**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 4 staff members (Staff T, Nursing Assistant Certified - NAC) reviewed for hand hygiene, 1 of 3 residents (Resident 35) reviewed for transmission-based precautions (TBP), and 1 of 1 residents (Resident 5) reviewed for oxygen use. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriate hand hygiene practices during meal tray delivery, and failed to ensure oxygen tubing supplies were stored and maintained properly. These failures placed all residents and staff at risk of potential infection.Findings include .Review of the facility policy titled, Transmission Based Precautions Conventional Plan, revised 06/16/2025 documented enhanced based precautions (EBP) refer to infection control interventions designed to reduce transmission of multi-drug-resistant organisms that employ the use of targeted gown and gloves use during high contact resident care activities . residents recommended for EBP are residents with open wounds, and indwelling medical devices such at catheters (tubing inserted into the body to drain urine).Review of the facility policy titled, Hand Hygiene, revision 02/11/2022 documented hand hygiene is the single most important procedure for prevention the spread of infection . opportunities for hand hygiene such as before touching a resident, after touching resident, after leaving the residents room, after removing gloves, after any contact with residents belongs or objects.During an observation on 08/04/2025 at 11:49 AM, Staff T, NAC was observed to remove a lunch tray from cart in the hallway and brought it into room [ROOM NUMBER] and placed it on the resident’s bed table, remove the cover from meal tray, exited the room and did not perform hand hygiene. Staff T removed another lunch tray and entered room [ROOM NUMBER], placed the lunch tray on the bed table and exited the room and did not perform hand hygiene. Staff T removed another lunch tray from the cart and entered room [ROOM NUMBER]. Staff T placed the lunch tray on the bed table for the resident in 6B. Staff T was observed touching resident’s silverware with bare hands to cut up the food for them and applied seasoning to the food. Staff T then exited the room, did not perform hand hygiene, removed another lunch tray from the cart and brought it to the resident in room [ROOM NUMBER]A and placed it on their overbed table. The resident did not want lunch and asked Staff T to remove the tray. Staff T was observed to remove the lunch tray from the room and put it on the cart with the other lunch trays that still needed to be passed. No hand hygiene was performed. At 11:54 AM, Staff T removed a lunch tray from the cart and entered room [ROOM NUMBER]. Staff T was observed to place the lunch tray on the bed table, touched personal items in the room and readjusted the bed table. Staff T then used the silverware to cut up the resident’s food with their bare hands. Staff T exited the room and did not perform hand hygiene. Staff T removed another lunch tray from the cart in the hallway and brought it to room [ROOM NUMBER] where they were observed handling the silverware to cut up the resident’s food with bare hands. Staff T exited the room and did not perform hand hygiene. During an interview on 08/04/2025 at 11:59 AM, Staff T did not respond when asked when hand hygiene should be done during meal pass. Staff T reported that they had not done hand hygiene while passing lunch trays. <HAND HYGIENE>In an observation on 08/04/2025 at 11:39 AM, Staff T, Nursing Assistant Certified (NAC) was observed to remove a lunch tray from the meal cart in the hallway, no hand hygiene was observed prior to handling tray. Staff T entered room [ROOM NUMBER], where a resident resided placed lunch tray down in the resident room, exited and did not perform hand hygiene. Staff T then grabbed another lunch tray from the meal cart and entered room [ROOM NUMBER]. Staff T were observed to touch with their bare hands the residents belonging, including their walker, and personal items on their bed table. Staff T, then placed the lunch tray on the over the bed table and removed the cover off the plate. Staff T were then observed to touch with the bare hands the resident’s silverware and cut up the resident’s food for them. Staff T left the silverware for the resident to use. Staff T exited the resident room, was observed to not perform hand hygiene, and walked into room [ROOM NUMBER] and was observed to assist with repositioning of another resident with their bare hands. The staff then touched the residents’ linens to assist in scooting them up in bed. Staff T then left the resident room and did not perform hand hygiene and entered the kitchen. At 11:44 AM Staff T exited the kitchen, dropping two hot beverage containers to room [ROOM NUMBER], and were not observed to perform any hand hygiene. At 11:47 AM, Staff T grabbed another lunch tray from the meal cart and walked to room [ROOM NUMBER], placed the tray on the bed table, grabbed a cup from the resident’s room and walked to the kitchen, no hand hygiene was observed. At 11:49 AM, Staff T pushed a second meal cart down to the other unit, no hand hygiene was observed. <TRANSMISSION BASED PRECAUTIONS>In an observation on 08/06/2025 at 10:07 AM, Staff T, NAC were observed to enter room [ROOM NUMBER], where there was a sign outside that room that stated the resident was on EBP. Staff T were observed to place gloves on their hands and enter the room. Staff T were then observed to assist the Resident 35 from the bedside commode. Staff T was observed to only be wearing gloves for PPE. Staff T were asked what the sign outside the room was instructed. Staff T stated that it was just a precaution and that you may have to use some of the PPE in the bin (they pointed at a PPE bin filled with gloves, gowns, mask and eye protection). Staff T stated they assist Resident 35 to use the restroom all day, that Resident 35 had an indwelling device and they do not ever wear anything but gloves in the room. Staff T was not able to explain what the purpose of EBP was, or when it was the appropriate time to use it with a resident. In an interview on 08/07/2025 at 10:19 AM, Staff B, Director of Nursing Services and Infection Preventionist stated that their expectation for all staff in the facility about EBP, where they were implemented when a resident had an open wound or indwelling device for all high contact care areas. Staff B stated toileting would be considered a high contact care area. Staff B stated it was their expectation that all staff were performing hand hygiene either with hand gel or hand washings for all interactions with residents and their belongs, during meal tray pass and they should be gelling in and out of every resident room. Staff B was not aware of the observations made during meal tray pass or observations of care for EBP. <RESIDENT 5> Resident 5 was admitted to the facility on [DATE]. Review of a physician order, dated 11/29/2024, showed Resident 5 received supplemental oxygen (O2) as needed for comfort and/or a change in their respiratory status. A physician order was received on 07/12/2025 for the resident to receive medication via a nebulizer (a small machine that turns liquid medicine into mist that could be easily inhaled) as needed every six hours for shortness of breath or wheezing. Review of Resident 5’s 07/01/2025 through 08/05/2025 Medication Administration Record and Treatment Administration Record (TAR), showed no direction to the nurse to change the O2 and nebulizer tubing. In an observation on 08/04/2025 at 12:30 PM, Resident 5 was in their room. The O2 concentrator (a medical device that provides pure O2) was stored against the wall, not in use and the O2 tubing with a nasal canula (NC - a tube that delivers O2 into the nose) was touching the floor. Resident 5 stated they did not know the last time they used it, but thought they used it when having some difficulty breathing. In an observation on 08/05/2025 at 8:08 AM, Resident 5 was using their oxygen concentrator. The NC was draped over their nose. When asked about using the O2, Resident 5 placed the NC prongs were placed into their nares. In an observation on 08/06/2025 at 8:45 AM, Resident 5 was sitting on the side of their bed. The O2 tubing was hung across a positioning bar on the right side of the bed and the and was not in a plastic bag. There was a nebulizer machine observed on top of a nightstand in the corner of their room. The nebulizer tubing was not dated, the mask was connected to the tubing, appeared dirty, and was not in a plastic bag. In an observation on 08/06/2025 at 11:17 AM, Resident 5’s O2 tubing was observed hanging over the positioning bar on the bed, the NC was resting in a shoe next to their bed, and the nebulizer was in the same position. In an interview on 08/06/2025 at 11:18 AM, Staff C, Registered Nurse, stated O2 and nebulizer tubing was changed weekly and as needed. Staff C stated the tubing should be labeled, dated when changed, and stored in a bag when not in use. Staff C located the O2 tubing was dated 08/03/2025 with blue ink. Staff C observed Resident 5’s NC in the resident’s shoe. Staff C stated if O2 tubing was observed on the floor or touching any other surface, it should be replaced. In an interview on 08/06/2025 at 11:25 AM, Staff N, Nursing Assistant Certified (NAC), stated the nurse or the NAC could change the residents O2 tubing. Staff N stated the tubing was not labeled/dated when changed. In an interview on 08/06/2025 at 2:24 PM, Staff B, Chief Nursing Officer, stated O2 and nebulizer tubing were changed weekly. Staff B stated the nebulizer should be taken apart, cleaned, air dried, and stored in a bag. Staff B stated the nurse would document on the TAR when the O2 or nebulizer