention directing staff to discuss concerns the resident had regarding their pain management with the physician and the consulting pharmacist. In an observation and interview on 03/17/2024 at 08:10 AM, Resident 52 was observed sitting in their wheelchair while decluttering their nightstand without any pain issues and stated their pain varies throughout the day, some days were better than others. Resident 52 expressed having multiple pain issues including neck pain that radiated to their left shoulder/arm and pain on both their knees. Resident 52 stated they were being administered several pain medications. Review of the March 2024 Medication Administration Record (MAR) on 03/18/2024 showed Resident 52 was prescribed four pain medications including: A sublingual (under the tongue) dissolving film for their chronic pain twice a day; a patch for the left shoulder daily at night; a gel for their left shoulder four times a day; and a cream for their bilateral knees twice a day. The MAR showed Resident 52 refused the pain patch 11 out of 17 days; refused the pain gel at least once 12 out of 17 days; and refused the pain cream at least once 14 out of 17 days. Review of Resident 52's progress notes from 03/01/2024 until 03/17/2024 did not show the nurse notified the physician and/or consulting pharmacist regarding the resident's refusal to receive the pain patch, pain gel, and pain cream. In an interview on 03/20/2024 at 10:46 AM, Staff C (Assistant Director of Nursing) stated it was important to ensure Resident 52's medication list was reviewed for unnecessary medication use to decrease the resident's pill burden [the number of medications taken or administered to a person on a regular basis] since Resident 52 was refusing to receive them. Staff C stated the nurses should, but did not notify the physician regarding Resident 52's medication refusals for proper reassessment and better care planning. REFERENCE: WAC 388-97-0960(1). .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure expired medications were disposed of timely and controlled pain medications were properly secured for 1 of 1 medication room reviewed for medication storage. This failure placed residents at risk for receiving medications with decreased effectiveness and predisposes the staff to potentially diverting medications (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings included . <Facility Policy> Review of the facility policy titled, Storage and Expiration, Dating of Medications, Biologicals [a therapeutic substance such as a vaccine or drug], revised 08/07/2023, the facility would ensure medications and biologicals that expired were destroyed or returned to the pharmacy. The policy showed after controlled substances (medications prone to misuse and abuse) were received and added in the inventory, the facility would ensure they were immediately placed in a separate compartment within the locked medication carts. <Medication Room> Observation of the medication room on 03/18/2024 at 12:08 PM with Staff M (Infection Preventionist) showed 10 single-dose syringes of Covid-19 (a respiratory infection) injectable medication with a beyond use date of 03/14/2024 inside the medication refrigerator and 13 swab collection tubes in the overhead cabinet that expired 10/31/2023. Observed a plastic bag of medications located at the bottom drawer of a metal cabinet and inside the bag were: 30 tablets of blood pressure medications that expired 09/28/2023; 30 capsules of nerve pain medications that expired 11/30/2023; 37 tablets of antidepressant medications that expired 09/28/2023, and 15 tablets of antianxiety medications that expired 09/21/2023. At the same date and time, 21 tablets of narcotic (controlled substance) pain medications were observed inside the same plastic bag of expired medications and the drawer where these medications were located was left unlocked/unsecured. In an interview on 03/18/2024 at 12:47 PM, Staff M stated the expired injectable medications and swab collection tubes should be discarded/thrown away to ensure resident safety and to avoid obtaining false positive/negative results if/when the expired collection kit was used. Staff M stated medications that were meant to be returned to the pharmacy should not be left forgotten because it was unsafe. Staff M stated the staff need to be educated on how to dispose medications properly when residents discharge from the facility. Staff M stated controlled substances, including narcotic pain medications, should not be left unattended and must be kept locked/safe at all times. In an interview on 03/22/2024 at 9:12 AM, Staff A (Administrator) stated it was important to audit the facility's medication storage room for presence of expired medications to ensure resident safety. Staff A stated they expected the nursing staff to ensure controlled substances such as narcotic pain medications were locked up at all times for staff accountability because these were high-risk medications and must be safeguarded. REFERENCE: WAC 388-97-1300 (1)(b)(ii), (c)(ii-iv). .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to assess and ensure prompt dental care and services were provided for 2 of 9 residents (Residents 42 and 46) reviewed for oral/dental health. The facility's failure to assess and/or follow-up on dental exam recommendations placed resident at risk for oral pain, unmet dental needs, and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Dental Services, revised 12/30/2022, the facility would assist the residents in obtaining routine and 24-hour emergency dental care. The policy showed the social services department would coordinate dental services including prompt referrals and would document all dental interventions performed in the resident's medical record. <Resident 42> Review of the 01/05/2024 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 42 admitted to the facility on [DATE], had clear speech, and understood others during communication. The MDS showed Resident 42 had broken teeth and needed set-up and clean-up assistance from staff for their oral care/hygiene. The 06/12/2023 oral/dental Care Plan (CP) showed Resident 42 was identified with broken teeth. A 12/12/2022 CP intervention directed staff to coordinate arrangements for dental care and to monitor/document/report signs and symptoms of oral/dental problems needing attention to the physician. On 03/18/2024 at 9:14 AM, Resident 42's two front lower teeth were observed broken and the root of these teeth were exposed. Resident 42 stated their teeth broke and fell out a while back and that the resident had not seen the dentist since their admission to the facility. A 03/01/2023 physician order showed Resident 42 had an order to see the dentist as needed. Review of Resident 42's medical records showed an 02/06/2023 dental consultation recommending dental cleaning, dental x-rays (a diagnostic procedure), and the extraction of several identified teeth. A following dental consultation dated 11/16/2023 showed the same referral for teeth extractions identified from the previous dental consultation on 02/06/2023. The facility was not able to provide any documentation to support the dental recommendations were performed, followed-up, or completed. In an interview on 03/21/2024 at 10:35 AM, Staff O (Social Services Director) stated the facility offered both in-house and outside dental care and services and the social services department was responsible for managing resident's oral/dental health. Staff O confirmed Resident 42 was not seen by the dentist since the resident's last dental consult and the recommendations were not done. Staff O stated the facility's dental tracking process needed improvement. In an interview on 03/22/2024 at 8:50 AM, Staff A (Administrator) stated it was important to provide oral/dental care and services to residents who needed them to foster nutritional health/support and to enhance residents' dignity and quality of life. <Resident 46> According to the 12/12/2023 Quarterly MDS, Resident 46 had impaired memory and did not have broken teeth. The MDS showed Resident 46 required maximal assistance from staff with their oral care. The MDS showed Resident 46 had no refusals of care during the assessment period. According to the 09/11/2023 Significant Change MDS, Resident 46 had inflamed gums and loose teeth. Observations on 03/17/2024 at 11:27 AM showed Resident 46 had no teeth or dentures in their mouth. Review of Resident 46's dental consult dated 11/02/2022 showed the resident had remaining 2 lower teeth that were very loose and required a follow-up appointment ASAP (as soon as possible). Resident 46's record review showed there was no follow-up documentation related to Resident 46's dental care. The facility was not able to provide any documentation to support Resident 46 was provided dental care and services after the 11/02/2022 dental consultation. In an interview on 03/20/2024 at 1:14 PM, Staff O confirmed there was no documentation indicating the facility followed-up with Resident 46's dental consult recommendations. Staff O stated the staff should have assessed the resident's oral/dental status and followed-up on the recommendations made by the dentist, but they did not. REFERENCE: WAC 388-97-1060(3)(j)(vii). .

CONCERN (D)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure the arbitration agreement was signed by the resident's Durable Power of Attorney (DPOA) for financial affairs as required for 1 of 1 residents (Resident 41) whose Arbitration Agreements (AA) were reviewed. This failure placed Resident 41 and residents at risk of forfeiture of their right to a jury or court trial and a diminished quality of life. Findings included . <Resident 41> According to the 03/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 41 was non-English speaking, non-communicative, had memory impairment, and was incapable of daily decision-making. In an interview on 03/17/2024 at 10:05 AM, Staff Q (Regional Director of Operations) stated the AA was offered to residents and their representatives during admission and was conducted by the facility's Business Office Manager (BOM). Staff Q stated on Resident 41 had an active AA on file. Review of Resident 41's AA 03/18/2024 showed the resident's name was not written in the AA and was signed by Resident 41's representative on 07/23/2021. In an interview on 03/20/2024 at 8:40 AM, Staff Q confirmed Resident 41's name was not written in the AA and stated the AA would not be considered valid without the name of the resident who entered into the AA. In an interview on 03/21/2024 at 1:19 PM, Staff P (Social Services Assistant) stated Resident 41 did not have an DPOA for financial affairs on file. The facility was not able to provide any documentation to support and/or validate Resident 46's representative, who signed the arbitration agreement on the resident's behalf, was the same representative responsible for Resident 41's financial affairs to ensure validity of the AA as required. In an interview on 03/21/2024 at 1:26 PM, Staff R (BOM) stated it was important to ensure AAs were understood by residents and/or their representatives for legal and liability purposes. Staff R stated they acquired the AA responsibility recently on January 2024 and had not received education from the facility regarding AA. Staff R stated, when obtaining a resident representative's signature for the AA, they were under the impression they needed to follow the order of responsible payee for the resident, .all I know is that AA is just a part of the admission agreement/packet which I have to complete. On 03/22/2024 at 11:59 AM, Staff L (Chief Nursing Officer) stated the facility did not have policies and procedure in place for residents who entered into a binding AA. REFERENCE: WAC 388-97-1620(2)(a)(b)(i), -0180(1-4). .

CONCERN (E)

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

Deficiency F0570 (Tag F0570)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure 21 of 24 residents (Residents 33, 31, 9, 21, 11, 19, 23, 15, 17, 1, 20, 7, 8, 2, 5, 42, 51, 12, 46, 4, 37, 41, 40, & 27) who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . <Facility Document> According to the 07/09/2021 Surety Bond, the facility purchased a surety bond to secure and/or replace residents' personal funds that were deposited with the facility, including any interest accrued by these accounts, if misappropriated, misplaced or otherwise lost, withheld, or improperly distributed. The document showed the bond amount covered was not to exceed $21,000 and was effective on 06/30/2021. Record review of the facility's Trial Balance report showed 24 residents had funds in trust accounts. Three of the personal fund accounts totaled $21,036.60 (surety bond limit). The trust account report showed a total current balance of $33,771.68 for all 24 residents as of 03/18/2024, and was in excess of the facility's purchased surety bond. In an interview on 03/21/2024 at 1:26 PM, Staff R (Business Office Manager) stated the surety bond should be more than the total amount in the trust accounts. Staff R confirmed the facility's surety bond did not cover the current facility trust account balance. REFERENCE: WAC 388-97-0340(6). .

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 3> Review of the 02/29/2024 admission MDS showed Resident 3 had diagnoses of heart failure, end stage kidney fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 3> Review of the 02/29/2024 admission MDS showed Resident 3 had diagnoses of heart failure, end stage kidney failure requiring dialysis, and a fracture to their lower leg. Review of Resident 3's SS admission evaluation showed Resident 3 did not have an AD. This form did not indicate if Resident 3 wished to formulate an AD or if Resident 3 was offered assistance to formulate an AD. In an interview on 03/19/2024 at 8:19 AM, Staff O stated ADs were reviewed on admission and quarterly. If a resident did not have an AD, they were offered a packet with information regarding ADs. Staff O stated they did not document Resident 3 was provided information regarding ADs. REFERENCE: WAC 388-97-0280(3)(c)(i-ii). <Resident 30> According to the 02/29/2024 Quarterly MDS, Resident 30 had clear speech and had medical conditions including chronic pain, heart disease, memory impairment, anxiety, and mood disorder. Review of Resident 30's medical records showed a 01/04/2019 AD Policy Record form indicating Resident 30 did not have a written AD and that information and assistance was offered. The facility was not able to provide any documentation to support a follow-up was made for Resident 30. In an interview on 03/19/2024 at 8:19 AM, Staff O stated offering assistance to formulate and/or obtain an AD was important so the resident would have a support system in place in the event where they could no longer voice their own needs from memory decline. Staff O stated Resident 30 should have an AD or guardianship in place, but did not. <Resident 226> According to 02/22/2024 admission MDS, Resident 226 admitted to the facility on [DATE], had clear speech, understands, and understood others during communication. The MDS showed Resident 226 had medical conditions including a systemic infection, lung disease, and malnutrition. In an interview on 03/17/2024 at 1:32 PM, Resident 226 stated they did not have an AD and was not provided education or offered assistance by staff. Resident 226 stated they wanted to involve their family member in formulating an AD. Review of Resident 226's SS notes from 02/15/2024 until 03/20/2024 did not show documentation to support Resident 226 was educated or provided assistance to initiate an AD. In an interview on 03/19/2024 at 8:19 AM, Staff O stated, .we missed that one.Based on interview and record review the facility failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 6 of 21 residents (Residents 60, 44, 28, 30, 226, & 3) reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed. Findings included . <Facility Policy> Review of the facility's policy titled Advanced Directives, revised May 2023, showed facility staff would determine upon admission whether the resident had an AD and if not, the resident would be offered information regarding ADs. This policy showed staff would document in the resident's record whether an AD was executed and each offering of information to the resident regarding ADs. <Resident 60> According to the 02/21/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 60 had multiple complex medical conditions including kidney failure with dependence on dialysis (a treatment to filter waste from the blood) and unstable blood sugar levels in the body. Review of the 11/20/2023 Social Services (SS) progress note showed Resident 60's representative would drop off healthcare Durable Power of Attorney (DPOA) paperwork. There was no copy of an AD for Resident 60 showing their family had DPOA. In an interview on 03/20/2024 at 12:40 PM, Staff O (SS Director) stated they communicated with Resident 60's representative, but did not follow up. Staff O stated they should have followed up and assisted the resident to initiate an AD, but they did not. <Resident 44> According to the 02/29/2024 Annual MDS, Resident 44 was admitted to the facility on [DATE], had clear speech and was able to understand others during communication. The assessment showed Resident 44 had multiple medical conditions including weakness to one side of their body from a stroke, and a brain injury related to cancer. In an interview on 03/19/2024 at 12:37 PM, Resident 44 stated they did not have an AD. Resident 44 stated they were not offered assistance from the facility to initiate an AD. Review of Resident 44's medical records showed there was no AD or DPOA paperwork in Resident 44's record. In an interview on 03/20/2024 at 12:50 PM, Staff O reviewed Resident 44's record and stated there was no AD or DPOA paperwork in Resident 44's record. Staff O stated they should have followed up with Resident 44's representative about AD or DPOA paperwork, but they did not. <Resident 28> According to the 02/19/2024 admission MDS, Resident 28 admitted to the facility on [DATE], had clear speech and was able to make their own decisions. The assessment showed Resident 28 had complex medical conditions including uncontrolled blood sugars and heart failure. In an interview on 03/20/2024 at 11:29 AM, Resident 28 stated they did not have an AD or a DPOA. Resident 28 stated staff did not communicate with them about initiating an AD. Resident 28 stated they did not meet with SS staff since they were admitted to the facility. Review of Resident 28's medical record showed no documentation of an AD or DPOA paperwork in Resident 28's record. In an interview on 03/20/2024 at 12:52 PM, Staff O reviewed Resident 28's record and stated there was no AD or DPOA paperwork in Resident 28's record. Staff O stated they should have offered assistance to initiate an AD for Resident 28, but they did not.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Cold Water> <Resident 277> In an interview on 03/17/2024 at 10:54 AM, Resident 277 stated the water was cold in the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Cold Water> <Resident 277> In an interview on 03/17/2024 at 10:54 AM, Resident 277 stated the water was cold in the bathroom when they would wash their hands and face. In an observation on 03/18/2024 at 12:32 PM, the surveyor turned the water on in the bathroom and let it run for one minute. The water temperature at that time was 80.7 degrees Fahrenheit (a more appropriate water temperature for a swimming pool than water from a hot water tank). <Resident 58> In an observation and interview on 03/18/2024 at 9:26 AM, Resident 58 stated the water in the bathroom was cold. Resident 58 stated staff gave the resident a cold washcloth earlier in the morning and stated [staff] had the water going for a while. In an observation at that time, the surveyor turned the hot water on and left it running for one minute, the water remained cool and did not get warm after one minute. Observations on 03/22/2024 at 10:10 AM showed the hot water in the bathrooms of room [ROOM NUMBER], 32, 45, and room [ROOM NUMBER] remained cool. In an interview on 03/22/2024 at 9:58 AM, Staff U stated they were aware of the cold water in resident rooms since August of 2023. Staff U stated there was an issue with a value that was not resolved. REFERENCE: WAC 388-97-0880. <Overhead Paging> Observation on 03/18/2024 at 9:17 AM, showed an overhead announcement was made regarding a resident needing assistance from a nursing staff in their room. Observation on 03/18/2024 at 10:22 AM, showed an overhead announcement was made informing residents who wanted to attend the activity to gather in the main dining room. Observation on 03/18/2024 at 1:30 PM, showed an overhead announcement was made requesting a nurse to answer a phone call and get report for a resident who was getting admitted to the facility. In an interview on 03/22/2024 at 8:58 AM, Staff L (Chief Nursing Officer) stated it was important to provide residents with a homelike environment and to decrease and/or eliminate institutional characteristics such as using the overhead paging system, .this [facility] is their [residents] home, we [staff] should be respectful of it . <Window Treatments> <Resident 226> According to 02/22/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 226 had clear speech, understands, and understood others during communication. Observation and interview on 03/17/24 at 1:43 PM showed some of Resident 226's bed was by the window and the blinds were missing pieces/broken, allowing sunlight to enter the room when the blinds were closed. Resident 226 stated the condition of their window treatment affected them because they sunburned easily and often, the sunlight coming from the window in the afternoon was intense. In an interview on 03/22/2024 at 8:58 AM, Staff L stated the facility should be maintained to provide residents a homelike environment. In an interview on 03/22/2024 at 9:58 AM, Staff U (Maintenance Director) stated it was important to provide residents a homelike environment, so the residents felt comfortable living in it. Staff U confirmed the condition of the window blinds in Resident 226's room and stated, Yes, the blinds needed repair. Based on observation and interview, the facility failed to ensure a clean, comfortable, and homelike environment for 4 of 4 halls. The failure to ensure resident rooms were free of wall scrapes, to provide an environment free of institutional-style overhead paging, to ensure resident bedroom windows had adequate coverings, and to ensure sufficiently warm water temperatures in resident bathrooms left residents at risk for a diminished quality of life, and a less than homelike environment. Findings included . <Walls> Observation on 03/17/0224 at 8:52 AM showed the wall behind bed 1 in room [ROOM NUMBER] had considerable scrapes where the head of the bed rubbed against the wall. There were black marks and gashes of exposed drywall. Observation on 03/17/2024 at 9:20 AM showed the baseboard in room [ROOM NUMBER]'s bathroom and on the wall outside the bathroom door had multiple dents and had areas where the paint was scraped off. Observation on 03/19/2024 at 10:07 AM showed in B hallway, in front of room [ROOM NUMBER] and 17, wallpaper was coming off. In an interview on 03/22/2024 at 12:09 PM, Staff U (Maintenance Director) stated keeping up with maintenance of the facility's walls was a chronic problem. Staff U observed the scraped wall behind bed 1 in room [ROOM NUMBER] and stated it needed to be painted.

CONCERN (E)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> Review of a 03/10/2024 Nursing Progress Note (NPN) showed nursing staff assessed Resident 49 with shortness ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> Review of a 03/10/2024 Nursing Progress Note (NPN) showed nursing staff assessed Resident 49 with shortness of breath and a low blood-oxygen level. The NPN showed Resident 49 was transferred to the hospital by ambulance. Review of Resident 49's census information showed the resident was hospitalized on [DATE] and readmitted to the facility on [DATE]. Record review did not show documentation indicating the LTCO was notified of Resident 49's transfer as required for their 03/10/2024 hospital transfer. <Resident 42> According to the 01/05/2024 Annual MDS, Resident 42 had clear speech, understands and understood others during communication, and had medical conditions including unstable blood sugar levels in the body and malnutrition. In an interview on 03/18/2024 at 9:11 AM, Resident 42 stated they recalled being sent out to the hospital because of a bladder infection. Review of Resident 42's records showed a 05/23/2023 NPN indicating Resident 42 had increased confusion and the physician ordered to transfer the resident to the hospital for further evaluation. Review of Resident 42's census information showed the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The facility was not able to provide any documentation to show the LTCO was notified for Resident 42's hospitalization as required. In an interview on 03/21/2024 at 10:23 AM, Staff O (Social Services Director) stated they did not complete the state's LTCO notification process or maintained communication logs in the facility's record. In a joint interview on 03/22/2024 at 9:39 AM, both Staff A (Administrator) and Staff L (Chief Nursing Officer) stated they expected the social services department to notify the ombudsman of residents' transfer/discharge to the hospital as required. Staff L confirmed the facility's ombudsman notification process was not being followed. REFERENCE: WAC 388-97-0120(1)(2). Based on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 3 of 4 sampled residents (Residents 60, 49, & 42) reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . <Facility Policy> According to the facility policy titled, Bed-Hold: Notification Notice of Bed-Hold Policy and Return (Voluntary Transfer to Hospital and Therapeutic Leave, revised 09/2022, the facility would provide the LTCO a copy of the transfer/discharge notices completed for hospitalized residents. <Resident 60> According to the 11/10/2023 and 01/12/2024 Discharge Minimum Data Sets (MDS - an assessment tool), Resident 60 was discharged to an acute hospital twice: On 11/10/2023 and was readmitted to the facility on [DATE]; and on 01/12/2024 and was readmitted on [DATE] respectively. Review of Resident 60's medical records did not show documentation indicating the LTCO was notified of the resident's hospital transfers for either the 11/10/2023 or 01/12/2024 discharge as required.

CONCERN (E)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> Review of a 03/10/2024 Nursing Progress Note (NPN) showed Resident 49 was transferred to the hospital for sh...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 49> Review of a 03/10/2024 Nursing Progress Note (NPN) showed Resident 49 was transferred to the hospital for shortness of breath and a low blood-oxygen level. Review of a 03/11/2024 Transfer/Discharge Notice/Bed Hold form for Resident 49 showed the bed hold portion of the document did not indicate whether the resident accepted or declined a bed hold. <Resident 42> Review of Resident 42's medical records showed a 05/23/2023 NPN indicating the resident had increased confusion and the physician ordered the resident's transfer to the hospital for further evaluation. Review of Resident 42's census information showed the resident was discharged to the hospital on [DATE]. Review of Resident 42's 05/24/2023 Transfer/Discharge Notice/Bed Hold form showed the bed hold portion of the document did not indicate whether Resident 42 accepted or declined a bed hold. In an interview on 03/20/2024 at 11:43 AM, Staff C (Assistant Director of Nursing) stated it was a resident's right to be notified of the facility's bed hold policy to assist the resident in making an informed decision, .whether to hold their bed and be accountable for the expenses that would be incurred or to decline the bed hold and be amenable to being given a different room/bed upon their return to our facility. Staff C stated the facility's bed hold notice did not include an acknowledgment that indicated the resident/representative's choice regarding their bed hold status and the document should show the decision made by the resident/representative. In a joint interview on 03/22/2024 at 9:39 AM, both Staff A (Administrator) and Staff L (Chief Nursing Officer) stated they expected staff to conduct the facility's bed hold process as required. Staff L confirmed the current bed hold electronic form documented in residents' medical records did not support and/or ensure resident rights were safeguarded because the option to select a choice was lacking. REFERENCE: WAC 388-97-0120(4). Based on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed hold policy, at the time of transfer or within 24 hours, for 3 of 4 sampled resident's (Residents 60, 49, & 42) reviewed for discharge. This failure placed the residents and/or their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Findings included . <Facility Policy> According to the facility policy titled, Bed-Hold: Notification Notice of Bed-Hold Policy and Return (Voluntary Transfer to Hospital and Therapeutic Leave, revised 09/2022, the resident and/or representative would be provided a written notice of the bed hold policy. The policy showed, within 24 hours after transfer, the facility would elicit verbal communication regarding the resident/representative's choice whether to accept or decline a bed hold. The policy showed the resident/representative's bed hold decision was documented in the resident's medical records (progress notes) or in the business office file. <Resident 60> According to the 11/10/2023 and 01/12/2024 Discharge Minimum Data Sets (an assessment tool), Resident 60 was discharged to an acute hospital twice: On 11/10/2023 and was readmitted to the facility on [DATE]; and on 01/12/2024 and was readmitted on [DATE]. Review of Resident 60's medical records did not show bed hold documentation to indicate Resident 60 or their representative accepted or declined a bed hold for both occurrences during their hospitalization.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

<Resident 42> According to the 01/05/2024 Annual MDS, Resident 42 had clear speech, understands and understood others during communication, and had a diagnosis of diabetes (unstable blood sugar ...

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<Resident 42> According to the 01/05/2024 Annual MDS, Resident 42 had clear speech, understands and understood others during communication, and had a diagnosis of diabetes (unstable blood sugar levels in the body). The MDS showed Resident 42 had adequate vision. The 11/02/2023 vision care plan showed Resident 42 had altered sensory function related to their visual disturbance. On 03/18/2024 at 9:17 AM, Resident 42 was in bed wearing their eyeglasses and was observed squinting while reading their electronic device. Resident 42 stated their eyes were bad and the grade in their eyeglasses were no longer appropriate. Resident 42 attempted to read the facility's daily activity chronicle but was only able to read the heading and stated they could not read the rest. Review of Resident 42's medical records showed a 05/23/2023 physician note indicating the resident had a diagnosis of diabetic eye disease (eye complication characterized by poor vision). A 06/05/2023 physician note showed Resident 42 complained of seeing double and was referred to see a specialist to rule out stroke (brain damage). In an interview on 03/20/2024 at 11:58 AM, Staff D stated it was important to ensure the MDS was completed accurately because it was the basis of the CP for resident care. Staff D stated they did identify Resident 42's vision impairment and the MDS was coded inaccurately. In an interview on 03/22/2024 at 8:31 AM, Staff A (Administrator) stated having adequate vision enabled resident's independence in performing their activities of daily living. In an interview on 03/22/2024 at 8:42 AM, Staff L (Chief Nursing Officer) stated Resident 42's vision deficit should have, but was not properly assessed during the MDS completion. Refer to F685- Treatment/Devices to Maintain Hearing/Vision. REFERENCE: WAC 388-97-1000(1)(b). Based on observation, interview, and record review the facility failed to ensure 8 of 24 residents' (Residents 55, 6, 7, 15, 27, 44, 60, & 42) Minimum Data Set (MDS - an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs. Findings included . <Facility Policy> The facility's revised 03/2024 MDS/RAI [Resident Assessment Instrument] policy showed the facility adhered to the Long-Term Care RAI 3.0 User's Manual for all policies related to MDS completion. <Resident 55> According to the 02/03/2024 Annual MDS Resident 55 had a severe memory impairment and required substantial/maximal assistance or was totally dependent on staff for care. The MDS showed Resident 55 had diagnoses including a history of stroke, and difficulty swallowing. The MDS showed Resident 55 had a feeding tube (a tube connected directly to the stomach to provide nutrition artificially). According to this MDS, Resident 55 received less than 25% of their daily caloric intake, and a daily average of less than 500 Cubic Centimeters (CCs) of artificial nutrition via their feeding tube daily during the assessment lookback period (from 0128/2024 through 02/03/2024). Review of the Physician's Orders (POs) showed a 07/18/2023 PO showing Resident 55 should not receive food or medication by mouth, and a 07/11/2023 PO to provide 1200 Milliliters (ML) of 1.5 calories/ML liquid nutrition daily via a feeding tube. The January 2024 Medication Administration Record (MAR) showed on 01/28/2024, 01/29/2024, 01/30/2024, and 01/31/2024 Resident 55 received 1200 ML of liquid nutrition which represented 100% of their caloric intake. The February 2024 MAR showed on 02/01/2024, 02/02/2024, and 02/03/2024 Resident 55 received 1200 ML of liquid nutrition which represented 100% of their caloric intake. This showed the MDS was inaccurate in assessing Resident 55 received 25% or less of their caloric intake via the feeding tube. In an interview on 03/20/2024 at 12:43 PM Staff D (MDS Specialist - Registered Nurse) stated the 02/03/2024 Annual MDS did not accurately reflect Resident 55's status regarding the total amount in ML, and percentage of their total nutrition provided via a feeding tube. Staff D stated that part of the MDS was complete by a contractor remotely. Staff D stated the MDS should have but did not accurately reflect the percentage of dietary intake the tube feeding tube provided for Resident 55. <Resident 6> According to the 01/04/2024 Annual MDS Resident 6 did not receive nutrition through a feeding tube while a resident. The MDS showed Resident 6 received 25% or less of their nutrition and a daily average of less than 500 CCs of artificial nutrition via their feeding tube daily during the assessment lookback period. Review of Resident 6's POs showed no tube feeding orders. <Resident 7> According to the 02/08/2024 Quarterly MDS Resident 7 did not receive nutrition through a feeding tube while a resident. The MDS showed Resident 7 received 25% or less of their nutrition and a daily average of less than 500 CCs of artificial nutrition via their feeding tube daily during the assessment lookback period. Review of Resident 7's POs showed no tube feeding orders. <Resident 15> According to the 02/25/2024 Quarterly MDS Resident 15 did not receive nutrition through a feeding tube while a resident. The MDS showed Resident 15 received 25% or less of their nutrition and a daily average of less than 500 CCs of artificial nutrition via their feeding tube daily during the assessment lookback period. Review of Resident 15's POs showed no tube feeding orders. <Resident 27> According to the 12/08/2024 Annual MDS Resident 27 did not receive nutrition through a feeding tube while a resident. The MDS showed Resident 27 received 25% or less of their nutrition and a daily average of less than 500 CCs of artificial nutrition via their feeding tube daily during the assessment lookback period. Review of Resident 27's POs showed no tube feeding orders. <Resident 44> According to a 02/19/2024 Annual MDS, Resident 44 did not receive nutrition through a feeding tube while a resident. The MDS showed Resident 44 received 25% or less of their nutrition and a daily average of less than 500 CCs of artificial nutrition via their feeding tube daily during the assessment period. Review of Resident 44's POs showed no tube feeding orders. <Resident 60> According to the 02/21/2024 Quarterly MDS, Resident 60 did not receive nutrition through a feeding tube while a resident. The MDS showed Resident 60 received 25% or less of their nutrition and a daily average of less than 500 CCs of artificial nutrition via their feeding tube daily during the assessment period. Review of Resident 60's POs showed no tube feeding orders. In an interview on 03/20/2024 at 12:43 PM Staff D stated the most recent quarterly and Annual MDSs for Residents 6, 7, 15, 27, 44, and 60 were all inaccurate with regard to tube feeding. Staff D stated because the residents did not use feeding tubes, the sections assessing the amount of nutrition these residents received should have been marked with dashes rather than given a value.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 276> Review of a 03/12/2024 emergency department provider note showed Resident 276 arrived at the emergency depa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 276> Review of a 03/12/2024 emergency department provider note showed Resident 276 arrived at the emergency department after a fall resulting in a fractured pelvis. The note showed Resident 276 denied bowel or bladder dysfunction. Review of a 03/13/2024 hospital Occupational Therapy (OT) evaluation showed OT recommended Resident 276 use a bedside commode for toileting. Review of a 03/15/2024 facility OT evaluation and plan of treatment showed Resident 276 admitted to the facility on [DATE]. The evaluation showed Resident 276 was independent with toileting prior to their fall. The functional skills portion of this assessment showed Resident 276 was dependent on staff for transferring to the toilet. Review of Resident 276's 03/15/2024 activity of daily living CP showed a different resident's name other than Resident 276's name. This CP identified the resident was incontinent of bowel and bladder and was not toileted. This CP did not address the correct resident or accurately identify Resident 276's needs. In an interview on 03/17/2024 at 12:06 PM, Resident 276 stated staff told the resident to pee in their diaper. In an interview on 03/19/2024 at 6:58 AM, Resident 276 stated they were still using their diaper as a bathroom. In an interview on 03/20/2024 at 11:19 AM, Staff Z (OT) stated they were able to assist Resident 276 to the toilet three times the previous day. In an interview on 03/22/2024 at 8:39 AM, Staff C (Assistant DON) stated Resident 276's CP was not accurate and confirmed it needed to be updated. <Resident 226> According to 02/22/2024 admission MDS, Resident 226 had clear speech, understood others during communication, and had medical conditions including systemic infection, pulmonary disease, and muscle weakness. Observation on 03/17/2024 at 9:00 AM showed Resident 226 lying in bed and receiving three Liters Per Minute (LPM) of supplemental oxygen via a nasal cannula; an oxygen concentrator (a medical device that delivered supplemental oxygen) with a humidifier was on and situated next to Resident 226's bed. Review of a 02/27/2024 PO showed staff were to administer two LPM of supplemental oxygen to Resident 226 every 12 hours as needed for shortness of breath. Review of the 02/15/2024 respiratory CP showed Resident 226 had asthma related to allergies and directed nursing staff to monitor the resident's oxygen saturation (amount of oxygen in the blood). The CP did not show Resident 226 received supplemental oxygen. In an interview on 03/19/2024 at 1:31 PM, Staff C confirmed the use of supplemental oxygen was not captured in Resident 226's CP and stated the resident's CP should be revised, but was not. <CP Meetings> <Resident 71> Review of the 02/29/2024 admission MDS showed Resident 71 admitted to the facility on [DATE], had clear speech, their memory was intact, and understood others during communication. On 03/17/2024 at 12:04 PM, Resident 71 stated they did not recall being involved in the discussion of their CP or had a CP meeting since their admission. Review of Resident 71's social services progress notes from 02/22/2024 until 03/20/2024 did not show documentation that a CP meeting was conducted for the resident. In an interview on 03/21/2024 at 9:57 AM, Staff O (Social Services Director) stated a CP meeting was important to have because the meeting allowed the resident the opportunity to be informed of their care and to solicit their input. Staff O confirmed there was no CP meeting held for Resident 71 and stated they should have conducted one, but did not.<Resident 28> According to the 02/19/2024 admission MDS, Resident 28 admitted to the facility on [DATE], had clear speech, and no memory impairment. The assessment showed Resident 28 had complex medical conditions including uncontrolled blood sugars and heart failure. In an interview on 03/17/2024 at 11:41 AM, Resident 28 stated they did not have a CP meeting since they admitted to the facility. Review of Resident 28's record did not show documentation Resident 28 had a CP meeting since their admission. In an interview on 03/20/2024 at 1:12 PM, Staff O reviewed Resident 28's record and confirmed there was no documentation regarding a CP meeting. Staff O stated they should have a CP meeting with the resident, but they did not. <Resident 44> According to the 02/29/2024 Annual MDS, Resident 44 was admitted to the facility on [DATE], had clear speech and no impaired memory. The assessment showed Resident 44 had multiple medical conditions including weakness to one side of their body from a stroke, and brain injury related to cancer. In an interview on 03/18/2024 at 9:29 AM, Resident 44 stated they did not recall having CP meeting for a long time. Review of Resident 44's record showed Resident 44's last CP meeting was documented on 01/10/2023, over 14 months ago. In an interview on 03/20/2024 at 12:58 PM, Staff O reviewed Resident 44's record and confirmed Resident 44 did not have a CP meeting for over a year. Staff O stated there should be CP meetings scheduled on admission, quarterly, annually, and as needed for any condition changes. Staff O stated they should have scheduled a CP meeting for Resident 44 quarterly, but they did not. REFERENCE: WAC 388-97-1020(2)(c)(d). Based on observation, record review, and interview the facility failed to ensure Care Plans (CP) were updated and/or revised as needed to reflect person-centered care for 3 of 21 (Residents 15, 276, & 226) sample residents whose CPs were reviewed, and failed to provide CP meetings for 3 of 5 sample residents (Residents 71, 28, & 44) reviewed for CP meetings. The failure to update and/or revise CPs or provide CP meetings left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings inlcuded . <Facility Policy> Review of the Care Planning Process facility policy revised 05/19/2023 showed the comprehensive CP was an interdisciplinary tool that must have measurable objectives with time frames and described the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The CP must be reviewed and revised at a minimum on admission, quarterly, and with a significant change in condition. <CP Updates/Revisions> <Resident 15> According to the 02/25/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 15 had diagnoses including a seizure disorder. Review of Resident 15's Physician's Orders (POs) showed 03/01/2023 and 10/24/2023 POs for a daily medication to treat seizures. Review of the 06/22/2022 seizure disorder CP showed this CP was not updated to include Resident 15's treatment with an anti-seizure medication. In an interview on 03/22/2024 at 9:45 AM, Staff B (Director of Nursing - DON) stated it was important for CPs to be updated for accuracy. Staff B stated Resident 15's CP should be updated to address the use of an anti-seizure medication.

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 9> According to the 01/15/2024 Quarterly MDS, Resident 9 had medical conditions including severe memory impairme...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 9> According to the 01/15/2024 Quarterly MDS, Resident 9 had medical conditions including severe memory impairment, depression, contractures, and adult failure to thrive. The MDS showed Resident 9 had functional limitations with their Range of Motion (ROM) on all four extremities and was assessed to require maximal assistance from staff for their oral hygiene. The 02/14/2024 ADL CP showed Resident 9 had a self-care performance deficit because of their cognitive impairment and limited ROM. A 04/29/2016 CP intervention showed Resident 9 needed one person assistance with their oral care. On 03/17/2024 at 10:08 AM, Resident 9 was observed sitting in their wheelchair and when the resident smiled, their teeth were noted black colored and severely carious/decayed. Food residue lined Resident 9's gum line and some were lodged in between the resident's front teeth. During a resident's representative interview on 03/17/2024 at 5:10 PM, Resident 9's representative stated they told staff the resident's teeth needed to be brushed more frequently because the representative observed Resident 9's teeth were unclean when they came to visit. In an observation and interview on 03/20/2024 at 2:33 PM, Resident 9 was observed in bed after eating their lunch with food residue still in their teeth/mouth. Staff N confirmed Resident 9's oral health condition and stated the resident's teeth needed better cleaning. <Resident 30> According to the 02/29/2024 Quarterly MDS, Resident 30 had clear speech and had medical conditions including memory impairment, anxiety, and a mood disorder. The MDS showed Resident 30 was assessed to require assistance with their personal hygiene. The 11/22/2023 ADL CP showed Resident 30 had a self-care performance deficit because of their cognitive impairment. A CP intervention directed staff to provide Resident 30 minimal to moderate assistance with their grooming and personal hygiene. In an observation and interview on 03/17/2024 at 8:38 AM, Resident 30's fingernails were observed to be long, some jagged, and with black residue under the nails. Resident 30 stated they wanted staff to trim and clean them. Similar observations regarding the condition of Resident 30's fingernails were observed on 03/19/2024 at 12:33 PM. In an interview on 03/20/2024 at 2:28 PM, Staff OO (Certified Nursing Assistant - CNA) stated it was important to keep residents' nails clean and trimmed for infection prevention, .germs could get lodged under the nails and that would be bad for residents with memory impairment, especially when they pick up and eat their food with their hands . Observation on 03/20/2024 at 9:10 AM showed Resident 30 was wearing a red stripped shirt and a pair of red and black plaid pants. On 03/21/2024 at 8:12 AM of the following day, Resident 30 was observed wearing the same set of clothes with brown stains on the left lower portion of the shirt. In an interview on 03/21/2024 at 12:21 PM, Staff KK (CNA) stated they were assigned to Resident 30 on 03/20/2024 during day shift and confirmed the clothes Resident 30 was wearing at that time were the clothes they helped the resident put on the day prior. In an interview on 03/21/2024 at 12:25 PM, Staff NN (CNA) stated they were the nursing aide assigned to Resident 30. Staff NN stated they did not assist Resident 30 with changing their clothes, .[Resident 30] was up and already dressed when I came in this morning. In an interview on 03/21/2024 at 12:28 PM, Staff C confirmed Resident 30 was wearing the same clothing from the previous day and stated, .yes, I have noticed the same thing too. Staff C stated the nursing staff should have provided Resident 30 dressing assistance but did not. In an interview on 03/21/2024 at 12:41 PM, Staff B (Director of Nursing) stated personal hygiene and grooming assistance, including nail care, should be provided to residents who were dependent on staff for resident comfort and dignity. <Resident 27> According to the 12/08/2024 Quarterly MDS Resident 27 had moderate memory impairment and diagnoses including dementia, one-sided paralysis, and heart conditions. The MDS showed Resident 27 required partial to moderate assistance with personal hygiene. According to the 11/17/2021 ADL self-care performance deficit CP, Resident 27 required total assistance with personal hygiene tasks. Resident 27's [NAME] (instruction to CNAs) showed Resident 27 required total assistance with personal hygiene tasks. Observation on 03/17/2024 at 1:16 PM showed Resident 27's nails were dirty, with a brown residue under the nails. At that time, Resident 27 stated their nails should be cleaned. Observation on 03/22/2024 at 10:23 AM showed Resident 27's fingernails were dirty with a brown residue under the nails. At that time Staff LL (LPN) stated Resident 27's nails were dirty. Staff LL offered to clean and trim Resident 27's fingernails Resident 27 refused fingernail trimming stating they like the length but stated they wanted their fingernails cleaned because they were dirty. REFERENCE: WAC 388-97-1060(2)(c). <Resident 46> According to the 12/12/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 46 had impaired memory and had a diagnosis of depression. The MDS showed Resident 46 required maximal assistance from staff with transferring, toileting, and personal hygiene. The MDS showed Resident 46 did not refuse care during the assessment period. The 06/06/2023 revised ADL Self Care deficit Care Plan (CP) showed Resident 46 required one person assistance for bathing and personal hygiene. The CP showed Resident 46 did not have a preference for nail care. Observations on 03/17/2024 at 11:25 AM, 03/18/2024 at 11:51 AM, and 03/21/2024 at 9:08 AM, showed Resident 46's fingernails were long and dirty, and their toenails were thick and curled under. In an interview on 03/20/2024 at 11:17 AM, Staff N (LPN - Licensed Practical Nurse) confirmed Resident 46 had long fingernails. Staff N stated the shower aide should have clipped Resident 46's fingernails. Staff N stated they would check with Social Services (SS) to add Resident 46 to the podiatrist list. In an interview on 03/20/2024 at 1:38 PM, Staff C (Assistant Director of Nursing) stated nail care was important for dependent residents. Staff C stated shower aides and nurses were educated to clip resident's nails weekly, but staff did not follow the instructions. Staff C stated staff should have clipped Resident 46's fingernails weekly, but they did not. Staff C stated staff should have notified SS so they could add Resident 46 to the podiatrist list for toenail care. Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 of 5 (Residents 9, 30, & 46) who were assessed to be dependent on staff for ADLs, and 1 supplemental resident (Resident 27). The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> According to facility's 12/20/2022 Personal Needs policy showed the facility would provide ADL support to all residents who required assistance. The policy showed residents' ADL needs would be care planned, and identified bathing, nail care, and oral care would be provided by the facility.

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

<Resident 44> According to a 02/19/2024 Annual MDS Resident 44 had functional limitations in their ROM on the left side of their body and was provided therapy services until 02/16/2024. The MDS ...

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<Resident 44> According to a 02/19/2024 Annual MDS Resident 44 had functional limitations in their ROM on the left side of their body and was provided therapy services until 02/16/2024. The MDS showed Resident 44 did not reject care from staff. Review of a revised 08/31/2023 self-care deficit CP showed directions to restorative staff to place a splint on Resident 44's left hand three to six hours as tolerated three to six times per week and check skin before and after splint application. Observations on 03/17/2024 at 11:21 AM, 03/18/2024 at 9:34 AM, 03/19/2024 at 12:05 PM, and 03/21/2024 at 9:33 AM showed Resident 44 lying in their bed and their left hand was clenched in a fist. There was no splint applied to Resident 44's left hand. In an interview on 03/21/2024 at 9:49 AM, Resident 44 stated the restorative aide never splinted left hand. Resident 44 stated their family needed to learn how to apply the splint themselves during their last visit with Resident 44. In an interview on 03/21/2024 at 9:53 AM, Staff S (Restorative aide) stated they did not apply splint to Resident 44's left hand as assigned. Staff S stated they should have provided the splinting program every day, but they did not. In an interview on 03/21/2024 at 10:53 AM, Staff L stated it was important to provide the RNP including ROM and splinting programs to improve resident's health and to prevent further contractures (joint tightenening). Staff L stated staff should provide the RNP as plan of care. Staff L stated the splinting program should be done as assigned to Resident 44's left hand to prevent further contracture, but it was not done. 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 restorative nursing services were provided for 3 of 4 residents (Residents 7, 55, & 44) reviewed for rehab/restorative. This failure left residents at risk for diminished Range of Motion (ROM), loss of function, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 12/2022 Restorative Nursing policy, the facility would utilize the facility's Restorative Nursing Program (RNP) as needed to help residents attain or maintain their highest practicable level of physical, mental, and psychosocial functioning. The policy identified splinting as one type of RNP. <Resident 7> According to the 02/08/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 7 had a moderate memory impairment and diagnoses including traumatic brain dysfunction, left-sided paralysis following a stroke, and a left-hand contracture (a permanent tightening of the muscles, tendons, and nearby tissues that causing ROM issues in joints). The MDS showed Resident 7 did not refuse care during the assessment's seven-day lookback period and did not receive restorative nursing services during the lookback period. A 03/28/2022 Physician's Order (PO) showed staff should apply a splint (a device to stretch tightened muscles and tendons to prevent worsening of contractures) to Resident 7's left hand contracture each morning. The PO showed staff should remove the splint after eight hours. The 08/23/2023 self-care deficit related to stroke Care Plan (CP) included an intervention for staff to place a splint on Resident 7's left hand each morning. The CP showed the splint should be removed after eight hours, corresponding with the PO. Observation on 03/18/2024 at 9:59 AM showed Resident 7's left hand was clenched in a fist. There was no splint applied to Resident 7's left hand. Observation on 03/19/2024 at 10:14 AM showed Resident 7 up in their wheelchair. There was no splint observed on Resident 7's hand. At that time, Resident 7 stated nursing staff never splinted left hand. Observation on 03/20/2024 at 9:51 AM showed Resident 7 did not have a splint on their left hand at that time. In an interview 03/21/2024 at 10:53 AM Staff L (Chief Nursing Officer) stated it was important to provide RNPs including splinting programs to maintain or improve residents' health. Staff L stated staff should provide the RNP as care planned. Staff L said the splinting should be done daily per the CP schedule. <Resident 55> According to the 02/03/2024 Annual MDS Resident 55 had diagnoses including non-traumatic brain dysfunction, a history of stroke, right-sided paralysis, and a contracture. The MDS showed Resident 55 required substantial to maximal assistance with toileting, dressing, personal hygiene, and moving side to side in bed, and was totally dependent on staff for transfers and showering. The MDS showed Resident 55 did not refuse care during the MDS's seven-day lookback period. A 03/05/2024 PO directed staff to splint Resident 55's right hand all day. The PO showed it was permissable to remove the splint for up to half an hour with turning. The PO showed the splint should be removed at night. The revised 01/25/2024 self-care performance deficit CP showed Resident 55 required daily splinting of their right hand. The CP showed to splint the right hand all day and stated it was permissable to leave off for up to 30 minutes, and to remove at night. Observation on 03/18/2024 at 12:44 PM showed Resident 55 in bed with no splint to their right hand. Resident 55 stated they did not recall staff ever splinting their hand. Further observations of Resident 55 with no splint on their right hand were made on 03/20/2024 at 12:26 PM and on 03/21/2024 at 1:03 PM In an interview on 03/21/2024 at 1:47 PM, Staff J (Certified Nursing Assistant) stated they never assisted Resident 55 with their splint because that was the responsibility of the restorative aide. Staff J stated they occasionally saw Resident 55's right hand splinted. In an interview 03/21/2024 at 10:53 AM Staff L stated Resident 55 should have received their RNP program according to the order and the CP.