tubing was changed. Refer to WAC: 388-97-1320 (1)(a)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had access to Saturday mail deliveries for 2 of 6 sampled residents (Residents 27 and 2) reviewed for mail delivery. The failure to ensure residents had access to Saturday mail services placed them at risk for isolation, frustration and diminished quality of life. Findings included . Review of the facility policy titled Resident Rights, dated 10/15/2022, showed residents have a communication right of private and unrestricted communication that includes the right to receive, send and mail sealed, unopened correspondence. <RESIDENT 27> Resident 27 admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 06/24/2024, the resident had moderate cognitive impairment. In an interview on 07/29/2024 at 10:00 AM, Resident 27 stated they had received an email on Saturday that mail had been delivered by the postal service, but no one goes and gets the mail so they couldn't have that mail on Saturday, and they had to wait. <RESIDENT 2> Resident 2 admitted to the facility on [DATE]. According to the quarterly MDS, dated [DATE], the resident had no cognitive impairment. In an interview on 07/29/2024 at 10:00 AM, Resident 2 stated the postal service brings the mail into the building on Saturdays, but it's not distributed to residents until Mondays. In an interview on 07/29/2024 at 11:27 AM, Staff M, Business Office, confirmed that mail was not passed out on the weekends. In an interview on 07/29/2024 at 11:32 AM, Staff N, Hospitality Aide, stated they retrieve the mail from the box on the weekends, and they place it in Staff M's box until Monday. Refer to WAC 388-97-0500 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 33> Resident 33 admitted to the facility on [DATE]. During an interview on 07/25/2024 at 1:54 PM, Resident 33 reported they were unable to wear their upper denture as it did not fit. Resident 33 stated the facility had not done anything to assist them with their dental issue. Review of a Clinical Evaluation admission Assessment, dated 05/10/2024, showed Resident 33 had an upper partial denture that did not fit. Review of Resident 33's care plan on 07/29/2024, showed a Focus area, dated 05/10/2024, that the resident did not wear their upper partial denture because it did not fit. The intervention showed staff were to coordinate arrangements for dental care. Review of the admission MDS dental section, dated 05/16/2024, showed the question for loose dentures was not marked for Resident 33, hence the Dental CAA was not triggered and not completed. During an interview/record review on 07/29/2024 at 2:33 PM, Staff B, RN/Clinical Resource, stated the MDS for Resident 33 was not coded correctly and that they would have the staff modify the document. Refer to WAC 388-97-1000 (1)(b) Based on observation, interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments (CAA), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 3 of 4 residents (4, 9, and 33) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs. Findings included . The RAI consists of three basic components: the Minimum Data Set (MDS - a resident assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information). The CAA process was designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers use current, evidence-based clinical resources to conduct an assessment of the potential problem and determine whether or not to care plan for it. The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident. <RESIDENT 4> Resident 4 admitted to the facility on [DATE] with diagnoses to include schizophrenia (a mental health condition that impairs how one thinks, feels or behaves), dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), anxiety and major depressive disorder. The resident had significant cognitive impairment. Review of the significant change MDS assessment, dated 02/13/2024, showed the CAAs did not contain input from the resident's representative on actual or potential problems or needs. The cognitive loss/dementia, behavioral symptoms, mood state and psychotropic (medications that affect mood, behavior or thoughts) drug use CAAs did not contain a comprehensive assessment of the resident's needs, strengths, goals, life history or preferences. <RESIDENT 9> Resident 9 admitted to the facility on [DATE] with diagnoses to include dementia and delusional disorder and depression. The resident had significant cognitive impairment. Review of the Annual MDS assessment, dated 10/21/2023, showed the CAAs did not contain input from the resident's representative on actual or potential problems or needs. The cognitive loss/dementia, and psychotropic drug use CAAs did not contain a comprehensive assessment of the resident's needs, strengths, goals, life history or preferences. In an interview on 07/30/2024 at 11:30 AM, Staff F, Registered Nurse (RN)/ MDS nurse said they completed the MDS assessments remotely with telephone input from the nursing staff at the facility. Staff F said they tried to address the CAA triggers then plug the information from the CAA into the care plan using the RAI manual as their reference. Staff F said that Staff E, Social Services was responsible to complete the mood, behavioral symptom and cognitive loss/dementia CAA's. Staff F said they completed the psychotropic CAA's. Staff F said at times they will add items to Staff E's CAA's or sometimes they just add everything from each triggered area into to the ADL CAA . Staff F said they were aware they should document Refer to the ADL CAA for specifics on each referred CAA. In an interview on 07/30/2024 at 12:06 PM, Staff E, Social Services, said they were responsible to complete the CAA sections C (cognitive patterns), D (Mood), E (Behavior) and Q (participation in assessment and goal planning of resident or responsible party). Staff E said in the past, the MDS nurse worked in the facility, in person and completed the entire MDS and CAA's but now that the MDS nurse worked remote, they (Staff E) were responsible for certain sections. Staff E said they will document to the residents BIMS score (tool to determine cognitive status) for the dementia cognitive loss CAA. Staff E said they did not document to current status, strengths, goals or medications for cognitive loss/dementia, mood state or behavioral symptoms. Staff E said they did not include detailed information about the triggered areas but would do so moving forward. In an interview on 07/30/2024 at 12:24 PM, Staff A, Director of Nursing Services said they were unaware of CAA issues until yesterday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with an indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) received appropriate treatment and services to prevent catheter-associated urinary tract infections (CAUTIs) for 1 of 1 sampled resident (Resident 3) reviewed for indwelling urinary catheter care/management. The facility failed to develop individualized plans for the prevention of CAUTIs including developing individualized, specific clinical indications for changing the catheters and/or catheter bags and to avoid routine irrigation/accessing of the closed catheter system. These failures placed residents with indwelling urinary catheters at an increased risk for UTI's and associated complications. Findings included . Review of the Centers for Disease Control (CDC), Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, 2009, showed the following: Changing indwelling catheters or drainage bags at routine, fixed intervals are not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Review of a facility policy titled Indwelling Catheters, dated 04/12/2022, showed care and treatment were to be provided to reduce catheter associated complications such as a urinary tract infection. The policy indicated that the ongoing care protocols adhere to professional standards of practice and infection prevention and control procedures. The policy also indicated infection control is followed in the care of indwelling catheters and a sterile, closed drainage system is maintained, to avoid routine catheter irrigation, and to avoid routinely changing indwelling catheters and drainage bags at set intervals but change as necessary or unless specified by a physician's order for a specified medical reason. Resident 3 re-admitted to the facility on [DATE] after a hospitalization from 02/29/2024 - 03/01/2024 for a urinary tract infection (UTI) secondary to a chronic suprapubic catheter (a catheter that is surgically connected between the urinary bladder and the lower abdominal skin and is used to drain urine from bladder in individuals with obstruction of urinary flow). According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 06/30/2024, the resident had no cognitive impairment. The resident also had a diagnosis of a neuromuscular dysfunction of the bladder. Review of a hospital Discharge summary, dated [DATE], showed Resident 3 had discharge diagnoses to include a UTI secondary to a chronic suprapubic catheter. In an observation on 07/25/2024 at 11:37 AM, Resident 3 had an indwelling urinary catheter that was connected via a tube to a urine collection bag, the urine was dark yellow and had sediment (matter that settles in the bottom of a liquid) and hazy urine in the tubing. Review of Resident 3's July 2024 Medication Administration Records (MAR) /Treatment Administration Records (TAR) showed an order dated 06/21/2024 to change the suprapubic catheter monthly on the 21st of every month, and a nurse had signed off they had changed the catheter on 07/21/2024. There was also an order dated 11/05/2022 to flush the catheter with 60 cubic centimeters (cc) of saline every Monday, Wednesday, and Friday, and nurses had initialed they had flushed the resident's