CONCERN (E)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

<Resident 3> Review of the 02/29/2024 admission MDS showed Resident 3 had a diagnosis of ESRD requiring dialysis. The MDS showed Resident 3 did not have an impaired memory. Review of the 03/18/...

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<Resident 3> Review of the 02/29/2024 admission MDS showed Resident 3 had a diagnosis of ESRD requiring dialysis. The MDS showed Resident 3 did not have an impaired memory. Review of the 03/18/2024 PO's showed a 02/23/2024 order directing staff to document the facility received post dialysis paperwork from the dialysis center upon Resident 3's return to the facility. This order directed staff to call the dialysis center if post dialysis paperwork was not received and document in a progress note. Review of Resident 3's March 2023 medication administration record showed staff documented on every dialysis day from 03/01/2024 to 03/19/2024 that the post dialysis paperwork was not received from the dialysis center. Review of Resident 3's progress notes from 03/01/2024 to 03/19/2024 showed no progress notes indicating nursing staff followed up with the dialysis center to obtain the post dialysis paperwork. In an interview on 03/21/2024 at 8:44 AM, Staff W (Medical Records) stated they collected post dialysis paperwork from a box at the nurse's station. Staff W stated residents on dialysis should have their own binder they take to and from dialysis that included post dialysis paperwork. Staff W stated they did not have Resident 3's post dialysis paperwork. In an interview on 03/21/2024 at 8:47 AM, Resident 3 stated they did not have a binder they took with them to dialysis. Resident 3 stated yesterday was the first day the dialysis center sent paperwork back with the resident. In an interview on 03/21/2024 at 9:06 AM, Staff Y (Licensed Practical Nurse), stated the dialysis center was supposed to send post dialysis paperwork back to the facility with Resident 3. Staff Y stated if the dialysis center did not send paperwork back, the nurse was supposed to call the dialysis center to obtain the paperwork. In an interview on 03/21/2024 at 9:45 AM, Staff B (Director of Nursing) stated the post dialysis paperwork was important to obtain because it was a form of communication between the dialysis center and the facility. Staff B stated the form would include recommendations from the dialysis center and specific things to monitor the resident for post dialysis treatment. Staff B stated nursing staff should be calling the dialysis center to obtain post dialysis paperwork and document in Resident 3's record that the dialysis center was contacted, but staff did not. In an interview on 03/21/2024 at 10:01 AM, Staff L (Chief Nursing Officer) confirmed there was no post dialysis paperwork in the facility for Resident 3. REFERENCE: WAC 388-97-1900 (1), (6)(a-c). Based on interview and record review, the facility failed to ensure ongoing communication and collaboration about resident's health with the kidney center occured regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 2 of 2 sampled residents (Resident 60 & 3) reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes. Findings included . <Facility Policy> According to the facility's undated Dialysis Management (a type of dialysis treatment done in a clinic) policy the facility would coordinate with the dialysis center to ensure the resident's treatments needs were met. The policy directed nurses to ensure there was ongoing communication between the nursing home and dialysis staff. <Resident 60> According to the 02/21/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 60 had multiple complex medical conditions including kidney failure with dependence on dialysis and uncontrolled blood sugars. The MDS showed Resident 60 required dialysis. Review of Resident 60's Physician Orders (POs) showed the following: an 02/08/2024 PO for dialysis three times a week at a local kidney center, an 01/30/2024 PO directing nurses to complete a dialysis communication form including vital signs and medication list with Resident 60 to the dialysis center on dialysis days; an 01/30/2024 PO directing nurses to receive the communication form back from the dialysis center when Resident 60 returned to the facility. The 01/30/2024 PO directed nurses to contact the dialysis center if they did not receive the dialysis communication form back from the dialysis center and to notify medical records to follow up. The 11/14/2023 Hemodialysis Care Plan (CP) showed Resident 60 required hemodialysis related to their diagnosis of End Stage Renal Disease (ESRD). The Hemodialysis CP interventions directed staff to monitor the resident for post dialysis bleeding, seizures, and septic shock. Review of the dialysis communication sheets on 03/20/2024 showed the sheets were divided into three sections. The first section was to be completed by facility staff prior to Resident 60's departure to the dialysis center and included areas for nurses to document the resident's vital signs taken at the facility (including the resident's weight), identify the location of the dialysis access site, document the resident's pain level, and concerns, if any. The second section was to be completed by the dialysis center and included areas for the center staff to document Resident 60's vital signs at dialysis, their weight before and after the treatment, the location of the resident's access site, the times the treatment began and ended, and areas to document if any medications were provided, and any changes occurred during dialysis. The third section included areas where a nurse should document Resident 60's vitals upon return to the facility, an area to document nurses assessed blood flow at the access site, and signature that they received the communication form back. Review of the dialysis binder for Resident 60 showed only four communication forms for the month of February and March 2024. Two out of four communication forms were incomplete. Review of Resident 60's progress notes from 12/01/2023 to 03/19/2024 showed no progress notes indicating nursing staff followed up with the dialysis center to obtain the post dialysis paperwork. In an interview on 03/20/2024 at 1:27 PM, Staff C (Assistant Director of Nursing - ADON) stated the facility's process was to send the completed dialysis communication form with the resident to the dialysis center on dialysis days and dialysis staff would fill the form out and send it back with the resident to the facility. Staff C stated facility nurse received the communication form from the resident, reviewed the communication form and send it to medical record to be scanned into the resident's medical records. Staff reviewed the dialysis binder for Resident 60 and only four forms were filed, and no other communication forms were scanned in Resident 60's record. Staff C stated the dialysis communication sheets were an important tool to facilitate communication between the facility and the dialysis center. Staff C stated it was important for nurses to complete the sheets so Resident 60's health status was adequately communicated between the facility and the dialysis center. Staff C stated nurses should have followed the PO to send and receive the communication form to and from the dialysis center, but they did not.

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide timely assistance with toileting and call light response in accordance with established clinical standards as evidenced by information provided from 8 (Resident 52, 3, 228, 276, 60, 178, 44, & 277 ) resident interviews, information provided by 2 (Resident 22 & 7) Resident Council residents, review of facility grievance forms for Residents 10, 8, 60, & 48, call light reports for Resident 277, 276, & 56, and staff interviews provided by Staff KK (Certified Nursing Assistant - CNA), Staff MM (Registered Nurse), and Staff N (Licensed Practical Nurse). The facility had insufficient staff to ensure Restorative Nursing Programs (RNPs) were provided to Residents 7, 55, & 44. These failures placed residents at risk for unmet care needs and other negative health outcomes. Findings included . <Facility Policy> Review of the Resident Call System facility policy dated 09/2022 showed when a resident utilized the call light system, staff should respond to the resident's needs in a reasonable amount of time. <Resident Interviews> <Resident 52> In an interview on 03/17/2024 at 8:10 AM, Resident 52 stated they had to wait for two and a half hours on a regular basis to get assistance and the wait time usually occurred after 3:00 AM on a given day. Resident 52 stated they used the bed pan or bedside commode on their own when they did not get help. <Resident 3> In an interview on 03/17/2024 at 10:10 AM, Resident 3 stated staff did not come when the resident called. Resident 3 stated it usually took an hour or so for staff to answer the call light. Resident 3 said I usually take myself to the bathroom to keep from wetting myself. <Resident 228> In an interview on 03/17/2024 at 11:39 AM, Resident 228 stated staff were respectful but the facility was understaffed. Resident 228 stated Sundays were especially bad and it sometimes took staff several hours to answer Resident 228's call light. <Resident 276> In an interview on 03/17/2024 at 12:06 PM, Resident 276 stated they had to lie in their soiled undergarments all night. Resident 276 stated a male staff person answered their call light after Resident 276 waited for more than one hour. The male staff person told Resident 276 the staff member needed to get another staff member help to provide care to Resident 276. Resident 276 stated the staff member never came back. <Resident 60> In an interview on 03/17/2024 at 1:33 PM, Resident 60 stated I do not think they have enough staff .my call light does not get answered on time, I have to sit in my [bowel movement]. <Resident 178> In an interview on 03/18/2024 at 9:14 AM, Resident 178 stated they had to wait a long time at night when they needed to be changed. Resident 178 stated sometimes staff come sooner but most of the time, there were not enough staff. <Resident 44> In an interview on 03/18/2024 at 9:39 AM, Resident 44 stated the facility did not have enough staff. Resident 44 stated they usually waited 30 to 40 minutes to get the call light answered if they needed to be cleaned for a bowel movement. <Resident 277> In an interview on 03/18/2024 at 1:21 PM, Resident 277 stated staff were sometimes pretty slow to answer the call light. Resident 277 stated at 3:30 AM, they had to [urinate] in the bed because staff did not answer the call light in time. Resident 277 stated day time call light response was slow but nighttime was worse. <Resident Council Interviews> <Resident 22> During a resident council meeting on 03/21/2024 at 11:00 AM, Resident 22 stated [staff] could be faster with call lights, it's like [staff] don't care. Resident 22 stated they called the front desk on occasion when their call light was not answered. Resident 22 stated they waited over an hour for the staff to assist the resident to lie down. <Resident 7> During the resident council meeting on 03/21/2024 at 11:12 AM, Resident 7 stated staff take too long to answer their call light. Resident 7 stated If I scream, then they come. <Grievance Forms> <Resident 10> A 01/24/2024 grievance form showed Resident 10 stated call lights were not answered timely at night. <Resident 8> A 01/24/2024 grievance form showed Resident 8 stated there were not enough staff, nurse's aides needed more training on the evening and night shift. <Resident 60> A 02/01/2024 grievance form showed Resident 60 stated nurse's assistants do not answer call lights timely. This form showed Resident 60 stated yesterday it took [staff] 40 minutes to get my light, I was almost late for dialysis [outpatient appointment to filter waste from blood]. <Resident 48> A 02/21/2024 grievance form filed by Resident 48's spouse showed Resident 48 had their call light on for an hour around 4:00 PM. After waiting an hour, Resident 48 called their spouse who called the facility and was put on a 20-minute hold. Resident 48's spouse called the facility again, staff answered and told Resident 48's spouse they would send staff in to assist Resident 48. Resident 48 called their spouse after an additional 20 minutes passed without receiving assistance. <Call Light Report> <Resident 277> Review of the facility's call light report showed on 03/15/2024 at 2:31 AM, Resident 277 turned on their call light. This report showed the call light was answered at 2:49 AM, 18 minutes later. Review of the call light report showed on 03/15/2024 at 8:32 AM, Resident 277 turned on their call light. At 8:57 AM, the call light was answered, nearly 25 minutes later. Review of the call light report showed on 03/15/2024 at 7:47 PM, Resident 277 turned their call light on. At 8:09 PM, the call light was answered, 20 minutes later. Review of the call light report showed on 03/19/2024 at 10:41 PM, Resident 277 turned their call light on. At 11:04 PM, Resident 277's call light was answered, 23 minutes later. <Resident 276> Review of the call light report showed on 03/17/2024 at 7:55 PM, Resident 276 turned on their call light. At 8:14 PM, Resident 276's call light was answered, 19 minutes later. Review of the call light report showed on 03/18/2024 at 10:22 PM, Resident 276 turned on their call light. At 10:40 PM, Resident 276's call light was answered, 18 minutes later. Review of the call light report showed on 03/20/2024 at 5:57 AM, Resident 276 turned on their call light. At 6:36 AM, Resident 276's call light was answered, 39 minutes later. <Resident 56> In an observation and interview on 03/19/2024 at 5:09 AM, Resident 56 had their call light on. The call light monitoring system at the nurse's station showed Resident 56's call light was on for 44 minutes. In an interview at that time, Resident 56 stated they needed a bed pan. Resident 56 stated they turned their call light on around 4:00 AM. Resident 56 stated they eventually used their cell phone to call the nurse's station to get help. Resident 56 stated staff provided assistance about 15 minutes after the phone call. When Resident 56 was told their call light was on for 44 minutes, Resident 56 replied yes, that is pretty accurate. <Staff Interviews> <Staff KK> In an interview on 03/17/2024 at 8:10 AM, Staff KK stated staffing was up and down. Staff KK stated they used to work night shift but the night shift was always short-staffed so they decided to move to day shift. <Staff MM> In an interview on 03/20/2024 at 8:59 AM, Staff MM stated they were normally a night shift nurse. Staff MM stated they were asked to stay over for a couple of hours that morning after working the night shift because of a staffing conflict. <Staff N> In in interview on 03/20/2024 at 10:08 AM, Staff N was orienting a new nurse and stated they were responsible for residents on both Hall C and Hall D that day. Staff N stated there were days when there were four nurses and days when there were only three nurses and today is one of those days [where there were only three nurses]. <RNP> <Resident 7> A 03/28/2023 Physician's Order (PO) directed staff to apply a splint to Resident 7's left hand each morning and remove the splint after eight hours. Observations on 03/18/2024 at 9:59 AM, 3/19/2024 at 10:14 AM, and 03/20/2024 at 9:51 AM showed Resident 7 without the splint to their left hand. <Resident 55> A 03/05/2024 PO directed staff to apply a splint to Resident 55's right hand daily. Observations on 03/18/2024 at 12:44 PM, 03/20/2024 at 12:26 PM, and on 03/21/2024 at 1:03 PM showed Resident 55 without the splint to their right hand. In an interview on 03/21/2024 at 1:47 PM, Staff J (CNA) stated it was the restorative aide's responsibility to apply the splint to Resident 55's right hand. <Resident 44> Review of an 08/31/2023 Self-Care Deficit care plan directed restorative staff to place a splint on Resident 44's left hand for three to six hours as tolerated, three to six times weekly. Observations on 03/17/2024 at 11:21 AM, 03/18/2024 at 9:34 AM, 03/19/2024 at 12:05 PM, and 03/21/2024 at 9:33 AM showed Resident 44 without a splint to their left hand. In an interview on 03/21/2024 at 9:49 AM, Resident 44 stated the restorative aide never splinted the resident's left hand. In an interview on 03/21/2024 at 2:57 PM Staff C (Assistant Director of Nursing) stated when staff called in, restorative aides would sometimes be pulled to work the floor instead of their restorative duties. In a joint interview on 03/21/2024 at 2:44 PM, Staff B (Director of Nursing) stated they expected call lights to be answered in a timely manner. Staff L (Chief Nursing Officer) stated a timely manner meant a call light should be answered within 15 minutes. Staff B acknowledged night shift had a trend toward long call light response times and they were aware of the grievances regarding long call light wait times. Staff B stated their expectation was that staff performed rounding on residents every two hours by checking if the resident needed toileting assistance, repositioning assistance, or if the resident had any pain, or other needs. Refer to: F688 Increase/prevent Decrease in Range of Motion/mobility. REFERENCE: WAC 388-97-1080(1). .

CONCERN (E)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 4 sample residents (Residents 52) reviewed for food concerns received the diet prescribed to them, and 5 supplemental residents (Residents 227, 13, 37, 39, & 20). Failure to ensure residents received their diet as ordered, placed residents at risk for an inappropriate diet and related negative health outcomes. Findings included . <Resident 52> According to the 02/17/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 52 had clear speech, their memory was intact, and had medical conditions including heart failure, high blood pressure, localized edema, and diabetes (unstable blood sugar levels). The MDS showed Resident 52 was administered injectable and oral medication to treat high blood sugar level daily during the assessment period. The 02/15/2024 therapeutic diet care plan showed the staff should encourage food choices consistent with Resident 52's medical conditions and listed an intervention directing staff to serve the diet as ordered. Review of Resident 52's physician orders showed a 03/03/2023 dietary order indicating Resident 52 was on a Consistent Carbohydrate (CCHO) diet. Observation and interview on 03/17/2024 at 8:10 AM showed Resident 52 was served breakfast in their room; their tray was observed to have a piece of ham, two pancakes, one small syrup package, five packets of regular sugar, a glass of apple juice, a glass of milk, a cup of cream of wheat. Resident 52 stated they had heart failure and the ham had too much salt content in it which was bad for their existing medical condition. Resident 52 stated they could not understand why the staff kept on giving them regular sugar packets with their coffee, .I am diabetic, and I cannot have these [regular sugar] and pulled out their own supply of artificial sweetener. In an interview on 03/20/2024 at 10:08 AM, Staff F (Registered Dietician) stated, for residents with heart failure and blood pressure issues, they would try to liberalize [remove or loosen restrictions] the diet by asking the resident's preferences for salt intake and would document this information in their assessment notes. Review of a 02/08/2024 nutrition evaluation showed Resident 52's diagnosis of heart failure was identified in the assessment, including the presence of bilateral lower extremity edema as the clinical manifestation. The evaluation did not show Resident 52's preference not to eat foods high in salt content was captured during the assessment. In an interview on 03/20/2024 at 10:42 PM, Staff C (Assistant Director of Nursing) stated the nursing aides were responsible for passing the beverages including the sugar packets. Staff C stated they expected staff to look at the resident's meal ticket and/or the [NAME] (directions to staff regarding how to provide care) and refer to these resources when distributing beverages. Staff C stated Resident 52 should be served artificial sweetener and not regular sugar packets because of the resident's medical condition.<Trayline Observations> Review of the facility's breakout menu (a menu showing required portion sizes, texture alterations, and substitutions for residents with identified nutritional needs) showed residents on a CCHO diet should be served half a portion of the cake on the regular menu. The breakout menu showed for resident's requiring the cardiac diet, staff should serve pears. Observation of the facility's lunch preparation on 03/21/2024 at 11:39 AM showed three four staff preparing resident lunch trays: Staff E (Dietary Manager), Staff K (Dietary Aide), Staff BB (Dishwasher), and Staff CC (Cook). Staff K set up trays with silverware, napkins, and desserts. At 11:59 PM Staff E reminded Staff K that Cardiac gets pear, CCHO gets half a cake. At 12:02 PM Staff K prepared the lunch tray for Resident 227. Staff K served Resident 227 pears. Resident 227's tray ticket indicated they required a CCHO tray. (Review showed Resident 227's record included a 03/20/2024 order for a CCHO diet.) At 12:09 PM Staff K prepared the lunch tray for Resident 13. Staff K served Resident 13 pears. Resident 13's tray ticket indicated they required a CCHO tray. (Review showed Resident 13's record included a 05/02/2023 order for a CCHO diet.) At 12:13 PM Staff K prepared the lunch tray for Resident 37. Staff K served Resident 37 pears. Resident 37's tray ticket indicated they required a CCHO tray. (Review showed Resident 37's record included a 06/18/2023 order for a CCHO diet.) At 12:16 PM Staff K prepared the lunch tray for Resident 39. Staff K served Resident 39 pears. Resident 39's tray ticket indicated they required a CCHO tray. (Review showed Resident 39's record included a 04/11/2023 order for a CCHO diet.) At 12:21 PM Staff K prepared the lunch tray for Resident 20. Staff K served Resident 20 pears. Resident 20's tray ticket indicated they required a CCHO tray. (Review showed Resident 20's record included a 11/07/2023 order for a CCHO diet.) At 12:42 PM the tray with the incorrect dessert was observed to be provided to Resident 39. At 12:46 PM the tray with the incorrect dessert was observed to be provided to Resident 227. In an interview on 03/22/2024 at 8:05 AM Staff F stated the lunch menu for 03/21/2024 had a half serving of cake for CCHO residents. Staff F stated they expected dietary orders to be followed. Staff F stated the residents with CCHO diets should have received half a serving of cake per the menu. In an interview on 03/22/2024 at 12:29 PM Staff E stated the residents with CCHO diets should have been provided the correct dessert. Staff E stated Staff K was nervous. REFERENCE: WAC 388-97-1200 (1). .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to store and prepare food under sanitary conditions for 1 of 1 kitchens. The failure to ensure food items in the dietary department were properly labeled and stored, adequate hand washing supplies were available to dietary staff, and food brought to residents from outside the facility was properly, placed residents at risk for consuming expired/spoiled foods and potential exposure to food-borne illness. Findings included . <Facility Policies> According to the facility's July 2014 Preventing Food Illness - Food Handling policy, food would be stored, handled, and served in a manner to minimize the risk of foodborne illness. According to the facility's undated Safe Handling for Foods from Visitors facility staff would remind visitors to let a member of staff know when they brought food from outside the facility to a resident. The policy showed if the food brought in was intended to be eaten later, facility staff were responsible to ensure the food was contained adequately, labeled with the resident name and date of receipt, and refrigerated if not shelf stable. <Handwashing Sinks> Observation on 03/17/2024 (a Sunday) at 07:55 AM showed no paper towels were available from either of the two handwashing sinks in the facility's kitchen. A cloth rag was placed on top of each dispenser and staff were observed using the cloth rags to dry their hands after washing. In an interview at that time, Staff G (Cook) stated that supplies of spare paper towels were locked away on weekends and if dietary staff used a roll to its end on the weekend they needed to wait until Monday to refill the paper towel dispensers. Observation on 03/19/2024 at 8:43 AM showed the kitchen towel dispensers remained empty. At this time, a roll of paper towels was placed on top pf each dispenser, allowing staff to dry their hands with paper towels but still preventing staff from dispensing the towels in a manner that prevented the rest of the roll from contamination. At 03/19/2024 at 11:04 AM, Staff A (Administrator) and Staff C (Assistant Director of Nursing) observed the paper towels placed on top of the empty dispensers in the facility kitchen. Staff C expressed frustration at the situation and stated staff education would be necessary. <Extractor Fan Cleanliness> Observation on 03/17/24 08:08 AM showed an extractor fan located directly above the steam table where staff prepare meal trays for residents. The fan was covered in a layer of black-ish dusty and grease. The fan was noted to still be covered with greasy dusty build up on 03/21/2024 at 12:39 PM. Dust, grease, and grime was observed to be stuck on the ceiling next to the fan, spreading out in a triangular shape to a support beam where more dust/grease splatter collected. In an interview on 03/22/2024 at 12:29 PM Staff E (Dietary Manager) stated they were aware of the buildup of dust and grease over the food preparation area. Staff E stated it had the potential to contaminate resident meals. Staff E stated they notified the facility's maintenance department, but the problem was not yet fixed. <Cold Storage> Observation on 03/17/2024 of the facility's cold storage from 7:58 AM to 8:03 AM showed an opened bag of shredded lettuce in the refrigerator, a frozen, undated zip-top food storage bag containing cubed ham, and a refrigerated, open, undated ham loaf. Staff did not add a date to the lettuce bag indicating when they opened it. The lettuce was observed to be slimy and spoiled. The frozen cubed ham was covered in ice crystals (freezer burn). The refrigerated ham loaf was partially in its vacuum-packed plastic packaging, and staff wrapped the open end with plastic kitchen wrap. In an interview on 03/17/2024 at 8:02 AM, Staff G stated all opened food should have a date of opening to indicate how long it was appropriate to use. Staff G stated these foods were stored in a way that meant they should now be disposed of. In an interview on 03/22/2024 at 10:09 AM Staff D stated all opened food packages should be labeled with a date upon opening. Staff D stated spoiled and/or inappropriately stored food should be disposed of. <Outside Food> Observation on 03/20/2024 at 9:55 AM showed a reusable plastic container of bean stew on the dresser nearest the door in room [ROOM NUMBER]. The container did not have a date of receipt or the resident's name. The container of bean stew was observed on the dresser in room [ROOM NUMBER] again on 03/21/2024 at 9:47 AM and 1:55 PM. On 02/21/2024 at 2:39 PM Staff I (Director of Infection Prevention) observed the stew on the counter and stated it should be disposed of. Staff I stated the bean stew should have been handled more thoughtfully, and in accordance with the facility's outside food policy. In an interview on 03/22/2024 at 10:09 AM Staff D stated the handling of food brought by guests to residents was the responsibility of the nursing department. Staff D stated the food in room [ROOM NUMBER] should have been but was not stored correctly. REFERENCE: WAC 388-97-1100 (3), -2980. .

Dec 2023 1 deficiency 1 IJ (1 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0678 (Tag F0678)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician order to initiate CPR and signed POLST (Physician Order for Life Sustaining Treatment- a form indicating the resident's wishes to have or not have CPR) for life-sustaining care and services. The failure to train staff on the facility's expectation how to respond to a resident requiring CPR, locate, for immediate reference, resident POLST/Advanced Directives, and accurately assess signs of irreversible death, resulted in staff not following Resident 1's CPR directives, and placed 38 of 69 other current residents (Resident 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, & 39) with CPR directives at risk of not receiving CPR and/or full medical interventions in an emergency which constituted an Immediate Jeopardy (noncompliance that has caused or is likely to cause, serious injury, harm, impairment, or death to a resident) The facility corrected the above deficient practice prior to the initiation of the abbreviated survey on [DATE]. This failure was a past noncompliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) Immediate Jeopardy situation and is no longer outstanding. The facility removed the immediacy by auditing the records of all residents, auditing the POLST binder, scanning the POLST forms into the resident's records for immediate access in emergencies, educating staff on the CPR policy and how to assess for irreversible signs of death, performed CPR drills on the day, evening and night shifts, and implemented a plan of correction to sustain ongoing compliance. Findings included . The 08/2023 Facility CPR Policy showed a resident's POLST form communicated to medical personnel the medical treatments the resident would want based on their diagnosis, prognosis, and goals of care. The facility staff would review a resident's current POLST or assist the resident to complete a new POLST form at admission. The facility staff would obtain physician orders based on the resident's decision for CPR on the POLST form. The POLST form and the physician orders were to be kept in the electronic medical record for access and review in emergencies. The policy directed staff to perform CPR to residents who were a full code (had physician orders to perform CPR). The policy showed if there was an unwitnessed arrest for a resident with full code, the nurse would assess for obvious signs of irreversible death including liver mortis (lividity or pooling of blood in dependent body parts), rigor mortis (hardening of muscles, rigidity), and injuries incompatible with life such as decapitation. The policy directed staff to initiate CPR if no signs of irreversible death were present. Staff would continue CPR until emergency medical personnel arrived and took over responsibility for emergency treatment. The policy does not define who is permitted to pronounce death. Documentation of all cardiac arrests would include: time the resident was found without vital signs, significant events preceding arrest, resident's code status, presence of end-stage or terminal conditions, description of the resident's condition upon discovery, reason for decision to withhold CPR, notification of the physician, and resident responsible party and time notified, transfer order if transferred, person that pronounced death, name of the funeral home, and date/time of release of the body, coroner notification. Review of Resident 1's POLST form showed it was signed by the resident on [DATE] and signed by the Nurse Practitioner on [DATE]. The form showed Resident 1 wanted CPR if they were not breathing and had no pulse. The form showed Resident 1 wanted full treatment to prolong life by all medically effective means including transfer to the hospital and intensive care. A review of Resident 1's electronic medical record showed a physician order for CPR dated [DATE]. There was no POLST form scanned into the electronic record. The care plan showed the Advanced Directive would be followed but did not contain information about the contents of the POLST form or the CPR order from the physician. Review of the [DATE] nurse progress note showed Staff B (Licensed Practical Nurse- LPN) found Resident 1 at 6:30 AM passed on, the body was still warm to touch, there was no pulse and no respirations. Staff B did not document their assessment for obvious signs of irreversible death identified in the facility policy, their inability to locate the POLST form, the resident's code status, the physician's CPR order, the reason for their decision to withhold CPR, the time of notification of the physician, the time of notification of the power of attorney, the time and details of the 911 call, the time death, or who pronounced Resident 1's death as directed in the facility CPR policy. The [DATE] facility interview with Staff B showed Staff B reviewed the CPR order in the electronic medical record, went to the POLST binder at the nurse's station to verify the CPR order with the POLST form and was not able to find the POLST form in the binder. Staff B's interview stated they did not do CPR because Resident 1 appeared expired because Resident 1's skin was pale, they had no vital signs and their fingers were cold. Staff B stated they asked another LPN to assess Resident 1 for death, Staff B notified the physician of Resident 1's death, notified the power of attorney of Resident 1's death, and then called 911 and requested assistance with Resident 1's death . Staff B's interview showed the Emergency Medical Services (EMS) responders came to check Resident 1 and pronounced Resident 1 deceased . Review of the [DATE] EMS dispatch records showed the call from Staff B was received at 6:45 AM, 15 minutes after Resident 1 was found with no pulse and was not breathing. The record showed EMS dispatch was designated as non-emergent without lights and sirens. EMS personnel arrived at the facility 6:53 AM and assessed Resident 1 with no vital signs, rigor mortis-obvious sign of irreversible death, and pronounced Resident 1 as deceased at 6:58 AM. Review of the [DATE] 6:45 AM audio of the EMS call showed Staff B asked for the police department because Resident 1 passed away unexpectedly. The operator asked if Staff B wanted to try CPR. Staff B responded that Resident 1 died peacefully. The operator stated they would send EMS personnel to help. Review of the [DATE] facility investigation report showed findings that Resident 1 was a full code. The report showed the Staff B did not initiate CPR to Resident 1 who required CPR according to the facility policy and physician orders. The investigation showed the POLST form for Resident 1 was in the POLST binder at the nurse's station, the POLST was not scanned into the electronic medical record, the POLST was not located by Staff B in the emergency, and Staff B decided to not initiate CPR for Resident 1 who was a full code. A review of the electronic medical records, on [DATE], showed 38 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, & 39) had a current physician order to receive CPR according to the facility policy. These 38 residents all resided in the facility on [DATE]. In an interview on [DATE] Staff A (Interim Director of Nursing) stated all staff were expected to follow the physician orders and initiate CPR and call 911. Staff A stated Staff B did not perform CPR for Resident 1 who had a full code CPR status. Staff A stated the facility had completed an investigation, reviewed the facility CPR policy, audited all resident records, corrected records for identified residents, provided CPR policy training to staff, completed CPR drills with additional training, and initiated an ongoing plan of correction. REFERENCE: WAC 388-97-1060(1). .

Aug 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure pharmacy services were provided to meet the residents needs for 4 of 5 residents (Residents 1, 2, 3, & 5) reviewed. The failure to ensure medications were acquired and administered on the day of admission, follow facility process for medications that were not available for administration, reconcile medications delivered from the pharmacy for accuracy, ensure proper storage and disposition of medications that required disposition / return to the pharmacy, and reconcile medications upon resident discharge placed the resident's at risk for adverse health complications, significant medication errors, and diminished quality of care. Finding included . <Policy> According to the facility's December 2022 revised Medication Administration Policy, the licensed staff were directed to verify the prescription label on the drug matched the Medication Administration Record (MAR) and if there was a discrepancy, they would check the original Physician Order (PO) and notify the pharmacy. The licensed staff would also indicate on the MAR any omitted doses and document the reason for the omission in the progress notes/administration note. The policy noted it was not acceptable to omit a dose by indicating the medication was not available. The staff were directed to remove the dose from the Emergency (E-Kit) medication dispensing system or contact the pharmacy and request the medication be sent as soon as possible. <Resident 1> According to the 06/14/2023 5-Day Minimum Data Set (MDS-an assessment tool), Resident 1 admitted to the facility on [DATE]. Resident 1's primary admission diagnosis was atrial fibrillation (a serious heart rhythm condition that can lead to blood clots that can dislodge and block blood vessels in the brain, heart, and lung; and can result in death without proper treatment). Resident 1's other diagnoses included stroke, heart failure, and heart attack. In an interview on 08/09/2023 at 11:34 AM, Resident 1 stated they arrived at the facility on 06/07/2023 at 11:30 am and on that evening, they did not receive their heart medications ordered by their Physician. Resident 1 stated the nurse on duty said their medication was not received from the pharmacy yet. Resident 1 asked the nurse if they had the medication available in the emergency supply. Resident 1 stated the nurse told them to take the medication from their own supply if they had it, which they did not. Review of Resident 1's June 2023 MAR showed on 06/07/2023 three medications were due for administration at 7:00 PM. The MAR showed Resident 1 was administered the medication for cholesterol and the medication to prevent blood clots but was not administered the medication for high blood pressure. The MAR showed to refer to the Nurse Progress Notes (NPN) for more information. On 08/09/2023 at 11:38 AM, Resident 1 stated they did not receive any of their medications on the evening of 06/07/2023. Review of the 06/07/2023 NPN showed no documentation to explain why Resident 1 did not receive their medication. Review of the Resident 1's Pharmacy Emergency Medication Transaction Report (EMTR) showed no medications dispensed for Resident 1 on 06/07/2023. In an interview on 08/23/2023 at 4:00 PM, Staff C, Assistant Director of Nursing, stated they were not aware Resident 1 did not receive their medication on the day of admission and would investigate the concern. Staff C stated licensed staff were expected to ensure the residents received their medications as ordered and if they were not available in the Emergency Medication Dispenser, they were required to contact the pharmacy and attempt to get the medication sent from a local pharmacy as soon as possible. Staff C stated if the pharmacy was unable to deliver the medication timely, the licensed staff were required to contact the Physician and notify them of the concern, ask for an alternative medication if appropriate, obtain an order to hold the medication until available, or transfer the resident to the hospital (in more serious circumstances). On 08/09/2023 at 11:40 AM, Resident 1 stated when they discharged from the facility on 06/15/2023 and were provided with a bag of medications in bubble packs (medication packing system). Resident 1 stated the nurse who discharged them appeared to be in a rush and did not review their medication instructions with them. Resident 1 stated they were very concerned because one of the medications sent home with them was an antidepressant medication they did not have a current order for, nor had they ever been ordered the medication. Resident 1 stated the medication card had their name on it and one tablet was missing out of 15 tablets that were dispensed. The dispense date said 06/07/2023, the day of admission. Review of Resident 1's 06/15/2023 9:16 AM Resident Discharge Summary/Instructions the Resident Care Manager (RCM) reviewed the medication list and provided the resident with a copy. The medication list showed four medications and the amount of each medication sent home with Resident 1. The antidepressant medication was not on the medication list. Staff E, RCM, who conducted the discharge was unable to be interviewed because they were no longer employed at the facility. Review of Resident 1's admission PO showed a 06/07/2023 order entered for the antidepressant medication, which was struck-out with the comment wrong chart. In an interview on 08/23/2023 at 4:15 PM, Staff D, RCM, stated on 06/07/2023 they were working on two admissions at the same time and during their two-nurse admission order double-check process, they recognized the error and struck-out the order. They did not know the pharmacy still sent the medication. On 08/23/2023 at 4:48 PM, Staff C stated the medication was not properly reconciled when it was received on 06/08/2023. Staff C stated the Pharmacy delivery arrived daily between midnight at 1:00 AM and the night shift licensed staff were required to reconcile the medication with the current order and put the medication away securely. If there were concerns, then the nurse was expected to clarify the order. If the medication was ordered in error, it should not be accepted and should be placed in the Medication Room storage box for pharmacy returns or disposal. Staff C stated clarification and removal of medications residents did not have current orders for was important because failure to do so placed the residents at a higher risk for medication errors. On 08/30/2023 at 11:55 AM, Staff B stated some of the licensed staff did not have access to the EMD system and some of the nurses stated the medications were not available. Staff A stated the licensed staff should have called the pharmacy and/or the physician to ensure the resident received their medication but they did not. <Resident 2> According to the 08/24/2023 admission MDS, Resident 2 admitted to the facility on [DATE] with the primary medical condition of a serious chest infection. Resident 2's other diagnoses included pneumonia, sepsis, serious bone infection, diabetes, high blood pressure, and asthma. Review of Resident 2's August 2023 MAR showed they were ordered to receive an diabetes medication (insulin) injection at 7:00 PM every day. The documentation on 08/17/2023 and 08/18/2023 showed the insulin injection was not administered and the nurse referred to the NPN. Resident 2 also had a sliding scale (short acting insulin) diabetes injection and blood sugar check (BS) due at 7:00 PM on 08/17/2023. The clinical record provided no BS check or insulin dose documentation. The nurse referred again to the NPN. Resident 2 had two oral medications scheduled for 7:00 PM every day and on 08/17/2023 the documentation showed they were not administered, refer to NPN. Review of Resident 2's 08/17/2023 and 08/18/2023 NPN showed no documentation to explain why the medications were not administered or why Resident 2's BS was not measured. Review of Resident 2's EMTR for the dates between 08/17/2023 and 09/08/2023 showed only one medication dispensed for Resident 2 on 08/18/2023 at 10:34 PM, and no medications were dispensed for Resident 2 on the day of admission. <Resident 3> Similar findings for Resident 3. According to Resident 3's Census record, they admitted to the facility on [DATE]. Review of Resident 3's August MAR showed seven medications were scheduled for administration at 8:00 PM on 08/30/2023. Two medications were documented as not administered; refer to NPN. Review of Resident 3's NPN provided no documentation to show why Resident 3's two medications were not administered. Resident 3 did not have an EMTR because no emergency stock medications were dispensed for Resident 3 on 08/30/2023, or any other day. <Resident 5> Similar findings for Resident 5. According to Resident 5's Census record, they admitted to the facility on [DATE]. Resident 5's August MAR showed four medications were due for administration at 7:00 PM on 08/23/2023. Three of the ordered medications were documented as not administered; refer to NPN. The MAR also showed two anti-coagulant (blood clot prevention - blood thinner) medications ordered for Resident 5. Review of Resident 5's 08/23/2023 NPN provided no documentation to show why the medications were not administered. Review of Resident 5's EMTR showed three medications were dispensed for Resident 5, one on 08/24/2023 at 12:12 PM, one on 08/24/2023 at 7:59 PM, and one on 08/30/2023 at 12:23 PM. No medications were removed from the EMD for Resident 5 on the day of admission. Review of Resident 5's Physician Order history showed on the day of admission, the provider entered one of the anti-coagulant orders at 2:00 PM, but then discontinued the order at 2:57 PM and documented wrong chart. Review of Resident 5's August 2023 Pharmacy bill showed the pharmacy dispensed and sent to the facility 30 tablets of the wrong anti-coagulant in addition to the correct anti-coagulant ordered by the Physician. Reference (WAC) 388-97-1300 (1)(a)(b)(i)(ii)(c)(i-iv)(3)(a)(b)(4)(a)(i)(c)(d)(5)(a)(b). .

Jul 2023 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0561 (Tag F0561)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident had the opportunity to exercise their autonomy and Resident Rights regarding activities and preferences important to them. The failure to provide a safe designated smoking area on the campus that maintained quality of life for 3 of 3 residents (Residents 1, 2, & 3) who were not notified of the smoking policy on admission was a violation of their Resident Rights and placed them at risk for unnecessary frustration, feelings of discrimination, and diminished quality of life. This failed practice caused psychological harm to one resident (Resident 1), who described they experienced feelings of discrimination, increased anxiety, and hopeless frustration when the facility failed to act on the resident's repeated requests smoke and contributed to their actions of cutting themselves to cope with their feelings. Findings included . <POLICY> Review of the facility policy titled, Smoking-[NAME] Center NO Smoking dated 08/2022, showed the facility did not permit smoking in the center or on its grounds (campus). The policy showed all residents/representatives would receive, and were required to sign, the smoking policy upon admission. All residents would be screened for smoking via the nursing admission Evaluation and a care plan (CP) would be developed. Residents who were assessed to smoke independently and were able to leave the campus according to the facility Leave of Absence policy, could leave to smoke. The smoking resident would use the Agreement to Accept Responsibility for Resident Smoking Log to document when they smoked. Residents assessed to need assistance to smoke would require a family member/visitor to assist them to leave the campus to smoke. Failure to follow the smoking policy could result in discharge. Review of the previous facility policy titled Smoking Policy & Procedure, undated, showed that all residents/representatives would be provided, and were required to sign, the Smoking Policy and Smoking Safety Guideline for a non-smoking campus, on admission, and with any changes. The facility would post a copy of the Smoking Safety Guidelines in the facility. On admission, all smoking materials would be collected, marked with the resident's name, and kept locked at the nurse station. For active smokers, a smoking evaluation would be completed on admission, quarterly, and as needed to evaluate their ability to smoke independently. The Smoking Safety Guidelines for a Non-Smoking Campus showed: If the resident was an independent smoker, they could follow the Leave of Absence policy and leave the campus to smoke. If they were not an independent smoker, they would have to be escorted by a visitor/representative off the property to smoke. Non-compliance with the Smoking Policy could result in a facility-initiated discharge, consistent with applicable regulatory requirements. If the resident continued to express desire to smoke after education of the Non-Smoking Policy, they would implement their Smoking Campus policy until time of appropriate discharge. The Smoking Safety Guidelines for a Smoking Campus showed: If the resident was assessed to be an independent smoker, they could smoke in designated areas of the campus. If the resident was assessed to not be an independent smoker, they could not smoke on the campus and had to be assisted off the campus by a visitor or representative to smoke. <Resident 1> According to the 05/25/2023 Annual Comprehensive MDS (Minimum Data Set - an assessment tool), Resident 1 admitted to the facility on [DATE]. Resident 1 had moderate memory problems, no behaviors or rejection of care, and needed supervision with bed mobility, transfers, and locomotion. Resident 1's diagnoses included asthma (breathing condition), seizures, and schizophrenia (a psychiatric disorder). Review of Resident 1's CP dated 12/07/2022 showed a focused Mood CP for depression due to Resident 1's history of isolation, irritability, negative thoughts/statements, history of suicidal ideations, and self-harm including wrist cutting and burning themselves. Interventions showed staff were to watch for behaviors and allow the resident time to express feelings. A 06/13/2023 CP update showed Resident 1 had cut themselves and was transported to the Emergency Department (ED). A 06/15/2023 CP intervention update showed Resident 1 had suicidal ideation, was placed on 15-minute checks for 24 hours and was moved to a room closer to the nurse station. Review of a Social Services Progress Note (SSPN), dated 05/19/2023 5:35 PM, showed Resident 1 had a pack of cigarettes and two lighters in their possession and told staff they desired to smoke. Staff C, Social Services Director, educated Resident 1 on the smoking policy and removed the smoking material from the resident's room. Staff C offered Resident 1 assistance to discharge to a smoking facility that would satisfy their desire to smoke, and the resident was agreeable. In an interview on 07/12/2023 at 4:45 PM, Staff C stated they still had the cigarettes and lighters locked up. Staff C stated Resident 1 signed the Non-Smoking policy on 05/16/2023 but was unable to find it in the clinical record. Staff C stated the smoking acknowledgement could still be in medical records to be scanned into the chart. Staff C was asked to provide the document, but no further information was provided. Review of a grievance form dated 06/01/2023, submitted by Resident 1, showed they wanted to smoke. The 06/02/2023 dated Grievance Summary Report showed Resident 1 was provided a copy of the smoking policy, the Administrator and Director of Nursing were consulted regarding smoking procedures, and Resident 1 was referred to the Physician for a smoking assessment. The 06/02/2023 dated Grievance resolution showed the grievance was not resolved and noted the IDT (Interdisciplinary Team) would review the smoking procedure and assess the resident appropriately. The signed smoking policy was not attached to the grievance documents. In an interview on 07/12/2023 at 4:50 PM, Staff C stated they spoke with the physician who told them they did not do smoking assessments; it was a nursing responsibility. Staff C stated it was discussed by the IDT but was unsure if a smoking assessment was completed. Review of NPN's dated 06/07/2023 at 4:40 PM and 06/11/2023 at 4:01 PM, Resident 1 continued to express the desire to smoke to nursing staff. One of the nurses informed the resident it was a non-smoking campus. There was no documentation in the NPN that the provider was notified, smoking cessation alternatives were offered, or Resident 1 was assessed to smoke. Review of a NPN, dated 06/13/2023 at 3:43 PM, showed Resident 1 exhibited increased anxiety from inability to smoke and had cut themselves. Resident 1 told the nurse they did it with scissors and refused to give the facility the scissors. Resident 1 then motioned with their finger, a line across their neck as if they were going to cut their neck with the scissors. The Resident was seen by psychiatry over telehealth and then transported to the ED for evaluation with Emergency Medical Services and Police escort. In an interview on 06/26/2023 at 8:50 AM, Resident 1 was observed sitting on the edge of their bed in their new room with their possessions still unpacked in boxes and bags around the room and in the closet. Resident 1 stated they were very upset about being moved to a different room and that the facility took their nail clipper kit, which included the scissors they used cut themselves. Resident 1 stated they told the facility they wanted to smoke over a month ago, but their requests were ignored. Resident 1 stated they smoked for 50 years. Resident 1 stated they had a pack of cigarettes and two lighters that were confiscated by the facility and were told they had to be evaluated first and could not smoke on the property because they were a non-smoking facility. Resident 1 stated there were two other residents who smoked, and they observed one of them on multiple occasions smoking on the property, outside the front entrance. Resident 1 stated they sat outside on the back patio; they were able to see staff smoking (and smelled the smoke) in the back of the facility. Resident 1 stated they felt punished because the facility would not let them do what other residents were allowed to do. Resident 1 stated they felt discriminated against, and it was unfair the facility expected residents to leave the property to smoke but the staff did not have to leave the property to smoke. Resident 1 stated they were so frustrated and upset the facility would not listen to their repeated requests to smoke, they cut themselves, because they didn't know what else to do. Resident 1 stated they were not going to let the facility play with their mind anymore and it was not a prison. On 06/27/2023 at 8:09 AM, the facility provided a delayed investigation report summary of Resident 1's 06/13/2023 self-harm event. The investigation showed the root cause of the incident was due to the resident's desire to smoke. The summary showed Resident 1 had no cognitive deficits, a history of self-harm, recent life stressors driving their desire to smoke again, and they would complete a smoking evaluation. The investigation included an attached copy of a 06/14/2023 PPN that showed Resident 1 was in obvious distress during the event and a 06/26/2023 12:34 PM Smoking Evaluation (41 days after Resident 1 first requested to smoke) that showed Resident 1 could safely smoke with supervision. In an interview on 07/12/2023 at 4:55 PM, Staff C stated the IDT team should have timely assessed Resident 1's smoking ability and provided Resident 1 with the opportunity to smoke, if able, but did not. Staff C stated they were unable to find Resident 1's signed smoking policy acknowledgements or admission Agreement documents in the clinical record. In an interview on 07/12/2023 at 5:00 PM, Staff E, Social Services Assistant, stated the staff smoked in the back of the facility under the carport. In an observation on 07/12/2023 at 5:05 PM of the covered staff smoking area located behind the maintenance office and on the property, the back patio where Resident 1 stated they sat to enjoy the fresh air was visible and easily accessible from the staff smoking area. In an interview on 07/12/2023 at 5:45 PM, Staff A stated the residents were notified the facility was a non-smoking facility on admission, as part of the admission Agreement process. Staff A stated the discharge planners at the hospitals were aware the facility was a non-smoking facility to help deter the admission of active smokers. Staff A stated they were unsure of the date the facility switched to non-smoking because they were not an employee at that time. Staff A stated Resident 1 should have had signed smoking policies in their clinical record, and they would continue to look in medical records. On 07/13/2023 at 12:57pm, Staff D, Assistant Director of Nursing, stated they were unable to find Resident 1's admission Agreement packet, or any of the smoking policy documents signed by Resident 1. The facility could not show Resident 1 was ever notified of the smoking policy on admission, when the facility switched to non-smoking, or when Resident 1 first began requesting to smoke on 05/16/2023. <Resident 2> According to Resident 2's census record, they admitted to the facility 07/26/2019, discharged [DATE], and re-admitted [DATE]. Review of Resident 2's 07/26/2019 admission Agreement showed no information regarding the facility smoking policy. There was no admission Agreement documentation for the 03/28/2023 re-admission in the clinical record. Review of a smoking evaluation, dated 04/05/2023 at 7:53 AM, showed Resident 2 was an independent smoker. Review of a 04/05/2023 smoking CP showed Resident 2 chose to smoke off the property during dialysis appointments. Record review showed no earlier smoking CP's. Review of the resident's clinical record showed no documentation that Resident 2 was provided with or signed the smoking policy on their original admission or their re-admission to the facility. A request for the signed smoking policies and the Resident Smoking Log was made on 07/12/2023. No further information was provided. Review of a 07/06/2023 3:34 PM Discharge Planning note showed Staff A, Staff C, and Staff D discussed transfer to another facility that allowed smoking. The resident declined because that facility was too far away from their family. In an interview on 07/12/2023 at 5:00 PM, Staff C stated Resident 2 smoked off the property and when they go to dialysis. In an interview on 07/14/2023 at 4:00 PM, Resident 2's representative, Collateral Contact (CC), stated Resident 2 smoked over a half pack per day and routinely smoked on the property, out the front door entrance, and within visual sight of the front offices. CC stated they never witnessed facility staff tell Resident 2 they could not smoke on the property. CC stated they attended a care conference recently and discussed Resident 2's healing progress and impact from smoking, but the facility did not say anything about not smoking on the property, or that Resident 2 was non-compliant with their smoking rules. CC stated they had never been notified they did not allow smoking on the property and was not aware they notified Resident 2 they could not smoke on the property. <Resident 3> According to the 04/18/2023 admission MDS, Resident 3 admitted to the facility on [DATE]. Review of a 04/19/2023 smoking focus CP showed they were at risk for injury due to history of smoking and interventions were to offer smoking cessation support and review the smoking policy with the resident. Review of a PPN, dated 04/17/2023, showed Resident 3 smoked a quarter of a pack of cigarettes per day and smoked marijuana. A review of the clinical record showed no smoking evaluation was conducted, and no signed smoking policy was found in the record. Review of Resident 3's 04/11/2023 admission Agreement documents showed patients would agree to follow the centers smoking policy and a copy would be provided to them. Each patient who wished to smoke would be evaluated for safety purposes and if allowed to smoke, they could only do so in designated areas, at designated times, and could not keep smoking materials in their personal possession. The Agreement was electronically signed by Resident 3 on 04/14/2023 at 3:55 PM. At the end of the admission Agreement packet was an undated, unsigned copy of the Smoking Policy, and the smoking safety guidelines for both a smoking campus and a non-smoking campus. None of the three policies were signed by Resident 3. REFERENCE WAC: 388-97-0900 (3). .