catheter 13 times from 07/01/2024 - 07/29/2024. Review of a progress note for Resident 3, dated 07/21/2024, showed no clinical indications were documented necessitating the catheter change on 07/21/2024. There was also no documentation a nurse had clarified the order for a catheter change in the absence of clinical indications. In an interview on 07/30/2024 at 10:59 AM, Staff B, Registered Nurse/Clinical Resource, was asked about the orders for monthly routine catheter changes and three times weekly saline flushes, Staff B stated they saw those orders and changed them yesterday, stating we shouldn't have been doing that. In an interview on 07/30/2024 at 11:07 AM, Resident 3 stated no, that staff had not informed them that routinely changing and accessing their catheter increased the risk of them getting a urinary tract infection. Refer to WAC 388-97-1060 (1)(3)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents remained free of unnecessary drugs for 1 of 5 sampled residents (Resident 10) reviewed for unnecessary drugs and for 1 of 1 resident (Resident 3) reviewed for bowel medications. The facility failed to provide nonpharmacological interventions for pain prior to giving as needed (PRN) pain medications and they failed to follow hold orders for bowel medications which resulted in the residents receiving unnecessary pain and bowel medications and placed them at risk for adverse medication-related side effects and a diminished quality of life. Findings included . <RESIDENT 10> Resident 10 admitted to the facility on [DATE] with diagnoses to include cancer of the pancreas and malignant neuroendocrine tumors (cancerous tumors that forms from cells that release hormones into the blood in response to a signal from the nervous system}. According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], the resident had severe cognitive impairment. On 07/30/2024, a review of Resident 10's current care plan showed a focus area dated 05/24/2023 for chronic pain related to precordial (the area of the chest wall covering the heart) pain. One of the listed interventions on the eMAR (electronic Medication Administration Record) initiated on 03/05/2024 stated, non-pharmacological interventions attempted prior to PRN (as needed) pain medication administration. 1=Reposition; 2=Reduced stimuli; 3=Warm towel/ice; 4=Relaxation techniques; 5=Distraction; 6=Music; 7=Massage; 8=Other (document in progress notes) R=Refusal. Review of Resident 10's MAR for July 1 - 30, 2024, showed an order for Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate), give 0.1 ml (milliliter) by mouth every 1 hours as needed for moderate to severe pain (6-10) or SOB (shortness of breath). Review of the record showed this medication was given four times and with no documentation of attempts at nonpharmacological interventions. Review of the June 1 -30, 2024, MAR showed six doses of the as needed Morphine 0.1 ml were given and there was no documentation of any attempts at non-pharmacological interventions. In an interview on 07/30/2024 at 10:42 AM, Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated Resident 10 can sometimes verbalize pain and other times they observe the resident's facial expressions and behaviors. Staff C stated they would try and attempt to reposition them or distract them with TV or music and if that did not work then they gave the resident their as needed pain medication. Staff C stated they would document the non-pharmacological interventions in the MAR or in a progress note. In an interview on 07/30/2024 at 10:53 AM, Staff D, LPN, stated when Resident 10 was in pain, they start with non-pharmacological approaches like music, TV, repositioning or giving the resident their stuffed animals, and if those do not work, then they would give the resident as needed pain medication. Staff D stated they document the non-pharmacological interventions in the MAR. <RESIDENT 3> Resident 3 most recently admitted to the facility on [DATE] and had diagnoses to include irritable bowel syndrome (IBS - an intestinal disorder) with diarrhea. According to the quarterly MDS, dated [DATE], they had no cognitive impairment. In an interview on 07/25/2024 at 11:39 AM, Resident 3 stated they had a lot of diarrhea two or three times a week, and they didn't know what it was from. Review of Resident 3's bowel function documentation from 07/01/2024 - 07/29/2024 showed they had bowel movements that were water, no solid pieces, and entirely liquid on 26 shifts. Review of Resident 3's MARs from 07/01/2024 - 07/29/2024 showed facility nurses continued to administer scheduled Senna tablets (medication used to treat constipation) daily (29 doses) though the Senna order indicated to hold for loose stools. Facility nurses also continued to administer Docusate Sodium (medication used to treat constipation) twice daily (56 doses) though the order indicated to hold for loose stools. In an interview on 07/29/2024 at 12:29 PM, Staff C, LPN/RCM, stated the nurses should have held the medications because the order indicated to hold the medications for loose stools. In an interview on 07/30/2024 at 11:07 AM, Resident 3 stated they did not know nurses had been giving them medications that were ordered to be held for loose stools. Refer to WAC 388-97-1060 (3)(k)(i) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate clinical records for 1 of 4 sampled residents (Resident 3) reviewed for urinary catheter care and services. The failure to consistently document urinary catheter output per the resident's orders placed the resident at risk for hydration issues, unmet care needs, and diminished quality of life. Findings included . Resident 3 re-admitted to the facility on [DATE] after hospitalization for a urinary tract infection (UTI) secondary to a chronic suprapubic catheter (a catheter that is surgically connected between the urinary bladder and the lower abdominal skin and is used to drain urine from bladder in individuals with obstruction of urinary flow). According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 06/30/2024, the resident had no cognitive impairment. The resident also had a diagnosis of a neuromuscular dysfunction of the bladder (occurs when nervous system is damaged, preventing the bladder's muscles and nerves from working together properly). Review of Resident 3's July 2024 Treatment Administration Records (TARs) showed an order dated 07/12/2024 to measure and record the indwelling catheter urinary output every shift for hydration. The TARs showed from 07/14/2024 - 07/25/2024 there was no documentation of urinary output for six shifts. In an interview on 07/29/2024 at 1:01 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, was unable to provide any information about the six shifts with no documented catheter urinary output, they stated they would have to look into it, no additional information was provided. Refer to WAC 388-97-1720 (1)(a)(i - iv)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the infection prevention and control Antibiotic Stewardship Program (ASP, a system-wide implementation of measures for monitoring/tracking of antibiotics along with reducing the risk of unnecessary antibiotic use) was implemented for one of two residents (Resident 3). This failure increased the resident's risk for development of multidrug-resistant organisms (a bacteria that are resistant to many antibiotics) along with the potential for unidentified nursing care trends that identify risk related to infection prevention. This failure had the potential for adverse outcomes associated with unnecessary or inappropriate antibiotic use and a decrease in quality of life for all facility residents. Findings included . Review of the facility policy titled, Antibiotic Stewardship, revised 10/15/2022, stated the facility's infection preventionist utilizes microbiologic, clinical symptoms and radiological findings to confirm clinical evidence of infection .validates the infection meets the definition of an active infection .coordinates facility-wide monitoring and prevention of healthcare-associated infections and audits, analyzes and reports data associated with microbiology culture results. RESIDENT 3 Resident 3 re-admitted to the facility on [DATE] after a hospitalization from 02/29/2024 - 03/01/2024 for a urinary tract infection (UTI) secondary to a chronic suprapubic catheter (a catheter that was surgically connected between the urinary bladder and the lower abdominal skin and was used to drain urine from bladder in individuals with obstruction of urinary flow). The quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 06/30/2024, showed the resident had no cognitive impairment. The resident also had a diagnosis of a neuromuscular dysfunction of the bladder (nervous system damage, preventing the nerves and muscles of the urinary system from working together properly). Review of Resident 3's hospital Discharge summary, dated [DATE], stated the final discharge diagnoses to include a UTI secondary to a chronic suprapubic catheter. Review of Resident 3's discharge physician orders, dated 03/01/2024, stated the resident had been prescribed amoxicillin-clavulanate (an antibiotic medication) 875-125 milligrams (mg). The order read to take one tablet, twice a day for five days. Review of Resident 3's electronic medication administration record for March 2024 showed the resident was administered the amoxicillin-clavulanate medication and received all doses ordered from 03/01/2024 - 03/06/2024. Review of Resident 3's medical record showed no clinical indication for the use of the antibiotic. The medical record had no laboratory or culture results related to an infection. There were no analysis of the resident's antibiotic orders, and no validation for the use of the antibiotic to confirm a true active infection. In an interview on 07/30/2024 at 10:13 AM, Staff G, LPN/Infection Preventionist stated they are responsible for follow up with the provider to ensure proper usage and indication for antibiotics in the facility. Staff G stated if a resident was sent to the emergency room, and they returned with an order for antibiotics the process would be for them to confirm the laboratory testing and culture were completed to confirm proper indication for usage of the antibiotic. Staff G stated they would then provide the in-house provider with all the documentation, and the provider would determine if the antibiotic was appropriate or not. Staff G was asked to provide that documentation and analysis for Resident 3's antibiotic use for their 03/01/2024 visit to the emergency department. Staff G stated they were unable to locate any documentation that showed the provider and the infection preventionist had review the Resident 3's antibiotic usage, or that it was validated as indicated. In an interview on 07/30/2024 at 12:09 PM, Staff A, Director of Nursing Services stated they were unaware that Resident 3's prescribed antibiotic was not reviewed for proper indication of use. Staff A stated ultimately the resident care manager and the infection preventionist are responsible for ensuring the providers are contacted when a new medication has been ordered after a resident returns from the hospital. REFERENCE: WAC 388-97-1320(1)(a)(2)(a-c)

Based on record review and interview, the facility failed to develop, implement and maintain an in-service training program to ensure 2 of 2 Nursing Assistants (Staff H and I) reviewed for the required 12 hour per year nurse aide training received the required amount of annual training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk of less than competent care and services from staff. Findings included . <EMPLOYEE FILE REVIEW> Review of Staff H's, Nursing Assistant Certified (NAC), employee record showed Staff H was hired February of 2022. For the year of February 2023 through February 2024, the facility was unable to provide documentation Staff H had completed the required 12 hours of annual in-service training. Review of Staff I's, NAC, employee record showed Staff I was hired in August of 2023. For the year of August 2023 through July 30,2024, the facility was unable to provide documentation Staff I had completed the required 12 hours of annual in-service training. The facility provided documentation that Staff I had received 6.10 hours of education. In an interview on 07/30/2024 at 12:44 PM, Staff A, Director of Nursing Services (DNS) said the expectation was that NACs were to have at least twelve hours of training annually. Staff A stated they were reassigning the 12 hours of education tracking to Staff G, Licensed Practical Nurse/Staff Development. Refer to WAC 388-97-1680 (1)(2)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NORTH HALL - RESIDENT 10 Resident 10 admitted to the facility on [DATE] with diagnoses to include cancer of the pancreas, and dementia. The quarterly minimum data set (an assessment tool) (MDS) dated [DATE] showed the resident had severe cognitive impairment. In an interview on 07/30/2024 at 8:26 AM, Staff D, Licensed Practical Nurse (LPN) stated their internet was down and they were unable to access the EMAR system. Staff D stated that the facility had printed out the medication administration record (MAR) on paper for them to conduct their morning medication pass. Staff D stated the physician orders were hard to read and they had to keep flipping the papers back and forth as the copies were not in order. Review of the printed MAR on 07/30/2024 that Staff D had referred to showed that the first few letters of all the orders were cut off and missing. All the orders were missing various parts of physician orders such as: the medication names, the route, the dose, the duration, directions or reason for use. In a joint interview/record review on 07/30/2024 at 8:30 AM, Staff D used printed MARs to prepare Resident 10's medications. The MARs had multiple medications that were not printed in their entirety and showed the following: - casone propionate nasal 50 micrograms of actuation (mcg/act) - Staff D stated that the medication was Fluticasone Propionate Nasal Suspension (medication to treat allergies) 50 mcg/act and presented bottle with the resident's name on the label, - iple vitamin-minerals tablet one tab by mouth one time a day - Staff D stated that the medication was Resident 10's multivitamin with minerals and presented a bottle of house supply medication matching this name, - ium oral table 2 mg zepam) 0.5 tab by mouth on time a day for a neuroendocrine cancer - Staff D stated that the medication was diazepam (valium) (medication used to treat anxiety) and presented bubble medication pack with the resident's name on the label, - nna oral tablet 8.6 milligrams (mg) by mouth one-time as for constipation hold for loose ols, - Staff D stated that the medication was the resident's senna (stool softener) 8.6 mg and presented house supply medication matching this name, - oprolol tartrate oral tablet 50 (metoprolol tartrate) 25mg by mouth two times a related to essential imary) hypertension, - Staff D stated that the medication was Resident 10's metoprolol (medication for high blood pressure) for their blood pressure and presented bubble medication pack with the resident's name on the label, - atoprazole sodium oral tablet yed release 40 mg atoprazole sodium) 40 mg by mouth two times a related to storintestional morrhade, unspecified, - Staff D stated that the medication was pantoprazole (medication for stomach acid reflux) 40 mg and presented bubble medication pack with Resident 10's name on the label, - taminophen oral table 325 (acetaminophen) 650 mg by mouth three times related to malignant oplasm of pancreas, - Staff D stated that the medication was Tylenol (pain medication) and presented house medication bottle of Tylenol, - bapentine oral capsule 100 mg bapentin)100 mg by mouth three times for pain - Staff D stated that the medication was Resident 10's gabapentin (medication for nerve pain) 100 mg capsule and presented bubble medication pack with the resident's name on the label, - ulin aspart flex pen cutaneous solution pen ctor 100 unit per milliliter (ml) (insulin as per sliding scale -69 = 0 units, - 99 = 0 units, 0 - 150 = 0 units, - 200 = 2 units, - 300 = 4 units, - 400 = 6 units, - 999 = 6 units recheck in 2 rs and notify provider if -450 - Staff D stated that the medication was Resident 10's insulin (medication injected into skin to manage blood sugar levels) pen and presented the insulin pen in a bag with the resident's name on the label, - etiapine fumarate oral tablet mg (quetiapine fumarate) 50 mg by mouth three times a related to malignant oplasm of pancreas - Staff D stated that the medication was Resident 10's Seroquel (medication that manages psychosis) and presented bubble medication pack with the resident's name on the label. In an observation on 07/30/2024 at 8:40 AM, Staff D was observed to administer the prepared medications to Resident 10. In an interview on 07/30/2024 at 9:59 AM, Staff D stated that they were now able to use the internet and were accessing the eMAR system for medication administration. Staff D was asked for copies of the printed MAR from the previous observed medication administration, and stated they were available in the binder next to the medication cart. Staff D stated they had not signed off on all the medications yet, they would need to go back and do that, stating they were just trying to get the medication pass done. SOUTH HALL - RESIDENT 9 In an observation on 07/30/2024 at 8:45 AM, Staff L, RN and Staff G, LPN, SDC/IP were passing medications on the South unit. The MARs on this unit had similar findings that showed the beginning letters of the medications missing for each resident's medication orders. <PHYSICIAN ORDERS> RESIDENT 27 Resident 27 admitted to the facility on [DATE] with diagnoses to include diabetes (medical condition in which the body doesn't use insulin properly), and protein calorie malnutrition. The quarterly MDS dated [DATE] showed the resident had intact cognition. In an interview on 07/25/2024 at 9:45 AM, Resident 27 stated that they have had a lot of episodes of diarrhea, and that they have talked to the nurse and the physician, but no one has done anything about it. Review of Resident 27's bowel monitoring record for 07/01/2024 - 07/30/2024 showed the resident had loose stool eleven times. Review of Resident 27's physician notes on 07/29/2024, showed the physician noted that the resident was having increased chronic diarrhea (loose stools), loperamide (anti-diarrheal medication) was advised to be administered, and there was an order to refer the resident to a gastrointestinal (GI) specialist. Review of Resident 27's physician orders showed an order for loperamide 2 mg, give one tab by mouth as needed for diarrhea and not to exceed 16mg in a 24-hour period. Review of Resident 27's MAR for 07/01/2024 - 07/30/2024 showed the resident had been administered the medication Loperamide, 17 times in the month of July. Review of Resident 27's medical record on 07/29/2024 showed documentation that the resident had been seen by a GI physician related to the chronic diarrhea. In an interview on 07/30/2024 at 10:37 AM, Staff K, LPN/Resident Care Manager (RCM) stated they believed Resident 27's diarrhea and loose stools were related to the medications that they were taking for their diabetes. Staff K was asked if there had ever been a GI consult completed, as the physician had noted that in their provider note on 05/29/2024. Staff K stated they were unaware of