CONCERN (E) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to implement their grievance policy to ensure resident concerns were acknowledged, investigated, documented, resolved timely, and resolution communicated to the concerned resident(s) for 2 of 2 Resident Council Meetings (May 2023-RC1 and June 2023-RC2) and for 23 of 23 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, & 23) who submitted grievances. The failure to resolve pervasive resident complaints regarding resident care, food palatability/temperature/diet accuracy/religious preferences, environmental cleaning, behaviors of other residents, transportation, and missing property left residents at risk for unmet care needs, frustration, diminished self-worth, feeling unheard, diminished quality of care, an undignified quality of life. Findings included . <Policy> According to the facility's 01/17/2023 revised Grievances Policy, the facility would designate a Grievance Officer (GO) which was the Administrator, review grievances immediately upon receipt, report all alleged violations, and conduct a thorough investigation to rule out abuse, neglect, misappropriation, exploitation, and injuries of unknown source. The facility would strive to resolve the grievances within five business days of receipt, document the investigative findings and resolution, follow up with the resident to communicate the findings and resolution, log all grievances, and retain all grievances for no less than four years. <Grievance Logs> A request for the facility Grievance Log was made on 06/26/2023 at 9:00 AM and again on 07/10/2023 at 10:00 AM. No information was received. On 07/12/2023 at 4:00 PM, the entire facility Grievance system was requested, including the individual Grievance Forms (GF). On 07/12/2023 at 4:10 PM, Staff C, Social Services Director, provided the Grievance binder which contained monthly tab dividers. There was no Monthly Grievance Log (MGL), or GFs found under the July tab. Behind the June tab was a two-page MGL that tracked the name of the resident, nature of the concern, date received, grievance confirmed, date of resolution, and date the resident was notified of the findings and resolution. Only three columns of the log contained information: The resident's name, nature of the grievance, and the date it was received. Behind the June MGL were the individual resident GF's. The June 2023 MGL showed 29 grievance entries (from RC2 and 16 different residents). Resident 1's 06/01/2023 GF was not logged on the MGL. Four residents who had concerns on the MGL did not have corresponding GFs in the binder (Residents 20, 21, 22, & 23). There were similar findings noted of the May 2023 MGL where the only information documented was the resident's name, the nature of their grievance, and the receipt date. There were 15 grievance entries (from RC1 and nine different residents). In an interview on 07/12/2023 at 4:15 PM, Staff C stated they were struggling to keep the grievance system functioning because they did not have an assistant for some time, and they were the only social services staff in the facility. Staff C stated if nothing was written in the column of the log then it was not completed. Staff C stated they had not initiated the July 2023 MGL yet but should have. <Resident 1> Missing Property: Review of a 05/23/2023 GF submitted by a staff member on behalf of Resident 1 showed they were missing multiple clothing items and the concern was signed as received by Staff C on 05/23/2023. The Grievance Summary Report (GSR) showed the facility checked the resident's personal inventory sheet for the clothing items, but the items were not on the inventory sheet. There was no further investigation or resolution of the grievance. The grievance was not reviewed by the GO. Smoking: Review of a 06/01/2023 Grievance Form submitted by Resident 1 showed they wanted to go out to the front of the facility and smoke. Staff C received the grievance on 06/01/2023. The GSR showed 'Resident 1 was provided copy of smoking policy.' The findings showed social services followed up with the Administrator and Director of Nursing for smoking procedures and the resident would be assessed by the physician. The Resolution of Grievance showed the concern was not resolved, the Interdisciplinary Team (IDT) would review the smoking procedures, and Resident 1 would be 'assessed appropriately' to smoke. The report was signed completed by Staff C. Staff C also signed the GO signature line. In a 07/12/2023 4:30 PM interview, Staff C stated they were the GO. Staff C stated they should have followed up timely with IDT to ensure Resident 1 was assessed to smoke but did not. Dentures: The 06/02/2023 GF for Resident 1 showed their dentures were lost/missing. The GF was not signed as received, the GSR was blank, there was no resolution, no follow up with Resident 1 regarding the concern, and no signature from the GO. Attached to the GF was a 06/02/2023 Consultation Report from a denture clinic that explained what was required for new dentures. <Resident 2> Review of Resident 2's 06/15/2023 GF submitted by an employee on the resident's behalf showed Resident 2 expressed concerns regarding unfair treatment by an employee. The GSR, investigative findings, resolution, and follow up with the resident were blank. The GO did not sign the grievance. <Resident 3> Review of Resident 3's 05/25/2023 GF showed they had concerns with housekeeping room cleanliness. The GF was not signed received. The GSR showed there was no resolution follow up with Resident 3. The GSR was signed reviewed by the GO on 05/30/2023. Review of Resident 3's 05/30/2023 GF submitted by an employee on the resident's behalf the regarding more housekeeping concerns. The GF was not signed as received. The GSR was blank, no resolution was documented, no resident follow up, and no GO signature. <Resident 4> Review of Resident 4's 05/12/2023 GF showed they were frustrated with the size of the sheets that did not fit their bed. This affected their positioning in bed. The GSR, investigative findings, resolution, follow up with the resident, and GO signature were blank. Review of Resident 4's two 05/30/2023 GF's showed concern regarding linens and food. The GSR's were blank, there was no resolution, and they were not signed by the GO. On 06/05/2023, Resident 4 submitted multiple GF's involving: improper transfers by nursing staff; food was terrible, kitchen out of butter, lack of choices, meal tickets not followed, preferences not followed, diet orders not followed, cold food, small portion sizes; transportation concerns; and customer service-nursing staff member made faces when their wound care was provided. All GSRs, investigative findings, and resolutions were blank. On 06/23/2023 Resident 4 submitted a GF regarding their roommate's noise levels not at a respectable level. The GSR was blank. Review of a 07/03/2023 GF showed Resident 4 reported to a staff member that the night prior, facility staff were providing care to their roommate, they did not close the door or pull the privacy curtain for the resident. On the day shift, staff did not remove or empty Resident 4's used urinal from their bedside table before they delivered their breakfast tray. Resident 4 asked the staff member to remove the urinal and the staff responded with I am passing trays. The GSR, findings, resolution, and GO signature were blank. Resident 4's 07/04/2023 GF showed repeated concerns about food, food preferences, and menu concerns. The GF showed the resident was unhappy with the lack of facility response and wrote, 'I did what they said I needed to do; we pay for this sucky ass food they serve. I am getting tired of this and will be calling the State on this.' The GSR, findings, resolution, and GO signature were blank. <Resident 5> Review of Resident 5's 01/18/2023 Food Preference Record showed they had religious/cultural food preferences which were no beef or pork. Resident 5's 06/22/2022 nutrition care plan (CP) showed they had religious food preferences-and a 02/01/2023 update CP intervention: No pork, No beef, No meat at all on Tuesdays. Review of Resident 5's 05/16/2023 GF showed on Tuesday 05/16/2023, they were served pork for breakfast and meat for lunch. The GSR showed the line staff was educated on reading the tray card accurately and modified the tray ticket to highlight the key items of No Pork, No Beef, and added to serve vegetarian entrée to the tray card. The GSR was signed by the person who investigated, but not by the GO. There was no documented follow up resolution with Resident 5. Review of Resident 5's 05/30/2023 GF showed their call light was not being answered timely and they were served chicken on Tuesday, again. Attached to the GF was Resident 5's tray card that showed, 'NO PORK, NO BEEF' and under special instructions 'NO MEAT OF ANY KIND ON TUESDAYS, GIVE VEGETARIAN ALTERNATIVE'. The GSR was blank, there was no documented resolution follow up or review from the GO. Review of a 06/06/2023 GF completed on behalf of Resident 5 showed the resident reported some nurse aids were verbally aggressive, medications were not given at the correct times, and medications were left on the resident's table. Review of the Mandatory Reporting Log for June 2023 showed this allegation was not reported or investigated. The GSR, resolution, findings, follow up with the resident, and GO signature were blank. A 06/14/2023 GF submitted by Resident 5 showed they received grilled cheese sandwiches three days in a row. The GSR, investigative findings, resolution, and follow up with the resident were blank. The GO did not sign grievance. <Resident 6> Review of Resident 6's 06/05/2023 GF showed the food was ice cold and not palatable. The GSR, investigative findings, resolution, and follow up with the resident were blank. The GO did not sign grievance. <Resident 7> Review of Resident 7's 06/05/2023 GF showed they reported some pain medications had been missed and it affected their ability to do daily activities. The GSR, findings, resolution, resident follow up and GO signature were blank. <Resident 8> Review of a 05/01/2023 GF submitted by Resident 8's Responsible Party showed Resident 8 was missing their radio since last year after a room move and was told it was in storage. The signature of the person who received the grievance was blank. The GSR, findings, resolution and GO signature line were blank. <Resident 9> Review of Resident 9's 06/23/2023 GF submitted by an employee on behalf of the resident showed on 06/22/2023, a red sticky substance that looked like juice was found dried on the floor. On 06/23/2023 the same employee spotted the same red stain on the floor. The GSR was blank, there was no investigation, resolution, or follow up with Resident 9. The grievance was not reviewed by the GO. <Resident 10> Review of Resident 10's 05/01/2023 GF showed their roommate's yelling was intrusive and they had to turn their TV volume to the maximum volume to drown out their roommate's yelling. The loud TV was affecting other neighbors. The GSR was blank, there was no investigation, no follow up resolution, and no review by the GO. The facilities failure to address the resident's concern of the roommate yelling likely contributed to Resident 10's verbal altercation on 05/20/2023 with their roommate. Review of Resident 10's CP showed a 03/08/2023 sleep disturbance problem and a new 05/23/2023 behavior CP problem for initiating verbal aggression with their roommate. <Resident 11> Review of a 05/13/2023 GF showed Resident 11 stated they wanted to get out of the facility. The rest of the GF was blank. The GSR and resident resolution was blank, and the grievance was not signed or reviewed by the GO. Review of a 05/18/2023 Provider Progress Note (PPN) showed Resident 11 requested to be sent to a different skilled nursing facility. The 06/14/2023 Social Services Quarterly evaluation showed there was no discharge plan. The remaining evaluation was incomplete. Review of Resident 11's progress notes showed one note from social services dated 07/07/2023. Resident 11 requested some clothing from their AFH, and social services notified proper authorities Resident 11 wanted to return to the AFH (56 days after submitting their GF they wanted to discharge). <Resident 12> Review of Resident 12's 05/15/2023 GF showed they were upset because they were served waffles, but the kitchen was out of syrup. There was no resolution to the grievance or follow up with Resident 12 and the GO did not review the grievance. According to the 06/19/2023 GF submitted by an employee on behalf of Resident 12, they received macaroni & cheese five days in a row. Resident 12 said when they talked to dietary staff, they said it was because pork had been served, but Resident 12's roommate was served chicken. The GSR, resolution, and resident follow up were blank, and the GO did not sign the grievance. <Resident 13> According to a 06/05/2023 GF submitted on behalf of Resident 13 who reported it took 45 minutes for their call light to be answered noise levels at night. The GSR, investigative steps, findings, resolution, and resident follow up were all blank. The grievance was not reviewed by the GO. <Residents14, 15, & 16> Similar findings were noted for Resident 14 who filed a grievance on 06/26/2023, Resident 15 who filed a grievance on 06/25/2023, and Resident 16 who filed a grievance on 06/21/2023 regarding missing clothing. The GSRs, findings, resolutions, resident follow up, and GO signatures were blank. <Resident 17> Review of a 06/17/2023 GF submitted by an employee on behalf of Resident 17 regarding a room placement concern. The GSR findings, resolution, resident follow up and GO signature were blank. <Resident 18> Review of Resident 18's 06/05/2023 GF showed the food 'sucked', meals were unseasoned, not cooked well, and improper portion sizes. The GSR, investigative findings, resolution, and follow up with the resident were blank. The GO did not sign grievance. <Resident 19> Review of Resident 19's 06/05/2023 GF showed staff were rough at times. The GSR, investigative findings, resolution, and follow up with the resident were blank. The GO did not sign the grievance. <Resident 20> Review of the June 2023 Grievance Log showed a grievance entry by Resident 20 on 06/01/2023 but the nature of the grievance was not documented, and it was not resolved. The GF was not found in the grievance binder. No further information was provided. <Residents 21, 22, 23> Similar findings were noted for Resident 21 with an undated concern on June 2023 Grievance Log for missing clothes, Resident 22 on 06/12/2023 for missing clothes, and Resident 23 on 06/19/2023 for medication concerns. There was no corresponding GF found in the binder. <Resident Council Concerns: RC1 & RC2> Review of the 05/12/2023 Resident Council (RC1) GF's included: Cold food at breakfast (soggy waffles/toast and cold coffee), housekeeping concerns, staff heard being verbally aggressive with residents, and long call light response. The RC staff facilitator documented they notified the department managers. There were no investigative or follow up actions documented, and they were not reviewed by the GO. Review of the 06/20/2023 Resident Council (RC2) GF's included: Housekeeping concerns, appointment transportation concerns, particular nursing assistant that turned off call lights before addressing the unmet needs of the residents, 45-minute call light wait times, nursing staff hiding in rooms at night, poor attitudes of certain staff, medication concerns: not ordering on time, not monitoring allergies, not telling residents what they are administering, Food concerns: moldy egg salad sandwich was served, expired cottage cheese, tasteless pasta, repeated meals, not serving what is on the posted menu, not following diet orders. GSR for the RC2 concerns were all blank. In a 07/12/2023 5:00 PM interview, Staff C stated they should have notified the Administrator they could not keep up with the grievances. Staff C stated they took the grievance to the morning meetings where the IDT discussed them, but Staff C was not able to keep up with the volume of concerns. Staff C stated they should make every effort to resolve a concern within 5 days to be timely, but the grievances were not resolved. In a 07/12/2023 5:30 PM interview, Staff A, Administrator, stated they discussed the grievance backlog concerns with Staff C to develop a plan to correct the system failures. Staff A was unaware of the number of unresolved grievances. Staff A stated the GFs should read as soon as received and they should be notified immediately of any allegations or potential violations, the SA should be notified, and a thorough investigation conducted to rule out abuse/neglect. Staff A stated the grievances should be discussed in the daily team meeting until there is a resolution, they should be completely documented, and accurately logged for trending. Staff A stated they were the GO of the facility. Refer to F561 Self Determination Refer to F675 Quality of Life Refer to F610 Investigate/Prevent/Correct Alleged Violations REFERENCE WAC: 388-97-0460. .

CONCERN (E) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to report and thoroughly investigate allegations of potential abuse/neglect/misappropriation/exploitation reported by residents who submitted grievances regarding undignified treatment by staff, potential neglect, missed pain medication, and rough handling by staff for 6 of 23 residents (Residents 1, 2, 5, 7, 13, &19) reviewed for grievances. The failure to identify resident grievances that rose to the level of potential violations that required the facility to immediately act to protect the residents, timely report to the State Agency (SA), and conduct thorough investigations to rule out abuse/neglect placed the residents at risk for unmet care needs, abuse, neglect, misappropriation, exploitation, diminished quality of care/quality of life. Findings included . <Policy> Review of the facility Grievances Policy, dated 01/17/2023, showed the Grievance Officer (GO), Administrator, or designee would read each grievance immediately upon receipt and if the grievance was an allegation of resident abuse, neglect, misappropriation of resident property, exploitation, or an injury of unknown source, they would take immediate action to prevent further potential violation of a resident right while the allegation was being investigated. According to the facility Preventing and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property policy, undated, showed when allegations met the definition of abuse, neglect, exploitation, misappropriation, or mistreatment, the facility would ensure all alleged violations were reported immediately, but no later than two hours after the allegation is made, if the allegation involved abuse or serious injury and no later than 24 hours if the allegation did not involve abuse or serious injury. The facility would thoroughly investigate and retain investigative documents of all alleged violations and report the results of all investigations to the SA within five working days. The facility would refer to the State regulation for additional guidance. Review of the Washington State Department of Social & Health Services Nursing Home Guidelines for Abuse Prevention and Protection, Incident Identification, Investigation, and Reporting The Purple Book, dated October 2015, showed facilities must maintain a state Reporting Log retained in the facility that is always readily accessible, at all times, to SA staff and others according to their authority. The Purple Book showed an immediate report to the SA was required when there was reasonable cause to believe a violation occurred. The Purple Book showed somekey triggers for neglect included failure to carry out orders for administration of medications or other treatments, failure to provide care and services per the resident's care plan, and failure to answer a resident's call light in a reasonable time frame or provide assistance they were assessed to require. The Purple Book showed some key triggers for mental abuse included purposely withholding cigarettes or some form of desired food, entertainment, or requested activity from the resident, <Resident 1> On 06/26/2023 at 9:00 AM, a review of a 06/13/2023 facility incident report showed Resident 1 took scissors and cut their wrist, refused to give the scissors to staff, and told staff they were going to cut their throat with the scissors. Resident 1 was angry, frustrated, exhibited increased anxiety, and was in distress. Resident 1 was transferred to the Emergency Department (ED) for psychiatric evaluation by Emergency Medical Services and Police escort. Resident 1's 06/13/2023 incident report was incomplete and was not thoroughly investigated. The incident report did not contain witness statements, a root cause analysis, or resident follow up. In an interview on 06/26/2023 at 9:10 AM, Staff D, Assistant Director of Nursing, stated the investigation was not finished and should have been completed by 06/18/2023(within 5 days of the incident). The June 2023 Mandatory Reporting Log (a SA requirement for reporting) was requested on 06/26/2023 at 9:00 AM, but was not readily available to review, as required. The Mandatory Reporting Log was received on 06/27/2023 at 12:57 PM. Review of the June 2023 Mandatory Reporting Log showed Resident 1's 06/26/2023 incident was not reported to the SA. Review of the SA electronic reporting system showed the facility did not report the 06/13/2023 via telephone or on-line. In an interview on 06/26/2023 at 9:10 AM with Staff B, Director of Nursing, and Staff D, Staff D stated they assumed the incident was reported to the SA by Staff C. On 06/27/2023 at 12:57 PM, the facility provided a completed investigation of Resident 1's 06/13/2023 incident that showed the root cause identified was Resident 1 wanted to smoke and included a 06/26/2023 smoking evaluation showing Resident 1 required supervision to smoke. <Resident 2> Review of Resident 2's 06/15/2023 Grievance Form (GF) showed concerns regarding unfair treatment by an employee and questionable employee behavior. Review of the June 2023 Mandatory Reporting Log showed the allegation was not reported to the SA or thoroughly investigated to rule out abuse, neglect, or exploitation. <Resident 5> Review of a 06/06/2023 GF for Resident 5 showed the resident reported some nurse aids were verbally aggressive, medications were not given at the correct times, and medications were left on the resident's table. Review of the June 2023 Mandatory Reporting Log showed the allegation was not reported to the SA or thoroughly investigated to rule out abuse, neglect, or misappropriation. <Resident 7> Review of Resident 7's 06/05/2023 GF showed they reported pain medications had been missed which affected their ability to do complete daily activities. Review of the June 2023 Mandatory Reporting Log showed the concern had not been reported or thoroughly investigated to rule out abuse, neglect, or misappropriation. <Resident 13> Review of a 06/05/2023 GF submitted by Resident 13 showed it took 45 minutes for their call light to be answered. Review of the June 2023 Mandatory Reporting Log showed the allegation was not reported to the SA or thoroughly investigated to rule out abuse or neglect. <Resident 19> Review of Resident 19's 06/05/2023 GF showed staff were rough at times during care. Review of the June 2023 Mandatory Reporting Log showed the allegation was not reported to the SA or thoroughly investigated to rule out abuse and neglect. In a 07/12/2023 interview at 5:30 PM, Staff A, Administrator stated any allegations of, including potential violations or allegations identified through the grievance process, should be reported timely to the SA and the facility should conduct a thorough investigation of the allegation to rule out abuse, neglect, misappropriation, or exploitation, but did not. Refer to F-585 Grievances REFERENCE WAC: 388-97-0640(6)(a). .

May 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to implement their facility policy to provide the necessary care and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers (PU) from developing for 5 of 5 Residents (Residents 1, 2, 3, 4, & 5) sampled for review of PU. The failure to: routinely monitor and document skin integrity, develop/implement/update care plan (CP) interventions, implement physician orders (PO), and routinely and accurately evaluate wound healing placed the residents at risk for delayed healing or worsening of unhealed wounds, development of new avoidable PUs, potential serious infections, avoidable pain/suffering, and diminished quality of care/quality of life. Findings included . <NATIONAL PRESURE ULCER ADVISORY PANEL STAGING GUIDANCE FROM FACILITY POLICY> Stage 1 Pressure Injury (PI): Intact skin with a localized redness does not blanche (turn white when you press on the skin showing adequate blood perfusion). Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis (second layer of skin) presenting as a shallow open ulcer. The wound bed is viable (not dead), pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (healthy revitalized tissue), slough (unhealthy/dead skin and fat cells) and eschar (hard black dry dead tissue) are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant loss of fat deposits (the coccyx) can develop deep wounds. Undermining and tunneling may occur. Underlying tissue structures including fascia (sheath around muscle), muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epiboly (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured (unable to visualize) full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is coverd by slough or eschar. Stable eschar (i.e., dry, adherent, intact without redness or moveable) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Deep Tissue Pressure Injury (DTPI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic (dead) tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. <Facility Policy> According to the facility's 02/03/2023 revised Wound Prevention and Treatment policy, the facility would consider all residents at risk for skin impairment and would implement interventions to prevent the worsening or development of new pressure ulcers including the reduction of pressure over bony prominences to minimize injury and protect against external mechanical forces (pressure, friction, and shear). Each resident's skin would be monitored on admission, weekly thereafter, upon a change of condition, when on leave of absence/return to facility, and on discharge. The evaluation would be documented on the Weekly Total Body Skin Evaluation (WTBSE) tool. The WTBSE would include the skin concern, new or old, the site of the concern, and a brief description the skin problem. All wounds (including surgical, vascular, diabetic, skin tears, and other skin conditions) would be monitored weekly and documented on a Weekly Skin Grid Evaluation (WSGE) which would include wound site, type/stage, size, color, odor, healing progression, and signs of infection. Residents with wounds of any type would be referred to the Wound Consultant Provider (WCP) for evaluation and treatment. According to the facility's 02/02/2023 revised Pressure Ulcer Prevention and Treatment policy, the facility would assess all residents on admission using the Braden Scale for Predicting Pressure Ulcer Risk (BPURS - a standardized scale for predicting PU development risk) assessment and implement a Skin Integrity: Alteration in Prevention and Management Care Plan (CP). The BPURS assessment evaluates the resident's barriers in key areas of PU preventative management: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The policy directed staff to use the BPURS to assist with the development of the Skin Integrity CP. All residents would be re-assessed weekly for four weeks, then quarterly or with a significant change of condition. On 05/19/2023 at 2:21 PM the facility wound report or list of residents who had unhealed PUs was requested. No further information was provided. In a 05/23/2023 4:00 PM interview, Staff C, Assistant Director of Nursing (ADON)-a new employee, stated they were not aware of a monthly wound report or a log of residents who had PUs. Staff C stated the WCP usually sent the Director of Nursing Services (DNS) or Administrator a copy of their wound report but would only include the residents they followed, and Staff C was not aware of a current report from the WCP. The facility did not have a system to track and trend residents who had hospital acquired PU, facility acquired PU, and non-pressure wounds. <Resident 1> According to the 05/15/2023 Discharge Return Anticipated Minimum Data Set (MDS-an assessment tool), Resident 1 was alert and oriented, required assistance with bed mobility/transfers/toileting, and was incontinent. Resident 1 diagnoses included end-stage kidney disease, diabetes, and peripheral vascular disease (poor blood perfusion to/from the limbs). Resident 1 was at risk for the development of PUs and had one unstageable PU present on re-entry to the facility on [DATE]. Resident 1's 05/02/2023 BPURS was 16-low risk. The facility policy for residents at low risk showed the following interventions to reduce or remove the underlying risk factors: frequent repositioning, maximal remobilization, reduce pressure to heels, manage moisture, nutrition, friction/shear, pressure-reduction support surfaces if bed/chair bound. The 05/02/2023 revised comprehensive (CP) showed Resident 1 had a focus problem: hospital acquired PU on the sacrum (just above the tailbone). The interventions were to: keep heels off the bed with pillows, manage friction and shear, do not massage over boney areas, monitor/document the wound(s) weekly measuring the wound bed, the skin around the wound, healing progress, signs of infection, and notify the physician of changes. The comprehensive CP also had a focus problem: hospital acquired PU on the left heel. The comprehensive CP failed to have a Skin Integrity: Alteration in Prevention and Management CP, provide staff direction on adequate pressure redistribution support surfaces for the bed and wheelchair, turning and repositioning guidance, nutrition, or how the staff should protect the residents skin from moisture. Review of a 05/02/2023 3:38 PM WTBSE, Resident 1 had a hospital acquired unstageable coccyx PU that measured 13.5 centimeter (cm) x 11 cm and a hospital acquired PU on the left heel that measured 1 cm x 2 cm x 0.1 cm. The 05/09/2023 11:09 AM WCP progress note showed Resident 1 had a hospital acquired unstageable PU on the coccyx that measured 9 x 10.5 cm with greater than 75% slough covering the wound bed. The WCP note did not show Resident 1 had a hospital acquired PU on the left heel, but did have a diabetic foot ulcer on the left heel and surgical hardware was exposed, with heavy bleeding, and measured 1 x 1 x 0.5 cm. The WCP wrote treatment orders and said they expected delayed wound healing due to the patient's risk for complications. A review of Resident 1's active physician orders (PO) showed a 03/09/2023 PO for a heel lift boot on the left foot and a 05/04/2023 PO for an air mattress. During a 05/11/2023 3:45 PM observation, Resident 1 was observed lying on a standard bariatric mattress, not positioned off their buttocks. Their left foot was wrapped with a new dressing, which had blood seeping out of the dressing and was lying on a pillow. The pillowcase had blood on it from the dressing. Their left foot was not in a heel lift boot. During an interview on 05/11/2023 at 3:49 PM, Resident 1 stated the staff had not put the heel lift boot on and was unsure where it was. Resident 1 stated they used the pillow to help offload their foot most the time while in bed and they were scheduled for surgical removal of their foot hardware on 05/15/2023 which would help their wound heal. Resident 1 stated they used to have an air mattress which was removed by the prior Administrator, and they needed it back. Resident 1 stated their physician ordered them to have an air mattress and believed it would help with wound healing and pain relief. On 05/11/2023 at 4:35 PM Staff A, Administrator, was notified Resident 1 stated they were supposed to be on air mattress and needed assistance with changing of bed linens. Review of Resident 1's clinical record showed they were transferred to the hospital on [DATE] and returned to the facility on [DATE]. There were no wound measurements located in Resident 1's clinical record for 05/15/2023 when Resident 1 transferred to the hospital. Record review showed there were no WSGE completed for Resident 1's coccyx PU and no WSGE completed for their non-pressure wounds since 02/22/2023. In an interview on 05/11/2023 at 3:50 PM, Staff C stated they expected all wounds be measured and evaluated weekly but was unsure whether they were expected to complete a WSGE when the WCP provided their documentation for the clinical record. Staff C stated they did not consider how the wounds would be documented on days when the WCP was not present for wound rounds or when a resident admitted , transferred, or discharged . Staff C stated they would contact their corporate oversight for clarification, but no further information was provided. Review of Resident 1's WTBSEs showed the facility did not routinely evaluate Resident 1's skin integrity. The WTBSEs due on 03/16/2023, 03/23/2023, 03/30/2023, 04/06/2023, 04/13/2023, 04/20/2023, 05/09/2023, and 05/15/2023 (discharge) were not completed. In a 05/26/2023 interview at 1:30 PM, Staff B, Interim Director of Nursing Services (DNS), stated they expected staff to complete the WTBSE weekly as scheduled and an off-cycle WTBSE could be done if a change of condition was identified. On 05/26/2023 at 1:32 PM Staff C, Assistant Director of Nursing Services (ADNS), stated nurses were expected to complete a full body skin evaluation on admission and weekly after admission, when transferred to the hospital, when re-admitted , when discharged , and upon a change of condition. Staff C stated the WTBSE's should have been done weekly but were not. The 05/21/2023 4:53 PM WTBSE completed on re-admission showed Resident 1's unstageable PU on the coccyx measured 10 cm x 8 cm and was covered with slough (non-viable tissue) and eschar (dead tissue). Resident 1 had a deep tissue pressure injury (DTPI - a pressure injury in evolution) on the right heel but no measurements were recorded. Resident 1's left foot was in a non-removable hard cast. There were no WSGE provided in the clinical record for the coccyx wound and the right heel wound. Resident 1's 05/21/2023 5:35 PM BPURS was 12-High risk. According to the facility policy, BPURS in the high category showed staff should evaluate and consider CP interventions for increase frequency of repositioning, supplement with small shifts in body position, pressure-reduction support surface, use of positioning devices for lateral positioning, and manage moisture, nutrition, friction, and shear. A review of Resident 1's comprehensive CP on 05/23/2023 at 5:00 pm showed no updates to address these concerns. Resident 1's May 2023 BPURS record showed they were not completed weekly after admission. The BPURS completed since Resident 1's last re-admission were completed on 05/02/2023, 05/10/2023, 05/21/2023. An observation on 05/23/2023 at 12:30 PM showed Resident 1 was lying on a standard bariatric mattress and not on an air mattress as ordered. In a 05/23/2023 12:30 PM interview, Resident 1 stated they came back from the hospital on [DATE] but still hadn't received the air mattress. Resident 1 stated their wound got worse but was not able to determine if it got worse at the facility or at the hospital. Resident 1 was asked to observe their wound, but they did not want the wound dressing removed due to pain. The facility failed to implement the 05/03/2023 PO for an air mattress. In an interview on 05/23/2023 at 12:50 PM, with Staff C and Staff D, Registered Nurse (RN), Staff D stated they were not sure what the process was for ordering an air mattress for a resident and there were no resources at the nurse station to guide them. Staff C stated they were not sure of the facility process since they were a new employee but would find out. On 05/26/2023 at 1:00 PM Staff C stated they were educated on the process for ordering the air mattresses, and Resident 1's air mattress was delivered on 05/25/2023. <Resident 2 > According to the 03/10/2023 admission MDS, Resident 2 had short-term and long-term memory problems, was dependent on staff for bed mobility/transfers/toileting and was incontinent. Resident 2 diagnoses included a recent amputation, peripheral vascular disease, diabetes, kidney impairment, and dementia. Resident 2 was at risk for PU development and had an unhealed Stage 2 PU which was present on admission. Resident 2's BPURS on 03/03/2023 was 10-High risk. According to the facility policy, BPURS in the high category showed staff should evaluate and consider CP interventions for increased frequency of repositioning, supplement with small shifts in body position, pressure-reduction support surface, use of positioning devices for lateral positioning, and manage moisture, nutrition, friction, and shear. The 03/03/2023 initiated comprehensive CP showed Resident 2 had a focus problem: a surgical incision on the left foot and a Stage 2 PU on the sacrum. The first CP intervention was added on 03/16/2023 which directed staff to assess/record/monitor wound healing weekly and as needed by measuring length, width, and depth where possible, assess and document status of the wound perimeter, wound bed, and healing progress, and report improvement or declines to the physician A 04/03/2023 CP update showed the addition of foam boots to both feet, however this was 30 days after admission. A 04/19/2023 CP update showed the addition of an air mattress, 46 days after admission. The facility failed to develop a Skin Integrity CP with interventions to address Resident 2's high risk for PU development based on the BPURS and the residents other underlying risk factors including offloading assistance required, repositioning needs, pressure redistribution support surfaces for the bed and wheelchair, moisture protection, and nutrition. An observation on 05/23/2023 at 3:30 PM showed Resident 2 lying in bed, on an air mattress, with blue heel lift boots on both feet, and pillows under their calves. Resident 2 appeared to be sleeping. The 03/03/2023 admission Skin Integrity evaluation showed Resident 2 had a moisture associated skin dermatitis (MASD - a skin rash caused by excessive moisture) on the coccyx. The admission skin integrity evaluation did not indicate Resident 2 had a PU and there were no WSGE provided in the clinical record. Review of the 03/03/2023 admission PO's showed wound care orders for the coccyx/sacrum and a referral for the facility WCP to evaluate and treat for pressure wounds. A 03/08/2023 1:11 PM Appointment/Transportation progress note showed the Resident 2's referral for evaluation and treatment of the PU was sent to the WCP via email. Review of WCP notes dated 03/14/2023 and 03/21/2023 showed Resident 2 was evaluated for a skin tear on the right elbow but was not evaluated for a coccyx PU. In an interview on 05/23/2023 at 3:45 PM, Staff C stated the resident was referred to the WCP on admission and the WCP should have evaluated Resident 2's PU but did not. Review of a 03/07/2023 9:13 AM Nurse progress note showed Resident 2 had a Stage 2 coccyx PU that measured 3 x 0.5cm with a pink wound bed (no depth recorded), a right elbow skin tear, a left foot second toe surgical wound, a left third toe ulcer, a left great toe ulcer, and left fifth toe ulcer. This was the first measurement of the PU provided in the clinical record by facility staff. There were no coccyx PU evaluations provided in the clinical record between 03/08/2023 and 04/12/2023. A 04/06/2023 1:55 PM WTBSE showed a skin concern was noted and described as admitted with wound and being followed by the WCP. According to a 04/12/2023 6:00 PM Nurse progress note, Resident 2 was found to have two PU's on their coccyx, they measured 2 x 5 cm and .5 x 5 cm, more than a month after admission. There was no depth, staging, or description of the wounds documented. There were no corresponding WSGE completed of the wounds and no WTBSE done with the change of condition. A 04/13/2023 11:35 AM Nurse progress note showed the nurse practitioner again ordered for Resident 2 to be evaluated by the WCP for the PU's on the coccyx. The WCP last visit was 03/21/2023 and the coccyx was not evaluated. Review of a 04/18/2023 11:56 AM WCP progress note showed Resident 2 now had an unstageable PU on the sacrum that measured 2 x 0.5cm and was covered with greater than 75% slough. There were no signs of infection, a new treatment order was written, and an air mattress was suggested for pressure redistribution. Between 04/18/2023 and 05/09/2023, there were no evaluations of Resident 2's sacrum PU provided in the clinical record. In a 05/09/2023 12:50 PM WCP note (21 days after the last WCP evaluation), Resident 2's coccyx PU measured 0.5 x 0.3 x 0.2 cm and the wound bed had greater than 75% granulated tissue (new health tissue on the surface of a healing wound), however the WCP did not stage the wound, since the slough was removed and the wound bed was visible. Review of a 05/16/2023 5:36 PM WCP note showed Resident 2's coccyx PU was 0.2 x 0.2 x 0.2 cm with no slough or eschar, but still staged the PU as unstageable. Review of Resident 2's WTBSE's showed the evaluations were not done weekly and WTBSE's which were completed did not adequately show the site or description of the skin concerns. WTBSE's due on 03/10/2023, 03/17/2023 were not completed. Resident 2's first WTBSE was done 03/21/2023 and showed a skin concern on the coccyx and Left toes and the description said, Treatment completed. A 03/30/2023 WTBSE showed a skin concern with no site, with description All wound present on admission, and being followed by the WCP. A 04/22/2023 WTBSE showed no skin concern noted, a 04/30/2023 WTBSE with skin concerns on the coccyx and left second toe, a 05/09/2023 WTBSE with no skin concerns noted, and a 05/17/2023 WTBSE with the following skin concerns: a. Left hallux foot ulcer, b. Left third digit ulcer, c. Left fifth metatarsal head ulcer, d. Left second digit incision and ulcer, e. sacrum wound, f. back of head-laceration. None of the WTBSE included wound measurements/descriptions and staff did not complete WSGE for the wounds. In an interview on 05/23/2023 at 3:50 PM, Staff C stated the skin evaluations were not done weekly as required and should have been completed. Staff C stated the WSGE were not completed because staff were under the impression the WCP monitored/documented the wound evaluations. Staff C stated Resident 2's wounds were not evaluated weekly and should have been. <Resident 3> The 04/28/2023 Quarterly MDS showed Resident 3 had mild cognitive impairment, required assistance with bed mobility/transfers/toileting, and was incontinent. Resident 3 diagnoses included kidney disease, diabetes, dementia, and fibrotic lung disease. Resident 3 was at risk for PU development and had one unhealed Stage 2 PU present on re-entry to the facility 01/16/2023. Resident 3's 02/08/2023 BPURS was 14-moderate risk. A 02/28/2023 skin focus problem CP showed Resident 3 had a recurrent skin rash and directed staff to observe for indicators of yeast. The facility failed to develop a Skin Integrity CP with interventions to address Resident 3's risk for PU development based on the BPURS and the residents other underlying risk factors including offloading assistance required, repositioning needs, pressure redistribution support surfaces for the bed and wheelchair, moisture protection, and nutrition. In a 05/23/2023 3:45 PM interview Staff D stated Resident 3 CP should have person-centered interventions that meet professional standards for preventing pressure ulcers or avoidable worsening of pressure ulcers. Staff D stated Resident 3's CP did not include individualized skin prevention interventions. Review of the 01/16/2023 hospital discharge summary showed Resident 3 had a history of PUs on the buttocks. Review of a 01/16/2023 untimed facility admission Skin Assessment form showed Resident 3 had a rash on both buttocks and other surgical skin concerns, but no measurements or descriptions. A 02/28/2023 3:56 PM WSGE showed Resident 3 had a facility acquired Stage 3 PU on the coccyx that measured 2.9 x 2.7 x 0.2cm, with drainage, yellow wound, and the physician was notified. Review of a 02/28/2023 8:57 AM WCP note showed Resident 3 was evaluated for a re-opening of a Stage 2 PU identified to be worse by nursing the week prior. The WCP said Resident 3 was primarily bed bound by choice and non-compliant with position changes and repositioning. Resident 3's Stage 2 coccyx PU measured 2.9 x 2.7 x 0.2cm and had greater than 75% granulation of the wound bed. The assessment/plan showed the PU was chronic and unavoidable due to the resident refusing to be up out of bed. In an interview on 05/23/2023 at 3:45pm, Staff C stated they would expect the nursing staff and the WCP assessments to match and was unsure why one evaluation staged the wound as a Stage 3 and the other staged the wound as a Stage 2. There were no wound evaluations provided in the clinical record for 03/07/2023. Review of the 03/14/2023 10:38 AM WCP note, completed 14 days after the last WCP evaluation, showed Resident 3's Stage 2 PU measured 3.2 x 4.8 x 0.2 cm. The WCP evaluated the PU again on 03/21/2023, 03/28/2023, 04/11/2023, 04/18/2023. There were no wound evaluations provided for 04/25/2023 and 05/02/2023. Review of a 05/05/2023 4:19 PM skin/wound Nurse Progress note showed the WCP was unavailable for wound rounds for that week and the Stage 2 coccyx PU measured 2 x 0.2 x 0 cm. No further description or details were recorded of the wound. The 05/09/2023 12:17 PM WCP note showed the coccyx Stage 2 PU measured 2 x 1 x 0.2cm. The assessment and plan showed chronic exacerbation of an unavoidable pressure injury and described it as multiple open areas measured as one, in various stages of healing. The 05/16/2023 10:10 AM WCP note showed the coccyx Stage 2 PU measured 2.5 x 5 x 0.2 cm which was improved and clinically appeared more like MASD. Review of Resident 3's WTBSE's showed they were not done weekly and WTBSE's which were initiated were incomplete and inaccurate. There were no WTBSE's done between 02/28/2023 and 03/20/2023. Of all the WTBSE completed, only three were done within a 7-day timeframe. None of the WTBSE included wound measurements for the coccyx PU. In a 05/23/2023 3:50 PM interview, Staff C stated the WTBSE's were not completed weekly as required and should have been. Staff C stated on weeks when the WCP was not available to attend wound rounds, they should have completed the WSGE to evaluate the wound progress but did not. <Resident 4> According to the 05/01/2023 Quarterly MDS, Resident 4 had memory problems, required assistance for bed mobility/transfers/toileting, and was incontinent. Resident 4 diagnoses included chronic obstructive pulmonary disease, malnutrition, depression, and schizophrenia. Resident 4 was at risk for PU development and had no unhealed PU or non-pressure ulcers. The 12/08/2022 Braden's Score showed Resident 3 was in the High-Risk category with a score of 10. Areas of most concern were moisture exposure to the skin from urine incontinence and perspiration, bed confinement, inability to make substantial position changes independently, inadequate nutrition, and problem with friction and shear. The 02/02/2023 Potential for PU CP listed interventions to manage friction/shear and keep the head of the bed less than 30 degrees as tolerated and notify the nurse of new areas of impairment. A 05/12/2023 Skin Concern CP showed Resident 4 had a right outer ankle PU 1 x 1 x 0.5cm with 05/12/2023 care interventions to monitor the wound weekly, refer to the WCP for evaluation and treatment, and provide wound care daily. The facility failed to develop a Skin Integrity CP with interventions to address Resident 4's high risk for PU development based on the BPURS and the residents other underlying risk factors including diagnoses, offloading assistance required, repositioning needs, pressure redistribution support surfaces for the bed and wheelchair, moisture protection, nutrition, history of previous pressure ulcers, and history of non-compliance. A 05/16/2023 9:49 AM WCP note showed the right outer ankle PU was a chronic recurring wound and suspected the wound was unavoidable due to Resident 4's choice of being bed bound, contractures (stiff/fixed joints) and other medical diagnoses. The unstageable PU measured 2 x 1.5 x 0.5cm. The WCP wrote wound care orders and a plan for healing which included a heel lift boot for the right lower leg. Resident 4's CP was not updated with WCP plan. Record review showed no WSGE completed for Resident 4's PU and their routine WTBSE were not completed weekly. <Resident 5 > The 04/14/2023 Annual Comprehensive MDS showed Resident 5 had severe cognitive deficits including short-term and long-term memory loss. Resident 5 was dependent on staff for bed mobility/transfers/toileting care and was incontinent. Resident 5 diagnoses included Multiple Sclerosis with paraplegia (inability to move the legs/arms), dementia, malnutrition, contractures of the lower extremities, and a chronic Stage 4 PU on the sacrum. Resident 4 was assessed at risk for PU development and had an unhealed Stage 4 PU which was not present on admission/re-entry. Resident 5's last BPURS was completed on 12/19/2022, 10-high risk. No BPURS were completed during Resident 5's 01/14/2023 Quarterly MDS assessment period or their 04/14/2023 Annual comprehensive assessment period. The facility failed to complete two quarterly BPURS. The 05/11/2023 revised Alteration in Skin integrity CP directed care staff to: monitor the wound weekly, assist with position changes routinely on rounds, use pillows for comfort/offloading, use pillows between legs to reduce pressure, foam boots to both feet for pressure relief, pressure reduction mattress and wheelchair cushion, tilt back wheelchair for repositioning while up in the wheelchair, moisture management interventions, and wound care updates. There were no WSGEs completed in Resident 5's clinical record since 03/04/2022. Review of Resident 5's WTBSE's showed they were not done weekly. Record review showed there were no WCP evaluations for Resident 5's PU on 03/07/2023, 04/25/2023, or 05/02/2023, when the WCP was unable to attend wound rounds. A 05/05/2023 4:17 PM skin/wound nurse progress note showed the WCP was not available for wound rounds and wound measurements were 2.5 x 1 x 0.4 cm, no further descriptive information was documented. In an interview on 05/23/2023 at 4:00 PM Staff C stated they were unsure if the WSGE were required to be completed but said they should be done on the days the WCP was unable to attend wound rounds, the wound still required to be evaluated and measurements documented, and they were not. REFERENCE WAC: 388-97-1060 (3)(b). .