any consultation orders and would follow up. In an interview on 07/30/2024 at 10:57 AM, Staff A, DNS stated they were aware that the resident was having diarrhea and/or loose stools. Staff A stated they had contributed the diarrhea/loose stools to Resident 27 ordering and having take-out food delivered. Staff A stated they were not aware that the provider had ordered a consult for a GI referral in May 2024. In a follow up interview on 07/30/2024 at 11:34 AM, Staff K stated they were able to locate the order and stated it had not been completed as ordered. In a joint interview on 07/30/2024 at 12:09 PM Staff A, DNS and Staff B Clinical Resource Nurse/Registered Nurse (RN), Staff A stated that the expectation when the internet or power was out was that medical records would print off the MARs from the emergency backup, for the licensed staff to administer medications and follow the physician orders. Staff A stated that they originally had printed MARs for the staff the day before (07/29/2024), as there was a schedule eMAR outage that was to occur from 11:30 PM (07/29/2024) - 1:30 AM (07/30/2024). Staff A stated the outage was to only be for a few hours, however the internet went down so they used the same printed MAR they had printed out on 07/29/2024. Staff A stated they were not aware that the printed MAR that was given to the licensed staff did not have the full orders and the copies were cut off and missing various parts of the physician orders including parts of the names of the medications, the route, the dose, the duration, directions or reason for use. Staff A stated there was no other way to confirm the physician orders were accurate, and that staff should not have used the pharmacy labels to verify the orders. Staff B stated the physician orders should have been clear, accurate, up to date, and there should have been a system in place to verify the orders. Refer to WAC 388-97-1620(1)(2)(b)(i)(ii) Based on observation, interview and record review, the facility failed to ensure professional standards were met for 2 of 2 halls (North and South) reviewed for medication administration, and 1 of 1 (Resident 27) residents reviewed for physician consultations. The facility failed to ensure that the paper medication administration record (MAR) had the physician orders printed clear and complete to allow for licensed staff to properly administer the prescribed medications during an internet outage where the licensed staff were unable to access the electronic medication administration records (eMAR). The facility failed to ensure the licensed staff followed a physician order, and failed to obtain a specialist referral that was ordered by the physician. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs. Findings included . Review of the facility policy titled, Medication Management, revised 10/15/2022 stated medications are administered by staff as prescribed by the attending physicians or other licensed independent practitioner . licensed staff who administer medications are responsible for staying proficient in administering medication following evidenced-based practice guidelines . physician's orders are clear, legible, and transcribed appropriately. <MEDICATION ADMINISTRATION> NORTH HALL - RESIDENT 13 In an observation on 07/30/2024 at 8:50 AM, Staff D, Licensed Practical Nurse (LPN) and Staff J, Resident Care Manager were both working to pass medications on the North Hall. Staff D flipped through the Medication Administration Record (MAR) binder and Staff J would look at the orders before punching the medications out of the card. Staff D said that they had an internet issue and had to resort to printed out MAR's instead of an electronic medical record (EMR). Staff D said whoever printed out the MAR's printed them, but it cut off the first letters of each medication. At 8:55 AM Staff J dispensed Miralax 17 GM (gram) in a glass of water. Review of the MAR showed the medication Lax powder Miralax 17 GM in 8 oz (ounce) water. Staff J dispensed Spironolactone 25 MG (milligram) when the MAR indicated onolactone 25 MG to be given. Staff J administered Iptropium Bromide Monohydrate 18 micrograms (MCG), the MAR showed opium Bromide Monohydrate Similar observations were Vitamin C card as min C, Xaban for Apixaban, Sate Sodium for Docusate sodium, gabalin for Pregabalin, bicort for Symbicort, and Sorbide for Isosorbide. At 9:00 AM, Staff J and D reviewed the MAR which read Semide 60 MG Staff J located a card that showed the medication Torsemide. This surveyor asked how they knew the medication was Torsemide and not Furosemide. Staff G, LPN/IP (infection preventionist) was present at the medication cart and said, Well the Torsemide card says it was for CHF (congestive heart failure). Staff G said the facility knew there was going to be a scheduled EMR outage so they printed the MARS yesterday but whoever printed them, printed them incorrectly so the first few letters were absent. Staff D and G said the MARS were only incorrectly printed for Resident 13. Staff G said the person who printed the MARS should have set up the printer as print to screen so the entire medication orders were clear. Staff G said there were not physician orders printed for them to verify the orders. Staff G said they understood the accuracy of the MARS should have been verified before they were put out for the nurses. Torsemide 60 MG was dispensed and administered to Resident 13 with the only means of verifying the order as the pharmacy card. In an interview on 07/30/2024 at 12:28 PM, Staff A, Director of Nursing Services and Staff B, Resource Nurse were informed of the concerns with Resident 13's med pass this AM. Staff A did not know there was an issue with the nurses not knowing how to correctly print out MARS. Staff A said medical records printed them out but did not select the box for print to page. Staff A and B said they would in-service the nurses on being able to print MARS. They were not aware this issue until today.

Based on interview and record review, the facility failed to ensure Nursing Assistants Certified (NACs) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 5 of 5 sampled staff (Staff H, I, Q, R, and S) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Employee Orientation, dated 11/28/2017 stated that the facility will validate nurse aide's competency in skills and techniques. Review of the facility assessment under the title Sufficiency analysis summary, dated 07/26/2023-07/25/2024, for resident population stated that education was provided through the orientation process, monthly competencies, and annual skills fairs. Monitoring of competencies was accomplished through senior leader rounding, mentoring program, return demonstration during monthly skills check, and staff coaching (mentorship program). Staff H, NAC, was hired by the facility on 02/22/2017. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff I, NAC was hired by the facility on 08/04/2023. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff Q, NAC was hired by the facility on 01/10/2023. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff R. NAC was hired by the facility on 11/10/2021. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff S, NAC was hired by the facility on 11/11/2022. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. In an interview on 07/26/2024 at 1:24 PM, Staff B, Registered Nurse/Clinical Resource Nurse stated the facility had not been completing competencies for their staff and they were unable to locate competencies for the five staff requested. In an interview on 07/30/2024 at 12:09 PM, Staff A, Director of Nursing Services stated that the Infection preventionist/Staff Development Coordinator role was responsible for completing competencies for all nursing staff. No further information was provided. Refer to WAC 388-97-1680(2)(a)(b)(i-ii)

Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 2 nurses (Staff D, Licensed Practical Nurse) during medication administration, for 1 of 1 laundry room, and failed to review and revise their infection control program annually. The facility failed to ensure the staff followed appropriate infection control practices during medication administration when the licensed staff did not use a barrier during medication administration or perform hand hygiene prior to administering medications. The facility failed to have a system in place where the staff were knowledgeable, trained and able to initiate appropriate processes for the handling of potential contaminated linens to prevent cross contamination. These failures placed all residents and staff at risk for potential infection. Finding included . Review of the facility policy titled, Infection Prevention and Control Program, revised 10/15/2022 stated the infection control prevention and control program was designed and implemented to identify and reduce the risk of acquiring and transmitting infections among residents, and staff. It was to maintain a safe and sanitary environment that involves all departments .the program will be reviewed at least annually and revise the infection control risk assessment when opportunities for improvement are identified . develop staff training and protocols to prevent the spread of infection. Review of the facility policy titled, Medication Management, revised 10/15/2022, stated authorized staff follows appropriate infection control practices when preparing and administering medications such as hand hygiene, and the use of barriers are utilized to promote infection prevention practices. <MEDICATION ADMINISTRATION> In an observation on 07/30/2024 at 8:28 AM, Staff D, Licensed Practical Nurse (LPN) entered the room of Resident 10 and placed an insulin (medication injected into the skin to regulate blood sugar