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide emergency respiratory care according to professional standards for 1 of 2 residents (Resident 1) reviewed for hospitalization. The failure to have emergency oxygen supplies available, trained staff to use emergency oxygen delivery systems, and a physician protocol for emergency oxygen administration placed residents at risk for deteriorated respiratory condition, respiratory distress, delayed hospitalization, and diminished quality of life. Findings included . Facility Policy The 09/2018 facility policy for oxygen administration showed a Physician's Order (PO) was required prior to administration of oxygen unless an emergency, in which oxygen could be administered per the physician-approved protocol. The policy showed the PO must include the oxygen liter flow (rate of oxygen delivery) . and mode of delivery (type of tubing or mask). The policy contained an oxygen conversion chart that directed staff to use an oxygen flow rate of 1-6 liters per minute (LPM) when using nasal cannula tubing (tubing for oxygen delivery thru the nose) and 10-15 LPM with a non-rebreather mask (NRB - a tight-fitted mask with a bag that holds oxygen, used for high-concentration of oxygen delivery at least 10 LPM, the mask prevents the resident from inhaling any air that was exhaled). The policy did not specify a physician-approved protocol for oxygen delivery in an emergency. Available Supplies Observation and interview on [DATE] at 4:05 PM with Staff C (Registered Nurse/Charge Nurse) in the oxygen storage room, showed 48 oxygen tanks and two oxygen concentrators (a machine that delivers oxygen). There were no oxygen tubing, nasal tubing, or oxygen masks in the oxygen storage room. Staff C stated all the oxygen tubing was kept in the central supply room at the other end of the building. In the central supply room, Staff C identified a cabinet for respiratory supplies. Observation showed there were no nasal cannulas or oxygen masks in the labeled containers in the cabinet. When asked, Staff C stated the respiratory cabinet was where nurses would expect to find oxygen supplies in the event of an emergency. Staff C verified there was no nasal cannulas or oxygen masks in the respiratory cabinet. On [DATE] at 4:11 PM, Staff B (Director of Nursing) entered the supply room and acknowledged there were no cannulas or masks in the respiratory supply cabinet. Staff B looked in other locations in the room and found a drawer under the counter that had basic oxygen masks inside. There were boxes on the floor in front of the counter and the drawers were not visible to staff. Observation of the contents of the respiratory cabinet showed no NRB masks. When asked where the NRB masks were located, Staff C and Staff B stated the facility did not have NRB masks and did not use NRB masks. Staff Training In an interview on [DATE] at 3:40 PM, Staff C stated in an emergency, nurses were allowed to administer oxygen at 2 LPM while contacting the physician. Staff C stated the physician would give an order to administer oxygen when contacted. Staff C stated there were no standing physician orders to direct staff how to use oxygen in an emergency. Staff C stated they did not receive any facility training on how to use a NRB mask and would have to look up the information to know how to use a NRB mask. In an interview on [DATE] at 4:34 PM, Staff B stated there had been no oxygen administration training to nurse staff since they started in 06/2022. When asked to provide staff training materials for oxygen use, Staff B did not provide any training documents. Staff B stated they did not receive any facility training on how to use a NRB mask. In an interview on [DATE] at 4:56 PM, Staff D (Licensed Practical Nurse) stated they did not receive any emergency oxygen administration training from the facility. Staff D stated the NRB masks were located on the emergency crash carts and they (Staff D) did not receive any facility training on how to use a NRB mask. Resident 1 The [DATE] admission Minimum Data Set (an assessment tool) showed Resident 1 admitted for rehabilitation with multiple complex diagnoses including heart failure, kidney failure, diabetes, sleep apnea (breathing repeatedly stops and starts while sleeping) and used a continuous positive airway pressure (CPAP, a device to keep the airway open while sleeping). Resident 1 was assessed with no other chronic respiratory diseases, no shortness of breath, and did not use supplemental oxygen. Review of a [DATE] physician visit note showed Resident 1 was complaining of cough and increased shortness of breath. The physician note showed Resident 1 was in mild respiratory distress, both lungs had abnormal breath sounds and the resident was not using supplemental oxygen. The note showed Resident 1 had acute bronchitis (a respiratory infection) and the treatment plan included a chest x-ray, nebulizer (breathing treatment with medication) and if Resident 1 did not improve, the staff was directed to refer Resident 1 to the emergency room (ER). There were no POs to start oxygen. In an interview on [DATE] at 3:40 PM, Staff C stated on [DATE] approximately 10:00 AM Resident 1 had trouble breathing and was seen by the onsite doctor. Orders for a chest x-ray and a nebulizer were received. Staff C stated the nebulizer was given. Later in the day, could not recall the time, Resident 1 had a low blood oxygen level of about 83% and difficulty breathing, so oxygen administration was initiated using a concentrator. In an interview on [DATE] at 4:56 PM, Staff D stated when Resident 1's blood oxygen level dropped to 84% they got an oxygen concentrator from the oxygen storage room, could not find nasal tubing in central supply so they took a NRB mask from the crash emergency cart and started Resident 1 on oxygen at 3 LPM and told Staff C. Staff D stated since they could not find the nasal tubing, they used what they could find. Review of the [DATE] transportation company's Patient Care Report (PCR) showed the facility nurse reported Resident 1 had been short of breath all day, started on oxygen at 11:00 AM for an oxygen level of 87%, was increasingly lethargic and was recovering from COVID-19 (coronavirus, a highly contagious respiratory infection). A [DATE] on-call Nurse Practitioner (NP) note showed Staff C called at 1:30 PM to report Resident 1 was started on supplemental oxygen due to a low blood oxygen level and difficulty breathing. The NP note showed Resident 1 was diagnosed with hypoxia (low blood oxygen). The NP note showed Staff C was directed to send Resident 1 to the ER for evaluation of shortness of breath. The note showed the NP thought the nurse called 911. Review of Resident 1's record showed no physician orders for supplemental oxygen .There was no documented change of condition respiratory assessment (an evaluation of breathing rate, level of consciousness, respiratory effort, lung sounds, chest rise and fall, depth of breath, pattern of respiration, skin color, cough, congestion, vital signs, and blood oxygen level) completed by the nurse prior to notifying the on-call NP to provide a full description of Resident 1's declining condition. In an interview on [DATE] at 3:40 PM Staff C stated they went to see Resident 1 before calling the on-call NP but did not complete a respiratory assessment or vital signs because Resident 1 was alert and talking. Staff C stated they spoke to an on-call NP and reported labored breathing and drop in blood oxygen level and staff started oxygen. Staff C stated the NP directed to send Resident 1 to the ER for shortness of breath. Staff C confirmed there were no orders to administer oxygen to Resident 1. Review of the [DATE] PCR showed the transportation company received a call from the facility at 2:00 PM for a non-emergency medical transport to the closest hospital. The transportation was dispatched at 2:46 PM, arrived at the facility at 3:09 PM, and arrived at Resident 1's bedside at 3:11 PM. In an interview on [DATE] at 3:40 PM when asked why Staff C decided to call a non-emergency transport company instead of 911, Staff C replied, the resident was talking, and it was not an emergency. In an interview on [DATE] at 12:56 PM, a Collateral Contact (CC, a Certified Emergency Responder) stated at the time of assessment, Resident 1 was in acute respiratory distress and required immediate medical attention. The CC stated the transport required an upgrade to a medical transport with basic life support (BLS) because Resident 1 required high-flow oxygen treatment and medical personnel support during transport. The CC stated Resident 1's symptoms of respiratory distress should have warranted a call from the facility to 911 for emergency transportation to the ER. The CC stated the facility should not have prescheduled a non-urgent transport vehicle for a resident in respiratory distress. Review of the [DATE] transportation company's PCR showed Resident 1 was assessed in bed, described as weak with labored breathing, had an increased respiratory rate of 40 breaths per minute, had an increased pulse of 107 beats per minute, abnormal lung sounds heard throughout both lungs, had congested breathing and cough. The PCR showed the minimum safe level of transportation was BLS, required a stretcher, and continuous oxygen. The PCR showed Resident 1's condition improved on 10 LPM of oxygen upon arrival to the ER. In an interview on [DATE] at 12:56 PM, the CC stated on arrival on [DATE] at 3:11 PM, Resident 1 was wearing a NRB mask with an oxygen flow rate of 3 LPM and was connected to a concentrator. The CC stated they immediately exchanged the oxygen concentrator to an oxygen tank and set the oxygen flow to 10 LPM as required by protocol for a NRB mask. The CC stated the NRB mask required high flow oxygen and anything less than 10 LPM could cause suffocation. Review of the [DATE] transportation company's PCR for Resident 1 showed, placed Resident 1 on 10 LPM of oxygen at 3:12 PM, and departed the facility at 3:29 PM. In an interview on [DATE] at 4:56 PM, Staff D stated it was over an hour from when the NP gave the order to send Resident 1 to the ER and when the transportation arrived. Staff D stated they went to Resident 1's room about 3:00 PM to assist and give a report to the transporters. Staff D stated the transport staff said the NRB mask was used incorrectly and required 10 LPM on an oxygen tank, not 3 LPM on a concentrator. Staff D stated Resident 1 was assisted to a stretcher and left the facility for the ER about 3:30 PM. In an interview on [DATE] at 3:40 PM, Staff C confirmed that a change in respiratory status, requiring start of oxygen and call to an on-call practitioner, receipt of an order to send the resident to the ER for shortness of breath (SOB) was criteria for emergency 911 transportation. Staff C acknowledged Resident 1 should have been sent to the ER by calling 911. In an interview on [DATE] at 4:34 PM, Staff B stated they were not aware the facility was out of nasal tubing, and it should always be available. Staff B stated they were not aware of the NRB mask used on Resident 1 while in respiratory distress, did not know where Staff D found the NRB mask and stated staff should be trained on equipment and supplies provided by the facility. Staff B stated they were not aware Staff C made the decision to use non-emergency transportation for Resident 1 while in respiratory distress, instead of calling 911. Staff B stated nurses are expected to use 911 for transport to the ER if residents have airway, breathing or circulation distress. Staff B stated in their professional nursing judgment, they would have called 911 for faster transport of Resident 1 to the ER. The [DATE] Hospital Discharge Summary showed Resident 1's primary diagnosis on admission to the ER was Acute Respiratory Failure with Hypoxemia (low oxygen in blood and tissues) and Resident 1 died on [DATE]. REFERENCE: WAC 388-97-1060(3)(j)(iv)(4), -1660(1)(a)(b). .

Dec 2022 40 deficiencies 2 IJ (1 facility-wide)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Menu Adequacy (Tag F0803)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food was prepared according to the required menu for modified food textures and thickened liquid consistencies and as ordered by the physician for 3 of 3 (Residents 42, 40, & 66) residents. This failure placed 27 total residents assessed to require altered food textures and/or thickened liquid consistencies, for safe swallowing, at risk for choking while eating, aspiration (inhalation of food/fluids into the lungs), pneumonia, and/or death. CFR 483.60 (c)(3)(5)(6) F-803 Menus meet Resident Needs/Prep in Advance/Followed. On 12/08/2022 at 5:31 PM, an Immediate Jeopardy was identified, and the Administrator was informed. On 12/09/2022 the immediacy was removed. The facility completed speech therapy swallowing screens of residents, reviewed and corrected breakout menus, updated recipes for altered textures, completed a crosswalk for dietary and facility diet types, reviewed resident diet orders and compared with the tray ticket system and care plans, educated dietary and nursing staff, and completed audits on the delivery of altered texture foods to the 27 residents. Findings included . Resident 42 According to the 09/06/2022 admission MDS (Minimum Data Set - an assessment) Resident 42 did not have a swallowing problem and was on a regular diet and thin liquids. The resident was assessed to require assistance with eating. The 09/26/2022 care plan (CP) showed Resident 42 required assistance for set up but could eat independently. According to a 09/14/2022 nursing progress note, Resident 42 choked (blocking of airway to prevent breathing) on a hotdog and required abdominal thrusts (a life-saving emergency procedure to remove an obstruction from a person's airway). Resident 42 was sent to the hospital, and treated for aspiration pneumonia (lung infection from inhaling food into lungs). The resident was newly diagnosed with a decline in their ability to chew and swallow, and discharged back to the facility on [DATE]. The resident's 09/26/2022 Physician Orders (PO) included a speech therapy evaluation for swallowing, a mechanically altered diet, thickened liquids, and one-to-one feeding assistance/supervision. Review of the December 2022 POs showed Resident 42's diet texture order was dysphagia (altered texture of foods and liquids that make swallowing safer) mechanical soft diet and nectar thick liquids. The 12/08/2022 lunch menu for dysphagia mechanical soft texture showed: ground sweet and sour pork (no pineapple), seasoned cream of rice, ground green beans, and a pureed roll. Residents who were on nectar thick liquids were designated a cup of nectar thick orange juice. Observation of the tray line on 12/08/2022 at 12:00 PM, showed Staff O (Cook) placed chopped broccoli on the plate for Resident 42. The tray ticket for Resident 42 showed ground green beans, dysphagia mechanical diet, nectar thick liquids. During a 12/08/2022 12:23 PM observation, Staff S (Certified Nursing Assistant) served Resident 42 their lunch tray. After setting the resident up at the edge of the bed, they did not remove the cover from the plate to observe what was being served or if the food matched the diet order on the tray ticket. Staff S left the room. On 12/08/2022 at 12:24 PM Resident 42 removed the cover from the plate where chopped broccoli was observed. The tray included a cup of thin milk and a bowl of un-chopped mandarin orange slices. On 12/08/2022 12:27 PM, Staff Q, LPN (Licensed Practical Nurse) in an interview, confirmed the chopped broccoli and thin milk was not the correct diet texture, removed them both from the tray, and took them to the kitchen for correction. An observation on 12/08/2022 at 12:32 PM showed Staff Q was provided nectar thickened milk, minced broccoli, and pureed orange slices from the kitchen staff, and delivered to Resident 42. Observation on 12/08/2022 at 12:39 PM showed Staff Q returned to Resident 42 who was found with a coffee mug of thin cocoa. Staff Q removed the thin cocoa and gave Resident 42 the correct broccoli, correct milk, and pureed oranges. Resident 42 began to consume the pureed oranges. Staff Q left the room, during ongoing observation no other staff provided one-to-one supervision for the meal as listed as an intervention on the CP. At 1:16 PM Staff Q reported that Staff S brought the thin cocoa to Resident 42. During a 12/08/2022 at 1:23 PM interview, Staff T (Licensed Speech Therapist) confirmed Resident 42's prescribed diet was dysphagia mechanical soft, nectar thick liquids, and supervision was required using strict precautions to prevent aspiration/choking. Staff T stated the only time it was safe for Resident 42 to consume thin liquids was during their speech treatment with the speech therapist. Staff T looked at the consistency of the chopped broccoli that was served to Resident 42 and stated the chopped broccoli pieces were not an appropriate substitution for ground green beans or a dysphagia mechanical soft diet. Staff T stated pureed mandarin oranges were not appropriate for Resident 42 because the consistency would be too thin for the resident to safely consume due to their swallow problem. Staff T said they would expect staff to supervise Resident 42 while eating as they would for any resident on altered texture diets due to chewing / swallowing problems. Staff T said the risk of not receiving the prescribed diet texture or liquid consistency placed the resident at risk for aspiration of food/fluids into the lungs and/or choking again. In a 12/08/2022 at 1:53 PM interview, Staff S stated they did not look at the tray ticket and compare it to the food on the plate when serving Resident 42. Staff S stated it was important that the resident received the diet ordered by the physician because they could choke and die if not served the correct diet. On 12/08/2022 at 4:15 PM Resident 42 said that sometimes they are served thin milk, cocoa, and coffee and sometimes it is thickened. They just drink drank what they were served.Resident 40 The 08/12/2022 PO showed Resident 40 was prescribed a regular diet with dysphagia mechanical soft texture, and nectar thick consistency fluids. The PO showed Resident 40 required implementation of standard aspiration precautions by staff to supervise size of bites, pace of eating, and alternating solids and liquids. Observation of the tray line on 12/08/2022 at 12:08 PM, showed Staff O placed chopped broccoli on the plate for Resident 40. The tray ticket for Resident 40 showed ground green beans, dysphagia mechanical diet, nectar thick liquids. Observation on 12/08/2022 at 12:21 PM showed Resident 40 sitting in bed with the head of bed at 30 degrees. The tray table was in front of the resident. The plate of food showed broccoli cut into one-inch pieces. Resident 40 was poking at the broccoli with the fork. No staff was observed in the room with Resident 40 while they were eating as directed in the CP. Resident 66 The 11/08/2022 PO showed Resident 66 was prescribed a regular diet with dysphagia advanced texture and thin consistency fluids. Resident 66's PO required supervision eating in the dining room to assist with aspiration precautions. Observation of the tray line on 12/08/2022 at 11:57 AM, showed Staff O (Cook) placed chopped broccoli on the plate for Resident 66. The tray ticket for Resident 66 showed ground green beans and dysphagia mechanical diet. In an interview on 12/08/2022 at 12:27 PM, Staff Q stated the chopped broccoli was not the correct texture for a dysphagia mechanical diet. Staff Q stated it should not be served to residents with swallowing problems due to risk of choking. Observation and interview during the tray line on 12/08/2022 at 12:10 PM showed Staff O began plating food for the room tray carts. Review of the 12/08/2022 menu for the lunch meal showed green beans as the vegetable of the day. When asked about the chopped broccoli instead of the green beans, Staff O stated, We don't have any [green beans]. Staff EE (Dietary Manager) was present and when asked if the broccoli was the right texture, Staff EE stated, Yeah. In an interview on 12/08/2022 at 1:27 PM, Staff T (Licensed Speech Therapist) looked at the chopped broccoli and stated it was not an appropriate substitution for ground green beans on the menu. Staff T stated the chopped broccoli was not the correct texture for a dysphagia mechanical diet and the broccoli should be minced into small pieces. Staff T confirmed Residents 42, 40 and 66 were assessed to require altered textured food and/or liquids. Staff T stated residents with swallowing problems are at high risk for choking if served the incorrect diet textures. REFERENCE: WAC 388-97-1160(1)(a)(b)(c)(iii-iv), -1180(1), -1200(1)(2). .

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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Based on observation, interview, and record review the facility administration failed to act swiftly and effectively to ensure the Emergency Exit (EE) doors were operable and in compliance with federal regulatory requirements. The failure to prioritize the life safety component of repairing the EE doors when found locked and inaccessible in emergent situations placed residents' health and safety at risk for serious harm including death and resulted in Immediate Jeopardy (IJ) on 12/01/2021. Administration failed to ensure supplies, including linens, wound care supplies, and over-the-counter medications were available to staff to provide care in a clean and comfortable manner and according to physician orders. This failure led to residents having inadequate linens on the beds, medication errors and alternate wound treatments. Administration failed to ensure an ongoing Quality Assurance and Performance Improvement (QAPI) program existed, was comprehensive, and sustainable through changes in facility management. This failure of administration detracted from the facility's responsibility to ensure quality care was provided to residents, identify areas for improvement and implement performance improvement plans to meet federal and state regulation compliance which placed residents at risk for decreased quality of care. CFR 483.70 Administration, F-835: A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 12/01/2022 at 4:55 PM, the Administrator was informed of an Immediate Jeopardy identified related to two locked, non-functioning EE doors. On 12/02/2022 the immediacy was removed. The facility unlocked the EE doors and installed magnetic door alarms to both doors. The EE doors remained disconnected from the fire alarm system when the immediacy was removed on 12/01/2022. Findings included . Emergency Exit Doors During a life safety inspection on 12/01/2022 from 8:45 AM to 9:50 AM, a Washington State Fire Marshal identified the two EE doors (door 2 and 3) on the east side of the building did not function as required. The Fire Marshal determined the EE doors were locked and could not be opened, which prevented residents and staff from exiting the facility in an emergency. The Fire Marshal found the EE doors were not connected to the fire alarm system and the keypad controllers which connected the doors to the fire alarm system were not functioning. The Fire Marshal called an IJ in Life Safety for K-222; the facility failed to maintain egress doors free of locks or latches requiring special knowledge or equipment. In an interview on 12/01/2022 at 12:10 PM with the Fire Marshal present, Staff A (Administrator) stated they discovered the two east hallway EE doors did not open during a building walk through last Friday (11/25/2022). Staff A stated they asked maintenance to repair the doors. Staff A stated they did not follow up with maintenance to ensure the two EE doors were repaired and functional. Staff A did not know how long the doors were locked but did acknowledge they were locked from 11/25/2022 to 12/01/2022, seven days. In an interview on 12/01/2022 at 3:13 PM Staff FF (Regional Maintenance Director) stated they were unsure why or when Staff I (Maintenance Assistant) disabled and locked the doors Staff FF stated the EE doors should never be locked. A 2022 12-month work order history log showed Staff I completed a test of the doors, locks, and alarms on 11/08/2022. The 11/08/2022 work order showed Emergency doors are not operational due to code alarm issues. The Director has been notified. In an interview on 12/12/2022 at 4:03 PM, Staff A stated they did not know Staff I had locked the doors. Staff A stated they interviewed Staff I and received information that Staff I locked the doors because the alarm kept going off and kept being set off. According to Staff A, Staff I also stated the keypad stopped working. Staff A acknowledged the work order history log which showed Staff I reported the non-functioning doors to a director on 11/08/2022. Staff A stated no staff reported the non-functioning door to them. Wound Supplies Observations on 11/30/2022 at 09:10 AM, 12/01/2022 at 11:02 AM, 12/02/2022 at 3:11 PM showed Resident 6 had a wound vacuum (equipment used for wound healing) in place on a sacral (lower back) wound. On 12/05/2022 at 10:07 AM Resident 6 was observed with no wound vacuum on their sacral wound. During an observation on 12/06/2022 at 10:46 AM, the wound team completed a wound assessment and treatment with Resident 6 and did not apply a wound vacuum. In an interview on 12/06/2022 at 10:49 AM, the wound care provider stated Resident 6 needed the wound vacuum and they did not know why the wound vacuum was not available from the facility. In an interview on 12/06/2022 at 1:37 PM, Staff C (Licensed Practical Nurse, LPN Unit Manager) stated Resident 6 required the wound vacuum treatment, but the facility ran out of the canisters for the wound vacuum. Staff C stated the wound vacuum treatment was discontinued because of no supplies. Staff C stated they notified the Administrator there were no more canisters last week on Friday (12/02/2022). Staff C stated there were no canisters ordered, and the wound care provider had to change the treatment orders until the supplies were received. In an interview on 12/12/2022 at 2:33 PM, Staff B (Director of Nursing - DNS) stated they were not informed of the wound vacuum treatment change or the canisters being out of supply. Staff B stated the supplies should always be available for the wound vacuum and should not run out. Staff B stated the Administrator oversees supply ordering. In an interview on 12/12/2022 at 3:46 PM, Staff A stated a nurse reported the canisters were out on Monday (12/05/2022) and they were ordered. Staff A stated a shipment was received on 12/12/2022, but Staff A did not know if the canisters were received in the shipment. Linens During an interview on 11/30/2022 at 8:53 AM Staff Y (Certified Nursing Assistant) stated the facility did not have enough fitted sheets and they told management for months there were not enough sheets. Observation at that time, of the linen carts, source of available linens to the caregivers, showed two of four linen carts had no sheets and one linen cart had four flat sheets. Observations on 11/30/2022 from 8:10 AM to 11:06 AM showed five residents (Residents 21, 33, 28, 8, & 55) lying on a bare mattress without any sheets. Observations on 12/06/2022 from 10:03 AM to 10:32 AM showed eight residents (Rooms 3, 6, 43, & 20) were lying on flat sheets instead of fitted sheets. In an interview on 12/05/2022 at 12:11 PM, Staff MM (Laundry Assistant) stated the facility did not have an adequate supply of fitted sheets. Staff MM showed the facility logs, dated August thru December 2022, documenting dates of when sheets were discarded due to holes, rips, and tares. Staff MM stated the facility had a new contracted laundry provider and the facility had not purchased linens in three months. In an interview on 12/12/2022 at 3:46 PM, when asked about the frequency of ordering sheets and other linens, Staff A stated the caregivers took all the linen and stored it in the resident rooms so there was none on the carts. Staff A stated there was plenty of linens if staff did not hide them. Staff A stated an order was placed and should be delivered soon. Staff A confirmed residents should have fitted sheets in good repair on the bed for comfort, dignity, and safety. Over-the-Counter Medications Review of November and December 2022 Medication Administration Records for seven sampled Residents (2, 42, 49, 4, 51, 65, & 32) showed Lidocaine (for pain) patches were not given consistently between November 1 thru December 10. Review of the resident progress notes for the dates a patch was not administered revealed the facility had no Lidocaine patches. In a medication pass observation and interview on 12/06/2022 at 09:28 AM, Staff Q (Licensed Practical Nurse) stated they were not able to administer two over the counter supplements because the facility supply was out. Staff Q stated if the medication was not on the cart, then the nurse checked the medication room, then went from cart to cart to see if there was any supply to give the resident. Staff Q stated the facility ran out of medications quite often, when asked to define quite often, Staff Q stated, this is not the first time. In an interview on 12/12/2022 at 2:33 PM, Staff B stated when they were informed about one of the over-the-counter medications being out of supply, a staff person was sent out to buy some from the local store. Staff B was not aware of the other supplement or the Lidocaine patches being out of stock. Staff B stated the nurses just need to ask for supplies or put a note under the DNS office door and the supplies would be ordered. In an interview on 12/12/2022 at 3:46 PM, Staff A described a par level system for ordering supplies and stated the staff responsible had been trained but was not keeping items in supply. Staff A stated they were not informed of being out of Lidocaine patches or other over the counter meds. Staff A stated there was an order form staff had to fill out to request supplies. Staff A was aware that prior to September orders were canceled by the corporate office but they had not been canceled since Staff A was doing the ordering. Quality Assurance Performance Improvement Program (QAPI) In an interview on 12/12/2022 at 3:46 PM Staff A stated since starting employment in September 2022 they held two monthly QA meetings on 09/29/2022 and 10/30/2022. Staff A stated in September 2022 the QA team discussed psychotropic drugs, survey readiness, recent citations, weight loss/gain and nursing documentation of showers. In October 2022 the QA team discussed administrative, pharmacy, Minimum Data Set assessments, business office items, ancillary items, staffing and nursing call lights, competency, citations, and discharges against medical advice. When asked if the QA team had any PIP's (Performance Improvement Plans) in place for identified areas, Staff A stated, No. When asked about QAPI documents or PIPs implemented prior to September 2022, Staff A stated there were no documents from any prior monthly or quarterly QAPI committee meetings. When asked if the Administrator was trained to facility and corporation policies and procedures, systems and expectations, Staff A stated they were not provided any training about the facility QAPI processes from the corporate staff or provided information on any current PIPs in place from prior administration. Refer to 689 Free of Accident Hazards/Supervision/Devices Refer to 584 Safe/Clean/Comfortable Homelike Environment Refer to 755 Pharmacy Services Refer to 736 Governing Body REFERENCE: WAC-388-97-1620(1). .

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1 of 18 residents (Resident 45) received necessary care and services in accordance with professional standards of practice related to hospitalization, significant change in condition, edema management, and medically related appointments. The facility's failure to recognize, accurately assess, and provide ongoing monitoring for worsening heart failure and kidney function; assess and adequately monitor progressively significant weight gain and edema; implement repeated physician orders for daily weights and multiple referral requests to Nephrology (kidney specialist); and ensure reliable transportation was established for appointments resulted in harm to Resident 45 who sustained avoidable acute kidney injury and acute respiratory failure, required two likely avoidable hospitalizations and one emergency room visit, avoidable psychological stress, and significantly diminished quality of life. Findings included . Resident 45 According to the The Fundamentals of Nursing -The Art and Science of Person-Centered Care, 9th edition (pages 1554-1578), alterations in fluid balance and electrolytes (potassium) are commonly caused by a malfunction of the kidneys ability to excrete excess fluids and heart failure that results in fluid accumulating (edema/swelling) in the lungs and dependent parts of the body (lower legs). Accurate assessment of fluid and electrolyte balance when symptoms occur is critical because such imbalances can have serious negative outcomes and could even be life-threatening. The Care Plan (CP) should include monitoring of fluid intake and output, daily weights- at the same time every day preferably in the morning, and routine labs. Daily weighing is the most accurate way to depict changes in fluid volume. A rapid increase or loss of 2.2 pounds is equal to one liter of fluid. Edema is graded from 1+ to 4+ and brawny (swelling that is so significant it will no longer show pitting) edema by pressing on the affected area and evaluating the level or pitting. A more accurate way to measure edema is measuring the affected body part, in the same area each day or routinely. A physical assessment should include an assessment of the skin, oral membranes, vital signs, oxygen saturation, respiratory and cardiac assessment - including lung sounds, edema grade and location, and weight changes. Moist crackles heard in the lungs is an indication of fluid in the lungs and may indicate fluid volume overload. According to the 09/17/2022 Annual Minimum Data Set (MDS, an assessment tool), Resident 45 had no cognitive deficits and had diagnoses including heart failure, kidney disease, high blood pressure, and diabetes. Resident 45 required supervision with ambulation and bed mobility and required limited assistance with transfers and toileting. Resident 45 did not have breathing difficulty. The MDS showed a weight of 258 pounds, which triggered a significant unplanned weight gain. Review of the 09/23/2022 revised CP showed no identification of problems related to heart failure, kidney disease, edema / weight gain, respiratory problems, or dental problems. There were no interventions to direct staff how to care for Resident 45 related to these medical care areas identified in the MDS assessment. In an interview on 11/30/2022 at 11:10 AM, Resident 45 stated they were very unhappy with the physician services provided by the facility and believed the provider did not know how to manage their care and was incompetent. Resident 45 stated they would have to start dialysis (treatment for filtering blood when the kidneys no longer functioned) much sooner than expected due to the medical mismanagement they experienced. Resident 45 said they were hospitalized several times over the past year because they did not receive the care they needed. Resident 45 stated their quality of life was severely impacted by the medical complications experienced in February 2022 when they were hospitalized for an oral gum infection after requesting to see the dentist and hospitalized again in October 2022 when they had such bad edema they had to go to the hospital, resulting in respiratory failure and diuresis (removal) of 74 pounds of water weight. Resident 45 said their medical circumstances had caused a considerable decline in their mood and made their anxiety almost unmanageable at times. According to record review, Resident 45 admitted to the facility on [DATE] and weighed 218 lbs. An 08/23/2021 Physician note showed Resident 45 was referred to Nephrology due to multiple abnormal kidney function labs and recurrent high potassium (an electrolyte) levels. The note showed Resident 45 weighed 220 lbs. A 12/10/2021 Physician note showed Resident 45's lower leg edema worsened over the past week and the provider adjusted Resident 45's medications to help decrease their edema. The provider failed to identify Resident 45 was not seen by Nephrology as ordered. Resident records showed on 12/10/2021 Resident 45 weighed 237 pounds. A 12/21/2021 Physician note identified the resident had edema but did not address the status of the Nephrology appointment or question why it was not followed up on. A 12/21/2021 document of blood work results showed Resident 45's kidney function had worsened. According to a 02/21/2022 hospital history and physical note, Resident 45 was admitted to the hospital due to an oral gum infection. The hospital admission weight showed Resident 45 weighed 252 lbs, an increase of 15 pounds. Resident 45's kidney function labs were abnormal, and Resident 45 received treatment to stabilize their kidney function. According to Resident 45's census record, they returned to the facility on 3/01/2022; they weighed 241 lbs. Review of the Physician Progress Notes showed from the date of the first Nephrology referral request on 08/23/2021 to 05/03/2022 (over 8 months), Resident 45 was evaluated by or received consult by facility Physician (or designee) providers 100 times. Facility staff and Physician providers failed to identify or question why Resident 45 had not been referred to a Nephrologist as ordered. On 05/03/2022, Staff II (Physician) placed another order into the electronic record, saying, Refer to Nephrology. A 06/02/2022 nutrition note identified Resident 45 weighed 258 lbs., an increase of 12 lbs. in two days. The note showed the interdisciplinary team (IDT) felt the weight was miscalculated and they would re-weigh Resident 45. The note indicated Resident 45 had a pending Nephrology referral for end stage renal disease (a condition in which the kidneys cease functioning on a permanent basis) and did not address issues with the residents's fluid balance or abnormal lab values. Resident 45's weight record showed the next weight assessed was 11 days later, on 06/13/2022, they weighed 242 lbs. A 07/06/2022 Physician note showed Resident 45 was seen for fluid volume overload, lower leg edema, and high blood pressure. The note showed there were no new labs drawn and no current weight. The plan for Resident 45's worsening chronic kidney disease was to avoid medications toxic to the kidneys, encourage the resident to increase fluids, and referenced abnormal labs drawn on 05/17/2022, which were not current labs. On 07/07/2022 Resident 45 weighed 266 lbs. (a 24-pound weight gain in 24 days). This weight gain triggered a significant increase alert to the nursing staff in the electronic medical record. There was no nursing assessment of the weight gain. There was no re-weight conducted and no evidence the provider was notified. A 07/17/2022 nursing note showed Resident 45 had significant edema to both legs, hips, low back, and now crackles were heard in the resident's lungs (an indication of increase fluid volume overload, worsening heart failure and/or kidney function). A 07/17/2022 after hours physician provider note showed nursing staff notified the provider of Resident 45's elevated blood pressure, severe edema from their hips to lower legs, and crackles heard in both lungs and that Resident 45 requested to go to the hospital. The provider noted they [Provider] did not think Resident 45 needed to go to the hospital and ordered an additional dose of their diuretic and lab work again. Resident refused the order and insisted to go to the hospital. According to the 07/17/2022 hospital notes, Resident 45 was treated for edema and was scheduled for a follow up with a Nephrologist on 08/23/2022 as the previously ordered Nephrology consults were never implemented by the facility. According to a 07/20/2022 Physician order (PO) staff were directed to obtain daily weights. Review of Resident 45's weight record showed staff failed to implement the daily weights, only weighing the resident on one day between 07/20/2022 to 08/31/2022. A 08/31/2022 Physician provider note showed Resident 45 had edema to both lower legs and had a newly identified heart murmur (abnormal heart sound). The provider again wrote refer to nephrology, encouraged increased fluid intake, and repeat the blood work. The provider documented, start daily weights if greater than 3-pound weight gain in 1 day or 5 pounds in 1 week, notify provider. The provider said to continue current medications. The provider note did not address the lack of daily weights in the resident's record or delay in obtaining the nephrology appointment. On 08/23/2022 Resident 45 had a Nephrology appointment scheduled. Resident 45 was ill that day and the appointment was rescheduled for 10/04/2022. Resident 45's weight record for September 2022 showed staff failed to obtain daily weights on six of 30 days. A 09/28/2022 Physician provider note repeated the order to, Refer to Nephrology. On 10/04/2022 Resident 45 missed their appointment to Nephrology due to the facility's failure to ensure transportation. The appointment was re-scheduled for 11/01/2022. Review of Resident 45's October 2022 weight record showed facility staff failed to obtain daily weights on five days between 10/01/2022 and 10/13/2022. Weight record showed on 10/04/2022 (281 lb.), on 10/02/2022 (288 lb.), and on 10/13/2022 (292 lb.- a 37 lb. weight gain in 30 days, a 51 lb. weight gain in 120 days, and 72 lb. weight gain in 245 days - the date of the first Nephrology referral request). Resident 45 was subsequently sent to the hospital related to significant edema from their lower legs to their abdomen, causing the resident breathing complications. According to the 10/13/2022 emergency room Physician note: Resident 45 had chest tightness and shortness of breath, lower leg swelling and abdominal edema. Their labs indicated acute kidney injury. The hospital physician stated Resident 45's declining kidney function was concerning. The physician note identified the resident never received the Nephrology referral recommended from the July 2022 emergency room visit. The physician documented, now today [their] renal function continues to decline, and [their] swelling has worsened significantly. The resident was admitted to the hospital with acute respiratory failure and acute kidney injury. According to a 10/14/2022 hospital Nephrology consultation, Resident 45 had acute kidney injury with chronic disease and Nephrotic Syndrome (a kidney disorder that caused the body to excrete too much protein). According to this Nephrology consult, the diuretic medication prescribed by the facility physician did not help control Resident 45's ongoing and worsening fluid overload. The kidney specialist prescribed a plan to use medication and fluids to remove the excess fluid from the resident's body and manage their recurrent critical electrolyte imbalance. Review of hospital documents showed on 11/05/2022 Resident 45 readmitted to the facility weighting 204 lbs.; a decrease in weight of 88 pounds in 23 days. According to the 11/12/2022 5 day Quarterly MDS, Resident 45 had diagnoses of acute respiratory failure and kidney disease. Resident 45 required extensive assistance with their bed mobility, transfers, walking, and toileting, which was a decline in function from the previous assessment. Resident 45 required oxygen therapy which was new for the resident. Resident 45 had a newly acquired Foley catheter (flexible tube inserted in the bladder to drain urine). Resident 45 weighed 229 pounds (lb.) and had a significant planned weight loss. The revised 09/23/2022 CP showed no new updates related to respiratory failure, oxygen, kidney disease, heart failure, edema, or daily weights. In an interview on 12/09/2022 at 3:45 PM with Staff B (Director of Nursing) and Staff KK (Corporate Clinical Nurse), Staff B stated they were not aware of the initial Nephrology referral ordered August of 2021. Staff B stated the process for referrals was the provider wrote a referral order and/or notified the nurse. The nurse notified transportation staff who would schedule the appointment and transportation. Staff B and Staff KK were not aware of transportation concerns or residents missing appointments due to transportation problems. Staff B stated, once referred, it was their expectation residents were evaluated by specialists as soon as possible, depending on the specialist availability. Staff B stated 15 months of repeated requests for referral was not an acceptable timeframe for Resident 45 to wait and other avenues should have been explored to obtain the referral but were not. Staff B stated they would call to other provider groups, get on cancellation lists, and do whatever it took to make sure the referring provider was aware of what the facility was doing to meet the residents' needs. Staff B stated if a resident had heart failure or problems with edema, their expectation was the resident would be weighed routinely according to the frequency ordered by the provider. Staff B expected nursing to monitor Resident 45's level of edema, skin condition, respiratory, and urinary status, and to document their findings and notify the provider as soon as possible of any changes or abnormalities identified. Staff B verified Resident 45 should have been seen by a specialist in a timely manner but was not. Staff B verified Resident 45 should have daily weights but did not. Staff B stated nursing staff should have notified and documented their communication to the provider when Resident 45's weight gain was outside the parameters of professional standards for fluid volume management and the provider's order, but they did not. In an interview on 12/13/2022 at 2:40 PM, Staff II (Physician) stated they were not aware of Resident 45's extent of referral requests for Nephrology because they didn't start seeing the patient until recently. Staff II stated they did not necessarily follow up with the nursing department management after daily weights were ordered for Resident 45 because they just expected to order it and it be done. Staff II stated there were some problems with transportation regarding Resident 45's appointments. Staff II stated they put orders for nephrology in the electronic ordering system and that is the process providers should be following. Staff II stated they will even print out the orders and deliver to the nurse on duty and provide a list of the residents seen for that day and orders to implement. REFERENCE: WAC 388-97-1060(1)(2)(a)(3)(i)(4). .

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide care and services that ensured privacy in a manner that maintained and promoted resident rights and resident dignity for 1 of 18 (Residents 50) sampled residents. Failure to communicate with residents in a dignified manner placed residents at risk for diminished resident rights, feelings of institutionalization, embarrassment, frustration, disrespect, and diminished self-worth. Findings included . Resident 50 On 12/08/2022 at 7:30 AM Resident 50 was observed to approach an unattended beverage cart left in the dining room. Staff Y (Certified Nursing Assistant) called out loudly to Resident 50 from the nurse's station outside the dining room directing the resident to get off the cart twice. Staff Y then approached Resident 50 and asked the resident if they wanted a drink. Resident 50 left the dining room in frustration and went to the resident lounge. In an interview on 12/09/2022 at 3:53 PM Staff C (Licensed Practical Nurse, Unit Manager) stated they expected staff to treat residents with courtesy. Staff C stated Staff Y should have approached Resident 50 and offered a drink without raising their voice from a distance. REFERENCE: WAC 388-97-0180(1-4). .

CONCERN (D)

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

Deficiency F0559 (Tag F0559)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide advanced written notice for room changes, to include the reason for the move, for 3 (Residents 2, 6 & 41) of 3 residents reviewed for room changes. These failures placed the residents at risk for feelings of powerlessness and decreased quality of life. Findings included . Facility Policy According to the facility's undated Change in Room/Roommate Assignment policy, the facility was to provide reasonable notice of the room/roommate change, including oral or written explanation of the reason of the change. The policy stated a resident had the right to refuse the room change if the purpose of the transfer was to relocate the resident from the skilled (short term) section of the center to the non-skilled (long term care) section of the center. The room move was to be documented in the medical record and include the reason for the move, effective date of proposed change, location of new room, discussion with the resident/family, and discussion with current and new roommate. Resident 6 According to the 11/02/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 6 admitted to the facility on [DATE] and was cognitively intact, able to make themselves understood and understood others. The MDS showed Resident 6 was able to participate by answering questions and making decisions about their care. Observation on 12/02/2022 at 10:54 AM showed Resident 6 moving down the hallway in their wheelchair wearing a hospital gown while staff moved Resident 6's belongings to another room. In an interview on 12/02/2022 at 10:57 AM, Resident 6 stated staff told them an hour ago they would be moving them to a different room. Resident 6 stated they did not know why staff had to move them. Resident 6 stated they liked their bed by the window in the previous room. Resident 6 stated they did not want to move and did not want to be in a bed by the door. In an interview on 12/02/2022 at 11:00 AM, Staff Y (Certified Nursing Assistant) stated they were told by Staff A (Administrator) to move Resident 6 to a different room and were following the boss's order. Resident 2 In an interview on 12/02/2022 at 2:53 PM, Resident 2 (Resident 6's new roommate) stated no one told them they were receiving a new roommate and just started moving someone's stuff into their room. Record Review showed no documentation of notification or monitoring of a new roommate. In an interview on 12/06/2022 at 1:55 PM, Staff C (Licensed Practical Nurse, Unit Manager) stated the facility's process was to notify the resident and the roommate prior to the room move. Staff C stated alert charting was expected to be initiated immediately after a resident moved to a different room and monitoring was documented in the resident's record. Review of Resident 6's record showed no documentation the resident was notified about the room move. Resident 6 was not placed on alert charting related to room move until 12/05/2022, three days later. There was no documentation of monitoring Resident 6's acceptance, settling in or interactions with the new roommate. In an interview on 12/09/2022 at 3:08 PM, Staff B (Director of Nursing) stated nursing staff was expected to notify the resident and their roommate about room moves and document in their records, but they did not. Resident 41 According to a 10/15/2022 MDS, Resident 41 was assessed as cognitively intact, had kidney failure, joint swelling and pain, and loss of sensation in their feet. In an interview on 11/20/2022 at 11:45 AM, Resident 41 stated they were required to move rooms by staff without notice or warning. Resident 41 stated on 11/29/2022 staff entered their room around 4:00 PM and started moving their bed. Resident 41 asked staff what was happening and was told it was time to move rooms. When Resident 41 asked why, staff informed the resident it was because they were no longer considered a short stay resident. Resident 41 stated their new room was not set up correctly as the bed was on the opposite side which made it more difficult for them to get in and out of bed. Resident 41 stated it took staff a couple days to get the TV and bathroom in the new room arranged to meet their needs. In an interview on 12/06/2022 at 1:55 PM, Staff C stated the facility's process was to notify the resident or family prior to a room move. Staff C stated alert charting was initiated immediately after a resident moved rooms and was documented in the resident's record. Review of Resident 41's record showed no documentation the resident was notified about the room move. There was no documentation noting Resident 41's toleration of the room move. Resident 41 was not placed on alert charting related to the room move. REFERENCE: WAC 388-97-0580(b)(i)(ii). .