levels) pen on the resident's bed on top of their blanket that was covering their body. Staff D then placed the nasal spray bottle and medication cup on top of the over the bed table next to the resident's food tray, no barriers were used. Staff D then administered the medications that were in the medication cup by placing medication cup at the resident's mouth and pouring in the pills with a bare hand, no hand hygiene was observed. Staff D then placed the medication cup back on the over the bed table and with a bare hand picked up the nasal spray and applied one squirt of medication spray into each nostril, placed the bottle back on the over the bed table, no hand hygiene was observed. Staff D then placed a pair of gloves on their hands, no hand hygiene was observed, lifted the shirt of the resident to expose their stomach, grabbed the insulin pen from the bed, wiped the skin with alcohol wipe and administered the injectable medication. Staff D then walked into the resident's bathroom, removed needle cap and disposed in an appropriate disposal bin, removed their gloves, no hand hygiene was performed. Staff D retrieved nasal spray from the over bed table and walked out of the room. Staff D walked to the medication cart placed nasal spray bottle and insulin pen on top of the medication cart, then performed hand hygiene. In an interview on 07/30/2024 at 8:34 AM, Staff D was asked if they were supposed to use a barrier when entering a resident's room with medications. Staff D stated I didn't use one, I forgot, and I should have. Staff D was asked about hand hygiene and stated they did when the left the room. Staff D did not offer any further information. <LAUNDRY PROCESSING> In an observation and interview on 07/30/2024 at 9:13 AM, Staff O, housekeeping attendant was observed to answer the door with sign that read soiled linen. Staff O was wearing an isolation gown and gloves. Staff O stated they were sorting and loading dirty linen. Staff O stated they used the soiled linen door side to enter the laundry room. Upon entering the door, the door was unable to open all the way as there were sorting bins behind and in front of the door. The flooring in the laundry room was observed to have numerous brown stains, and missing pieces of linoleum on the floor. The washing machines were observed to have thick dust and debris on top and the sides of the machines. Staff O stated they tried to periodically wipe the machines down when they had time, they stated there was no set time or procedure for wiping the machines down. Staff O was asked if they wiped the machines down between loads, and Staff O stated that was not what they were educated to do. The marked area for clean linen was very small area. The table where the clean linen was to be folded had only about 18-inch area to work in, as there was a large pile of clothes laying on top of most of the table. There were two laundry baskets full of clothes and linens, one basket was up against the clean linen door. Staff O stated, I don't really have any room in here, and all the piles of clothes are unlabeled, and they must find somewhere to put them. In an interview on 07/30/2024 at 10:38 AM, Staff P, Housekeeping Manager was asked what the process was for clean and disinfecting the washing machines between loads. Staff P stated they were not aware of any procedure. Staff P stated they were just promoted to the role of manager less than a month ago and had not had any training on infection control prevention policies and procedures for ensuring there was no cross contamination of infections through the washing process. <INFECTION CONTROL STANDARDS> Review of the facility policies and procedures for infection prevention and control on 07/26/2024 showed that all the policies and procedures requested had not been revised since October of 2022. In an interview on 07/30/2024 at 10:13 AM, Staff G, LPN/Infection Preventionist stated they were responsible for educating the staff on infection control practices at the facility. Staff G stated the expectation for licensed staff during medication administration was they should be performing hand hygiene appropriately, and always use a barrier for all items taken into the room to administer medications. Staff G stated they had not conducted any risk assessment or review of the infection control practices in the facility. In an interview on 07/30/2024 at 11:03 AM, Staff B, Registered Nurse (RN)/Clinical Resource Nurse stated they were trying to locate a risk assessment and review of the infection control practices. Staff B stated if they did not locate one, more than likely they did not have one. Staff B was unable to locate any information. In an interview on 07/30/2024 at 12:09 PM, Staff A, Director of Nursing Services stated that the expectation for all licensed staff performing medication administration was they were to use a barrier for all items brought into the resident's room. Staff A stated they were unaware that Staff P had not had any training for their new position as housekeeping manager, and that Staff P was unaware of the infection control practices related to laundry and processing of linens. Staff A was unaware that the infection control program and risk assessment of the facility had not been completed annually. Staff A stated Staff G was responsible for managing the infection control program and overseeing that all staff are educated and demonstrating proper infection control practices. Refer to WAC 388-97-1320(1)(a)(c)(2)(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident with diabetes mellitus 2 (DM- a medical condition in which the body doesn't use insulin properly), received care and services needed to manage their blood glucose (BG - the amount of concentrated sugar in the blood) for 1 of 4 sampled residents (Resident 1) reviewed for diabetic management. This failure place other residents at risk for unmet care needs and medical complications. Findings Included . Review of the facility policy titled, Diabetes Mellitus, Guidelines for Management, revised 08/01/2023, documented the goal was to quickly restore normal cerebral function, prevent hyperglycemia (high BG) or hypoglycemia (low BG), recognize, treat, or prevent complications commonly associated with DM. Nurses were directed to document the resident's BG levels and frequency measured per physician orders, notification of the physician of the change in condition and/or diagnostic results, notification of family/responsible party of change in condition and update the resident care plan as necessary. Resident 1 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), aortic stenosis (narrowing of the valve in the large blood vessel branching off the heart), DM Type 2. Review of the Quarterly Minimum Data Set (MDS- an assessment tool), assessment, dated 06/20/2024, showed Resident 1 was assessed to have a Brief Interview for Mental Status (BIMS - a structured cognitive interview) of a 15 out of 15 indicating they were cognitively intact. Review of Resident 1's care plan, dated 12/20/2023, showed they had DM with a goal of no complications through the review date of 12/13/2024. Interventions included: - Administration of diabetic medications as ordered by the physician and to monitor/document side effects and effectiveness. - If hypoglycemic (their BG was below 70), treat per the hypoglycemic protocol and document treatment interventions/symptoms/assessment in the progress notes. - Monitor/record/report to the physician as needed any signs/symptoms of hypoglycemia including sweating, tremors, tachycardia, pallor, nervousness, confusion, slurred speech, lack of coordination, or staggering gait. There were no interventions for the nursing aides to follow related to Resident 1's diagnosis of DM type 2, and no documentation the resident used a continuous BG monitoring system. Review of the facility incident report dated 07/02/2024, showed Resident 1 was interviewed and voiced being fearful during the hypoglycemic episode on 06/03/2024. The facility incident report also showed that Resident 1's physician was notified of their hypoglycemic episode, that occurred on 06/03/2024, on 6/29/2024 (26 days after it occurred) which resulted in changes in Resident 1's insulin order. In an interview on 06/27/2024 at 9:50 AM, Resident 1 stated they had an episode of low BG sometime in the beginning of June 2024 starting around 2:00-2:30 AM. Resident 1 stated their BG monitor was beeping to alert them their BG was low. Resident 1 stated they got out of bed by themselves because no one was responding to the beeping of their monitor. Resident 1 stated they looked at the monitor, and their BG was very low at 47 milligrams per deciliter (Mg/dL - a normal BG range is 70-99 Mg/dL). Resident 1 stated they were awoken by the alarm on the machine and alerted them to their low BG. Resident 1 stated they had their call light on for a while and no one answered it, they waited an additional 15 minutes, and decided that they needed help. Resident 1 stated they were confused, out of breath (winded), sweating, and had a headache. Resident 1 stated they wheeled themselves in their wheelchair to the nurse's station, without the use of their oxygen. Resident 1 stated the nurse was at the nurse's station and they felt their BG was even lower at that point. Resident 1 stated they were feeling weak, the nurse wheeled them back to their room and got them juice and a peanut butter and jelly sandwich. Resident 1 stated that it took a while, about an hour, for their BG to return to an acceptable range. Resident 1 stated the incident aggravated them because they jeopardized my life. Review of Resident 1's progress notes from 06/01/2024 through 06/28/2024 showed no documentation the resident had low BGs levels