CONCERN (D)

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

Deficiency F0570 (Tag F0570)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure 15 of 28 residents who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account. Findings included . Record review of the facility's Trial Balance report showed 28 residents had trust accounts. The trust account report showed a current balance of 25,984.29 dollars on 12/06/2022. Review of the facility's surety bond, effective July 2021 showed the bond amount covered a trust account balance of $21,000 which did not cover the total trust account balance. In an interview on 12/12/2022 at 11:14 AM, Staff G (Business Office Manager) stated, Yes, the surety bond should be more than the amount in trust. REFERENCE: WAC 388-97-0340(6). .

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments (CAAs), were completed within 14 days from the date of determination for 3 of 3 residents (Residents 27, 42, & 19) reviewed for significant changes in status. The failures to identify the need for a SCSA for: decline in cognition, eating abilities, new swallowing disorder, and repeated falls for Resident 42; decline in ability to feed self, decline in mood, and significant weight loss for Resident 19; and a terminal prognosis with initiating hospice services for Resident 27 placed the residents at risk for further decline, diminished quality of life/quality of care, and unmet care needs. Findings included . Resident 27 According to the Resident Assessment Instrument manual (a document directing staff when assessments of resident status is required) a . SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. Record review of the 07/07/2022 Hospice Notice of Election Benefit/Consent Form, Resident 27's hospice start of care date was 07/28/2022. The 07/28/2022 Hospice Plan of Care information showed Resident 27 was admitted to hospice services due to a severe heart condition. Review of Resident 27's Minimum Data Set (MDS- an assessment tool) assessments showed a 08/18/2022 SCSA was completed for Resident 27, 22 days after the date of determination on 07/28/2022, which is the hospice provider's start of care date. In an interview on 12/09/2022 at 1:03 PM, Staff NN (MDS Specialist, Licensed Practical Nurse) confirmed the completion of Resident 27's SCSA did not happen within 14 days as required. Staff NN stated, Unfortunately, the communication [with billing services] is very poor . as the correct hospice start of care date was not made known in a timely manner that led to the late SCSA completion. Resident 42 According to the 09/12/2022 modified admission MDS, Resident 42 had no cognitive deficits. Resident 42 was assessed to require assistance for bed mobility, transfers, toileting, and eating. Resident 42 did not have a swallowing problem and was on a regular textured diet. On 09/14/2022, the resident choked on a hot dog and required the Heimlich maneuver (an emergent procedure to clear the airway of obstruction) prior to being sent to the hospital. On 09/26/2022 the resident returned to the facility with a new diagnosis of dysphasia (difficulty chewing/swallowing), on a physician ordered soft textured diet with thickened liquids, and required 1:1 feeding assistance for eating. Review of the nursing and provider progress notes showed Resident 42 was having an increase in confusion and decline in cognition which was identified as the root cause for several of the resident's falls. Review of the resident's MDS record showed the facility failed to identify and conduct a SCSA related to the residents decline in cognition, decline in swallowing requiring altered texture diets, requirement for 1:1 feeding assistance, fluctuating diabetic management, and repetitive falls after the resident re-admitted to the facility. In a 12/09/2022 1:10 PM interview, Staff NN said they should have identified the need for a SCSA and should have completed it within 14 days of the change, but did not. Resident 19 The 12/29/2021 SCSA showed Resident 19 had moderate to severe cognitive impairment, indicators of depression, was receiving an antidepressant (AD), only required supervision with set up assistance to eat, and weighed 103 pounds. The 03/31/2022 Quarterly MDS showed Resident 19 had further decline in their cognition, an increase in indicators of depression, was not receiving an AD, showed a decline in their ability to eat independently, and had a significant weight loss of 14.5% of their total body weight in three months. In a 12/09/2022 1:10 PM interview, Staff NN validated the facility failed to identify this as a significant change for the resident and did not complete a SCSA when they should have. REFERENCE: WAC 388-97-1000(3)(b). .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and/or implement comprehensive, person-centered, and/or individualized care plans for 5 of 18 residents (Resident 12, 27, 45, 49, & 51) whose care plans were reviewed. Failure to establish care plans that were individualized and accurately reflected care needs, placed residents at risk of unmet care needs due to inaccurate or absent direction to staff. Resident 12 According to the 11/20/2022 Quarterly Minimum Data Set (MDS, an assessment tool) Resident 12 required total assistance during transfers from the bed to the chair and the support was provided by two staff during the assessment period. The MDS showed Resident 12 did not reject care from staff. Review of the 06/20/2022 Care Plan (CP) indicated Resident 12 would sit in chair for 2-3 hours a day every day for the rehabilitation of their weakened muscles and for trunk control. The CP stated staff would ensure Resident 12 was sitting in the chair for meals and that staff would assist Resident 12 into their chair. Observations on 12/01/2022 at 12:11 PM, 12/05/2022 at 1:10 PM, 12/08/2022 at 7:49 AM, and 12/08/2022 at 12:22 PM showed Resident 12 was eating their meal in bed. In an interview on 12/08/2022 at 12:29 PM, Resident 12 stated staff served their meals in bed. Resident 12 was asked if they had ever sat up in a chair during meals, Resident 12 stated, No, not yet I haven't. Resident 12 was asked if they recall staff asking them if they want to get up and sit in the chair for meals, Resident 12 stated, No. In an interview on 12/08/2022 at 12:41 PM, Staff S (CNA, Certified Nursing Assistant) stated they have served Resident 12's meal tray only in bed. In an interview on 12/08/2022 at 12:46 PM, Staff Q (LPN, Licensed Practical Nurse) was asked if they had seen Resident 12 sitting up in the chair during meals as instructed in the CP for the past three days, Staff Q stated, No. In an interview on 12/09/2022 at 11:04 AM, Staff B (Director of Nursing) stated the expectation from staff was that they follow the CP and whatever is written. Resident 27 According to the 08/18/2022 Significant Change in Status MDS, Resident 27 was transferred to the wheelchair once or twice during the seven day look back period. The assessment showed Resident 27 was cognitively intact and did not reject care from staff. Review of the 05/04/2022 revised Activities of Daily Living (ADL) CP showed Resident 27 had decreased ADL function due to a severe heart condition and difficulty of breathing. The CP indicated Resident 27 required stand-by assist, assist of two persons for transfers from the bed to the wheelchair. Observation on 11/30/2022 at 11:14 AM showed Resident 27 was in bed reading a book. The same observation was noted on 12/06/2022 at 8:47 AM and on 12/08/2022 at 11:28 AM. Record review of Resident 27's transferring task from 11/09/2022 until 12/08/2022 did not show Resident 27 refused transfer assistance from staff. In an interview on 12/08/2022 at 11:58 AM, Resident 27 confirmed staff did not offer transfer assistance to get them out of the bed since their facility return from the hospital on [DATE]. Resident 27 stated, I should be getting up but was not. Resident 49 According to the 11/17/2022 admission MDS, Resident 49 had multiple medically complex diagnoses including diabetes. The assessment showed Resident 49 received insulin (a medication used to treat diabetes) for seven days during the assessment period. The 11/10/2022 CP did not include any monitoring of Resident 49's current insulin use. Review of Resident 49's November 2022 and December 2022 Medication Administration Record (MAR) did not show staff were monitoring Resident 49 for any signs and symptoms that would indicate worsening diabetes. In an interview on 12/12/2022 at 11:33 AM, Staff C (LPN Unit Manager) validated the importance of monitoring high-risk medications including insulin. Staff C stated there was no insulin monitoring in place for Resident 49. Resident 51 According to the 10/06/2022 admission MDS, Resident 51 had multiple medically complex diagnoses, was cognitively intact, had clear speech, was understood, and able to understand others. In an observation on 12/07/2022 at 1:04 PM, Resident 51 was lying in bed when a nurse brought their medications into the room. The nurse attempted to do a blood pressure check to the resident's right arm and Resident 51 stated, no, no, remember you have to do my blood pressure on my left arm because I had a mastectomy [surgical removal of one or both breasts,]. In an interview on 12/07/2022 at 1:12 PM, Resident 51 stated they were instructed by their doctor to only have blood pressures done on the left arm. The resident stated they took medications for severe low blood pressure and often could not get out of bed due to feeling dizzy. Review of an 11/30/2022 provider progress note showed Resident 51 had a history of cancer, had a mastectomy to both sides, and was taking medications for low blood pressure. Review of Resident 51's CP on 12/02/2022 revealed these concerns were not addressed and no direction was given to staff with interventions needed for the resident. In an interview on 12/12/2022 at 8:16 AM, Staff C stated having accurate and complete CPs was important so staff would know what care and interventions to provide to the residents. Resident 45 According to the 11/12/2022 5-Day MDS, Resident 45 their own natural teeth and had obvious or likely cavities and broken or natural teeth. The MDS history of the dental assessment showed this was also identified on five previous assessments (07/07/2021, 09/16/2021, 12/17/2021, 03/19/2022, and 06/19/2022). The 09/23/2022 revised CP showed no focus problems for dental concerns and no interventions for dental problems. In an interview on 12/12/2022 1:35 PM interview, Staff B, Director of Nursing said the resident's CP should of had interventions and a plan to address the resident's dental issues, but did not. The 09/17/2022 Annual MDS showed Resident 45 had medical diagnoses including heart failure, anemia, high blood pressure, and kidney disease. The resident had a significant weight gain and received a diuretic (water pill) 3 of 7 days during the observation period. Review of the 09/23/2022 revised CP showed there were no interventions or CP problems to address the resident's comprehensive care needs and management of heart failure, fluid balance / diuretic use, edema, and kidney disease. In the 12/12/2022 1:35 PM interview, Staff B said the resident's CP should of had problems/interventions to direct staff to care and monitor the residents issues related to anemia, edema, cardiac problems and kidney disease, but did not. REFERENCE: WAC 388-97-1020(1),(2)(a)(b). .

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure weekly skin assessments, documenting and monitoring of wounds for infection, and wound treatment supplies were available for 1 of 3 (Resident 6) residents reviewed for Pressure Ulcers (PUs). Failure to complete weekly skin checks as ordered, assess and document wound progress, and/or ensure the availability of ordered skin care and treatment supplies placed residents at risk for deterioration in skin condition, and diminished quality of life. Findings included . According to the facility's undated Wound Prevention and Treatment policy, pressure injuries would be monitored weekly, and documentation of the size, color, odor, healing progression, notifications, and other information related to skin condition would be documented in the medical record, including physician and resident/responsible party notifications. Resident 6 According to the 11/02/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 6 admitted to the facility on [DATE], had multiple medically complex diagnoses including PUs (open wounds caused by pressure), bone infection of their spine and tail bone area (sacrum), and loss of movement and sensation of their lower body. The MDS showed Resident 6 was at risk for PUs, had two Stage Three (wound gone through all skin layers to the fat tissue) and one Stage Four (deep wound reaching to the muscles and bones) PU, and required extensive assistance with all activities of daily living. Observations on 11/30/2022 at 11:03 AM, 12/01/2022 at 8:02 AM, 12/02/2022 at 10:07 AM, and 12/05/2022 at 9:20 AM showed Resident 6 lying in bed, on an air mattress with a wound vac (a device to promote wound healing using negative pressure) on the tail bone wound. Observation on 12/06/2022 at 7:42 AM, showed no wound vac dressing on Resident 6's tail bone wound. In an interview on 12/06/2022 at 7:45 AM, Resident 6 stated they were unsure why the staff removed the wound vac pump. Resident 6's Physician Orders (POs) included a 10/17/2022 PO to clean the tail bone wound with Dakins (wound cleaning solution to prevent infection) cover with a foam dressing, set the wound vac to 70-75 mmHg (mmHg - millimeters of mercury), and change the wound vac dressing three times per week. A 07/27/2022 PO for weekly skin assessments directed nurses to Document (-) for No area of impairment; Document (+) for ANY area of impairment whether new or old. IF NEW complete A and I (accident and investigation), and document in progress note and notify MD . In an interview on 12/06/2022 at 11:59 AM, Staff C (Licensed Practical Nurse - LPN/Unit Manager) stated they did not have wound vac canisters available (container to hold the wound drainage) for the dressing change. Staff C stated they told Staff A (Executive Director) last week to order the canisters, but they were still out of stock. POs were directed to continue with the wound vac. Observation on 12/06/2022 at 12:23 PM showed the outside wound care provider completing the wound treatment for Resident 6 in their room. In an interview on 12/06/2022 at 1:02 PM, the outside wound care provider stated the facility ran out of wound vac supplies, and they did not have canisters for the wound vac pump. The wound care provider stated they provided wound assessment documentation to the facility weekly after wound rounds. Observations on 12/07/2022 at 2:49 PM, 12/08/2022 at 9:02 AM, and 12/09/2022 at 5:52 PM showed Resident 6 had no wound vac dressing on their tail bone. Review of Resident 6's October and November 2022 MARs showed nursing staff failed to complete the weekly skin assessments as directed by the Physician. Review of Resident 6's outside wound provider documentation showed no documentation after 10/25/2022. In an interview on 12/07/2022 at 12:08 PM, Staff C confirmed weekly skin documentation was not completed as ordered and the outside wound provider's documentation after 10/25/2022 was not in Resident 6's record. Staff C stated weekly nursing skin check documentation and the wound provider's wound assessment documentation should be in Resident 6's record but was not. In an interview on 12/07/2022 at 1:26 PM, Staff B (Director of Nursing) stated the facility should follow POs and document in the resident's record. Staff B stated if documentation of care was not in the record, the care was not completed. REFERENCE: WAC 388-97-1060(3)(b). .

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents that can eat enough orally is not fed by enteral (feeding by tube into body) methods for 1 of 1 resident (Resident 40) reviewed for tube feeding. The failure to complete on-going interdisciplinary team (IDT) assessments of the clinical indications and rationale to continue tube feeding and to identify the residents wishes and requests for oral intake placed Resident 40 at risk for possible unnecessary artificial tube feeding and diminished quality of life. Findings included . Resident 40 The 10/13/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 40 admitted to the facility on [DATE] from another skilled nursing facility. Resident 40 had diagnoses including recent stroke, aphasia (difficulty speaking), dysphasia (difficulty swallowing), unable to take food or fluids by mouth and had a tube into the stomach for administration of nutrition and fluids. A 09/24/2022 speech therapy discharge summary showed Resident 40 could safely tolerate two meals per day with an altered food texture and thickened liquids. The discharge summary recommended Resident 40 eat one meal per day in the supervised dining room. Staff was instructed to supervise, prevent aspiration (food or fluids inhaled into the lungs), and provide cueing precautions for rate of eating, bite sizes and alternation of bites of food and sips of liquids. The 07/11/2022 physician order directed staff to stop the tube feeding at 9:00 AM and Resident 40 to be out of bed and in the assisted dining room every day for lunch. The 08/12/2022 diet order showed a mechanically altered texture and thickened liquids with standard aspiration precautions and supervision during meals. Review of November 2022 meal intake records showed 20 of 30 days the staff documented Resident 40 was able to eat by mouth between 25-100% of the meal. An additional 3 days showed Resident 40 attempted to eat, but intake was under 25%. In an observation and interview on 12/05/2022 at 12:30 PM, Resident 40 was in bed watching a video on a tablet. When asked if they were going to have lunch, Resident 40 stated want pizza then stated kung [NAME] chicken. The more Resident 40 talked, it was more difficult to understand. Resident 40 confirmed they were hungry and wanted lunch. Observation at 12:45 PM showed Resident 40 was eating in bed using a fork and eating independently without staff supervision. Resident 40 was observed to eat lunch in the room independently on 12/06/2022, 12/07/2022, 12/08/2022, 12/09/2022 and 12/12/2022. In an interview on 12/09/2022 at 2:33 PM, Staff B (Director of Nursing) stated there has not been an IDT assessment or discussion between nursing, speech, and dietician about Resident 40's oral intake, requests for oral intake or the continued necessity for the artificial tube feeding. Staff B confirmed an IDT assessment of Resident 40's oral intake and tube feeding was necessary to determine if the tube feeding should continue. Staff B stated if the IDT team could determine Resident 40 could eat on their own, it would be very impactful on Resident 40's quality of life. REFERENCE: WAC 388-97-1060(3)(f). .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the attending physician failed to ensure and/or adequately supervise the complete medical care for 1 of 20 (Resident 45) residents reviewed. The failure to follow up on the status of repeated orders given to nursing staff for a referral to a kidney specialist, address the omission of daily weight monitoring, and facility failure to follow Physician orders (POs) resulted in Resident 45 not being evaluated for worsening fluid balance status by a kidney specialist for over 12 months, required a possibly avoidable hospitalization with the removal of a significant amount of water weight, experienced acute kidney injury and acute respiratory failure. Findings included . Resident 45 According to the 08/23/2021 provider visit note, the resident was referred to Nephrologist (kidney specialist) due to recurrent abnormal and worsening kidney function lab values and critical potassium levels. A 05/03/2022 nurse note showed the Physician ordered repeat labs due to worsening kidney function labs and repeated Refer to Nephrology as the resident had not been set up for a Nephrology appointment yet. A 08/01/2022, 08/31/2022, 09/14/2022, 09/20/2022, 09/28/2022 provider note showed refer to nephrology. The first Nephrology specialty appointment was finally scheduled for 08/23/2022, one year after the first request for referral. Resident 45 was ill that day and unable to attend and the appointment was rescheduled for 10/04/2022. A 10/05/2022 provider note showed Resident 45 missed the 10/04/2022 appointment due to facility's failure to establish reliable transportation. The provider said the resident's potassium level was at a critical level and ordered a medication to help bring the potassium level back to normal. The provider reviewed the resident's medication to manage edema because the resident was complaining of increased edema to the lower legs and abdomen. The provider said the resident's current weight was 287.5 pounds (a 29-pound weight gain in 30 days) and they questioned the current weight trend but did not elaborate as to why. The provider assessed the resident as having pitting edema to both lower legs and up to the trunk (abdomen) and addressed labs values from 10/03/2022 that had significantly worsened. The provider adjusted the residents' medications and said, Refer to Nephrology ASAP (As soon as possible). On 10/13/2022 the Resident was sent to the hospital due to breathing complications related to fluid volume overload. The 10/13/2022 hospital records showed the resident was admitted to the hospital weighting 292 pounds and diagnoses acute respiratory failure, acute kidney injury, high potassium level, and protein in the urine (nephrotic syndrome). The resident was transferred back to the facility on [DATE] and weighed 204 pounds (a loss of 88 pounds in 18 days). In a 12/13/2022 2:30 PM interview, Staff II, facility Physician, said they did not recall reviewing the weight list and had not had any conversations with facility administration regarding the facility's failure to obtain daily weights as ordered. Staff II said they write the order and expect the nurses follow the order. Staff II said they were not aware the request for Nephrology referral was first initiated in August of 2021 because they started seeing the patient around May of 2022. They were unsure of the reason it was taking the facility so long to obtain the appointment and was only made aware of a transportation issue. Staff II said a resident waiting 12 to 15 months for a nephrology referral was not acceptable. Staff II said they did not have any conversations with the facility administration regarding the resident not getting into the specialist as ordered or that orders were not followed thru to monitor Resident 45's fluid balance status. Staff II was asked if there was anything else that could have been done to get the resident into the specialist sooner for specialized kidney treatment and possibly slow the progression of kidney failure, need for hospitalization, and now the need for life altering hemodialysis (for instance a provider to provider call to expedite the waiting period, calling other specialists, getting on cancellation lists) and Staff II said they have in the past, but was unsure if it would have been helpful for this situation, and they were not from this area or familiar with the specialists in this area. Refer to F684 Quality of Care Refer to F658 Services Provided to meet Professional Standards REFERENCE: WAC 388-97-1260(3)(a). .

CONCERN (D)

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

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure residents with dementia receive the appropriate treatment and services for 1 of 2 (Resident 20) residents reviewed for dementia care. The failure to assess residents individualized care needs through an interdisciplinary approach and implement a person-centered care plan prevented the facility from supporting residents to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings included . Resident 20 The 09/17/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 20 had clear speech, was able to make self-understood and was able to understand others. The MDS showed Resident 20 was not able to complete a cognitive interview and had a diagnosis of dementia. The MDS showed Resident 20 had no adverse behaviors, no wandering, and no refusals of care. Resident 20 was assessed to require extensive physical assistance with toileting, supervision, encouragement and cueing for eating. The MDS did not match the comprehensive care plan (CP) for Resident 20. A 09/19/2022 wandering assessment showed Resident 20 had a history of elopement, impaired cognition, was restless, independent with ambulation, unable to locate their room and had a wander guard device (mobility tracker) on the left ankle. The 11/10/2022 CP for wandering directed staff to allow for safe wandering, use of a wander guard device at all times, collect data on elopements, intervene as appropriate with conversation, reassurance, and redirection. The CP did not show individualized wandering behaviors of Resident 20, such as time of day, location of wandering, triggers, or interventions for staff to provide to support safe wandering. An 11/17/2022 incident investigation showed Resident 20 was wandering without supervision and had a fall. Resident 20 was diagnosed in the emergency room with a scapula (shoulder) fracture. A subsequent incident investigation on 12/05/2022 for an unwitnessed fall, showed Resident 20 tripped over a rug in the hallway. Resident 20 was diagnosed in the emergency room with a nose fracture. Review of the 11/18/2022 fall CP and the 11/10/2022 wandering CP showed no updates or new person-centered interventions were added after the investigations to prevent falls or increase supervision during times of wandering. A 09/23/2022 nutrition monitoring and evaluation assessment showed Resident 20 had a weight loss of 14 pounds in six months. The assessment showed food preferences were obtained but were not listed on the assessment. The 09/23/2022 CP for nutrition directed staff to enhance diet to increase calorie intake, offer alternate food choices when meals were refused, offer Resident 20 preferred foods when possible. There were no person-centered food items listed on the CP. The 11/10/2022 CP for activities showed Resident 20 had supplies to participate in activities in their room independently, remind resident of activities occurring daily, invite/escort to group activities as needed including religion, bingo and music, events, and socials. There were no person-centered interventions specific for Resident 20, with dementia, to engage in activities. The 03/30/2022 CP for Activities of Daily Living showed Resident 20 was independent with nail care, independent with oral care, independent with eating after set-up, independent with toilet transfers, hygiene, clothing management and ambulation. This CP was not updated after the 09/17/2022 MDS to accurately direct the person- centered care for Resident 20. An observation on 11/30/2022 at 10:57 AM, Resident 20 was in their room lying in bed, feet were exposed from the blankets with long, thick toenails. Fingernails observed long and debris under nails. Breakfast tray was observed on the table next to the bed. No food was eaten from the tray, more than two hours after breakfast was served. An observation on 12/06/2022 at 1:20 PM showed Resident 20 eating lunch sitting on the side of the bed at the bedside table. Resident 20 was cutting the brownie with a piece of cardboard. Resident 20 had eaten the main dish with their hands. The silverware on the tray was untouched. The resident was not supervised while eating to provide An interview on 12/06/2022 at 1:22 PM, Resident 20's roommate reported that Resident 20 had used the shared toilet and it was now backed up and needed attention. Observation of the toilet showed that it had been used, the bowl was filled with toilet tissue, there was brown debris on the toilet seat and toilet tissue on the floor. In an interview on 12/12/2022 at 2:44 PM, Staff B (Director of Nursing) stated the CP should be updated to reflect individual person-centered care needs. Staff B reviewed Resident 20's CP and stated it was not updated to include person-centered dementia care interventions. Staff B was asked to provide the Dementia Care policies or procedures, none were provided. REFERENCE: WAC 388-79-1040(1)(a-c). .

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Resident 49 According to the 11/17/2022 admission Minimum Data Set (MDS, an assessment tool) Resident 49 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication. Review of Resident 49's December 2022 Physician Order (PO) summary showed an order for an antianxiety (AA) medication dated 11/10/2022 for a diagnosis of anxiety. The November 2022 Medication Administration Record (MAR) showed Resident 49 started receiving the AA medication on 11/10/2022 and started receiving the antidepressant (AD) medication on 11/11/2022. Review of Resident 49's medical records showed the consent form for the AA medication use was completed on 12/06/2022, 26 days after Resident 49 started receiving the AA medication. The consent form for the AD was completed on 12/06/2022, 25 days after Resident 49 started receiving the AD medication. Resident 32 Similar findings for Resident 32 who was prescribed three AD medications and one AA medication, did not have timely consent forms signed and did not have medications and behaviors monitored or reviewed by an IDT team to determine ongoing need for these AD and AA medications. In an interview on 12/09/2022 at 2:33 PM, Staff B (Director of Nursing) when asked about psychoactive medication review, consents, and audits, Staff B stated consent forms are required to be signed prior to the psychotropic medication being administered. Staff B stated audits of psychotropic medications were not being completed and there was no IDT monthly reviews of residents using psychoactive medication. Resident 66 According to the 11/11/2022 Admissions MDS Resident 35 was cognitively intact. The MDS showed Resident 35 had diagnoses including a history of stroke, difficulty swallowing, and depression. Record review showed Resident 66 had a 11/26/2022 PO for an AD medication. The PO stated the AD medication was prescribed for for depression, appetite stimulant. Resident 66's Comprehensive Care Plan (CP) included an 11/18/2022 Antidepressant CP. This CP included an 11/18/2022 goal for Resident 66 to remain free from discomfort or adverse reactions related to antidepressant therapy . The CP did not identify which ASEs to monitor for the AD medication. Record review showed no documentation of monitoring for ASEs. Resident 32 Similar findings for Resident 32. The CP did not identify ASEs to monitor for the AD and AA medications and record review showed no documentation of monitoring for ASEs. In an interview on 12/12/2022 at 1:02 PM, Staff C stated the facility was not but should be monitoring for ASEs from the AD medication. REFERENCE: WAC 388-97-10603)(k)(i). Based on interview and record review, the facility failed to ensure resident's drug regimens were free from unnecesary psychotropic medications for 2 (Residents 32 & 49) of 5 residents and one supplemental resident (Resident 66) reviewed for unncessary medications The failure to obtain consent and review the risks and benefits of psychotropic medicaitons and failure to monitor for Adverse Side Effects (ASEs) left residents at risk for use of unnecessary psychotropic medications, adverse side effects and diminished quality of life. Findings included .

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent (%). Failure of 1 of 3 nurses (Staff Q) to properly administer 3 of 26 medications for 1 of 8 residents (Resident 23) observed during medication pass resulted in a medication error rate of 11.54%. This failure placed residents at risk for adverse side effects due to improper medication administration. Findings included . Facility Policy The undated facility policy titled, Medication Administration, showed the licensed nurse and/or medication assistant would document administration of medication on the Medication Administration Record (MAR) as soon as medications were given. The policy instructed nursing staff to remove a dose from the back-up supply when medications were not available. Resident 23 Observation of the medication pass on 12/06/2022 at 9:28 AM showed Staff Q (Licensed Practical Nurse-LPN) prepare medications for Resident 23. Staff Q went to Resident 23's room, administered one type of eye drops, handed Resident 23 the medicine cup containing oral medications, and left the room. No other medications were administered to Resident 23. Review of the December 2022 MAR showed a second type of eye drop and a medication for constipation were to be administered to Resident 23 but were not given on 12/06/2022. The MAR showed Staff Q documented administration of a topical pain gel to Resident 23 but was not administered during medication pass. In an interview on 12/06/2022 at 9:32 AM, Staff Q was asked to recheck the availability of the second type of eye drops for Resident 23 in the medication cart. Staff Q found the second type of eye drops and stated the generic names of the two types of eye drops created the confusion. Staff Q stated the second type of eye drops was not administered during medication pass. In an interview on 12/06/2022 at 9:43 AM, Staff Q was asked about the documentation of administration of the pain medication gel noted in the MAR. Staff Q stated, I must have clicked it [pain medication gel] by accident. Staff Q confirmed the pain medication gel was not provided to Resident 23 and should have been during medication pass. In an interview on 12/07/2022 at 3:25 PM, Staff U (LPN) stated a bottle of the constipation medication was found at the back of the cabinet in the medication room. Staff Q acknowledged the constipation medication for Resident 23 was not administered during medication pass on 12/06/2022. REFERENCE: WAC 388-97-1060 (3)(k)(ii). .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure expired medications, liquid feeding supplement, and medical supplies were disposed of timely in accordance with current accepted professional standards of practice for 1 of 1 medication room, 1 of 3 medication carts, and 1 of 2 emergency crash carts reviewed. These failures placed residents at risk for receiving compromised supplies and medications with decreased or no potency. Findings included . Medication Room Observation of the medication room on 12/02/2022 at 10:06 AM with Staff E (Registered Nurse-RN Unit Manager) showed five bottles of Iron supplement that expired 10/2022, five bottles of liquid feeding supplement that expired 12/01/2022, six anti-nausea suppositories that expired 10/2022, two boxes of alcohol swabs that expired 08/2022, nine swab collection tubes, two urinary catheters (tube that drains urine from the bladder) that expired 07/10/2021 and one urinary catheter that expired 10/11/2022. In an interview on 12/02/2022 at 10:33 AM, Staff E validated the dates of the expired medications, liquid feeding supplement, and medical supplies found. Staff E stated expired medications and supplies should not be kept in the medication room for resident safety. Medication Cart- Hall D Observation of the medication cart in Hall D on 12/05/2022 at 12:12 PM with Staff C (Licensed Practical Nurse-LPN Unit Manager) showed one bottle of pain reliever that expired 11/2022. In an interview on 12/05/2022 at 12:18 PM, Staff C confirmed the expired date and stated it should not be kept in the medication cart. Emergency Crash Cart- Dining Room Observation of the dining room emergency crash cart on 12/07/2022 at 8:45 AM showed one suction catheter (a device used to clear oral and nasal secretions) that expired 03/02/2022, one suction catheter tip that expired 10/28/2022, and one disposable syringe (a device used to draw liquid medications) that expired 07/31/2022. In an interview on 12/07/2022 at 9:07 AM, Staff C confirmed the dates of the expired supplies. Staff C stated the facility should check the crash cart every night to ensure no expired supplies were kept, but they did not. Medication Room Refrigerator Review of the facility's Refrigerator Temperature Log form on 12/06/2022 on 3:25 PM with Staff E showed the refrigeration temperature should be kept at 41 degrees Fahrenheit (ºF) or below. Record review of the November 2022 medication room refrigerator log showed 19 of 60 opportunities the refrigeration temperature was 42ºF and above. Record review of the December 2022 medication room refrigerator log showed 3 of 12 opportunities the refrigeration temperature was 42ºF and above. In an interview with Staff C and Staff B (Director of Nursing) on 12/12/2022 at 1:05 PM, stated the temperature readings documented above 42ºF on both the November 2022 and December 2022 refrigerator temperature logs were out of range. REFERENCE: WAC 388-97-1300(1)(b)(ii),(2). .

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Resident 49 The 11/17/2022 admission MDS showed Resident 49 had multiple medically complex diagnoses including chronic lung disease, a heart problem, and diabetes. Review of the November 2022 MAR showed three POs for staff to obtain lab work for Resident 49, including a CMP and CBC. Review of November 2022 MARs showed lab work was not signed as completed by staff. The MAR showed four opportunities (11/17/2022, 11/18/2022, 11/21/2022, and 11/28/2022) where lab work was scheduled, but not obtained. According to the 12/02/2022 provider note, CMP, CBC order for 11/21 [2022], STILL pending. REORDERED AGAIN for 11/28 [2022] and is still pending today. In an interview on 12/12/2022 at 8:16 AM, Staff C stated the expectation was for staff to follow physician orders and ensure lab work was completed as ordered. Staff C was asked if the facility had documentation of Resident 49's lab work results. Staff C stated they would look into Resident 49's medical records. No further information was provided by Staff C. Resident 32 Record review showed a 07/24/2022 PO for lab services including a CBC, CMP, Hgb A1C, Vitamin D and Lipid panel for Resident 32. Record review showed no lab results from the 07/24/2022 physician order. In an interview on 12/09/2022 at 2:33 PM, Staff B (Director of Nursing) confirmed the lab results were not in the record. Staff B stated nurses were expected to order labs according to physician orders, receive the lab results, report to the physician and document actions in the record. Staff B stated there was not a system to reconcile orders with lab services and receipt of lab results with report to the physician. Staff B stated a system needed to be implemented. REFERENCE: WAC 388-97-1620 (2)(b)(i). Based on interview and record review, the facility failed to obtain timely laboratory services to meet the needs of 3 (Residents 51, 49, and 32) 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 . Review of an undated facility Laboratory/Diagnostic Test Values- Monitoring policy showed the facility strived to ensure each resident's laboratory/diagnostic test order requested was ordered. This policy identified the daily nurse manager's responsibility was to ensure all scheduled labs were drawn and if a test was missed, make arrangements for the lab/diagnostic test to be completed that day or have it rescheduled. This policy stated the unit manager must notify the provider and Director of Nursing. Resident 51 According to the 10/06/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 51 had multiple medically complex diagnoses including malnutrition, diabetes, and a thyroid disorder. Review of November 2022 Medication Administration Records (MAR) showed Resident 51 had physician ordered medications for diabetes and the thyroid disorder. According to this MAR, a new order was added on 11/16/2022 for staff to obtain lab work including a CBC (Complete Blood Count - a comprehensive blood test), CMP (Comprehensive Metabolic Panel - a comprehensive blood test), TSH (Thyroid Stimulating Hormone - a test to determine thyroid function), and Hemoglobin A1C (a test that reflects long term blood sugar levels). Record review showed these labs were not drawn in November 2022 as ordered. According to a provider note on 12/01/2022, As of today still no labs as ordered. Recommend this be evaluated. Review of Resident 51's physician orders (POs) showed new orders on 12/01/2022 for CMP, CBC, TSH, Hgb [Hemoglobin] A1C .Have been ordered 2x [two times] already and no results. Please do today . Record review showed these labs were not drawn until 12/05/2022, five days after the 12/01/2022 order and 19 days after originally ordered by the provider on 11/16/2022. According to the 12/05/2022 lab results, the TSH was not performed due to not having enough of a blood sample and the facility staff were notified. On 12/07/2022 new orders were given to obtain a Hemoglobin A1C and TSH. The physician order was not signed as completed by staff until 12/08/2022 (21 days after originally ordered by the provider on 11/16/2022). In an interview on 12/07/2022 at 1:04 PM, Resident 51 was talking with staff about their lab work and stated, I'm kinda worried about my thyroid, so I'm glad they are checking it. In an interview on 12/12/2022 at 8:16 AM, Staff C (Licensed Practical Nurse - Unit Manager) stated their expectations were for staff to follow physician orders and ensure lab work was completed as ordered. Staff C stated lab work was important so staff and providers could monitor residents' lab values and make changes as needed to their care.

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure 1 of 6 residents (Resident 45) reviewed for dental services was assisted in obtaining emergent dental care. The facility's failure to follow through with the resident's request for outside emergent dental care, failure to follow a hospital transfer order for dental services follow-up, failure to follow up on two separate dental exam recommendations for emergent dental care placed resident at risk for an oral infection, hospitalization, pain, and diminished quality of life. Findings included . According to the undated facility dental policy, when residents require emergency dental service for acute pain in teeth, gums, or palate; broken or otherwise damaged teeth; any problem requiring the immediate attention of a dentist, the facility would schedule an appointment and arrange transportation. Resident 45 According to the 11/12/2022 5 Day Minimum Data Set (MDS, an assessment tool) Resident 45 had their own natural teeth and had obvious or likely cavities and broken or natural teeth. The MDS history of the dental assessment showed this was also identified on five previous assessments (07/07/2021, 09/16/2021, 12/17/2021, 03/19/2022, and 06/19/2022). The CP showed no focus problems for dental concerns and no interventions for dental problems. A 12/13/2021 social services note showed Resident 45 last saw dental services on 08/21/2021 and a six month follow up was recommended. According to the 12/13/2021 social services note, Resident 45 requested to see the dentist and the writer said, will add to dental list. A 01/24/2022 nurse communication note showed nursing notified the physician of Resident 45's complaints of tongue swelling and mouth pain. The provider was notified, and the resident was ordered treatment for an oral yeast infection. In a 11/30/2022 11:10 AM interview, Resident 45 said the doctor came to see her when her mouth was hurting, and her tooth had been hurting for several weeks. Resident 45 said the doctor ordered a medication for an oral yeast infection and the resident said they told the provider, Are you kidding me? What about my bad tooth?. Resident 45 said they felt the provider was not listening to them and they were concerned they were not getting the care they needed. On 02/11/2022, Resident 45 was seen by the in-house denture specialist. The exam notes showed Resident 45 had red and irritated gum tissue. There was no evidence the facility followed up on the abnormal exam. A 02/19/2022 nursing progress note showed Resident 45 had complaints of weakness, dizziness, and felt shaky. The nurse stated the right side of Resident 45's face was swollen. The Provider was notified and according to a 02/19/2022 provider note (an eight-minute non-face-to-face visit via phone call) showed Resident 45 had right facial edema, acute pain of their right face/cheek, and swollen lymph nodes (an indication of infection). There were no new order changes. According to a 02/21/2022 health status note, on 02/20/2022 Resident 45 had worsening weakness, began to have respiratory complications, and increased confusion, so the nursing staff sent the resident to the hospital. Resident 45 was admitted for an abscess (confined pocket of pus usually due to an infection) of the mouth and right cheek. According to the 02/21/2022 hospital provider notes, Resident 45 went to the emergency department with a temperature of 101.9 and had elevated white blood cell count indicating infection. A scan of Resident 45's head and neck showed soft tissue swelling of their right face which extended down their neck. Resident 45's kidney function was abnormal, and their potassium level was high. Resident 45 was admitted to the hospital and required intravenous antibiotics, fluids, and medication changes stabilize their kidney function and treat the infection of the infection. A 02/25/2022 operative report showed Resident 45 required a surgical procedure to have the abscess of their right face drained. A drain was attached to Resident 45's face after surgery to allow the abscess to continue to drain and heal. Record review showed Resident 45 was transferred back to the facility on [DATE]. According to the 03/01/2022 facility transfer discharge orders; Resident 45 was referred to the Ear-Nose-Throat (ENT) specialist and the Dentist. A 03/08/2022 Registered Dental hygienist cleaning visit note showed Resident 45 was examined and their teeth were cleaned. The hygienist checked the box that said, Refer to Dentist and wrote the resident requests to see the Dentist to evaluate #32 fractured tooth for treatment options. Has a large lesion on it too. Finished antibiotics yesterday for right side abscess - monitor healing. A 09/14/2022 Registered Dental hygienist cleaning visit note showed Refer to Dentist for a large hole inside one of their teeth causing nerve pain and follow up for the lower right lesion and abscess noted in their 03/08/2022 visit. They would like to have it evaluated soon by outside dental. Between 12/13/2021 and 11/30/2022, the facility failed to obtain a dentist appointment for Resident 45 after resident request, the hospital physician referral for Dentist, and two separate dental hygienist exam recommendations. In an interview on 11/30/2022 at 11:10 AM, Resident 45 stated they had their own natural teeth, and they have lots of problems with them. Resident 45 stated they saw a dental hygienist a couple of times at the facility for cleaning, but that is all they were allowed to do. I have asked to see the dentist, but it has not happened yet. I am from Seattle, and I just don't know where to start to find a dentist in this area. Resident 45 said the facility did not help with setting up a dentist appointment. Resident 45 said they had to go to the hospital in February of 2022 because they had a horrible oral and cheek infection that went from their gum to their whole right cheek. Resident 45 said they had been asking to see the dentist since sometime in December of 2021 and now it has been almost a year, and I (Resident 45) still have not seen the dentist. In an interview on 12/06/2022 at 1:33 PM, Staff L (Social Services Assistant) stated they managed the routine dental exams in the facility and when there are recommendations / requests for dentist needs, Staff JJ (Certified Nursing Assistant) handled the appointment setting and transportation. Staff L stated they are notified by verbal notifications, written on exams, and orders. Staff L stated an acceptable timeframe for getting an emergent dental visit scheduled and for the resident to attend would be a couple weeks. In an interview on 12/12/2022 at 3:12 PM, Staff JJ (Certified Nursing Assistant responsible for transportation and appointments), stated they took over the transportation responsibility several months ago. Staff JJ stated they were recently made aware of Resident 45's request to see a dentist. Staff JJ stated Resident 45 had an appointment scheduled. Staff JJ stated they were not notified of any out-lying appointments that had not been finished when they took over the duties. Staff JJ had a system that provided adequate communication and tracking of appointments on a computer system that management had access to. Staff JJ stated it was important for residents to make it to their appointments, so their care needs were met to prevent bad outcomes. REFERENCE WAC: 388-97-1060 (3)(j)(vii). .

CONCERN (D)

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

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide foods according to the resident's preferences for 1 of 2 (Resident 52) residents reviewed for food preferences. The failure to accommodate a resident's religious dietary preferences placed residents at risk for inadequate nutrition and well-being. Findings included . Resident 52 According to the 11/08/2022 Quarterly Minimum Data Set (MDS, an assessment tool), Resident 52 readmitted to the facility on [DATE], was assessed as cognitively intact, able to make themselves understood and understood others. The MDS showed Resident 52 was able to participate by answering questions and making decisions about their care. The MDS showed it was very important to Resident 52 to have snacks available between meals. In an interview on 11/30/2022 at 9:10 AM, Resident 52 stated they did not get to make choices about food. Resident 52 stated they did not eat pork or beef according to their religion but the facility kept serving them bacon with breakfast. Resident 52 stated they told the staff multiple times, but no change happened, and they had to ask their family to bring food from home. In an interview on 12/05/2022 at 1:11 PM, Staff C (Licensed Practical Nurse, LPN Unit Manager) stated the dining system for managing resident dietary needs and preferences did not show Resident 52's pork and beef religious restrictions. In an interview on 12/06/2022 at 10:09 AM, Staff NN (Registered Dietitian - RD) stated they were not able to locate any documentation about Resident 52's religious food preferences in the resident's record. Staff NN stated the facility should have obtained the religious dietary preferences and put the information in the kitchen's diet orders and on the CP. REFERENCE: WAC 388-97-1100(1). .

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a designated interdisciplinary team member appointed as the responsible party for coordinating care and communication with hospice services, and to ensure the development of a coordinated plan of care for 1 of 1 residents (Resident 27) reviewed for hospice care services. These failures placed the resident at risk for not receiving necessary hospice services, lack of continuity of care, and unmet care needs. Findings included . Facility Policy The undated facility policy titled, Hospice Residents- admission and Discharge of and Care and Treatment Provided to, showed the Center would designate a Registered Nurse (RN) from the interdisciplinary team to be responsible for working with hospice representatives in coordinating care for hospice residents receiving facility and hospice services. The policy showed Hospice and the Center would jointly develop and agree upon a coordinated plan of care and the description of the services furnished by the Center to attain or maintain the hospice resident's highest practicable, physical, mental, and psychosocial well-being. The policy showed the facility would obtain the Physician Certification of Terminal Illness (CTI) and the names and contact information for hospice personnel involved in hospice care for each hospice resident. Resident 27 According to the [DATE] Hospice Notice of Election of Benefit/Consent Form, Resident 27's hospice start of care date was [DATE]. Review of Resident 27's hospice documentation did not show Resident 27's CTI. Review of Resident 27's medical records did not show a designated RN by the facility to be responsible for coordinating care and communicating with hospice services. In an interview on [DATE] at 5:07 PM, Staff C (Licensed Practical Nurse- LPN Unit Manager) stated they were instructed by Staff A (Executive Director) to direct all hospice services questions to Staff G (Business Office Manager- BOM), who was not a registered nurse. In an interview on [DATE] at 5:18 PM, Staff G was asked if the facility had or obtained a copy of Resident 27's CTI from the hospice provider. Staff G stated they did not have Resident 27's CTI but would inquire about the matter from Resident 27's hospice provider. Staff G was asked about the facility's hospice designee for care and services collaboration for Resident 27. Staff G stated, Honestly, I do not know. Staff G was asked if they had any written documentation that indicated the facility had designated a member from the interdisciplinary team, Staff G stated, No, I do not. Record review of the [DATE] Hospice Plan of Care information showed Resident 27 was admitted to hospice services due to complex medical diagnoses including a severe heart condition. The hospice plan listed Resident 27's care and service needs, but the plan showed no information available regarding the hospice interdisciplinary group members. The undated How and When to Call Hospice communication form was entirely blank. Review of the [DATE] Care Plan (CP) showed the facility initiated a hospice care plan on [DATE], 35 days after Resident 27's hospice start of care on [DATE]. The CP goal target date [DATE] was expired. The CP did not show a coordinated plan that addressed Resident 27's pain needs. The CP did not identify the facility's designated person responsible for coordinating care and services with hospice. In an interview on [DATE] at 11:01 AM, Staff G stated, I do not even really know what to show you. Staff G acknowledged the review of Resident 27's medical records did not show any coordinated plan of care with hospice. REFERENCE: WAC 388-97-1060 (1). .

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to establish an infection prevention and control program that included developing an antibiotic (ABO) stewardship program to promote appropriate use of antibiotics; failed to analyze and complete monthly surveillance effectively for 4 of 4 months (July 2022 to October 2022) reviewed; failed to have an effective Infection Control Committee to meet regularly and analyze/review Antibiotic usage in the facility. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics and an increased risk for multi-drug resistant organisms (MDRO). Findings included . The October 2018 revised facility policy named Infection Prevention and Control Program showed the facility would use surveillance tools to recognize the occurrence of infections .and detecting unusual pathogens with infection control implications. The facility would use culture reports, sensitivity data and antibiotic usage reviews for surveillance activities, data gathering, and analysis and medical criteria is used to recognize and mange infections as part of the antibiotic stewardship program. In an interview on 11/30/2022 at 2:07 PM, Staff F (ICP, Infection Control Preventionist) stated they were new to the position starting in September 2022 and the first month of infection control data gathering and analysis they had completed was October 2022. Staff F did not have any other prior months of infection control surveillance, analysis, or data reports. On 11/30/2022 at 2:17 PM, Staff F was asked to provide the line list surveillance that was in place for November 2022. Staff F was not able to print the document from the cloud program at the time and asked to provide it later. (It was received on 12/02/2022, two days later.) At 2:28 PM Staff F asked the DNS where to find the infection control data from the prior months. The DNS stated they did not have them and to check in another office. On 11/30/2022 at 2:28 PM, Staff F was asked to provide the monthly infection control surveillance tools used to recognize and track infections including pathogens, antibiotic guideline criteria used, infection maps, analysis summaries and MDRO list. Staff F stated they would need to talk to the Director of Nursing (DNS) to obtain the monthly documents and summaries for June, July, August, September 2022 that were completed by the prior ICP. The data analysis from July, August, and September 2022 was not provided during the time of the survey investigation. A review of the October and November 2022 line list of antibiotic use cases in the facility showed the type of bacteria was not identified to ensure the prescribed antibiotic was appropriate for each infection, the line list did not show infections were reviewed with a nationally recognized stewardship tool to verify requirements of antibiotic use prior to treating infections. In a phone interview on 12/20/2022 at 10:12 AM, Staff KK (Chief Nursing Officer) when asked about the prior months of infection control reports and surveillance data, stated they were kept in another office in the facility and Staff F and B should have been able to provide them easily. Staff KK was asked to send the infection control surveillance tools, analysis reports, infection mapping and any other documents the facility used for antibiotic stewardship processes from July August, and September of 2022. Only an antibiotic case list was received from Staff KK. The case list did not show each infectious pathogen in relation to the antibiotic treatment, the antibiotic criteria used to determine antibiotic use criteria was met. The analysis of antibiotic use, monthly analysis summaries, pharmacy reports, laboratory reports and other documents were not provided to support an ongoing antibiotic stewardship program was in effect in the facility for the past five months. REFERENCE: WAC 388-97-1320(1)(a)(2)(a-c).

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 49 According to the 11/17/2022 admission MDS, Resident 49 admitted to the facility on [DATE], presented with clear speech, and was cognitively intact. The assessment showed Resident 49 had a personal history of COVID-19 infection. Record review showed an 11/10/2022 physician order for Resident 49 to have the 2-step COVID vaccine but no information regarding if the resident had offered or received the COVID-19 vaccination. On 12/07/2022 at 1:06 PM, Resident 49 was asked if the facility offered them the COVID-19 vaccine since their admission to the facility on [DATE]. Resident 49 stated, No and stated they would like to receive the COVID-19 vaccination. In an interview on 12/12/2022 at 1:55 PM, Staff F confirmed the facility should, but did not, educate and offer COVID-19 vaccinations to residents per guidelines upon admission. REFERENCE: WAC: 388-97-1780(1)(2)(a)(i)(b). Based on interview and record review the facility failed to ensure 2 of 5 residents (Resident 51 and 49) were offered the COVID-19 (a highly transmissible infectious virus that causes respiratory illness, in severe cases can cause difficulty breathing and could result in impairment or death) vaccination and had education on the benefits and potential risk associated with COVID-19. These failed practices placed the residents at risk of COVID-19 infection and placed residents at risk for not having their medical records reflect complete and/or accurate information to be considered when making a medical decision. Findings included . Review of a revised November 2021 facility COVID-19 - Vaccination of Residents policy showed each resident would be offered the COVID-19 vaccine unless the immunization was medically contraindicated, or the resident had already been immunized. This policy stated the resident had the opportunity to accept or refuse a COVID-19 vaccine, and to change their decision. The policy stated the resident's records would include documentation that indicated, at a minimum, the following: the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine; signed consent; and each dose of COVID-19 vaccine that was administered to the resident. If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination or refusal, appropriate documentation would be made in the resident's records. Resident 51 According to the 10/06/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 51 admitted to the facility on [DATE], had multiple medically complex diagnoses, clear speech, was understood, and able to understand others. Record review showed a 09/29/2022 physician order for Resident 49 to have the 2-step COVID vaccine but no information regarding if the resident had received the COVID-19 vaccination. A 10/06/2022 Pneumococcal, COVID-19 and Annual Influenza Vaccine Information and Request (PCAIVIR) form showed Resident 51 was offered and refused the annual influenza vaccine but the section for the COVID-19 vaccine was blank. Review of a 06/22/2022 PCAIVIR form showed Resident 51 was offered and declined the COVID-19 vaccine during their previous admission. In an interview on 12/09/2022 at 11:10 AM, Resident 51 stated they were interested in receiving the COVID-19 vaccine. Resident 51 stated staff had talked with them a long time ago but reported it was not brought up since the resident was readmitted to the facility on [DATE]. In an interview on 12/12/2022 at 1:55 PM, Staff F (Infection Control Preventionist) stated staff should educate and offer COVID-19 vaccinations to residents upon admission or readmission and re-approach those residents who previously refused.

CONCERN (E)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents had the ability to exercise self-determination related to aspects of life in the facility that was significant to the resident including the frequency and type of bathing for 3 of 3 residents (Residents 51, 6, & 65) reviewed for choices. The facility's failure to identify and/or honor resident preferences related to bathing placed residents at risk for feelings of un-cleanliness, powerlessness, decreased self-worth and diminished quality of life. Finding included . Resident 51 According to a 09/29/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 51 was cognitively intact, with clear speech, able to understand others, and be understood. This MDS indicated Resident 51 reported it was very important to choose between a tub bath, shower, bed bath or sponge bath. In an interview on 12/02/2022 at 10:44 AM, Resident 51 stated they get bathing, one time a week if you're lucky. The resident stated they preferred to have showers at least twice weekly. Review of a 09/28/2022 Activities of Daily Living Care Plan (CP) showed no preferences for bathing were identified for Resident 51. According to the November 2022 shower log documentation, Resident 51 only received four showers in 30 days. In an interview on 12/12/2022 at 8:16 AM, Staff C (Licensed Practical Nurse, Unit Manager) stated their expectation was for staff to follow Resident 51's preferences and provide bathing twice weekly. Resident 6 According to the 11/02/2022 Quarterly MDS, Resident 6 admitted to the facility on [DATE], was cognitively intact, and able to be understood and get understand in conversation. The MDS showed Resident 6 required extensive assistance with personal hygiene and showers. In an interview on 12/01/2022 at 11:21 AM, Resident 6 stated they did not get to make choices about bathing, and they did not receive a shower for a month. Resident 6 stated they preferred showering at least twice weekly but never got a shower. Observations on 12/02/2022 at 8:09 AM, 12/05/2022 at 11:33 AM, and 12/08/2022 at 10:01 AM showed Resident 6's face was not shaved and their hair was greasy. Review of Resident 6's records showed no documentation of their preference of showers vs. bed baths, or frequency of bathing. Review of Resident 6's bathing records showed from 11/01/2022 through 12/01/2022, the resident received four bed baths in 30 days, but no showers. In an interview on 12/07/2022 at 12:04 PM, Staff C stated Resident 6's CP should have, but did not, reflect Resident 6's preferences for bathing. Staff C stated staff was expected to assist Resident 6 with showers according to the shower schedule twice a week, and per the resident's preferences. Staff C stated staff should shave Resident 6 daily or as the resident preferred. Resident 65 According to the 11/02/2022 admission MDS Resident 65 readmitted to the facility on [DATE] and was cognitively intact, able to be understood and to understand conversation. The MDS showed it was very important to Resident 65 to choose between a tub bath, shower, bed bath or sponge bath. In an interview on 11/30/2022 at 11:30 AM, Resident 65 stated they did not get to make choices about bathing. Resident 65 stated they wanted a shower twice a week but only received bed baths. Review of Resident 65's Preference CP showed instructions for bathing (SPECIFY). The CP did not indicate Resident 65's preference for frequency or type of bathing. Review of Resident 65's bathing records showed they received one shower on 11/27/2022 and bed baths on 11/19/2022 and 11/23/2022 since their 10/27/2022 admission. In an interview on 12/07/2022 at 12:04 PM, Staff C stated resident 65 should receive bathing at least twice a week and the CP should specify the resident's preferences. REFERENCE: WAC 388-97-0900(1)(3). .

CONCERN (E)

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

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 3 (Residents 221, 223, 222) of 3 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required. Additionally, the facility failed to notify 2 (Residents 38 & 2) of 28 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. Findings included . According to a 12/01/2017 facility Personal Funds- Your Rights policy, the facility would notify a resident who receives Medicaid benefits when the balance of the resident trust account is 200 dollars less than the resource limit. The facility would advise the resident they may lose eligibility for Medicaid if the amount in the account was to reach the limit. OFR Fund Disbursement Resident 221 Record review showed Resident 221 was discharged on 09/26/2022. Review of trust records showed the resident a balance of $2060.00, which was not transferred to the OFR until 11/23/2022, two months after discharge. Resident 223 Record review showed Resident 223 was discharged on 11/01/2022. Review of trust records showed the resident had a balance of $600.02, which was not transferred to the OFR as of 12/12/2022. Resident 222 Record review showed Resident 222 was discharged on 07/08/2022. Review of trust records showed the resident had a balance of $440.00, which was not transferred to the OFR as of 12/12/2022. In an interview on 12/12/2022 at 11:14 AM, Staff G (Business Office Manager) stated the accounts were not closed timely and the money should be sent to the OFR within 30 days of a resident's discharge. Staff G stated, as of today, the checks have not been written. Notice of Medicaid Balances Record review of the facility's Trial Balance report showed, as of 12/06/2022, the trust account balance for Resident 38 was 2297.71 dollars and for Resident 2 was 11,165.19. This was over the resource limit beneficiaries could possess. In an interview on 12/12/2022 at 11:14 AM, Staff G stated they had not provided notification to Resident 38 or Resident 2 regarding being over their resource limits. Staff G stated notification was important as the residents are at risk of losing their benefits if they are over the resource limit. REFERENCE: WAC 388-97-0340(4)(5). .

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 9 (Residents 6, 35, 45, 52, 20, 32, 65, 12, & 40) of 18 residents reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed. Findings included . Resident 6 According to the 11/02/2022 Quarterly Minimum Data Set (MDS, an assessment tool) Resident 6 admitted to the facility on [DATE] and was cognitively intact, able to make themselves understood and understood others. Review of Resident 6's record on 11/30/2022 at 1:03 PM, showed no AD documentation. In an interview on 12/01/2022 at 7:48 AM, Resident 6 stated no one from the facility spoke with them about an AD. Resident 6 stated they needed assistance to complete an AD. In an interview on 12/06/2022 at 10:09 AM, Staff L (SSD, Social Service Assistant) stated the admission coordinator completed an AD task at admission, the SSD would discuss the AD in the resident's care conference if it was not initiated at admission. Staff L stated the facility documented an AD in the resident's record. If AD documentation was not in the resident record, then it was not done. In an interview on 12/12/2022 at 11:00 AM, Staff G (Business Office Manager) stated the admission coordinator completed the admission agreement upon admission and offered an AD to the residents or their representatives using the form in the admissions packet. Staff G reviewed Resident 6's admission agreement papers and confirmed an AD should have been completed but was not. Residents 35, 45, 52, 20, 32 & 65 Similar findings were identified for Residents 35, 45, 52 and 65 for whom Staff G was unable to locate AD documentation in the resident's admission agreement records, and there was no documentation an AD was offered to these residents. Resident 12 & 40 Similar findings were identified for Resident 12 and 40 who were assessed to require a legal guardian related to cognitive loss. Resident 12 and 40 each had a petition for guardianship on 06/20/2022 and there was no further follow up after 09/22/2022. There was no documentation in the resident record that the residents or the resident's representative were offered assistance with an AD. In an interview on 12/09/2022 at 2:33 PM, Staff B (Director of Nursing) stated the corporate staff who submitted the guardianship application no longer worked for the company. Staff B stated the SSD facility staff who followed up also does not work for the facility any longer. Staff B stated follow up should have been ongoing through changes in staff. Staff B provided documentation that no follow up occurred after 09/22/2022. Staff B verified there was no documentation found in the record regarding guardianship follow up after 09/22/2022. REFERENCE: WAC 388-97-0280(3)(a-c),(i-ii). .

CONCERN (E)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to provide timely notice, in writing, of changes in payment status and potential charges for services not covered by Medicare/Medicaid for 2 of 3 (Residents 27 & 371)residents reviewed for Advanced Beneficiary Notices (ABN, a notification of costs when services provided may not be paid by Medicare) and assist residents or their representatives to understand these notices or assist with the appeal process placed residents at risk for insufficient information to make informed decisions about care and finances. Findings included . Resident 27 On 05/21/2022 Resident 27 began skilled nursing/therapy services under their Medicare A benefit. Resident 27 was issued a Notice of Medicare Non-Coverage (NOMNC) on 06/15/2022 showing their last day of Medicare A coverage was 06/17/2022. In a 12/07/2022 10:30 AM interview, Staff G (Business Office Manager) stated Resident 27 should have been issued the federally required ABN because they no longer qualified for skilled nursing services under their Medicare A benefit and continued to reside at the facility. Staff G was not able to locate the ABN document and stated staff should have but did not issue the required ABN to Resident 27. Resident 371 Resident 371 began skilled nursing/therapy services under their Medicare A benefit on 06/16/2022. The 07/26/2022 NOMNC showed Resident 371's last covered day under their Medicare A benefit was 07/27/2022. The NOMNC was electronically signed on 07/27/2022, less than 48 hours from the required 48-hour timeframe for issuance of a NOMNC. In a 12/07/2022 10:30 AM interview, Staff G stated the NOMNC was not issued timely. Staff G stated no signed ABN was found in the record for Resident 371. Staff G could not confirm that an ABN was issued as required. REFERENCE: WAC 388-97-0300(1)(e)(5)(6). .

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a clean, comfortable, homelike environment for 4 of 4 Wings (Wings A, B, C & D) reviewed. Facility failure to ensure a sufficient supply of linens in adequate condition, hallways were clean and homelike, resident rooms were free of wall gouges and damaged furniture, hand sanitizer dispensers were intact, call lights were within reach, clocks in resident rooms were accurate, and Blood Pressure cuffs were kept clean left residents at risk for a diminished quality of life and a less than homelike environment. Findings included . Linens On 11/30/2022 at 8:53 AM Staff Y (CNA, Certified Nursing Assistant) reported to surveyors that the facility did not have an adequate supply of fitted sheets. Staff Y stated the CNAs told the facility about it for months. Observation on 11/30/2022 from 8:56 AM to 9:01 AM showed the linen cart in Wing D had four flat sheets and some pillowcases but no other bed sheets, the linen cart in the hallway in Wing A had no bed sheets of any kind available, the linen cart in Wing B had no bed sheets, and the linen cart in Wing C had over 20 pillowcases and no other bed sheets. In an interview on 11/30/2022 at 9:16 AM Staff LL (Laundry Assistant) stated the facility was short on flat and fitted sheets. On 11/30/22 at 8:10 AM, Resident 21 was observed lying on an uncovered mattress with no bottom sheet. On 11/30/2022 at 9:45 AM, Resident 22 was observed to be lying on a bare mattress with no sheet. On 11/30/2022 at 11:07 AM Resident 28 was observed to be lying on a bare mattress with no sheet. On 12/01/2022 at 9:56 AM Resident 8 was observed lying on a bare mattress without a sheet. On 12/02/2022 at 11:06 AM Resident 55 was observed in room [ROOM NUMBER] lying on a bare mattress. The following observations were made of residents lying on beds with flat sheets instead of fitted sheets: on 12/06/2022 at 10:03 AM in room [ROOM NUMBER]; on 12/06/2022 at 10:04 AM in room [ROOM NUMBER], both residents had flat sheets on their mattresses and the sheet on the window bed was threadbare in two areas over 5 inches in length; on 12/06/2022 at 10:14 AM both beds in room [ROOM NUMBER] had flat sheets on both beds; on 12/06/2022 at 10:17 AM a resident was observed lying on a mattress with a flat sheet; on 12/06/2022 at 10:19 AM a resident was in bed with a flat sheet on the mattress; on 12/06/2022 at 10:32 AM a resident was observed in room [ROOM NUMBER] lying in bed with a flat sheet on their mattress In an interview on 12/12/2022 at 3:46 PM, Staff A confirmed residents should have fitted sheets in good repair on the bed for comfort, dignity, and safety. In an interview on 12/05/2022 at 12:11 PM Staff MM (Laundry Assistant) stated the facility did not have an adequate supply of fitted sheets. Observation on 12/06/2022 at 9:26 AM showed Staff Y trying to find bed linens from the linen cart. Staff Y was unable to find the linens they required. In an interview on 12/08/2022 at 10:45 AM Staff Y stated the supply of linens showed no improvement and was the same for over a year. Staff Y stated having an available supply of linens was important for CNAs to perform their responsibilities. In an interview on 12/05/2022 at 11:20 AM, Staff A (Administrator) stated Staff I (Maintenance Assistant) was the person responsible for ordering linens. Review of the linens purchase order showed from 10/5/2022 through 11/29/2022 showed the facility had purchased a total of 48 extra wide fitted sheets and 36 regular fitted sheets. Hallway Fans and Trim Observation on 12/01/2022 at 11:50 AM showed a fan installed in a window at the end of the East Hall, next to Emergency Exit 2. The fan was attached to the window at eye level with two layers of plastic paneling that were not flush and were attached crookedly. The panels were screwed to the frame using unfinished wood. The screws used to attach the panels were not screwed in flush. Plexiglass was used to cover the horizontal window panels and was also attached to the unfinished wood. There was a layer of dust and cobwebs on the plexiglass, in the corners of the window, and on the fan. The fan had two hinged legs attached that indicated it was intended as a standing fan, not a window fan. Observation of the window to the right of Emergency Exit 3 on at 12/01/2022 at 11:52 AM showed a square, white, plastic panel was installed at eye level. The panel had one-foot diameter white tubing that dangled from the window to the floor. The square, white, plastic panel was attached to a secondary white panel with two black screws that were not flush, and mounted on unfinished wood, screwed to the window frame. There was a layer of dust in and around the window. Observation on 12/02/2022 at 10:49 AM showed a fan mounted high on wall outside room [ROOM NUMBER] encrusted with a thick layer of dust on the blades. In an interview on 12/02/2022 at 10:50 AM Staff C (Resident Care Manager) stated the fans were used to cool the hall in the summer. Staff C stated they couldn't begin to tell when the last time the fans were cleaned. In an interview on 12/12/2022 at 10:03 AM Staff H stated the windows near the Emergency Exits 2 and 3 were dirty, and unkempt. Resident Rooms The following observations were made in resident rooms: On 11/30/2022, a large triangular hole was noted at the bottom of the closet in room [ROOM NUMBER]; On 11/30/22 at 8:20 AM the night stand for bed 3 was noted with broken drawer and the walls was noted to have significant wall gouges in room [ROOM NUMBER]; On 11/30/2022 at 8:49 AM torn wallpaper was observed behind bed 1 in room [ROOM NUMBER]; On 11/30/2022 at 9:31 AM foot long wall gouges were noted behind bed 2; On 12/01/2022 at 10:48 AM similar wall gouges were noted in room [ROOM NUMBER] behind bed 1; On 12/06/2022 at 9:21 AM the light chain over Bed 2 in room [ROOM NUMBER] was observed to be too short for the resident to use. During environmental rounds on 12/12/2022 at 10:37 AM, Staff H took note of the concerns with resident rooms and stated they would be addressed. Hand Sanitizer Dispensers On 12/01/2022 at 10:19 AM the hand sanitizer dispenser by room [ROOM NUMBER] was observed not to be working. On 12/01/22 at 11:55 AM, the hand sanitizer dispenser outside was observed to be removed outside room [ROOM NUMBER], leaving a mark on the wall. Call Lights Observations on 11/30/2022 at 1:06 PM, on 12/01/2022 at 10:34 AM, on 12/01/2022 at 12:11 PM, on 12/06/2022 at 8:23 AM, and on 12/08/2022 at 2:32 PM showed Resident 6's call light was inaccessible to them, either on the floor, or on a table beyond their reach. In an observation and interview on 12/08/2022 at 2:33 PM, Staff D (Registered Nurse, Unit Manager) confirmed the call light was on the floor. Staff D stated the light should be but was not reachable at that time. Wall Clocks On 12/05/2022 at 11:23 AM the wall clock in room [ROOM NUMBER]-1 showed a time of 5:32. On 12/07/2022 at 8:32 AM the wall clock in room [ROOM NUMBER] showed a time of 11:25. During environmental rounds on 12/12/2022 at 10:37 AM, Staff H stated the clocks should be accurate and stated they would fix them. Blood Pressure Cuffs In an interview on 12/06/2022 at 9:12 AM, Resident 45 stated they were concerned the facility's blood pressure cuffs did not fasten well because the Velcro was matted with hair. Resident 45 stated they were concerned whether their Blood Pressure measurements were accurate as the cuffs did not fasten well. Observation on 12/06/2022 at 9:40 AM showed a layer of hair enmeshed in the cuff's Velcro and the fabric of the cuff was frayed. The layer of hair and fraying fabric prevented the cuff from staying attached as required. Two other cuffs were noted in similar condition. Refer to F835 Administration. REFERENCE: WAC 399-97-0880. .

CONCERN (E)

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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to implement a system to ensure resident concerns were identified and addressed timely and the outcome communicated to residents, including concerns brought up during Resident Council meetings. Facility failure to identify, address timely, and provide residents with the outcome of the grievance investigation left residents at risk for unresolved concerns, feeling unheard, frustrated, diminished self-worth and decreased quality of life. Findings included . On 12/07/2022 at 12:58 PM, Staff M (Life Enrichment Director) provided all available Resident Council Meeting Minutes from the last 6 months. Meeting minutes were provided for meetings on 10/25/2022 and 11/16/2022. Staff M stated they were unable to provide any other meeting minutes, the two sets of Minutes provided were the only ones available. Staff M stated they held the position of Life Enrichment Director since 10/04/2022 and did not know if/where their predecessor stored meeting minutes. Staff M stated their predecessor didn't leave me any records. Staff M stated they reached out but couldn't make contact to establish where the previous records were kept, if anywhere. Staff M stated they would provide previous months' Life Enrichment calendars which should include the dates of any Resident Council Meetings. Review of the Life Enrichment Calendars from July 2022 through December 2022 provided by Staff M showed the Resident Council met on 9/20/2022 at 2:30 PM and was scheduled to meet on 12/14/2022. The calendars showed no evidence the Resident Council met in July or August 2022. Staff M stated they expected their predecessor to keep and file the previous Resident Council Meeting Minutes, but it appeared they did not. The 10/25/2022 Resident Council Minutes identified seven residents by name who attended the meeting. The Minutes included an Old Business section that listed the following past resident concerns: the building was too cold, and residents wanted to be able to use headphones when they watched television. The meeting minutes did not make clear which residents shared which concerns, what if anything facility staff did to fix the concerns, or whether residents were satisfied with the outcome. Under New Business, the 10/25/2022 Minutes identified the following concerns: the building was too cold, residents suggested quiet hours after 10:30 PM, resident wanted to be able to use headphones when they watched television, residents were not happy with the TV service and wanted to switch back to the former provider, and residents felt staff spoke too loudly at night. Under Nursing, the Minutes identified resident concerns with sugar being served to residents with diabetes, and call light wait times were too long. Under Housekeeping, the Minutes identified resident concerns with the timing of floor cleaning. Under Dietary, the Minutes identified resident concerns with staff rushing when serving meals, residents receiving foods they did not like or that was too cold, and the menu was repetitive. According to the Minutes, Staff EE (Dietary Manager) attended the meeting and informed the residents in attendance they intended to meet individually with residents to address dislikes, and was working to change the menu up and have an alternate menu available. Under Maintenance, residents identified concerns with clocks around the building being set to the wrong time. The 10/25/2022 Resident Council Minutes did not identify which residents had which concerns. The 11/16/2022 Resident Council Minutes identified four residents by name who attended the meeting. The Minutes included an Old Business section that listed the following past resident concerns: the building was too cold, residents suggested quiet hours after 10:30 PM, resident wanted to be able to use headphones when they watched television, residents were not happy with the television service and wanted to switch back to the former provider, and residents felt staff spoke too loudly at night. The meeting minutes did not make clear which residents shared which concerns, what if anything facility staff did to fix the concerns, whether residents were satisfied with the outcome. The New Business section of the 11/16/2022 Resident Council Minutes included concerns the building was now warmer, staff were no longer having loud conversations outside resident rooms, and residents wished to change television provider. The Minutes did not indicate if residents were satisfied with, or agreed with these outcomes, or whether the residents who identified the concern the previous month were in attendance that month (and if not, how they were informed). The Nursing section of the 11/16/2022 Resident Council Minutes included concerns that floor staff can be loud first thing in the morning contradicting the earlier claim that staff noise was addressed, and ongoing dissatisfaction with call light waiting times. The Housekeeping section included no concerns. The Maintenance section included a request for more snack options. The Maintenance section included the same concern from October 2022 that clocks around the building were set to the wrong time, and would like the Garden Room cleared out so they could use it. The Minutes did not indicate which residents shared which concerns. Review of the October 2022 and November 2022 Grievance Logs showed no indication the resident concerns identified during the 10/25/2022 and 11/16/2022 Resident Council Meetings were processed as grievances. From 10/26/2022 through 12/07/2022 only one new grievance of any kind was logged facility wide on 11/13/2022. This grievance pertained to missing property and was not related to concerns raised at Resident Council. In an interview on 12/09/2022 at 11:14 AM, Staff M stated some matters raised at Resident Council were handled informally and others referred to the correct department for handling. Staff M stated Staff A (Administrator) received a copy of the minutes, but they were unsure if Staff A was the facility's grievance officer. Staff M stated they did not process any of the concerns raised in the October 2022 Resident Council Meeting as a grievance including resident concerns with the choice of television channels but asked Staff I (Maintenance Assistant) about changing back to the old television provider. Staff I stated to Staff M it was not possible. Staff M stated there was no way to establish from the minutes which residents had which concerns. Staff M stated no concerns from the November 2022 Resident Council Meeting were processed as Grievances. Staff M stated they could not locate Resident Council Meeting Minutes from May 2022 through September 2022. In an interview on 12/09/2022 at 11:38 AM, Staff A stated L (Social Services Assistant) was the grievance officer. A copy of a sample of three grievances from the Grievance Log was requested from the facility: the 11/13/2022 missing property grievance, a 09/30/2022 grievance regarding missing medication, and an 08/08/2022 grievance related to call lights, cold food and other dietary issues. In an interview on 12/09/2022 at 1:59 PM, Staff L stated they were only the Grievance Officer since 12/01/2022 after the former Social Services Director (SSD) left on 11/30/2022. Staff L stated they assisted the SSD with grievances but were unsure how grievances should be processed in total as they did not complete the process by themselves. REFERENCE: WAC 388-97-0460. .

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 27 On 11/30/2022 at 11:14 AM, Resident 27 stated they had trouble hearing in both ears. Resident 27 stated staff provided them with hearing aids. Resident 27 stated they kept the hearing aids in a box located on the bookshelf across from the bed and they preferred not to wear them since they stick out. According to the 08/18/2022 Significant Change MDS, no hearing aids or other hearing appliance were used when completing Resident 27's hearing assessment. The 03/29/2022 revised communication CP showed a goal of care for Resident 27 was to improve their hearing with the use of hearing aids. The CP intervention directed staff to ensure Resident 27 wore hearing aids on both ears. In an interview on 12/09/2022 at 1:03 PM, Staff NN acknowledged they should have validated the presence of Resident 27's hearing aids and used them during the hearing assessment, but did not. Staff NN stated the MDS assessment was inaccurate. Resident 49 According to the 11/17/2022 admission MDS, Resident 49 received an antibiotic during the assessment period. Record review of Resident 49's November 2022 Medication Administration Record (MAR) did not show any antibiotic use. In an interview on 12/09/2022 at 1:03 PM. Staff NN stated Resident 49 did not take any antibiotic during the assessment period. Staff NN stated the admission MDS was inaccurate. REFERENCE: WAC 388-97-1000 (1)(b). Resident 6 According to the 11/02/2022 Quarterly MDS Resident 6 admitted to the facility on [DATE] and was cognitively intact. This MDS showed Resident 6 had no broken or missing teeth, and no weight loss in last quarter. Resident 6's weight record showed Resident 6 lost more than five percent weight in 30 days. Resident 6's weight on 10/05/2022 was 270.3 pounds (lbs) and on 10/30/2022 was 250 lbs (down 20 lbs in 25 days). Observations on 11/30/2022 at 11:04 AM and on 12/05/2022 at 10:25 AM, showed Resident 6 had a front broken tooth and multiple missing teeth. Resident 6 stated they had been broken tooth for a while. In an interview on 12/6/2022 at 11:22 AM, Staff C stated the MDS was incorrect as Resident 6 had broken and missing teeth and experienced a significant weight loss. Resident 55 According to a 11/18/2022 Quarterly MDS, Resident 55 had clear speech, was understood, and able to understand others. The MDS showed Resident 55 had no dental concerns. In an interview on 12/01/2022 at 10:22 AM, Resident 55 stated they only had two lower teeth. In an observation at this time, the resident opened their mouth, moved their two teeth back and forth, and stated look at this. Review of a 05/13/2022 Care Plan (CP) showed Resident 55 had an oral/dental health problem related to having no teeth or dentures. Review of a 11/02/2022 dental consult showed Resident 55 had active an dental disease and the two remaining teeth were very loose. In an interview on 12/12/2022 at 8:16 AM, Staff C (Licensed Practical Nurse, LPN Unit Manager) stated if a resident had dental concerns, they should be coded accurately on the MDS so the CP and follow up can be addressed. Resident 51 According to the 10/06/2022 admission MDS, Resident 51 was cognitively intact with clear speech, was understood, and able to understand others. The MDS showed staff assessed Resident 51 with no dental concerns. In an interview and observation on 12/02/2022 at 10:49 AM, Resident 51 stated they had broken teeth. Resident 51 opened their mouth and showed a broken tooth to the upper left side and a broken tooth to the lower ride side of mouth. In an interview on 12/12/2022 at 2:00 PM, Resident 51 stated they had the broken teeth for years. In an interview on 12/09/2022 at 1:03 PM, Staff NN (MDS Specialist, LPN) stated the MDS was inaccurate and should have identified the broken teeth. Based on observation, interview, and record review the facility failed to ensure Minimum Data Sets (MDS - an assessment tool) were complete and accurate for 6 of 20 (Residents 35, 55, 51, 6, 27, & 49) sample residents reviewed. Facility failure to complete accurate MDS assessments prevented the facility from transmitting accurate information to the Centers for Medicare and Medicaid Services (CMS) for facility quality ratings, and left residents at risk for unidentified and/or unmet needs. Findings included . Resident 35 According to the 10/31/2022 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 35 had diagnoses including debility (physical weakness), respiratory failure, and malnutrition. The MDS showed Resident 35 had no falls while a resident of the facility. According to the 09/16/2022 progress notes, Resident 35 was found on the floor of their room after a fall at 10:00 AM on 09/16/2022. Resident 35 was noted to have a 3 x 3 inch hematoma (build up of blood under the skin secondary to trauma) on their forehead. In an interview on 12/07/2022 at 10:33 AM, Resident 35 stated they recalled falling in the facility. In an interview on 12/09/2022 at 2:33 PM, Staff B (Director of Nursing) confirmed the MDS was inaccurate and the fall with injury was not, but should be, included on the MDS.

CONCERN (E)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 32 The 10/19/2022 Annual MDS showed Resident 32 admitted to the facility on [DATE] from another skilled nursing facility. The MDS showed Resident 32 had a PASSR Level 2 completed. Record review showed a PASRR Level 2 dated 05/31/2019 prior to admission to a previous skilled nursing facility. Review of Resident 32's CP showed no interventions identified by the Level 2 PASRR evaluator were implemented. Resident 18 According to a corrected 05/23/2022 PASRR completed by Staff L (Social Services Assistant), Resident 18 had diagnoses of schizophrenia, mood disorder, anxiety, and evidence of serious functional limitations during the previous six months related to a serious mental illness. PASRR Section IV showed a Level 2 evaluation referral was required. There was no Level 2 evaluation found in Resident 18's record. On 12/06/2022 at 2:15 PM Staff L provided a 05/31/2022 social services progress note that showed a PASRR Level 2 evaluation referral was made. Staff L said they did not follow up to see if the Level 2 evaluation was completed. In an interview on 12/12/2022 at 3:13 PM, Staff L stated Level 2 evaluation referrals should be obtained timely with recommendations implemented and incorporated into the resident's CP so staff know how to provide day to day care when a resident is affected by mental health illness. REFERENCE WAC: 388-97-1915(4). Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained, and/or implemented and incorporated into the Care Plan (CP) for 2 of 5 (Residents 55 and 32) residents and 1 supplemental resident (Resident 18) reviewed for PASRR. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . Resident 55 According to a Quarterly Minimum Data Set (MDS - an assessment tool), Resident 55 had medically complex diagnoses including depression and required the use of an antidepressant medication. Review of Resident 55's records revealed a 05/31/2022 Level 1 PASRR completed by facility staff that identified the resident with a serious mental illness indicator of depression. Staff identified Resident 55 required a Level 2 evaluation referral for the serious mental illness diagnosis. Record review showed a social services progress note on 06/02/2022 at 11:32 AM that identified a plan to update Resident 55's Level 1 PASRR screen and request a Level 2 evaluation based on depression with secondary diagnosis of dementia. No further documentation was found in Resident 55's records of a Level 2 evaluation being obtained or implemented into the resident's CP.

CONCERN (E)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 3 of 5 (Resident 51, 34, and 49) residents and 1 supplemental (Resident 18) resident reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . According to an undated facility MI [mental illness]/MR [developmental disability] Preadmission Screening policy, staff were to determine if a new resident had a Level 1 screen, directed staff to review the Level 1 screen, at least quarterly, ensure the Level 1 screen was filed in the resident's record, and accurately reflected the resident's current status. This policy stated the state mental health authority, as applicable, upon admission, annually, promptly after a significant change in mental or physical condition of a resident who had a mental disorder for resident review, or upon learning of an MI/MR diagnosis which was previously unknown. Resident 51 According to the 10/06/2022 admission Minimum Data Set (MDS, an assessment tool), Resident 51 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication. Review of Resident 51's records revealed a 09/28/2022 Level 1 PASRR that was incomplete. This form had sections one through three blank and did not identify that Resident 51 had a diagnosis of depression. Resident 34 According to a 09/14/2022 Quarterly MDS, Resident 34 had multiple medically complex diagnoses including dementia and bipolar disorder (a mental health condition that causes extreme mood swings) and required the use of psychotropic medications. Review of Resident 34's records revealed an 11/04/2021 Level 1 PASRR that identified Resident 34 with a bipolar disorder. This PASRR did not identify Resident 34 also had diagnoses that included hallucinations and anxiety according to the resident's records. Staff failed to ensure Resident 51 had an accurate Level 1 PASRR completed in their resident records. Resident 49 According to the 11/17/2022 admission MDS, Resident 49 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication. Review of Resident 49's December 2022 physician order summary showed an order for an antianxiety medication dated 11/10/2022 for a diagnosis of anxiety. Review of Resident 49's records showed an 11/10/2022 Level 1 PASRR that was inaccurate. The form did not identify the presence of Resident 49's mental illness diagnoses of depression and anxiety. In an interview on 12/12/2022 at 3:13 PM, Staff L (Social Services Assistant) stated timely and accurate Level 1 PASRRs are important to know if a resident required a Level 2 assessment and to know how mental health can affect day to day care. Staff L confirmed Resident 51, Resident 34, and Resident 49's Level 1 PASRR should have, but did not accurately reflect the resident's mental health condition. REFERENCE: WAC 388-97-1915(1)(2)(a-c). .