on 06/03/2024. Review of Resident 1's June 2024 Medication Administration Record (MAR), showed an order, dated 11/30/2023, for the resident to have their BG checked daily at 3:00 AM if they had received a corrective (sliding scale) insulin dose in the evening. On 06/03/2024 at 5:30 AM, Resident 1's BG was documented as 118 Mg/dL. Resident 1's MAR showed they used a continuous BG monitoring system. Resident 1's MAR for June 2024 showed that none of the above orders were marked as being utilized on 06/03/2024. Review of Resident 1's MAR dated June 2024, showed the resident had orders in place if they experienced hypoglycemic symptoms which included: - Ordered on 11/28/2023, for the nurse to check their BG as needed for hypoglycemic or hyperglycemic symptoms (shakiness, sweating, headache, nausea, confusion). If their BG was less than 70, initiate the facility's hypoglycemic protocol and notify the doctor as indicated. If their BG was more than 300, notify the doctor and follow directives for hypoglycemic/hyperglycemic symptoms. - Ordered on 11/28/2023, for the nurse to follow the hypoglycemia protocol as needed for hypoglycemia. If their BG less than 70 Mg/dL and the resident was able to take food/drink by mouth staff were to follow the 15/15 rule. The 15/15 rule was 1)give 15 grams (gm) of a fast acting carbohydrate, 2) recheck the resident's BG in 15 minutes, 3) if the BG was still less than 70, give another 15 gm fast acting carbohydrate, 4) recheck second BG in 15 minutes, if not above 70, give additional 15 gm quick carbohydrate and notify the physician for further orders and 5) once above 70, provide a protein snack or assist to next meal. - Ordered on 04/12/2024, for the nurse to give Glucose Oral Gel 77.4 percent (%), give 20 grams by mouth as needed for the hypoglycemia protocol. May repeat in 15 minutes if hypoglycemia persisted. In an interview on 06/28/2024 at 11:45 AM, Staff C, Licensed Practical Nurse (LPN), stated they could not recall if they received report that Resident 1 had a low BG at the beginning of June 2024. Staff C stated if a resident experienced a low BG episode, there was a protocol that was required to be followed which included providing something for the resident to eat and/or providing the ordered interventions. Staff C stated if a resident had low BGs and interventions were provided, the expectation was that it would be documented in the resident's clinical record. Staff C stated Resident 1 used a continuous BG monitoring device that provided continuous monitoring of their BG levels. Staff C stated Resident 1's device stayed in their room, and they thought the device kept a record of resident's past BGs. When asked to show the record for 06/03/2024 from Resident 1's device, they were not able to locate it and stated they would have to search the internet to find out how to obtain it. In an interview on 06/28/2024 at 11:47 AM, Staff D, Nursing Assistant Certified (NAC), stated they worked the evening/overnight shifts routinely. Staff D stated they could not recall the day, but around 5:00 AM the nurse alerted them while on break that Resident 1 had low BG levels, but they had taken care of it. Staff D stated they had informed the nurse and the other aide they were going on break. Staff D stated when Resident 1's glucose monitoring device beeped, they informed the nurse. Staff D stated they did not finish their break, checked in on Resident 1 who was eating in their room, and checked their BG monitor, however, could not recall the reading. In an interview on 06/28/2024 at 12:00 PM, Staff B, Registered Nurse (RN)/Director of Nursing [NAME] (DNS), stated Resident 1 had not shown any low BG per the MAR on 06/03/2024. When asked about the continuous glucose monitoring system Resident 1 utilized, Staff B stated they had not cross referenced the history of the device with the documented BG in the medical record. On 06/28/2024 at 12:15 PM, Staff A, Administrator, stated they did not have a policy or procedure on how to use/gather information from Resident 1's continuous BG monitoring system. Staff A accessed Resident 1's BG monitoring system history which showed Resident 1 had BG below 70, as low as 50, during the early morning of 06/03/2024 from approximately 2:00 AM until 5:00 AM. In an interview on 07/01/2024 Staff E, LPN, stated Resident 1 had experienced low BGs levels on and off and they had woken them up on a semi-regular basis to have them eat/drink something. Staff E stated they always checked Resident 1's BG at 3:00 AM and rechecked them at the end of their shift. Staff E stated Resident 1's BG levels had dropped into the 50's-60's at times, when it happened, they assessed the resident and asked how they were feeling. Staff E stated when Resident 1's BG were around 112 Mg/dL, they were on high alert for the resident and any changes in their BG. Staff E stated if Resident 1's alarm had been going off after the 3:00 AM check, they would have done a recheck of their BG and documented the information in the resident's clinical record. Staff E stated they were the nurse on 06/03/2024 when Resident 1 had low BG levels and they recalled the resident's BG had been in the 60's around 5:00 AM. Staff E stated they were at the nurse's station when Resident 1 had wheeled themselves to the nurse's station, they made them eat a peanut butter and jelly sandwich and drank a glass of milk. Staff E stated they did not notify the physician, had thought they placed the resident on alert, and gave report to the oncoming nurse but should have documented the resident's low BG in the nursing progress notes. Staff E stated they were in and out of Resident 1's room throughout the night as their roommate required medications and care. Staff E stated they checked the resident's BG at 3:00 AM. When asked about the printout from Resident 1's glucometer for 06/03/2024, Staff E stated they would have heard the glucometer alarm and must not have. Staff E stated they had read the paperwork that came with the BG monitors, and it was available to all the nurses at the nurse's desk. Refer to WAC 388-97-1060 (1)(2)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure behavioral health needs were identified and met for 1 of 1 resident (Resident 2) reviewed for behavioral-emotional health. Failure to identify behavioral health needs and utilize person-centered interventions developed by an interdisciplinary team (IDT) placed residents with behavioral needs, at risk for unidentified behavior triggers, unmet behavioral needs, refusal of care, self-neglect, lack of behavioral services and support, loss of dignity, and diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses to include hip fracture, leukemia, chronic pain, anxiety disorder, and adjustment disorder with depressed mood. Review of the Discharge summary dated [DATE], for the hospital stay from 03/24/2024 through 04/03/2024, showed Resident 2 had significant post operative disorientation, agitation, somnolence, and confusion. The summary noted this improved with the reduction of polypharmacy (taking five or more regular medications). The discharge exam showed Resident 2's mental status was alert and oriented to person, place, and time. The psychiatric section showed Resident 2's mood and affect were not dysphoric (very unhappy, uneasy, or dissatisfied). Resident 2's behavior was not inappropriate, and they did not exhibit disordered thought content. Review of the Nursing Clinical Evaluation Summary progress note, dated 04/03/2023, showed Resident 2 was pleasantly confused. Resident 2 had some post-op delirium that was gradually improving. Resident 2 rated their pain at an eight out of ten, on the zero (no pain) to ten (severe pain) pain scale. Review of the Nursing Health Status Note, dated 04/04/2024, showed Resident 2 was confused, alert and oriented to only self. Resident 2 was continuously taking off their clothing and incontinent brief on the night shift. Review of Collateral Contact (CC) 3, Medical Doctor, progress note, dated 04/05/2024, showed Resident 2 had post operative delirium and the staff noted Resident 2's mentation waxed and waned. The physical exam section noted the resident was alert and oriented x 4 (person, place, time, and event), and mood and affect were appropriate. No behavioral health symptoms were addressed. Review of the admission Minimum Data Set (an assessment tool) assessment, dated 04/09/2024, showed the mood assessment had a total severity score of two indicating minimal level of depression. Resident 2's behaviors of verbal and other behavioral symptoms occurred on one to three days of the seven-day assessment period and no rejection of care was coded. Review of the Behavioral Symptoms Care Area Assessment (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned), dated 04/09/2024, showed Resident 2 had behaviors toward staff and behavior monitoring was in place. Long standing mental health problems associated with behavioral disturbance such as anxiety disorder, depressive disorder, pain, diabetes, and infection were noted that could cause behavior problems. Resident 2's behavioral symptoms were noted to be addressed in Resident 2's care plan to minimize risks. Review of the Psychotropic Drug Use CAA, dated 04/09/2024, showed Resident 2 received two antidepressants. The resident's diagnoses were noted to be depression, anxiety, and adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior). Resident 2's psychotropic drug use would be addressed in the care plan due to the resident's diagnoses and treatments and the resident's behaviors were monitored. Review of Resident 2's current Care Plan showed the following focused behavioral health and psychotropic medication problems and associated interventions: • Use of antidepressant