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 22 According to a 10/27/2022 Quarterly MDS, Resident 22 was assessed to have impaired memory, multiple medically complex conditions, lack of bladder control, and was at risk for developing pressure injuries. Resident 22 had no rejection of care. Observations on 11/30/2022 at 9:45 AM, 12/02/2022 at 10:14 AM, and 12/05/2022 at 9:42 AM, showed Resident 22 lying in bed, on their back. An observation on 12/08/2022 at 11:26 AM, showed Resident 22 receiving a bed bath. At that time, Resident 22 was noted to have a suprapubic catheter (a tube surgically placed in the belly to drain urine from the bladder). Record review of an 11/07/2022 physician's note showed Resident 22 had a partial thickness (loss of some skin) pressure ulcer to their tailbone. The physician's note indicated staff were to off-load pressure from the tailbone every two hours as tolerated by Resident 22. Review of the active Potential for Pressure Ulcer CP dated 01/07/2020, showed no goals or interventions related to Resident 22's current pressure ulcers. The CP did not identify Resident 22 had current pressure ulcers. Review of Resident 22's [NAME] (a tool directing staff on the type of care a resident needs) did not identify Resident 22's pressure ulcers. It did not direct staff to off-load pressure from Resident 22's tailbone every two hours as indicated by the physician. Review of Resident 22's bladder CP dated 05/07/2020, directed staff on the care of Resident 22's urethral catheter (a tube inserted into the urethra to drain urine from the bladder and does not require surgical placement). The CP did not address Resident 22's current suprapubic catheter. In an interview on 12/12/2022 at 11:20 AM, Staff C (LPN - Licensed Practical Nurse, Unit Manager) stated Resident 22 obtained the wounds during a recent hospitalization. Staff C stated pressure ulcers and wounds should be care planned so staff know what care to provide. Staff C verified Resident 22 had a suprapubic catheter and the CP should match the appliance Resident 22 currently had. REFERENCE: WAC 388-97-1020(5)(b) Resident 42 The 09/12/2022 modified admission MDS showed Resident 42 had no cognitive deficits and diagnoses including multiple falls, fracture related to falls, and had experienced 2 or more falls after admission to the facility. Review of the revised 09/26/2022 CP directed the staff to make sure the call light was within reach, encourage the resident to use the call light, proper non-skid footwear, provide safe environment, increase supervision, and refer to therapy as needed. The CP failed to include person-centered interventions to address the resident's fall history with fractures, care needs, and was not updated with new interventions after the first two falls sustained after they admitted . Review of the facility Reporting log showed Resident 45 had fallen a total of 10 times since admission. Review of the facility Incident Reports showed the facility consistently failed to update the resident's care plan with new fall interventions to prevent further falls. Review of the most recent 09/26/2022 CP showed only one fall intervention CP update. In an interview on 12/12/2022 at 1:30 PM interview Staff B confirmed the care plan was not updated to address new careplan interventions to prevent falls or address the resident's identified blood pressure concerns and change in cognition and orientation, but should of been. Resident 6 According to the 11/02/2022 Quarterly Minimum Data Set (MDS-an assessment tool) Resident 6 admitted to the facility on [DATE] and was cognitively intact, able to be understood and understand conversation. This assessment indicated Resident 6 had no broken or missing teeth and no weight loss in last quarter. Observations on 11/30/2022 at 11:04 AM and on 12/05/2022 at 10:25 AM showed Resident 6 had broken and missing teeth. Resident 6 was also observed eating meals in their bed. Resident 6 stated they had broken teeth for a while and had no problem eating their meals after tray set up. Review of Resident 6's record showed no care plans (CP) about Resident 6 missing teeth or losing weight. According to a 07/27/2022 Activities of Daily Living (ADL) CP, staff interventions included totally dependent on staff for eating. In an interview on 12/05/2022 at 1:23 PM, Staff C stated Resident 6 was able to eat meals by themselves after tray set up. Staff C stated the care plans should have been revised but was not. According to a 07/27/2022 CP Resident receiving IV antibiotics for Sepsis (body's response to an infection), had a PICC line (a thin tube inserted into the vein to give intravenous medicine or fluids) in left arm. Review of Resident 6's record showed no physician order for any intravenous antibiotic medication. Observation on 12/02/2022 at 10:23 AM showed no PICC line in Resident 6's left or right arm. In an interview on 12/06/2022 at 1:23 PM, Staff C stated the CP was not accurate, and it should be updated. In an interview on 12/09/2022 at 3:08 PM, Staff B (Director of Nursing) confirmed multiple CPs were not updated but they should be updated on time. Resident 52 According to the 11/08/2022 Quarterly MDS Resident 52 readmitted to the facility on [DATE], was assessed as cognitively intact, and had diagnoses including stroke with right side weakness, seizure, anxiety, and depression. This assessment identified it was very important for Resident 52 to participate in religious activities and go outside in the fresh air. Review of Resident 52's record showed an activity evaluation completed on 06/21/2022. This evaluation indicated activities that were very important to Resident 52. In an interview on 12/05/2022 at 1:02 PM, Resident 52 stated they wanted to participate in activities in their room. A review of Resident 52's comprehensive CP showed no CP was developed indicating activities of Resident 52's interest. According to a 06/28/2022 ADL CP, staff interventions included required 1:1 feeding and get resident out of bed for all meals. Observations on 11/30/2022 at 12:23 PM, 12/01/2022 at 8:07 AM, 12/02/2022 at 11:45 AM, and 12/07/2022 at 8:03 AM showed Resident 52 was eating their meals in their bed without assistance. In an interview on 12/05/2022 at 11:23 AM, Resident 52 stated they did not need help with feeding. In an interview on 12/09/2022 at 3:08 PM, Staff B confirmed multiple care plans were not updated and they should have been updated on time. Resident 65 According to the 11/02/2022 admission MDS Resident 65 readmitted to the facility on [DATE], was assessed cognitively intact, and had medically complex diagnoses including Bullous Pemphigoid (a skin condition causing large fluid filled blisters), asthma and diabetes. The 10/27/2022 Skin Concern CP showed location (SPECIFY) and Goal included Areas of concern will resolve (SPECIFY). Another 10/27/2022 Resident Preferences CP showed interventions included bathing preferences (SPECIFY: morning or evening), go to bed (SPECIFY: time), wake up at (SPECIFY). In an interview on 12/06/2022 at 1:23 PM, Staff C confirmed there were multiple CPs with issues, goals and interventions which included (SPECIFY) that should be updated, and individualized but were not. In an interview on 12/09/2022 at 3:08 PM, Staff B confirmed multiple CPs were not but should be updated on time. Resident 51 Review of Resident 51's Physician Orders showed a 10/05/2022 order for a regular diet. Review of Resident 51's 09/28/2022 nutrition CP showed interventions that directed staff to provide diet as ordered and identified the resident's diet as carbohydrate controlled, with no added salt. Review of a 10/18/2022 alteration in neurological status CP showed Resident 51 had a persistent vegetative state with no detectable consciousness. This CP had a goal to maintain quality of life within limitations imposed by their neurological deficits. In an interview on 12/12/2022 at 8:16 AM, Staff C (Licensed Practical Nurse - Unit Manager) stated the nutritional CP for Resident 51 needed to be revised. Staff C stated they were unsure why the CP regarding Resident 51's neurological status was in place and confirmed the resident was cognitively intact with clear speech, able to understand others, and be understood. Resident 34 Review of Resident 34's 08/11/2022 COVID-19 CP showed the resident had tested positive for COVID-19 on 08/11/2022 and gave directions to staff to implement precautions as indicated. Review of an 08/22/2022 progress note showed staff documented Resident 34 had completed their 10-day isolation and the resident would be removed from precautions at that time. In an interview on 12/12/2022 at 8:16 AM, Staff C stated Resident 34's CP needed to be updated and revised. Resident 55 Review of Resident 55's 08/11/2022 COVID-19 CP showed the resident had tested positive for COVID-19 on 08/11/2022 and gave directions to staff to implement precautions as indicated. Review of an 08/22/2022 progress note showed staff documented Resident 34 had completed their 10-day isolation and the resident would be removed from precautions at that time. Review of a 05/13/2022 pain CP showed Resident 55 had chronic pain as described or exhibited by, there was no further information provided as to why the resident had chronic pain. In an interview on 12/12/2022 at 8:16 AM, Staff C stated their expectation was that resident CPs should be updated and revised with changes to reflect the current resident conditions. Staff C stated Resident 55's CP needed to be updated and revised. Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were revised and implemented for 9 (Residents 35, 51, 34, 55, 42, 6, 52, 65, & 22) of 20 sample residents reviewed. The failure to include residents and/or their resident representatives participation in the CP process prevented residents from exercizing their rights in developing person-centered care plans and deterred the facility from providing individualized resident informaiton to staff caring for residents placing residents at risk for unmet needs, feeling institutionalized, depersonalization, and diminished quality of life. Findings included . Facility Policy According to an undated Care Plans facility policy, the facility was to review and revise care plans. The care plans were written to be consistent with the services provided. The policy identified care plans were not only driven by resident issues or conditions but also by their unique characteristics, strengths, and needs. The facility was to re-evaluate the resident's status at prescribed intervals and modify the individualized care plan as appropriate and necessary. Resident 35 According to the 10/31/2022 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 35 had diagnoses including debility (physical weakness), bipolar disorder, Post Traumatic Stress Disorder (PTSD), and a nightmare disorder. According to progress notes, Resident 35 had an unwitnessed fall with injury on 09/16/2022. The fall caused a 3 x 3 inch hematoma on Resident 35's forehead. Resident 35's comprehensive CP included a revised 05/03/2022 high risk for falls CP. The CP included a 05/03/2022 intervention for floor mats to be placed on both sides of Resident 35's bed to reduce the risk of injury from a fall., and a 05/03/2022 intervention for a perimeter mattress for safety. The CP did not reflect Resident 35's 09/16/2022 unwitnessed fall with injury. Observations on 12/05/2022 at 12:02 PM and on 12/06/2022 at 1:53 PM and 3:31 PM showed no fall mats in place by Resident 35's bed. In an interview on 12/07/2022 at 10:33 AM Resident 35 stated they did not recall fall mats being placed on both sides of their bed. In an interview on 12/08/2022 at 3:09 PM Staff C (Licensed Practical Nurse - LPN/Unit Manager) stated the CP should have been revised to reflect the 09/16/2022 fall. Staff C stated new interventions should be implemented after a fall. Staff C stated the facility no longer utilized fall mats after a previous Administrator discontinued their use facility wide, and the Fall CP required revision. Record review showed a 09/18/2022 intervention for Bolsters to mattress added to Resident 35's revised 05/03/2022 Edentulous (Lacking Teeth) CP. Resident 35's [NAME] (a set of care instructions for Aides generated from the CP) did not include the bolsters and included an intervention for floor mats to reduce the risk of injury should a fall occur. Resident 35's comprehensive CP included a revised 05/10/2022 CP for a antihypertensive (blood pressure reducing medication) used to treat nightmares, and a revised 05/10/2022 for a hypnotic medication prescribed as a sleep aid related to Resident 35's PTSD and nightmares. Record review showed Resident 35 had no current orders for the antihypertensive medication or the hypnotic medication. Both medications were discontinued on 09/15/2022. In an interview on 12/08/2022 at 3:14 PM Staff C stated that both medications were discontinued, and the CP needed revision to reflect the medication changes.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 41 According to a 06/2022 Respiratory Practice Manual facility policy, the facility required a physician's order be obtained prior to the administration of oxygen. The orders were to include how much oxygen was to be given to the resident and the duration of use. The oxygen tubing was to be placed in a plastic bag, labeled with the date and resident's name when not in use. Tubing was to be changed weekly. According to a 10/15/2022 Quarterly MDS, Resident 41 was assessed to have no memory impairment, diagnoses of heart failure, kidney failure, and respiratory failure. In an observation and interview on 12/01/2022 at 9:46 AM, an oxygen machine and oxygen tubing were observed in Resident 41's room. The oxygen tubing was draped over the resident's bed and not contained in bag. There was no date on the tubing. Resident 41 stated they only used the oxygen at night, and they kept the flow at two liters per minute. In an observation and interview on 12/05/2022 at 11:26 AM, Resident 46's oxygen tubing was draped over the resident's bed. No date was observed on the tubing. Resident 41 stated they were not sure the last time the tubing had been replaced. Similar observations were noted 12/06/2022 at 9:42 AM. A 07/08/2022 Care Plan (CP) indicated Resident 41 was to receive oxygen therapy as ordered by Resident 41's physician. Review of Resident 41's records showed no orders instructing staff the resident required oxygen therapy. The record contained no instructions for the amount or duration of oxygen the Resident 41 was to receive. There were no orders instructing staff to change the oxygen tubing every week as the facility policy indicated. In an interview on 12/08/2022 at 2:44 PM, Staff C stated they expected Resident 41 to have oxygen orders in their record if they are receiving oxygen. Signed for Tasks Not Performed Resident 51 The 10/06/2022 admission MDS showed Resident 51 had multiple medically complex diagnoses including malnutrition, diabetes, and a thyroid disorder. A physician's order was written on 11/16/2022 for staff to obtain lab work for monitoring of Resident 51's diabetes and thyroid disorder. Review of Resident 51's November 2022 MAR showed nursing staff signed the order for lab work was completed on 11/16/2022. Record review showed lab work was not completed in November 2022. In an interview on 12/12/2022 at 8:16 AM, Staff C stated staff should not sign for orders when not competed. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). Resident 6 The 11/02/2022 Quarterly MDS showed Resident 6 was admitted to the facility on [DATE] and had diagnoses including Neurogenic Bladder and Bowel (lack of bladder and bowel control), and Pressure Ulcers (open wounds caused by pressure). This MDS showed Resident 6 had a foley catheter (a tube inserted in the bladder to drain the urine) and required extensive assistance with catheter care. Observations on 11/30/2022 at 9:10 AM, 12/01/2022 at 11:40 AM, 12/02/2022 at 3:12 PM, 12/05/22 at 8:17 AM, and 12/08/2022 at 4:52 PM showed Resident 6 had a foley catheter in bladder continuously. Review of Resident 6's December 2022 Physician Orders (POs) showed no orders related to the foley catheter size, care, when to change the catheter or monitor for functioning. In an interview on 12/09/2022 at 1:01 PM, Staff C stated Resident 6 had the foley catheter in since admission for neurogenic bladder. Staff C stated POs were required to provide any treatment to the residents. Staff C stated they should have received the physician orders for foley catheter size, care and when to change but they did not. Resident 40 The 10/13/2022 Quarterly MDS showed Resident 40 was unable to complete a cognitive assessment, had chronic pain and received medication to treat their pain. The assessment showed Resident 40 was to receive more than 51 percent of their nutrition requirements via tube feeding (a process that carried liquid nutrition through a flexible tube into the body). A 05/19/2022 PO showed Resident 40 was to receive a topical pain gel to their left shoulder and knees every shift. The order did not specify how much of the topical pain gel was to be applied to each area. In an interview on 12/12/2022 at 11:33 AM, Staff F (Infection Control Preventionist) confirmed the PO needed clarification and any nurse administering the gel should have identified the order needed to be clarified. A 07/12/2022 PO for Resident 40 directed the nurse to turn the tube feeding off at 9:00 AM and turn back on at 1:00 PM. An observation on 12/02/2022 at 2:37 PM showed Resident 40 did not have the tube feeding connected and running. In an interview on 12/02/2022 at 2:47 PM, Staff C acknowledged the order to start the tube feeding at 1:00 PM and Resident 40 did not have the tube feeding running. Staff C stated they forgot to turn the tube feeding back on. In an interview on 12/02/2022 at 3:15 PM, Staff B stated nurses are expected to follow PO and the tube feeding should have been started at 1:00 PM and was not. Based on observation, interview, and record review the facility failed to ensure nursing services were provided within professional standards of nursing for 6 of 18 (Residents 45, 51, 34, 6, 40 & 41) residents reviewed. Nursing staff failed to follow physician orders (Resident 45, 51, & 34), clarify physician orders (Residents 45, 51, 6, & 40), and signed for tasks not performed (Residents 51), which placed the residents at risk for medication and treatment errors and adverse outcomes. Findings included . Follow Physician Orders (PO) / Edema Monitoring Resident 45 Professional Standard: According to the American Heart Association, the monitoring of fluid balance status in the management of a resident with heart failure (which usually directly affects the kidney function) is to weight the resident at the same time of the day, everyday. For a weight increase of three pounds in two days or five pounds in a seven days, the nurse should notify the provider of the increase and the resident most recent labs / lab trends, vital signs including oxygen saturation, edema assessment, and symptoms observed (shortness of breath with physical exertion, when lying flat, or at rest), lung sounds, intake and output. The resident lab values should be monitored routinely at frequent intervals. The resident should be under the care of a cardiac and / or kidney specialist if the resident's fluid balance and lab values are not easily stabilized or progressively worsening. The 11/12/2022 5-Day/Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 45 had a diagnosis of heart failure and kidney disease. Resident 45 was assessed as cognitively intact and capable to make decisions about their daily care. Review of Resident 45's physician visit notes showed a 08/23/2021 provider note and the provider referred the resident to a kidney specialist. A 05/03/2022 Physician order (PO) showed Resident 45 was again ordered to be referred to a kidney specialist because the facility failed to get the resident scheduled an appointment between 08/23/2021 and 05/03/2022. Resident 45's record showed they went to the Emergency Department on 07/17/2022, due to worsening fluid balance status and worsening kidney function lab values. The hospital scheduled Resident 45 for an appointment with the kidney specialist for 08/23/2022. Resident 45 was ill on 08/23/2022 and was unable to attend the kidney specialist appointment and the appointment was rescheduled for 10/04/2022. The facility failed to ensure the resident's transportation was established and the resident missed the 10/04/2022 appointment; the appointment was rescheduled for 11/01/2022. Resident 45 was unable to attend the 11/01/2022 appointment because they were in the hospital due to acute respiratory failure and acute kidney injury. The were evaluated by a hospitality kidney specialist to stabilize their condition, and received another referral for Nephrology with an appointment for 11/28/2022. Resident 45's first appointment with the kidney specialist was 11/28/2022, 15 months from the first referral. Review of Resident 45's POs showed orders for daily weights on 07/20/2022, 07/27/2022, and 09/17/2022. order to obtain daily weights. POs dated 08/31/2022 and 09/01/2022 directed staff to weigh daily and notify the provider of weight gain of three pounds in one day or five pounds in seven days. Review of the 07/2022, 08/2022, 09/2022, 10/2022, 11/2022, and 12/2022 Treatment Administration Records (TAR) and weight logs showed daily weights were not documented for Resident 45. According to the facility 12/2022 Edema Monitoring policy, residents with edema are monitored weekly, by measuring the grade of pitting of the affected area and documented on the TAR. Review of Resident 45's TARs for 07/2022, 08/2022, 09/2022, 10/2022, 11/2022, and 12/2022 showed no edema monitoring was assessed or monitored. In an interview 12/12/2022 at 1:30 PM, Staff B (Director of Nursing) stated the facility monitors edema and document the findings on the TAR. Staff B stated staff is expected to monitor edema according to the PO or at least weekly. Staff B said the resident should have been weighed daily after the provider ordered daily weights. Staff B looked in the resident's record and confirmed there was no edema monitoring or daily weights completed or documented. Staff B stated Resident 45 should have followed up with the kidney specialist within a month of the first referral, dependent on the availability of the specialist. Staff B confirmed 15 months to finally see a specialist was not acceptable timeframe, and the resident should have been seen as soon as possible after the first request in August 2021. Resident 51 The 10/06/2022 admission MDS showed Resident 51 had multiple medically complex diagnoses. The MDS showed Resident 51 had a recent history of multiple falls with one fall resulting in a fracture. Review of Resident 51's October 2022 Medication Administration Records (MAR) showed a 10/19/2022 order instructing staff to administer a medication for low Blood Pressure (BP) three times daily and to hold if the resident's systolic (a measure of the pressure in the arteries when the heart beats) BP was greater than 120. According to the October 2022 MAR nursing staff administered this medication on 11 occasions when the BP was greater than 120 and outside of parameters to be administered. The November 2022 MAR showed nursing staff administered this medication on 12 occasions when it should have been held. Review of December 2022 MAR showed nursing staff failed to hold this medication when outside of BP parameters on eight occasions in the first eight days of December. In an interview on 12/12/2022 at 8:16 AM, Staff C (Licensed Practical Nurse, LPN Unit Manager) indicated nursing staff should have followed the POs and held the medications when the BP was outside ordered parameters for Resident 51. Resident 34 According to a 09/14/2022 Quarterly MDS, Resident 34 had multiple medically complex diagnoses including high blood pressure. Review of November and December 2022 MARs showed Resident 34 had an 08/25/2020 order for a high blood pressure medication to be given once daily. This order gave parameters to hold medication if systolic BP was less than 100. No documentation of daily BP monitoring was found on the MARs prior to staff administering the blood pressure medication. In an interview on 12/12/2022 at 8:16 AM, Staff C stated their expectation was for staff to obtain Resident 34's BP prior to the administration of the medication and hold as directed in the order based on results. Staff C confirmed staff should have, but did not obtain Resident 34's BP daily. Clarify Physician Orders (PO) Resident 45 The 06/01/2021 revised Pharmacy Policy titled Peripheral Intravenous (IV, tube into a vein) Catheter showed specific flush orders must be obtained, documented, and submitted to the pharmacy that include the flushing agent, volume to use to flush, and frequency of flushing. An 11/28/2022 PO from the kidney specialist showed Resident 45 was to have an IV access placed for administration of an iron solution. An observation on 12/02/2022 10:00 AM showed Resident 45 had an IV access catheter (tube for intravenous infusion) in their left forearm dated 12/02/22. An observation on 12/08/2022 at 12:19 PM showed the same IV access catheter in place in the left forearm. The dressing was dated 12/4/22 and the dressing was hanging off the arm, not secured. On 12/08/2022 at 12:20 PM, Resident 45 said since the IV had been placed on Friday 12/02/2022, only one nurse had come in to flush the IV and changed the dressing on 12/04/2022, the IV site had not been moved. In an observation and interview on 12/08/2022 at 12:24 PM Resident 45 asked the nurse if they were going to flush the IV to keep it from getting clogged and secure the dressing. When interviewed, Staff Q (Licensed Practical Nurse) said there was no orders for on the TAR for IV maintenance, including flushes to keep open and securing the line to keep clean and prevent dislodgement. Staff Q said it was important to make sure the line was flushed and not clogged, and that the dressing was clean, dry and intact otherwise the resident could get an infection or a clot could be dislodged. Review of Resident 45's POs and December 2022 TAR (Treatment Administration Record) showed no instructions for flushing or maintaining the IV. In a 12/08/2022 12:30 PM interview, Staff Q stated they had not flushed the IV since it was placed and they should have received an order from the physician to flush the IV. In an interview on 12/09/2022 at 2:45 PM, Staff C said the nurses should follow the pharmacy policy for IV management, have orders for flushing the IV that include what to flush the IV with, should have orders when to change the IV site or when to discontinue, and confirmed there were no orders for Resident 45. Resident 51 According to the 10/06/2022 admission MDS, Resident 51 had multiple medically complex diagnoses including fractures and required the use of pain medication. Review of November 2022 MAR showed Resident 51 had two orders for pain medications to be used as needed for pain. The first order was an Over-The-Counter (OTC) medication to be given every six hours as needed for pain and the second order was for a narcotic pain medication to be given every four hours as needed for pain and rib fractures. There were no parameters given to nursing staff to identify which pain medication should be administered when Resident 51 was having pain. According to the November 2022 MAR, no OTC pain medication was administered by staff and the narcotic pain medication was administered 24 times. Each time the narcotic pain medication was administered, staff documented Resident 51's pain level ranged from zero to eight on a scale from zero to ten. In an interview on 12/12/2022 at 8:16 AM, Staff C stated each pain medication should have, but did not have parameters that directed nursing staff on which pain medication to administer. Staff C stated the OTC medication should be given for mild pain from zero to five and the narcotic pain medication for severe pain from six to ten on the pain scale.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement effective discharge planning processes to transition residents to post-discharge care for 2 of 3 (Residents 161 & 69) residents and 1 supplemental resident (Resident 51) reviewed for discharge planning. The failure to identify and plan for the individual discharge needs of each resident placed residents at risk for unmet needs after discharge, lack of medical equipment, distress about plans to go home, unsafe discharge location, and rehospitalization. Findings included . Resident 121 According to the 10/28/2022 admission Minimum Data Set (MDS, an assessment tool) Resident 121 admitted to the facility on [DATE], was cognitively intact, and made their own decisions. Resident 121 had medically complex conditions, including Atrial Fibrillation (A-fib, abnormal heart rhythm), Coronary Artery Disease (damage in the heart's major blood vessels), and Hypertension (high blood pressure). Resident 121 received a blood thinning (anti-coagulant) medication during the assessment period. Review of a 10/28/2022 Social Services Admission/Discharge evaluation showed Resident 121 was projected to stay in the facility three to four weeks and the plan was to discharge home independently with a walker. Review of a Resident 121's 10/21/2022 comprehensive care plan (CP) revealed the facility did not create a discharge care plan with goals and interventions. Review of a 11/17/2022 Nurse Practitioner (NP) telephone encounter note showed the facility staff called the NP about abnormal blood test results regarding Resident 121's blood thinning medications, values elevated indicated blood required extensive time to clot (prolonged bleeding that can be life-threatening). The NP ordered a coagulate medication (assists with blood clotting to stop bleeding) due to Resident 121's ongoing elevated blood test results. The NP directed staff to obtain a blood test on 11/18/2022 and monitor the resident closely for any signs of bleeding or bruising. Review of the 11/17/2022 blood test results showed the results were flagged and the report contained critical results. Review of the November 2022 Medication Administration Record (MAR) showed Resident 121 did not receive the coagulate medicate on 11/17/2022 when the NP ordered the medication. Resident 121 received the coagulate medication on 11/18/2022 at 7:49 AM. A 11/18/2022 NP note showed that Resident 121 received the coagulate medication and directed staff to re-check the blood test on 11/19/2022 and continue to monitor the resident for bleeding. Review of a 11/18/2022 Social Services discharge summary showed Resident 121 discharged from the facility on 11/18/2022 at 2:15 PM with a collateral contact for transportation. Home health services, for healthcare follow up at home, were set up to start on 11/22/2022, 4 days after the resident discharged from the facility. Review of a 11/18/2022 Interdisciplinary resident discharge note showed the facility provided no supporting education to the resident. The note showed Resident 121 required post-discharge treatments including lab tests for blood clotting monitoring. The summary was minimally completed with only three sections filled out; all other areas of the discharge summary were left blank. The form was not signed by Resident 121 or staff confirming that discharge instructions were provided to the resident or allowed the resident the opportunity to ask questions. An 11/18/2022 Nursing progress note showed discharged home with orders and belongings. Review of a 11/19/2022 NP discharge summary note showed that home health was arranged for Resident 121, and they are discharged in fair/stable condition. The NP documented for Resident 121 to obtain the blood test on 11/19/2022 in an outpatient setting and monitor the resident for bleeding. Resident 121 had already discharged from the facility without discharge instructions or the ability to ask questions about follow up medical needs. In an interview on 11/29/2022 at 10:29 AM with Resident 121's collateral contact (CC) stated they picked up the resident from the facility and was not provided any education or information about a medication that could cause bleeding, or information for an appointment for a blood test. The CC stated Resident 122 was having some shortness of breath and the CC decided to take Resident 121 to the emergency room where the resident was admitted for low blood pressure. The CC stated Resident 121 passed away five days being admitted to the hospital. During an interview on 12/6/2022 at 3:17 PM, Staff L (Social Services Assistant) stated Resident 121's discharge plan was to return home and acknowledged there was not a discharge CP in place for the resident. In an interview on 12/06/2022 at 3:27 PM Staff B (Director of Nursing) confirmed the NP placed orders on 11/18/2022 for Resident 121 to have a blood test completed and to monitor the resident for any signs or symptoms of bleeding. When asked who oversaw monitoring Resident 121 for bleeding, Staff B replied staff should have provided education to the Resident and the CC before discharge including signs and symptoms to monitor for bleeding and what to do if symptoms were observed. Staff B stated Resident 121's blood tests were unstable while the Resident resided in the facility and if the NP ordered blood tests for 11/19/2022 facility staff should have, but did not, set the Resident up with an appointment or information on how or where to get the blood test completed. When asked why home health was set up to start four days after the resident discharged , Staff B stated discharge was before a weekend, but it was a little long for the resident to wait. Resident 69 The 10/20/2022 admission MDS showed Resident 69 was admitted to the facility on [DATE] with the diagnoses of Urinary Tract Infection (UTI), new nephrostomy catheter (implanted urinary tube for draining urine) and received intravenous (IV, through a vein) antibiotics. Resident 39 was assessed as cognitively intact and able to make daily care decisions. The MDS showed Resident 69 discharged to an acute hospital, return not anticipated on 10/20/2022. In an interview on 12/08/2022 at 12:07 PM, the designated Resident Representative (RR) stated Resident 69 did not speak English, would not be able to make medical decisions if spoken to in English. The RR stated Resident 69 could understand simple English for easy daily task decisions. The RR stated there was not a translator used to help Resident 69 to make discharge plans or make decisions about their care. The RR stated they were not called about any care planning or discharge planning discussions, and did not talk to any social workers, nurses, or physicians. The RR stated Resident 69 called (the RR) on 10/20/2022 and asked to be picked up from the facility to go home. The RR was told by Resident 69 they were not getting the care they expected and wanted to leave. The RR stated they arrived to pick up the resident and the facility made the RR sign a form that Resident 69 was leaving against medical advice. The RR stated when Resident 69 left the facility, they wanted to go straight to the hospital to see a doctor, then was admitted for medical issues. A review of Resident 69's medical record showed no progress notes, assessments or discussions regarding discharge planning was completed with the resident or the RR. A 10/19/2022 progress note showed the interdisciplinary team discussed Resident 69's skilled care provided and current status. The note showed Resident [69] discharge plan is to return home . resident will not likely be available to safely discharge home . will continue to work with therapy on strengthening, social services director will speak with resident on discharge plan and may need to discuss palliative care needs. There was no further follow-up documentation from facility staff about discussion with the resident or the RR. In an interview on 12/09/2022 at 2:36 PM, Staff B stated Resident 69 should have had a discharge planning discussion with the social worker just a couple days after admission, then ongoing until discharge. Staff B stated the facility can provide translator services but did not provide for Resident 69's discharge planning. Staff B reviewed Resident 69's records and stated there was no discharge planning notes with the resident or the RR, there was no discharge CP, and there was no discharge summary from the physician as required. Staff B stated these items were not done by the facility staff as required. Resident 51 According to a 10/06/2022 admission MDS, Resident 51 was cognitively intact, had clear speech, was understood and able to understand others. This MDS indicated Resident 51 did not have an active discharge plan for the resident to return to the community and no referral to a local contact agency was needed. In an interview on 12/02/2022 at 10:48 AM, Resident 51 reported staff had not involved them in discussions regarding their care and stated they wanted to know if they had a discharge plan in place. Review of a 09/28/2022 discharge CP showed Resident 51 wished to discharge to their apartment where they lived alone with scheduled caregiver assistance, and wished to administer their own medications. This CP directed staff to ask resident their preferences of outside services post-discharge, complete a referral from the county if needed, discuss discharge goals/prognosis with the resident, provide with written instructions regarding their medications/exercise/nutrition, and plan family meetings as needed. Record review showed a 10/14/2022 provider progress note that stated Resident 51's discharge plan was to return home with family support and to continue follow up by facility social worker for discharge planning. On 11/09/2022 a provider progress note stated Resident 51 had participated in physical and occupational therapy, had been discharged from skilled Medicare services due to lack of progress, and was to have continued follow up by facility social worker for discharge planning. Record review revealed no documentation from social services that a discharge plan was in place or any plans had been discussed with Resident 51 since their readmission on [DATE]. In an interview on 12/12/2022 at 3:13 PM, Staff L stated their expectation is social services staff would meet with residents to discuss discharge planning and assist them as needed to obtain the referrals and equipment needed for a safe discharge. Staff L stated a resident's CP should be updated and revised if discharge plans change. The discharge expectations were not met for Resident 51. REFERENCE: WAC 388-97-0080. .

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 6 According to the 11/02/2022 Quarterly MDS, Resident 6 admitted to the facility on [DATE], was cognitively intact, and able to be understood and get understand in conversation. The MDS showed Resident 6 required extensive assistance with personal hygiene and showers. In an interview on 12/01/2022 at 11:21 AM, Resident 6 stated they did not get a shower for a month. Resident 6 stated they preferred showering at least twice weekly but never got a shower. Review of Resident 6's bathing records showed from 11/01/2022 through 12/01/2022, the resident received four bed baths in 30 days, but no showers. Observations on 12/02/2022 at 8:09 AM, 12/05/2022 at 11:33 AM, and 12/08/2022 at 10:01 AM showed Resident 6 was not shaved and had greasy hair. In an interview on 12/07/2022 at 12:04 PM, Staff C stated staff is expected to assist Resident 6 with showers and hair washing according to the shower schedule twice a week, and per the resident's preferences. Staff C stated staff should shave Resident 6 daily or as the resident preferred. Resident 41 A 10/15/2022 Quarterly MDS showed Resident 41 was assessed with no memory problems, was frequently incontinent of bowels, had mobility impairment, and used a wheelchair for mobility. The assessment showed Resident 41 did not reject care and depended on staff for bathing assistance. In an interview on 12/01/2022 at 9:49 AM, Resident 41 stated they had not received a shower in three weeks. In an observation at that time, Resident 41 had long thumb nails, large peeling flakes of dry skin on their left foot, and their hair was unkempt, sticking out in different directions. In an interview on 12/12/2022 at 11:07 AM, Staff C stated they used shower sheets (documentation signed and dated by staff indicating a resident had received a shower) to verify when residents received showers. Staff C stated if a resident refused a shower, it would be documented in the record. Record review showed the most recent shower sheet was dated 10/30/2022. There were no shower sheets found for the month of November or December. Review of Resident 41's progress notes from 11/01/2022 to 12/12/2022 showed no notes indicating the resident refused a shower. Resident 46 A 09/28/2022 admission MDS, showed Resident 46 was assessed to have memory impairment, no speech, sometimes understood, and usually understands others. Resident 46 had history of a stroke (blockage or bleeding of vessels in the brain) and had limited range of motion with one side of their body. Resident 46 did not reject care and required assistance from staff for dressing and hygiene. A 09/21/2022 care plan indicated Resident 46 would be neat, clean, and well-groomed daily. An observation on 12/01/2022 at 2:44 PM, showed Resident 46 with long fingernails and facial stubble to their cheeks and chin. Similar observations were noted on 12/02/2022, 12/05/2022, and 12/06/2022. On 12/07/2022 at 12:30 PM, Resident 46 was observed lying in bed and was wearing a night gown. Resident 46 had long facial stubble. In an interview on 12/07/2022 at 12:39 PM, Resident 46 was shown a typed question Do you prefer to have your face shaved?. Resident 46 said Yeah!. When Resident 46 was asked if they preferred to wear clothes, their eyes got very big, and the resident loudly stated Yeah! while nodding their head. In an interview on 12/08/2022 at 11:34 AM, Staff Y (CNA) stated sometimes Resident 46 had a long beard and sometimes it was shaved. In an interview on 12/12/2022 at 11:18 AM, Staff C stated orders were in the Medication Administration Record (MAR) for nurses to check resident's nails and hair daily. This check was for the nurse to determine if a resident needed their nails trimmed or hair washed. Record review showed no orders for nursing staff to monitor Resident 46's nails or hair daily. The record did not indicate Resident 46's preferences for shaving or dressing. REFERENCE: WAC 388-97-1060(2)(c). Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 5 of 18 residents (Resident 12, 51, 6, 41, & 46) reviewed for ADL care to dependent residents. The failure to provide dependent residents with bathing, nail care, oral care, and overall grooming placed them at risk for poor hygiene, embarrassment, and diminished quality of life. Findings include . Resident 12 According to the 05/13/2022 admission Evaluation, Resident 12 had a full upper denture and natural bottom teeth. The 12/02/2022 [NAME] (a care guide) showed Resident 12 required set up and standby assistance with oral care. A 07/08/2022 Sound Dental Care consultation showed Resident 12 needed help to remove and clean their upper denture. Observation on 11/30/2022 at 1:16 PM showed Resident 12's was wearing their upper denture. The upper denture was noted with food residue outlining the teeth and in between the gum line. When asked if they have rinsed their mouth or brushed their teeth yet, Resident 12 stated, No, not really. Observation on 12/08/2022 at 7:19 AM showed Resident 12 was sleeping in bed. At 7:49 AM, Staff S (CNA, Certified Nursing Assistant) came in the room with a meal tray, woke up Resident 12, and stated it was breakfast time. Staff S set up the resident to eat breakfast and left the room. Resident 12 was not provided any oral care assistance. On 12/08/2022 at 12:07 PM, before the lunch trays were served, Resident 12 was observed in bed, with the same obvious food residue wedged in between their teeth. Record review of Resident 12's personal hygiene task (dental/oral care including dentures) from 11/03/2022 until 12/08/2022 showed no documentation of oral or dental care was documented that staff provided oral care. The 09/23/2022 revised Care Plan (CP) did not have any care interventions listed for Resident 12's oral and denture care needs. In an interview on 12/09/2022 at 3:33 PM, Staff D (Registered Nurse, RN Unit Manager) stated the expectation was for staff to provide oral care and document accurately. Staff D confirmed there was no documentation of oral care provided, Staff D could not confirm staff provided oral care for Resident 12 as directed. Resident 51 According to an 10/06/2022 admission Minimum Data Set (MDS, an assessment tool) Resident 51 was cognitively intact with clear speech and had no rejection of care during the assessment period. This MDS assessed Resident 51 to require extensive physical assistance from staff for bed mobility, transfers, and personal hygiene and was totally dependent on staff for bathing. In an interview on 12/02/2022 at 10:44 AM, Resident 51 stated they get bathing, one time a week if you're lucky and stated, they [staff] wont cut my toenails, my fingernails and toenails are too long. Resident 51 explained they used to get weekly nail care due to their diagnosis of diabetes and reported it was only done once since September. Observation on 12/02/2022 at 10:58 AM, showed Resident 51 had long thick toenails that extended beyond the tip of both of their big toes and the rest of the toenails were long and curled over to the tip of the toes. Review of revised 09/28/2022 ADL CP showed Resident 51 required extensive assistance with bathing. A 09/28/2022 diabetic CP showed directions to staff to refer Resident 51 to a podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. According to November 2022 ADL Documentation, Resident 51 was scheduled for twice weekly bathing on Tuesday and Saturday but only received four showers in 30 days. Review of Resident 51's 09/28/2022 Physician Orders showed directions to staff to complete weekly hair and nail assessments every Tuesday and the resident may see podiatrist as needed. In an interview on 12/12/2022 at 8:16 AM, Staff C (Licensed Practical Nurse, LPN Unit Manager) stated staff is expected to provide bathing twice weekly as scheduled, provide nail care weekly, and refer residents to podiatry as needed.

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Emergency Exit Doors During a life safety inspection on 12/01/2022 from 8:45 AM to 9:50 AM, a Washington State Fire Marshal identified the two EE doors (door 2 and 3) on the east side of the building did not function as required. The Fire Marshal determined the EE doors were locked and could not be opened, which prevented residents and staff from exiting emergently. In an interview and observation on 12/01/2022 at 11:51 AM, Staff I (Maintenance Assistant) stated they took the door pins to their private home and needed to collect the pins before they could get the EE doors open. Staff I stated they removed pin from each of the push-bars for EE doors 2 and 3 after a resident wandered through the doors outside to the patio area, unsupervised. Staff I was unable to recall the name of the resident or the date they removed the pins from the door but stated that it was a while ago. Staff I was observed using multiple tools to install the pin into the push-bar and 11 minutes later EE Door 2 was unlocked and opened. At 12:08 PM, Staff I installed the pin into the push bar for EE Door 3 and it was unlocked. Both doors 2 and 3 were locked and non-functional for a total of two hours and 12 minutes after the Fire Marshal determined both doors were locked and not functioning as required by federal regulations. Observations on 12/01/2022 1:07 PM showed the EE doors were unlocked but no alarm sounded when opened, which allowed residents to exit the facility without staff knowledge. There was no staff present at the EE doors to watch for residents exiting through the unlocked EE doors. Observation on 12/01/2022 at 2:31 PM showed the facility tested the audible fire alarm system. The fire alarm response by staff cleared the hallways and all staff responded to the nurse's station preventing staff from monitoring the EE doors for residents exiting. The fire alarm sounded for 34 minutes while surveyors monitored the EE Doors for staff supervising for residents exiting. In an interview on 12/01/2022 at 2:48 PM Staff A, while the alarm was sounding, stated staff would be assigned to watch the unlocked/unsecured EE Doors 2 and 3 during the fire alarm testing. Observations of the EE doors 2 and 3 at 2:54 PM, 3:11 PM and 3:23 PM showed no staff present to prevent resident exit/elopement. Observation on 12/01/2022 at 2:48 PM showed Staff H and Staff FF (Corporate Maintenance) attempting to reset the EE doors connection to the fire alarm system. Staff H and Staff FF put the fire system in test mode and established that EE doors 2 and 3 did not open as they should when the alarm sounded. At 3:05 PM the facility concluded the test of the fire system and the alarms silenced. The EE doors 2 and 3 remained unlocked and staff was not present to supervise the doors. Observation on 12/01/2022 at 4:32 PM showed magnetic door alarms mounted to EE doors 2 and 3. The alarms were designed to sound when the magnet on the alarm attached to the door and the magnet attached to the frame separated. The alarms were designed to activate and deactivate with a key sticking out of the device. The alarms were noted to be installed and function as intended when a surveyor opened EE door 2 and the magnet alarm sounded. EE doors 2 and 3 remained disconnected from the main system so the main fire alarm did not sound. Observation on 12/02/2022 at 9:13 AM showed both EE doors 2 and 3 still with magnet alarms attached, with the key sticking out, and not connected to the fire alarm system. In an interview on 12/01/2022 at 3:13 PM Staff FF stated they were unsure why or when Staff I disabled the doors. Staff FF stated the EE doors should never be locked. Staff FF stated they would seek more information on the EE door functioning so they could assure the EE doors were fully functional and compliant with fire codes. REFERENCE: WAC 388-97-1060(3)(g). Based on observation, interview, and record review the facility failed to assess falls timely, identify cause of falls, and implement fall interventions to prevent recurrent falls for 4 (Residents 35,42, 51 & 20) of 8 residents reviewed for accidents, failed to provide required supervision while eating for 1 of 8 (Resident 66) and 4 supplemental (Residents 24, 46, 42, & 40) residents reviewed for nutrition and swallowing difficulty, failed to provide supervision of unsecured emergency exits, failed to maintain handrails in safe condition, and failed to secure construction materials and tools in the resident environment. These failures left residents at risk for falling, choking, aspiration, elopement, injury, and/or death. Findings included . Falls Resident 35 According to the 10/31/2022 Quarterly Minimum Data Set (MDS, an assessment tool) Resident 35 had intact cognition. The MDS showed Resident 35 had diagnoses including debility (physical weakness) and malnutrition. Review of the facility's September 2022 incident log showed Resident 35 had a fall on 09/16/2022. According to the facility's investigation of the 09/16/2022 fall, Resident 35 was found on the floor of their room at 10:00 AM on 09/16/2022 after crying out for help. The incident description showed Resident 35 sustained a 3 x 3-inch hematoma on their forehead, and that neurological checks (neuros - periodic evaluations to establish the presence of a neurological injury after a fall) were started. The 09/16/2022 investigation did not include any evidence neuros were completed. The 09/16/2022 investigation included a 09/15/2022 fall risk evaluation completed after Resident 35 returned to the facility after a stay at the hospital and did not reflect the fall Resident 35 had on 09/16/2022. No fall risk evaluation was found in the resident's record or included in the investigation to demonstrate Resident 35's risk for falling was reassessed after an actual fall. In an interview on 12/09/22 at 2:33 PM, Staff B (Director of Nursing) stated for an unwitnessed fall resulting in a forehead hematoma, neuros should be completed. Staff B stated evidence of the neuros should be included in the investigation. Resident 42 The 09/12/2022 modified admission MDS showed Resident 42 had no cognitive deficits and diagnoses including multiple falls, fracture related to falls, and had experienced 2 or more falls after admission to the facility. Review of the revised 09/26/2022 Care Plan (CP) showed the basic standard of care interventions used for all residents; directed the staff to make sure the call light was within reach, encourage the resident to use the call light, proper non-skid footwear, provide safe environment, increase supervision, and refer to therapy as needed. The CP failed to include person-centered interventions to address the resident's fall history with fractures, interventions for cardiac / medication related factors that commonly cause falls, care needs, or updated with new interventions after the first two falls sustained after admission. According to the facility Reporting log showed as of 12/09/2022, Resident 42 fallen 10 times since admission. Review of the 10 facility fall Incident Reports (IRs) showed the facility consistently failed to either identify new interventions to help manage falls, update the CP with planned fall interventions, and/or implement the interventions according to the IRs. After Resident 42's fall on 09/09/2022, the 09/11/2022 facility IR showed the new intervention was to encourage the door to be open to the room. The CP showed the new intervention had not been added to the CP until 09/15/2022. In a 12/12/2022 1:30 PM interview, Staff B stated the update was not timely and should have been added on 09/11/22. On 09/11/2022 at 12:45 AM, Resident 42 fell again. The facility IR showed a plan to have the pharmacist review the resident's medications. In a 12/12/2022 1:30 PM interview, Staff B stated they had not gotten the pharmacy review done and the CP was not updated, but should have been. Resident 42 fell on [DATE] at 8:28 AM and the facility IR showed the root cause of the fall was orthostasis (significant drop in blood pressure upon standing, often causing the resident to fall or faint). The plan was for orthostatic blood pressure review. The facility failed to complete neurological assessments, include orthosatic blood pressures, implement the plan, or update the CP. Similar findings for the falls on 10/05/2022, 10/12/2022, and 10/22/2022. Resident's sixth fall was on 10/24/2022. The facility IR showed the plan was for therapy to assess for the placement of anti-roll back brakes (a device placed on the back of the w/c to prevent it from rolling back if the resident stood up from the chair) on the wheelchair (WC). The CP was not updated and the interventions were not implemented. A 12/12/2022 12:38 PM observation showed the resident's wheelchair did not have anti-roll back brakes attached to the back of the wheelchair. On 10/30/2022, Resident 42 fell during a self-transfer without locking the WC brakes. The resident sustained a long abrasion on the middle of their back. The facility IR said the root cause of the fall was orthostasis. The IR showed no consideration or review of the effectiveness of previous planned interventions, identify they were not implemented, and/or care planned. On 12/12/2022 at 1:30 PM, Staff B agreed if the facility had implemented the anti-roll back brakes on the resident's WC, the resident may not have fallen on 10/30/2022 or 11/02/2022. Resident 42's ninth fall was on 11/10/2022. The facility IR showed the root cause was increase confusion, but no investigation into the reason Resident 42 was having increased confusion, or consider if the resident was having a change of condition. The plan was to place a sign on the bedside table to remind the resident to call for help before trying to self-transfer. During observations on 11/30/2022 at 1:30 PM and 12/12/2022 at 2:28 PM showed no sign on the bedside table. The CP was not updated and the interventions were not implemented. Resident 42's tenth fall was on 11/20/2022. The facility IR showed the resident had rolled from the bed and the plan was to place the resident on a mattress that had raised perimeter. An observation on 11/30/2022 at 1:30 PM showed the resident was lying on a perimeter mattress. An observation on 12/12/2022 at 11:30 AM showed resident 42 had moved to another room, but the perimeter mattress was not on the residents bed, it was left on the bed in the previous room. In the 12/12/2022 1:30 PM interview, Staff B stated the perimeter mattress should have been moved with the resident and should have been updated on the CP, but was not. Staff B said the investigations lacked witness statements and were not all thorough, the CP was not consistently updated as it should have been placing the resident at continued risk for falling and significant injury. Staff B said the post fall alert monitoring by the nurses was not consistently documented but should have been. Resident 51 According to the 10/06/2022 admission MDS, Resident 51 had multiple medically complex diagnoses including fractures. This MDS assessed Resident 51 with falls prior to admission that resulted in fractures. Review of the facility incident log showed Resident 51 had a fall on 08/10/2022. The incident report completed by staff showed the resident stated, help me, I fell and was found on the floor with a bump on her forehead. This incident report showed, at the time of the incident, Resident 51 had a bruise to their face and left shoulder. On the incident report staff left the following sections blank: Level of pain; level of consciousness; mobility; mental status; injuries post incident, predisposing environmental factors; and predisposing physiological factors. Review of progress notes showed a late entry note for 08/10/2022 for nursing communication to therapy. This note indicated Resident 51 showed a possible change in condition regarding falls and safety/judgement and requested the resident be evaluated and treated by therapy. No further progress notes by nursing staff regarding the fall were found in the Resident 51's records until 08/20/2022 at 4:11 PM, at which time staff documented a left shoulder x-ray completed on 08/11/2022 was placed in the provider file. Review of Resident 51's records revealed no alert monitoring or neuro assessments were completed by nursing staff after the residents fall on 08/10/2022 with injury to their head. In an interview on 12/09/2022 at 2:33 PM Staff B (Director of Nursing) stated nurses are expected to start the investigation by collecting information for the fall report at the time of the fall. The physician and family must be notified and all documentation of the fall is required to be in the progress notes. Resident 20 The 09/17/2022 Quarterly MDS showed Resident 20 was cognitively impaired, had diagnosis of dementia and at risk for falls. The MDS showed Resident 20 had no falls since the prior assessment. Resident 20 was assessed to require supervision with walking, transfers, and bed mobility and extensive physical assistance with toileting. Review of the facility's November 2022 incident log showed Resident 20 had a fall on 11/17/2022. Review of the 11/17/2022 investigation report showed Resident 20 had an emergency room (ER) visit and broken scapula (collar bone). Record review showed a 12/05/2022 7:55 PM progress note Informed resident family of fall that took place today with the information at hand. Family is going to meet resident at [NAME] ER. State report complete, DNS ADON AND ED notified of fall with Major injury - suspected fracture. The next progress note dated 12/05/2022 9:31 PM showed Nursing communication to Therapy. Resident is showing a possible change in condition in the following areas: Personal hygiene, Toileting/Continence, Falls. A 12/06/2022 5:23 AM progress note showed Resident came back from the hospital alert and verbally responsive. Resident arrived at the facility around 11:45 pm . went to hospital for non-witnessed fall. Resident sustained some injury on the nose . had displaced bilateral nasal bone fractures . periorbital hematoma. Resident continues neuros and on alert for three days [resident representative] informed about the discharge from the hospital. The progress note did not show cause of fall, notification of the physician, interventions put into place immediately. Review of progress notes 12/06/2022 day, evening, and night shift, 12/07/2022 day, evening shift showed no ongoing monitoring of Resident 20 after the fall with a nose fracture. In an interview on 12/06/2022 at 9:35 AM Staff B stated the nurses are expected to start the investigation at the time of the fall, make a progress note describing what happened and who was notified. Staff B stated the physician should have been notified immediately and it should be documented in the record. Staff B was told the information was missing from the progress notes and replied, It should be in there by now. In an interview on 12/09/2022 at 2:30 PM, Staff B was asked to provide a copy of the investigation that had been completed so far on the 12/05/2022 fall, 5 days prior. No documents were provided. In an interview on 12/12/2022 at 11:33 AM, Staff F (Infection Control Preventionist) stated they were the person on duty at the time of the fall and helped the nurse with the investigation and transferring Resident 20 to the ER. Staff F reviewed the progress notes and stated they were incomplete, missed the assessment of the resident after the fall, missed the initial findings of the cause of fall, missed the notification of the physician, and did not place the resident on alert monitoring upon return from the ER. Staff F stated the investigation had not been completed but had been given to the DNS. In an interview on 12/12/2022 at 2:32 PM, Staff B was asked to provide a copy of the investigation for the 12/09/2022 fall, 8 days prior. The document was not provided until the end of survey. Review of the 12/05/2022 fall investigation showed an intervention of a physical therapy evaluation which the resident refused. In an interview on 12/12/2022 at 2:32 PM, Staff B stated a complete fall investigation included interviews with the resident, staff, and other residents to rule out abuse and neglect, have a root cause analysis with interventions on the care plan to prevent future incidents. Alert charting is required after any incident and continues for three days or until stable. Neuro monitoring is required for any head injuries and should be documented in the investigation. Eating Supervision Resident 66 According to the 11/04/2022 admission MDS, Resident 66 had diagnoses including stroke and difficulty swallowing. The MDS showed Resident 66 required an altered texture diet and required supervision during. According to an 11/04/2022 Physician's Order (PO) Resident 66 should eat all their meals in the facility's dining room for supervision. The PO showed Resident 66 required aspiration precautions be in place. According to the 11/04/2022 Activities of Daily Living (ADL) CP Resident 66 had a self-care deficit related to weakness and deconditioning. The CP indicated Resident 66 required extensive assistance with eating. Observation on 12/06/2022 at 12:23 PM showed Resident 66 eating alone in their room. On 12/07/2022 at 12:17 PM Resident 66 was observed receiving their lunch tray from Staff S (Certified Nursing Assistant - CNA) who then left the room to a pass more trays. Resident 66 was left unattended to eat their lunch. On 12/08/2022 at 7:49 AM Resident 66 was observed eating their breakfast in their room without supervision. In an interview on 12/07/2022 at 12:22 PM Staff S stated they were unsure what level of supervision Resident 66 required. Staff S stated they usually worked the other side of the building. Staff S stated they could use the CP, the resident's tray ticket, or ask a colleague when working with residents they were less familiar with. Resident 24 According to the 09/14/2022 Quarterly MDS, Resident 24 had difficult chewing / swallowing, significant weight loss, received a mechanically altered texture diet, and required supervision for eating. The 07/13/2022 Nutrition CP directed staff to provide 1:1 (one-to-one) feeding assistance / supervision with meals and report to the nurse any signs of chewing or swallowing problems. The CP failed to include information for staff related to the residents' risk for aspiration and physician ordered diet textures for food/fluids. A constant observation on 12/08/2022 from 7:31 AM to 7:54 AM showed Staff PP (CNA) delivered the breakfast tray to Resident 24 who was lying in bed, with their head of bed at a 30 degree angle. Staff PP set the tray on the bedside table, did not elevate the residents head to ensure the resident was sitting upright for swallowing safety, then left the room. During the observation, Resident 24 was observed slowly feeding themselves and no staff ever came to the room to provide the 1:1 eating assistance and supervision the resident was required to receive. In a 12/08/2022 8:05 AM interview, Staff PP said Resident 24 could feed themselves and only required set up. When Staff PP was asked what the resident's care plan said for eating assistance required, they said the resident required supervision, but that did not always mean 1:1 -all the time. They said staff just needed to check on the resident often. Staff PP said they had not returned to check on the resident because they continued passing the hall trays for the unit and the nurse or other CNAs would need to help check on the residents. In a 12/08/2022 07:55 AM interview, Staff E (RN Unit Charge Nurse) reviewed Resident 24's CP and verified the resident is at risk for nutritional decline and is care planned to need 1:1 feeding assistance and supervision for eating. When Staff E was asked what does 1:1 mean, they said the resident normally eats in their bed and the CNAs are expected to sit with the resident during the entire meal, and not leave the resident alone with food because the resident is at risk for choking and aspiration (inhalation of food into the lungs). When asked who ensures the residents receive the 1:1 assistance they require and they are positioned safely for eating, Staff E said the nurses on the floor mainly, but its everyone's responsibility. Staff E said Resident 24 should have been sitting upright in the bed for eating and provided 1:1 assistance / supervision during the entire meal. Resident 46 According to a 09/28/2022 admission MDS, Resident 46 was assessed to have poor memory, limited mobility in one arm, and a history of a stroke (a blockage or rupture of blood vessels in the brain). In an observation on 12/07/2022 at 12:30 PM, Resident 46 was sitting up in bed with lunch on the bedside table, over the resident's lap. The plate contained pureed chicken, pureed cornbread, pureed French green beans and kidney beans. Resident 46 ate all the chicken and bread. No staff were observed in or around Resident 46's room while they were eating. A 12/05/2022 [NAME] (a tool directing staff on the type of care/assistance a resident requires) showed Resident 46 required extensive assistance and supervision with meals. Record review showed a 09/21/2022 diet order for dysphasia (difficulty swallowing food), pureed texture, thin consistency. In an interview on 12/07/2022 at 12:45 PM Staff M (Nursing Assistant Registered - NAR) stated they used a tablet which showed how much assistance a resident required. Staff M stated Resident 46 only needed set up help and could eat independently. Resident 42 According to the 09/06/2022 admission MDS, Resident 42 did not have a swallowing problem. The resident was assessed to require assistance with eating. On 09/14/2022, the resident choked on a meal and required the Heimlich maneuver (an emergent procedure to clear the airway of obstruction) prior to being sent to the hospital. On 09/26/2022 the resident returned to the facility with a new diagnosis of difficulty chewing/swallowing and on a physician ordered soft textured diet and thickened liquids. The 09/26/2022 CP showed the resident required 1:1 feeding assistance and supervision for meals. During an ongoing observation on 12/08/2022 from 12:23 PM to 1:16 PM showed Resident 42 was set up at the edge of the bed with their meal by the CNA without checking the meal tray for accuracy, then left the room without identifying the meal they delivered to the resident had three incorrect food textures and the wrong liquid consistency. (Refer to F803) After the correct meal was provided to the resident, staff left the room, and did not return to supervise the resident for their meal. During a 12/08/2022 1:23 PM interview, Staff T (Licensed Speech Therapist) said the resident should be supervised for meals due to their risk of choking and aspiration. Resident 40 The 10/13/2022 quarterly MDS showed Resident 40 was assessed with dysphagia (a swallowing problem) and was on a mechanically altered diet, requiring supervision and one person assistance for cueing for eating. A 07/11/2022 PO showed Resident 40 should be up in a wheelchair and in the assisted dining room for lunch. The 08/12/2022 diet order showed Resident 40 required a dysphasia mechanical soft diet with nectar thick liquids and supervision during meals for standard aspiration (inhaled food/fluids into lungs) precautions. Observation on 12/08/2022 at 12:21 PM showed Resident 40 was in bed, the head of the bed was at 30 degrees, too low for eating position, lunch tray was on the overbed table, holding a fork and eating holding head up from the mattress. There was no staff present providing supervision to prevent aspiration. In an interview on 12/09/2022 at 2:33 PM Staff B stated Resident 40 should eat in the assisted dining room, or if eating in their room, should have the required supervision for swallowing safety. Unsecured Building Materials On 12/06/2022 at 10:21 AM the door to room [ROOM NUMBER] was observed to have a sign hung indicating the room was under construction. The door was observed to be unlocked. Inside room [ROOM NUMBER] the following was observed: an open container of a putty-like compound, a half-full, 5-gallon paint can, a drill, a hammer, assorted hardware, painting supplies, a box of ceiling tiles on a cart, a second cart with box of all-purpose joint compound, a can of wall texture spray, and a step ladder. There was a large hole observed to be cut into the ceiling to provide access to water pipes. The bathroom inside room [ROOM NUMBER] was shared with room [ROOM NUMBER] which allowed the occupants of room [ROOM NUMBER] to access room [ROOM NUMBER] through the bathroom as well as from the hallway unsecure both from hallway and through bathroom to room [ROOM NUMBER]. In an interview at 12/06/2022 at 10:48 AM, Staff A (Administrator) stated it was their expectation that construction materials and tools were stored securely. Staff A stated room [ROOM NUMBER] should have been, but was not secured for resident safety. Handrails Observation on 11/30/2022 at 8:03 AM showed the handrail fixture next to storage room and opposite room [ROOM NUMBER] had a broken plastic bracket that was potentially sharp enough to tear the skin of residents using it. On 11/30/2022 at 8:39 AM the handrail outside room [ROOM NUMBER] was fractured and had exposed, sharp edges. On 12/09/2022 at 12:54 PM the handrailing on the corner of the office between the shower room and activity room near rooms [ROOM NUMBERS] was detaching from the brackets and wobbly. A 3x3 inch corner piece was not securely fastened and could be detached manually. The second bracket from the corner was missing. In an observation and interview on 12/12/2022 at 10:37 AM, Staff H (Maintenance Director) stated the rails needed to be repaired. Staff H stated they were unsure if they had the parts available but could order them.

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 20 The 09/17/2022 Quarterly MDS showed Resident 20 had an unplanned significant weight loss of 10% in last six months. Resident 20 had medically complex conditions with diagnoses including malnutrition, dysphasia, Vitamin D deficiency, thyroid disorder, and dementia. The MDS showed Resident 20 had no issues with swallowing, had no natural teeth, did not wear dentures and was on a mechanically altered diet. Resident 20 was assessed to require supervision with oversight, encouragement and cueing while eating. A 12/18/2018 CP showed Resident 20 required staff set up and staff participation to eat meals generally eaten in the main dining room, sometimes meals in room. The CP was not updated after the 09/217/2022 MDS to direct staff for Resident 20's required supervision, oversight, encouragement, or cueing. Review of Resident 20's recorded weights showed 02/07/2022 weight 126.3 pounds, 04/28/2022 weight 119 pounds, 07/07/2022 weight 115 pounds, 08/02/2022 weight 112 pounds, 10/04/2022 weight 109 pounds, 11/28/2022 weight 103 pounds, total of 23.3 pounds (18.45%) weight lost over nine months. A 09/23/2022 nutrition evaluation from the dietician showed resident was to be on weekly weight monitoring, have labs and monitor meal intake to prevent further weight loss and goal of intake at least 50% for all meals. Review of the 2022 weight log showed no weights were obtained in September 2022, only two weights obtained in October 2022 and only one weight obtained in November 2022. This did not follow the dietician recommendations for weekly weight monitoring. Observations on 11/30/2022 at 8:39 AM, 10:57 AM, and 11:20 AM showed Resident 20 in bed with the breakfast tray on the bedside table next to the bed not set up and not eaten, no supervision or cueing from staff was provided. In an interview at 11:24 AM, Staff Y (CNA) checked on Resident 20 and stated they are usually awake all night and sleeps through meals during the day. At 12:04 PM, the lunch tray was delivered to Resident 20 in their room. Observations at 12:17 PM, 12:21 PM, 1:33 PM showed Resident 20 was lying in bed and not eating lunch. At 1:56 PM, Resident 20 was sitting on the side of the bed, lunch untouched and eating a chocolate cupcake. During these observations Resident 20 did not have staff supervision, encouragement or cueing to reach the dietician goal of 50% intake each meal. Similar observations for Resident 20's meal trays served in the room on 12/05/2022 breakfast, 12/06/2022 breakfast, 12/07/2022 breakfast and lunch, 12/08/2022 breakfast and lunch. Observation on 12/06/2022 at 12:19 PM showed Resident 20 sitting on the side of the bed with the lunch tray in front of them. Resident 20 was cutting a brownie with a piece of cardboard from the tissue box and eating the main dish with their fingers. There was no staff present to assist with set up, supervision or cueing. In an interview on 12/01/2022 at 1:44 PM, the Resident's Representative (RR) stated they were concerned about weight loss and wanted Resident 20 to gain some weight. The RR stated Resident 20 needed more help from staff to help eat so they would gain weight. The RR stated when they visit, they provided help to Resident 20 to eat ice cream or something else. The RR stated the weight loss did not seem right if the staff was assisting the resident with eating. In an interview on 12/09/2022 at 2:36 PM, Staff B stated there is not an interdisciplinary team approach to review of weight loss. Behaviors identified by nursing are not discussed with the dietician for collaborative interventions to stabilize or improve intake. Staff did not identify Resident 20's sleep schedule in relation to eating and weight loss and put interventions in place to mitigate further weight loss. REFERENCE: WAC 388-97-1060(3)(h). Resident 51 According to the 10/06/2022 admission MDS, Resident 51 was cognitively intact, had multiple medically complex diagnoses including a thyroid disorder, diabetes, and malnutrition. This MDS assessed Resident 51 with weight loss of 5% or more in the last month, or 10% or more in the last six months and not on a physician-prescribed weight-loss program. In an interview on 12/02/2022 at 10:37 AM, Resident 51 stated they had, a lot of weight loss. The resident indicated they were not happy with the food and reported they would sometimes have food delivered from outside sources. According to a 10/11/2022 Nutritional Care Area Assessment (CAA), staff documented Resident 51 had weight loss in the last six months, the CP would address the nutritional goals/interventions, and nursing was to monitor intake every shift daily. Review of a 09/28/2022 nutrition CP showed the Resident 51 had inadequate oral intake, malnutrition, and recent hospitalization. This CP showed a goal the resident would consume at least 75% of meals and snacks, directed staff to offer preferred foods when possible, and to monitor weight weekly. Record review showed Resident 51 readmitted to the facility on [DATE] and according to the resident's weight records, was not weighed until 10/04/2022, five days after admission. Resident 51's weight on 10/04/2022 was documented as 113.4 pounds. A 10/05/2022 Nutrition Evaluation showed Resident 51 was at risk for severe malnutrition and the resident had unintended weight loss in the last six months related to inadequate oral intake. The evaluation identified new interventions for Resident 51 to start on a high protein health shake twice daily, directed staff to monitor weight and oral intake with a goal to have no significant weight changes for 90 days, and for oral intake to be at least 50% of most meals provided. On 10/13/2022 a weight of 111.9 pounds and a weight of 105 pounds was documented for Resident 51, a difference of 6.9 pounds. The resident did not have another weight documented until 10/20/2022 (seven days later) at which time Resident 51 was at 106 pounds, a weight loss of 6.53% since the re-admission weight less than 30 days prior. In an interview on 12/12/2022 at 8:16 AM, Staff C stated the resident should have been re-weighed to verify the weight discrepancy and follow up as needed. Review of a 10/21/2022 nutrition progress note showed staff would continue with weekly weights to determine stability. Record review showed a weight was obtained on 10/26/2022 which reflected Resident 51 weighed 107 pounds, a significant weight loss of 5.98% in less than 30 days. A 11/03/2022 nutrition note reflected Resident 51 appeared to be having true weight loss, indicated the protein supplements would be increased, and weights would continue to be obtained. Resident 51 was not weighed again until 11/28/2022 (over four weeks later) and was 109.9 lbs. In an interview on 12/12/2022 at 10:27 AM, Staff C stated the reporting of weight discrepancies by the CNA's to nursing staff was not consistent. Staff C indicated they expected weekly weights to be done if residents were losing or gaining weight and monthly weights if they were stable. Staff C stated staff should follow the facility policy regarding weights and resident CPs should be followed, updated, and revised as needed with changes. Based on observation, interview, and record review the facility failed to ensure 4 (Residents 19, 66, 51, & 20) of 8 residents reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure consistent and timely weights, notify physicians of changes, and implement interdisciplinary interventions and physician ordered nutritional supplements, placed residents at risk for weight loss and/or delayed implementation of interventions to prevent continued weight loss. Findings included . Facility Policy According to a revised 11/2022 facility Nutrition Assessment policy the facility was required to measure and record food intake three times daily with meals for all residents in the electronic medical record (EMR). If changes in intake or an intake less than 50% was noted, the resident's condition would be evaluated during the clinical meeting to determine if there were new risk factors for nutrition. This policy provided recommendations for consideration to develop individualized interventions for implementation based on IDT (interdisciplinary team) assessments that would promote the highest level of function and dignity, some recommendations included: implement pharmacological interventions to decrease depression and/or anxiety, offer replacements of similar nutritive value for uneaten food items, monitor lab values, obtain pharmacy and psychological consults, and obtaining weekly weights. According to the policy, CNAs (Certified Nursing Assistants) were responsible for weighing each resident within 24 hours of admission and weekly for four weeks and/or until the weight is determined to be stable by the IDT team, then monthly if stable. The weight was to be reported to the Licensed Nurse who was responsible for verifying accuracy. For residents who had a weight change of 5% or greater, the Licensed Nurse was responsible to supervise the re-weight; report verified weight loss/gain of 5% or greater to the immediate nursing supervisor, dietician, physician, and resident representative; review at the clinical meeting; review and revise the Nutritional Risks Care Plan as needed; monitor the resident's response to interventions; and re-evaluate interventions to determine effectiveness/need for Care Plan (CP) revisions. Resident 19 The 12/29/2021 Significant Change Minimum Data Set (MDS - an assessment tool) showed the assessment was initiated related to a discharge from hospice care, Resident 19 was [AGE] years old. The MDS showed Resident 19 had diagnoses of dementia and depression. Resident 19 was assessed with cognitive impairment, indicators of depression including poor appetite and weight loss with weight of 103 lbs. Resident 19 was prescribed an antidepressant (AD) and nutritional supplement. Resident 19's nutrition care plan (CP) was not updated after the 12/29/2021 significant change assessment. The 10/26/2020 nutrition CP showed Resident 19 had a nutrition risk due to inadequate intake, dementia, and a history of unplanned weight loss. The CP interventions included monitor weight and provide nutrition supplements. A 01/06/2022 provider note showed Resident 19 had severe protein calorie malnutrition and had increased risk of mortality (death) and morbidity (suffering from a disease or medical condition). The provider recommended Resident 19 remain on the AD for appetite stimulation and depression. Review of the AD order showed the diagnosis for use of the AD was not updated to use for appetite stimulation. On 01/20/2022, Resident 19's AD medication, with the diagnosis of depression only, was discontinued by a psychiatrist with the notation on the order no longer indicated. Review of the progress notes showed no mention of the AD being discontinued, no notification of nursing and no monitoring was initiated for mood, appetite, or weight loss. A 01/26/2022 primary physician progress note showed Resident 19 continued with severe malnutrition and was at increased risk for further malnutrition and weight loss, which would affect all aspects of their care, increase their risk of further decline, mortality, and morbidity. The physician's progress note showed to continue the AD for appetite stimulation. Review of the January 2022 physician orders showed no order to re-start the AD medication. On 01/31/2022 the weight log showed Resident 19 weighed 101 lbs. A 02/03/2022 psychiatry progress note showed no review of the discontinuation of the AD and no evaluation or assessment for increase in indicators of depression or decreased appetite. The 02/07/2022 weight log showed Resident 19 weighed 99.6 lbs. Review of the March 2022 Medication Administration Record (MAR) showed an order for a high calorie/high protein liquid supplement. Resident 19 was to receive 120 milliliters (mL) of the supplement four times daily. The MAR showed on 03/15/2022 the supplement was not given twice with a progress note it was not available and was on order. Of the 124 doses of the supplement prescribed in March 2022, 53 doses were not administered, and 24 doses showed only 90 mL was administered. A 03/24/2022 dietary progress note from the Registered Dietician (RD) showed a weight loss warning for Resident 19 with a significant weight loss. The note showed Resident 19's food and fluid intake was not enough to meet minimum nutrition or hydration requirements. The 03/10/2022 weight was 88 lbs. The RD note stated they questioned the accuracy of the weight and requested a re-weight. The RD evaluation did not identify the recent discontinuation of the AD as a possible contributing factor of the trending weight loss. There was no evaluation of the missed nutritional supplements and no change made to the CP. The weight log showed the next weight obtained was a month later, on 04/23/2022 Resident 19 was 96.0 lbs. A 03/31/2022 Quarterly MDS showed Resident 19 had a decline in their cognition and an increase in depression indicators from the previous assessment and was not receiving an AD. Resident 19 was assessed to have a decline in their ability to feed themselves and had a significant weight loss of greater than 10% of their total body weight in three months. The nutrition CP was not updated after the assessment. A 04/28/2022 dietary progress note showed a recommendation to provide one-to-one feeding assistance, add cocoa and fortified orange juice to the meal trays. The RD goal showed Resident 19's weight to return to greater than 100 lbs. A 07/22/2022 PO showed a change in nutritional supplement to 240 mL twice a day. Review of August 2022 MAR showed of 62 doses only 44 doses were given and only 60 mL were taken by Resident 19, two doses were not administered without a progress note, and 16 doses were not administered with progress notes showing the supplement was not available. The nutrition CP was not revised until 09/13/2022 and then included a goal of comfort care. The interventions were monitor weight, monitor intake, 1:1 feeding assistance with a mechanically altered texture, and provide nutritional supplements of high calorie/high protein and fortified orange juice. The 09/12/2022 weight log showed Resident 19 was 92.6 lbs. On 12/04/2022 the weight log showed Resident 19 weighed 91 lbs. On 12/05/2022 during a continuous dining room observation from 11:54 AM to 12:18 PM, Resident 19 was observed facing the wall with no other residents nearby. Resident 19 was sitting on the edge of the standard wheelchair, laying against the backrest, with their head rested on the top of the backrest of the wheelchair, an improper position for safe eating. There were no fluids on the table, including no cocoa or fortified orange juice supplement. Staff RR (CNA) was observed sitting next to Resident 19 repetitively placing the fork in front of their mouth and stated, take a bite. Staff RR removed the plate and utensils from the table and at 12:35 PM, Resident 19 had eaten less than 25% of their meal. In an interview on 12/07/2022 at 10:00 AM, Staff Q (Licensed Practical Nurse) confirmed Resident 19 did not have an order for an AD, required one-to-one assistance for eating, had and order for 120 mL of liquid supplement and a fortified orange juice at each meal. Staff Q stated CNAs are expected to report to the nurse when residents did not consume all the supplements, so it could be offered later. Staff Q was not informed of Resident 19 not receiving the fortified orange juice. In a 12/09/2022 3:00 PM interview Staff B (Director of Nursing) stated when an AD was discontinued, the practitioner is expected to report to nursing and complete a progress note, nursing was required to monitor and document for mood and meal intake, the RD is required to monitor weights, identify medication changes and nutritional supplement intake, update the CP, and put interventions in place related to the residents assessed dietary needs. Staff B stated Resident 19 was expected to be weighted weekly based on the identified weight loss trend. Staff B stated residents are expected to receive nutritional supplements as ordered and supplements are expected to be available. Resident 66 According to the 11/11/2022 Admissions MDS, Resident 66 admitted to the facility on [DATE]. The MDS showed Resident 66 had intact cognition, diagnoses including swallowing difficulties, a history of stroke, failure to thrive, and depression, and required a mechanically altered diet. The MDS showed Resident 66 required supervision while eating. The 11/08/2022 PO directed staff to provide an altered texture diet to Resident 66, and to provide all Resident 66's meals in the facility dining room. There was no POs regarding weight monitoring. According to the 11/07/2022 Nutrition Risk CP, Resident 66 was at risk nutritionally due to their swallowing difficulty, a history of stroke, failure to thrive, and depression diagnoses. The CP directed staff to provide Resident 66's diet as ordered and to collect weights per orders/policy. Observation on 12/05/2022 at 12:17 PM showed Resident 66 received their lunch tray in their bedroom from an unidentified staff member who then left the room, leaving the resident unattended to eat. Observations on 12/06/2022 at 12:23 PM and on 12/07/2022 at 12:37 PM showed Resident 66 eating in their room without the supervision they were assessed to require. Review of the November 2022 TAR (Treatment Administration Record) showed Resident 66 weighed 150 lbs. on 11/5/2022. Resident 66 was not weighed on 11/12/2022 or 11/19/2022, as scheduled on the TAR, and there was no documented refusal. The next recorded weight showed 146.5 lbs. on 12/4/2022. In an interview on 12/12/2022 at 1:02 PM Staff C (Resident Care Manager) stated Resident 66 was assessed to be at nutritional risk upon admission. Staff C confirmed Resident 66's weekly weights were not obtained per facility policy.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Resident 23 Review of Resident 23's MAR showed a physician order for a constipation medication. The medication should be given two times daily according to the MAR. Observation of Resident 23's morning medication pass on 12/06/2022 at 9:28 AM, Staff Q (LPN) found an empty bottle of the constipation medication inside Hall A medication cart. Staff Q proceeded to the medication room, looked at the supply of over-the-counter medications, and did not find the constipation medication. Staff Q asked Staff N (LPN) if they had the constipation medication in their medication cart but Staff N did not have the constipation medication either. Staff Q finally stated the constipation medication was not available and marked Resident 23's MAR as not given. Residents 2, 42, 49, 4, 65, and 32 Similar findings were revealed for Residents 2, 42, 49, 4, 65, and 32 with staff not administering the physician ordered pain patches consistently between November 1 through December 10. Review of these resident's progress notes for the dates when the patch was not administered revealed the facility had no supply of the pain patches. In an interview on 12/07/2022 at 10:23 AM, Staff Q was asked how often the supply of medications ran out, Staff Q stated, to be honest, it happens quite often. Staff Q was asked to quantify the statement quite often, Staff Q stated, this is not the first time for sure. Inventory of Controlled Substances Books Observation of Hall A medication cart on 12/05/2022 at 12:47 PM with Staff Q showed two inventory of controlled substances books with missing signatures on the shift count sheet. The first controlled substance book labeled August 2022 showed staff did not sign the book for seven of 30 opportunities for the month of November 2022 and one of four opportunities for the month of December 2022. The second controlled substances book labeled September 2022 showed staff did not sign the book for eight of 30 opportunities for the month of November 2022 and one of four opportunities for the month of December 2022. Observation of Hall B-C medication cart on 12/05/2022 at 11:26 AM with Staff N showed one inventory of controlled substances book with missing signatures on the shift count sheet. The book showed staff did not sign for three of 30 opportunities for the month of November 2022. Observation of Hall D medication cart on 12/05/2022 at 12:12 PM with Staff C showed one inventory of controlled substances book with missing signatures on the shift count sheet. The book showed staff did not sign for six of 15 opportunities for the month of November 2022 and four of four opportunities for the month of December 2022. Two consecutive days in December 2022 (12/01/2022 and 12/02/2022) showed staff did not sign the book for all shifts. In an interview on 12/05/2022 at 12:55 PM, Staff Q validated they were accountable for the controlled substances during their shift. Staff Q stated it was important to sign the inventory of controlled substances book to ensure that the count received was correct. In an interview on 12/05/2022 at 12:18 PM, Staff C stated the expectation from staff was to sign the inventory of controlled substances books every shift per facility protocol. Staff C acknowledged multiple signatures were missing and stated, I cannot argue with that. Refer to F835 Administrtion. REFERENCE: WAC 388-97-1300(1)(a)(b)(i-ii)(c)(ii). Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assured timely acquiring, receiving, and administering of all drugs) to meet the needs of each resident for 8 of 10 residents (Resident 51, 23, 2, 42, 49, 4, 65, and 32) reviewed. The facility failed to implement a system of medication records that ensures accurate reconciliation and accounting of all controlled medications for 4 of 5 inventory of controlled substance books reviewed from 3 of 3 medication carts. This failure resulted in residents not receiving their medications as ordered, placed residents at risk for adverse effects from not receiving prescribed medications, at risk for misappropriation of property, and drug diversion. Findings included . Unavailable Medications Resident 51 According to the 10/06/2022 admission Minimum Data Set (MDS - an assessment tool), Resident 51 had multiple medically complex diagnoses including depression and fractures and required the use of an antidepressant and scheduled pain medication. In an interview on 12/05/2022 at 9:29 AM, Resident 51 stated, I got my [pain] patch finally. The resident stated they had not received their pain patch for about a week and indicated the facility had none available. Review of Resident 51's November 2022 Medication Administration Records (MAR) showed staff failed to administer the resident's: antidepressant medication on 11/05/2022 or 11/06/2022; and pain patch to lower back and chest wall on 11/13/2022, 11/14/2022, 11/15/2022, 11/18/2022, 11/20/2022, 11/21/2022, 11/23/2022, 11/24/2022, 11/25/2022, 11/26/2022, 11/27/2022, 11/28/2022, 11/29/2022, and 11/30/2022. According to 11/05/2022 and 11/06/2022 progress notes, staff documented the antidepressant medication was not in stock. Progress notes reviewed between 11/13/2022 and 11/30/2022 showed staff documented the pain patch was not administered due to awaiting delivery, unavailable, awaiting arrival, not given none available, medication not on hand. Review of Resident 51's December 2022 MAR showed staff failed to administer the resident's pain patch to lower back and chest wall on 12/01/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/08/2022, and 12/09/2022. Review of progress notes between 12/01/2022 and 12/09/2022 showed staff documented the pain patch was not administered due to not given none available, not available, and facility out of patches. In an interview on 12/12/2022 at 8:16 AM, Staff C (Licensed Practical Nurse- LPN- Unit Manager) stated there were currently concerns regarding the facility supply of medications. Staff C stated residents should get medications as prescribed by their doctor.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure the availability of hand sanitizer, and failed to ensure staff: performed hand hygiene during medication administration, and performed wound care without wearing gloves in accordance with the Centers for Disease Control (CDC) recommendations. These failures placed residents at risk for the development and transmission of communicable disease and infections. Findings included . The facility's Infection Prevention and Control Program (IPCP) policy revised in October 2018 showed that IPCP was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Hand Hygiene The facility policy Handwashing/Hand Hygiene revised in August 2019 showed that staff were required to perform hand hygiene before and after direct contact with residents, before preparing and handling medications, after contact with medical equipment, Before and after entering the isolation precautions settings, before and after assisting the residents with meals or handling foods, and after removing PPE. The policy showed, unless hands were visibly soiled, an alcohol-based hand rub (ABHR) was preferred. Review of the undated facility policy titled, Medication Administration, showed procedural guidance that licensed nurse and/or medication assistant must wash their hands before and after medication administration. On 12/06/2022 at 8:59 AM, Staff Q (LPN, Licensed Practical Nurse) was observed for medication administration for Resident 49. Staff Q took one pain patch from the medication cart and proceeded to Resident 49's room. Staff Q put on gloves and applied the patch to Resident 49's left side without washing their hands before application. On 12/06/2022 at 9:28 AM, Staff Q was observed for medication administration for Resident 23. Staff Q entered Resident 23's room and set the medicine cup with pills and a glass of water mixed with medication for constipation on top of the over-bed table. Staff Q held Resident 23's hand, handed the medicine cup to the resident, and provided the glass of water without washing their hands before medication administration. Staff Q then put on gloves and instilled Resident 23's eye drops without washing their hands before administration. On 12/06/2022 at 10:19 AM, Staff Q pumped some pain gel for Resident 23 from the house supply bottle. Staff Q went to Resident 23's room, put on gloves, and applied the gel to Resident 23's shoulders. Staff Q took off their gloves and left the resident's room without washing their hands after providing treatment and proceeded to prepare another resident's medications at the medication cart. In an interview on 12/06/2022 at 10:25 AM, Staff Q confirmed they did not perform hand hygiene on three occasions when administering medications and treatments. Staff Q stated hand hygiene should be done before and after medication administration. Observations on 12/07/2022 at 12:49 PM showed Staff DD (CNA, Certified Nursing Assistant) performing incontinence care for Resident 55 after a bowel movement. Staff DD was wearing gloves and used wipes for cleaning during care provided. Staff DD, without changing gloves or performing hand hygiene, picked up a new brief and began positioning the brief into place under the resident. Staff DD used the same soiled gloves and opened the top drawer of the resident's nightstand, picked up a bottle, moved several other items around in the drawer, and touched Resident 55's left hip and knee. After providing care Staff DD removed the gloves, and without performing hand hygiene, put on a new pair of gloves, picked up the garbage, carried it down the hallway, and used a key to open the biohazard room to throw the garbage away. In an interview on 12/09/2022 at 3:53 PM, Staff F (ICP, Infection Control Preventionist) stated all staff were expected to perform hand hygiene before and after providing care to the residents including medication administration. Wound Care Resident 41 Review of a 10/15/2022 Quarterly MDS showed Resident 41 was being treated for a Stage Four pressure ulcer (breakdown of skin and underlying tissue caused by constant pressure) on their left heel. Review of Resident 41's December 2022 Medication Administration Record showed the resident recently finished a course of antibiotics for a bacterial skin infection on their right leg. Record review showed Resident 41 had several open areas on their right lower leg and were being followed by an outside wound team. An observation on 12/06/2022 at 9:24 AM, showed Staff E (Registered Nurse Unit Manager) used their bare hands to remove a soiled dressing from Resident 41's right lower leg. Four open areas were observed on Resident 41's right lower leg. Staff E washed their hands and exited the room to obtain gloves. At 9:27 AM, Staff E applied a solution to cleanse wounds to a gauze pad and proceeded to wipe the gauze pad around each different open area on Resident 41's right leg. Staff E did not use a separate gauze pad for each open area or get new gauze during the wound cleaning. An observation on 12/06/2022 at 9:45 AM, showed the soiled wound bandages removed from Resident 41's leg were lying on the floor, uncontained, next to the resident's bed. Staff E stated to Resident 41, they would pick up the soiled bandages. Sanitizer Dispensers According to Housekeeping Services and Agreement signed on September 12, 2022, the facility would be responsible for the supply and materials including all hand sanitizer. Observations on 11/30/2022 at 7:58 AM, 12/01/2022 at 10:19 AM, and 12/05/2022 at 9:27 AM showed the sanitizer dispenser in the hallway by room [ROOM NUMBER] was empty. Observations on 11/30/2022 at 7:58 AM, 12/01/2022 at 10:19 AM, and 12/05/2022 at 9:27 AM showed a broken sanitizer dispenser on the wall between room [ROOM NUMBER] and 30. Observations on 11/30/2022 at 8:47 AM and 12/05/2022 at 9:27 AM showed the sanitizer dispenser was empty in the hallway on the wall between room [ROOM NUMBER] and 34. Observations on 11/30/2022 at 9:22 AM showed hand sanitizer containers were empty in the [NAME] hallways wall for the staff to use. On 11/30/2022 at 12:18 PM observations showed Staff Y attempted to sanitize their hands using an empty dispenser on the wall, stated. Staff Y stated, it's empty, and proceeded to enter a resident's room. On 12/05/2022 at 9:27 AM the sanitizer dispenser was observed to be empty in the hallway on the wall between room [ROOM NUMBER] and 37. Observations on 12/05/2022 at 11:43 AM showed hand sanitizer dispensers in the hallway in front of room [ROOM NUMBER] and 36 was empty, staff had to walk to the end of the hallway to sanitize their hands. In an interview on 12/12/2022 at 11:33 AM, Staff F stated a few weeks ago they removed broken and empty sanitizer dispensers and as far as they knew, every dispenser was now working. Staff F indicated housekeeping staff was responsible for keeping them filled and expected them to be checked daily and replaced as needed. Staff F stated not having the dispensers functional and available to use could lead to staff not performing hand hygiene as needed. REFERENCE: WAC 388-97-1320(1)(a)(c), (5)(a) .

CONCERN (E)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 49 The 11/17/2022 admission MDS showed Resident 49 had multiple medically complex diagnoses. The assessment showed Resident 49 was less than [AGE] years old, cognitively intact, able to make decisions and had clear speech. Review of Resident 49's immunization record showed Resident 49 received the PCV13 on 01/22/2013 but did not receive the PPV23 as recommended by the CDC for people under [AGE] years old. An 11/16/2022 physician progress note showed an order for staff to administer the pneumococcal vaccine to Resident 49, as indicated and tolerated. Record review showed no documentation that Resident 49 was offered and/or declined the PPSV23 vaccination while they were in the facility. In an interview on 12/07/2022 at 1:06 PM, Resident 49 confirmed staff did not offer or administer any follow-up pneumococcal vaccination since their facility admission on [DATE]. In an interview on 12/09/2022 at 3:54 PM, Staff F stated the facility did not have a system in place for tracking resident's pneumococcal vaccinations per the CDC recommendations. REFERENCE: WAC 388-97-1340 (1)(2). Based on interview and record review, the facility failed to ensure influenza and/or pneumococcal vaccines were offered and/or provided for 4 of 5 residents (Residents 32, 34, 51, and 49) reviewed for immunizations/unnecessary medications. These failures placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza and pneumococcal disease. Findings included . The revised October 2019 facility Influenza Vaccine policy showed all residents who have no contraindications to the vaccine would be offered the influenza vaccine annually between October 1 and March 31 of each year. For those who received or refused the vaccine, documentation would be placed in the resident's records. The revised October 2019 facility Pneumococcal Vaccine policy showed all residents would be offered the vaccine series within 30 days of admission. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. Staff would document in the resident's records if the vaccine was administered or refused. The policy stated administration of the pneumococcal vaccines would be made in accordance with current Centers for Disease Control (CDC) recommendations at the time of the vaccination. The CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older .and adults 19 through [AGE] years old who have certain risk factors. The tables below provide detailed information .For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you .Give one dose of PCV15 or PCV20 [Pneumococcal conjugate vaccine] .For adults 65 years or older who have only received PPSV23 [Pneumococcal polysaccharide vaccine], CDC recommends .Give one dose of PCV15 or PCV20 .For adults 19 through [AGE] years old .who have only received a PCV13 [Pneumococcal conjugate vaccine] with or without PPSV23, CDC recommends .Give PPSV23 . The CDC guidelines went into effect on 10/21/2021 per recommendations from the Advisory Committee on Immunization Practices (ACIP). Resident 34 According to a 09/14/2022 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 34 received their 2021 influenza vaccine in the facility and the pneumococcal vaccine was not up to date due to being declined. Review of Resident 34's immunization record showed the resident received the influenza vaccine previously on 10/08/2021. Another entry for the influenza vaccine stated, consent refused, there was no date or staff listed to indicate when this occurred. There were three other entries that showed, consent refused for the pneumococcal vaccines with no dates or staff identified. A 10/08/2019 Pneumococcal and Annual Influenza Vaccine Information and Request form (a form that addresses, risks, benefits, and consent) showed Resident 34 requested the influenza vaccine annually and refused the pneumococcal vaccine. A 10/17/2022 Pneumococcal, COVID-19 and Annual Influenza Vaccine Information and Request form (PCAIVIR) was blank for the sections offering the Influenza and Pneumococcal vaccines. Record review revealed no documentation Resident 34 or the resident's representative received information regarding the risks and benefits of receiving the influenza vaccine since 2021 or the pneumococcal vaccines since 2019. Resident 32 The 10/19/2022 Annual MDS showed Resident 32 admitted to the facility on [DATE] from another skilled nursing facility and was assessed with up-to-date pneumococcal vaccinations. Review of Resident 32's record showed the PPV23 vaccination was received twice prior to admission on [DATE] and 09/09/2014. There was no documentation Resident 32 was offered the PCV15 or PCV20 vaccination per CDC recommendations. A 10/04/2022 and 10/17/2022 PCAIVIR form for Resident 32 showed the pneumococcal vaccine sections were blank. Record review showed no documentation that Resident 32 was offered, received or refused any additional pneumococcal vaccinations after admission to the facility. Resident 51 According to the 10/06/2022 admission MDS Resident 51 admitted to the facility on [DATE], had clear speech, was understood, and able to understand others. This MDS indicated Resident 51 was offered and declined the Pneumococcal Vaccine. A 10/06/2022 PCAIVIR form showed Resident 51 was offered and refused the annual influenza vaccine but the section for the pneumococcal vaccine was blank. Review of 10/05/2022 and 11/09/2022 provider progress notes showed directions to staff to provide influenza and pneumococcal vaccines as indicated and tolerated by patient. In an interview on 12/09/2022 at 11:10 AM, Resident 51 stated they were interested in receiving their vaccines. Resident 51 stated staff had talked with them a long time ago but reported it was not brought up since the resident was readmitted to the facility on [DATE]. In an interview on 12/09/2022 at 3:53 PM, Staff F (Infection Preventionist) stated residents should be offered the influenza and pneumococcal vaccines on admission per CDC recommendations and facility policy. Staff F stated if a resident refused, staff should provide education on the risks and benefits, make further attempts to offer, and document in the resident's record.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Unit Refrigerator A 11/30/2022 8:03 AM observation of the refrigerator (fridge) at the nurse's station showed the inside was unclean with dried debris on the bottom of the fridge. The thermometer showed the fridge temperature was 42 degrees. There was no temperature log observed on or near the fridge. Inside the fridge were two pints of sour cream that both had expired use by dates, were not dated when opened, and did not have names on them indicating who they belonged to; a large opened bottle of coffee creamer with no open date, no name, and had an expired used by date; a container of fast food with potatoes that had green mold on them visibly seen through the lid of the container, unlabeled and undated; an uncovered clear plastic cup with molding and rotting green grapes; a clear plastic dietary bin with a sticky note on it that said 11/29 and undated sandwiches and re-packaged pudding cups with lids, not dated with the repackage date; a container of what appeared to be egg salad with a resident's name on a piece of tape and a date from October 2022. On 11/30/2022 at 8:28 AM Staff E (Registered Nurse Charge Unit Manager), stated housekeeping was responsible for cleaning the fridge and temperature monitoring. They were unsure where the temperature log was kept. An observation on 12/01/2022 at 9:53 AM, the nurse's station refrigerator temperature showed 42 degrees. The refrigerator contained the same contents as observed on 11/30/2022, except the clear plastic bin from the dietary department was removed, and there was a new fast food container with no name or date on it. A 12/02/2022 10:32 AM observation showed the refrigerator temperature was 42 degrees and the fridge had the same contents as observed on 12/01/2022. A 12/05/22 8:59 AM observation showed the refrigerator temperature at 42 degrees and contained the same items observed on 12/01/2022 and 12/02/2022, with the addition of soda cans labeled with a resident's name. In a 12/05/2022 9:00 AM interview, Staff SS (Housekeeping Manager), stated housekeeping was not responsible for cleaning the fridge or checking the daily temperature and did not know who was. In a 12/05/2022 9:04 AM interview, Staff TT (Corporate Nurse), confirmed the fridge temp was 42 degrees which was not cold enough, was unclean, the moldy potatoes and rotting grape should have been labeled with the person who they belonged to, dated, and removed from the fridge after 5 days, but were not. Staff TT confirmed the unlabeled and expired food products should have been removed but were not. Staff TT was unsure which department the facility designated responsible for cleaning the fridge, temperature monitoring, and documenting daily on a temperature log, but would find out. REFERENCE: WAC 388-97-1100 (3), -2980. Based on observation, interview, and record review the facility failed to ensure food was stored, prepared and served in a sanitary manner and in accordance to professional standards for food service safety. The failure to ensure food: had cold storage temperature was maintained at or below 41 degrees; was stored in a clean refrigerator, was free of expired, unlabeled and undated food products for one of one unit refrigerators; failure to ensure staff performed adequate hand hygiene during food preparation and food service; and ensure food was prepared in a kitchen free of potential food contamination placed residents at risk for food-borne illness and unsavory food. Findings included . Facility Policy According to the facility's revised August 2019 Handwashing/Hand Hygiene policy, facility staff should perform Hand Hygiene (HH) using Alcohol Based Hand Rub (ABHR - hand sanitizer) before and after direct contact with residents. The policy showed staff should perform HH after contact with objects in the immediate vicinity of residents, and before and after handling food. Meal Service Observations Observation of breakfast service on 11/30/2022 showed the following: At 8:29 AM Staff OO (Certified Nursing Assistant - CNA) removed a dirty tray from room [ROOM NUMBER], placed the tray on the cart, and entered room [ROOM NUMBER] without performing HH. The ABHR dispenser on the wall was noted to be broken. At 8:35 AM Staff OO was observed returning a dirty breakfast tray to the cart. Staff OO then entered room [ROOM NUMBER] without performing HH. Staff OO left room [ROOM NUMBER] with another dirty tray and entered room [ROOM NUMBER] without performing HH. Staff OO removed a dirty tray from room [ROOM NUMBER], placed the tray on the cart and reentered room [ROOM NUMBER]. Observation during lunch service on 12/01/2022 at 11:50 AM in the dining room showed Staff Y (CNA) exit from a resident's room to the dining room with a dirty tray. Staff Y placed the dirty tray in the cart, and grabbed a clean meal tray for another resident without performing HH. At 11:59 AM Staff Y was observed bringing a dirty tray from a resident room to the cart in the dining room. Staff Y did not perform HH after placing the tray on the cart before taking Resident 20 their tray. At 12:00 PM Staff PP (CNA) was observed to exit room [ROOM NUMBER] without performing HH, before taking a tray from the cart to room [ROOM NUMBER]. Staff PP then adjusted a resident's bed using the bed controller and helped the resident sit up with the assistance of an unidentified staff member. Staff PP left room [ROOM NUMBER] and, without performing HH, took a lunch tray to room [ROOM NUMBER]. At 12:06 PM in the dining room, Staff X (CNA) was observed to rub their eye while feeding a resident. After rubbing their eye Staff X continued feeding the resident without performing HH. At 12:11 PM, an unidentified CNA was observed setting up a lunch tray for a resident on the over-the-bed table. The CNA left room [ROOM NUMBER] without performing HH, took another tray from the cart and entered room [ROOM NUMBER]. At 12:14 PM Staff X was observed feeding Resident 19 in the dining room. Staff X repositioned Resident 19 and continued to provide feeding assistance without performing HH. Kitchen Observations On 12/05/2022 at 2:10 PM, Staff QQ (Dietary Aide/Dishwasher) was observed washing dishes without wearing a hairnet. In an interview at that time, Staff EE (Dietary Manager) stated dietary staff must wear a hairnet when in the kitchen. During kitchen observations on 12/08/2022 at 10:45 AM, two window fans located over 12 feet in height on opposite sides of the window were noted to be covered in dust and cobwebs. On 12/08/2022 at 11:26 AM, dust was noted to have accumulated on the wall behind refrigerator 6. Streaks of dust stretched up the wall behind the fridge, extending above the height of the fridge by at least one foot. Similar accumulations of dust were noted behind Refrigerators 3 and 4 at that time. In an interview on 12/08/2022 at 10:53 AM, Staff EE stated the fans in the kitchen needed cleaning. Staff EE stated the fans probably were not cleaned since the summer and stated the dust on the fans had the potential to contaminate the food prepared in the kitchen. In an interview on 12/08/2022 at 11:27 AM, Staff EE stated the walls behind the refrigerators were not clean. Staff EE stated cleaning behind the refrigerators was the responsibility of the maintenance department, and the maintenance department experienced a lot of turnover recently. Staff EE stated the dust behind the refrigerators had the potential to contaminate food.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 43% turnover. Below Washington's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 3 life-threatening violation(s), 2 harm violation(s), $182,936 in fines. Review inspection reports carefully.
• 100 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $182,936 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.

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About This Facility

What is North Auburn Rehab &'s CMS Rating?

CMS assigns NORTH AUBURN REHAB & HEALTH CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is North Auburn Rehab & Staffed?

CMS rates NORTH AUBURN REHAB & HEALTH CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 43%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at North Auburn Rehab &?

State health inspectors documented 100 deficiencies at NORTH AUBURN REHAB & HEALTH CENTER during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 95 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates North Auburn Rehab &?

NORTH AUBURN REHAB & HEALTH CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CALDERA CARE, a chain that manages multiple nursing homes. With 125 certified beds and approximately 64 residents (about 51% occupancy), it is a mid-sized facility located in AUBURN, Washington.

How Does North Auburn Rehab & Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, NORTH AUBURN REHAB & HEALTH CENTER's overall rating (3 stars) is below the state average of 3.2, staff turnover (43%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting North Auburn Rehab &?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is North Auburn Rehab & Safe?

Based on CMS inspection data, NORTH AUBURN REHAB & HEALTH CENTER has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at North Auburn Rehab & Stick Around?

NORTH AUBURN REHAB & HEALTH CENTER has a staff turnover rate of 43%, which is about average for Washington nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was North Auburn Rehab & Ever Fined?

NORTH AUBURN REHAB & HEALTH CENTER has been fined $182,936 across 3 penalty actions. This is 5.2x the Washington average of $34,908. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is North Auburn Rehab & on Any Federal Watch List?

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

Facility Details

Beds: 125
Avg. Residents: 64
Occupancy: 51.6%
Ownership: For profit - Limited Liability company
Chain: CALDERA CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
3 Immediate Jeopardy citations: -36
2 Actual Harm citations: -10
100 Deficiencies: -10
Fines ($182,936): -15
Final Score: 0/100

Nearby Alternatives

REDMOND CARE AND REHABILITATIO... 5-star QUEEN ANNE HEALTHCARE 5-star SHORELINE HEALTH AND REHABILIT... 5-star

View all in AUBURN →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505195