medication related to depression and adjustment disorder initiated on 04/09/2024. Interventions included to administer the physician ordered medication and monitor and document effectiveness and potential side effects. • Use of hypnotic medication or sleep enhancing supplements related to sleep apnea initiated on 04/09/2024. Interventions included to use non-pharmacological person-centered interventions and to give medications as ordered and monitor/document effectiveness and potential side effects. • Resident 2 had impaired cognition related to post surgical delirium evidence by yelling out, resistive to care, impulsive and disrobing initiated on 04/10/2024. Interventions included to use Resident 2's preferred name, reduce any distractions, keep the resident's routine consistent, monitor/document and report any changes to the physician, specifically changes in decision making, memory, recall, awareness, difficulty understanding others, level of consciousness and mental status. Use of a white board to reorient Resident 2 to place and time. Review of Resident 2's April 2024 Medication Administration Record and Treatment Administration Record, dated 04/03/2024 through 04/25/2024, showed the following: <Psychotropic and Narcotic Medications and Monitoring> • Trazadone (an antidepressant and sedative) 100 mg daily for adjustment disorder. • Bupropion hydrochloride (HCL), an antidepressant, 75 mg two times daily for adjustment disorder with depressive mood. • Prochlorperazine (an antiemetic and antipsychotic) 5 mg every six hours as needed for nausea- two doses. • Oxycodone HCI (a narcotic) 5 mg every four hours as needed for pain due to hip fracture and surgery - 77 doses. • Non-Pharmacological interventions prior to as needed pain medications - zero interventions were documented. • Observed for side effects of psych/behavioral medication - 13 episodes of restless agitation, no indication the provider was notified. • Observed for side effects of opioid medication - 12 episodes of restless agitation no indication the provider was notified. <Behavioral Health Monitoring began on 04/08/2024> • 2 days of depressive statements. • 12 days of refusal of care. • 8 days of withdrawal with activities. • 4 days person centered interventions were effective. Review of Resident 2's Nursing Assistant Certified (NAC) documentation report, from 04/03/2024 through 04/29/2024, showed the following: • 11 episodes of depressive statements. • 32 episodes of disrobing. • 25 episodes of resistance to care. • 33 shifts of behavioral symptoms. Review of Nursing Progress Notes, from 04/03/2024 through 04/25/2024, consistently showed Resident 2 was alert, confused, and oriented to person. Resident 2 remained confused and had incidents of restlessness, attempts of getting out of bed independently, and disrobing. Review of a Nursing Progress Note dated 04/10/2024 at 2:17 PM, showed Collateral Contact (CC) 4, Advanced Registered Nurse Practitioner (ARNP), was notified of Resident 2's episodes of restlessness and would be assessed today. No provider notes were completed on 04/10/2024. Review of CC 4's progress note, dated 04/12/2024, showed a follow up visit which noted Resident 2 was slowly progressing with rehabilitation. Resident 2 was noted to be alert and oriented to person, place, time and event with no focal neuro deficits and appropriate mood and affect. No behavioral health concerns were noted or addressed. Review of CC 4's progress note, dated 04/15/2024, showed Resident 2 was alert and oriented to person place time and event, no focal neurological deficits, mood, and affect were appropriate. No behavioral health concerns were noted or addressed. Review of CC 5, ARNP, progress note, dated 04/17/2024, showed Resident 2 had complaints of nausea and sleepiness. No behavioral health concerns were noted or addressed. Review of CC 5's progress note, dated 04/22/2024, showed Resident 2 was seen for a trending low potassium level. Resident 2 was uncomfortable and restless lying in bed. Resident 2 endorsed discomfort and irritability. The resident's potassium was discussed. No additional concern reported by nursing staff today. No behavioral health concerns were noted to be addressed. Review CC 4's progress note, dated 04/24/2024, showed Resident 2 was alert and oriented to person, place, time, and event. Resident 2 was noted to be cooperative and had appropriate mood and affect. No behavioral health concerns were noted or addressed. In a phone interview on 04/25/2024 at 10:35 AM, CC 2, Resident 2's friend, stated they had known Resident 2 for the past 15 to 20 years. CC 2 stated they had spoken with Resident 2 on 04/24/2024, in the middle of the afternoon and Resident 2 had soiled themselves. CC 2 stated Resident 2 reported they had called for over an hour and no one came to help them. CC 2 stated it seemed like a long time since Resident 2 fell, had surgery, they were still not able to put full weight on their leg so far, and they were not up walking. In an observation and interview on 04/25/2024 at 2:30 PM, Resident 2 was lying in bed with only an incontinent brief that appeared to be wet with ripped up pieces scattered on the bed and the floor. Resident 2's call light was lying on the floor between their bed and the south wall of their room. The resident's bed did not have any sheets in place and the resident was without bed coverings. Resident 2 stated they had been laying there for hours and had called and yelled for help and nothing happened. Resident 2 stated the staff had come into their room that morning around 10ish. Resident 2 stated they would like to turn over but could not and could not find their call light. In an interview on 04/25/2024 at 3:12 PM, Staff E, NAC, stated they did not get report when they came onto shift. Staff E stated the facility had a staff meeting at 2:30 PM and then they had passed water. Staff E stated Resident2 was usually first on their list of residents to check on. Staff E stated they had found Resident 2 lying in their bed, which was wet, and had particles of their incontinent brief on the floor. Staff E confirmed that Resident 2's call light was on the floor when they entered the resident's room. Staff E stated they usually would find Resident 2 in a similar state and would let the nurses know. Staff E stated behavioral interventions were in the electronic documentation system. Staff E was asked about Resident 2's person centered behavioral interventions. Staff E stated the behavioral interventions were very vague, like reapproach. In an interview on 04/26/2024 at 3:33 PM, Staff F, Social Services, was asked their involvement in the facility's residents' behavioral health care. Staff F stated they would check with residents, if a resident was having problems, they would set up the resident's behavior monitor and would complete a progress note. Staff F stated they reviewed residents' refusal of care every morning, Monday through Friday and on Mondays they completed a 72-hour review. Staff F stated Resident 2 had a care conference on admission and today. Staff F stated they had only implemented the behavioral health interventions for Resident 2 after the care conference today. Staff F stated they had spoken with Resident 2, who stated they were not refusing care and did not remember refusing care. Staff F stated they had notified the nursing staff. In an interview on 04/26/2024 at 3:42 PM, Staff G, Licensed Practical Nurse/Resident Care Manager, stated in a way Resident 2 had been set in their ways. Staff G stated Resident 2 would state they were in pain, but they did not exhibit nonverbal signs of pain. Staff G stated as time progressed since Resident 2's admission, Resident 2 was not letting the staff assist them to dress or get up out of bed. Staff G stated Resident 2 did not want to keep their cloths on. Staff G stated they kept reapproaching, offering a fresh face, and they would educate Resident 2 on the risk and benefits of being clean and dry. Staff G stated their interventions should be documented in the resident's chart. Staff G stated Resident 2 refused all kinds of care every day. Staff G stated they thought a behavioral health referral was initiated after Resident 2's care conference. Staff G stated they had not assessed if Resident 2 had a history of this type of behavior. Staff G stated they had let Resident 2's providers know that they were refusing care and they had told them to keep reapproaching and educating the resident. Staff G stated reapproaching and educating the resident would eventually work. In an interview on 04/26/2024 at 3:54 PM, Staff H, Physical Therapist Assistant, stated Resident 2 was very challenging to get to participate in therapy. Staff H stated they would approach the resident two to three times a day but Resident 2 was adamant they did not want to do anything. Staff H stated Resident 2 had minimal participation in therapy. Staff H stated Resident 2 reported that they were in a lot of pain and had complained of a lot of nausea. Staff H stated anytime Resident 2 refused therapy they would talk with the nursing staff about the resident's refusal, level of pain, and complaints of nausea. Staff H stated they would check with the nursing staff to see when Resident 2 had their pain medications and sometimes would get assistance from the NAC staff to help get Resident 2 up out of bed. In an interview on 04/26/2024 at 4:29, Staff I, Physical Therapist, stated they had a meeting every morning and would discuss Resident 2's behaviors. Staff I stated they would read what happened the day before and discuss what they could do to help the resident. Staff I stated they discussed Resident 2's medication, the resident's nausea, vomiting, and they were unaware if anything had been changed. Staff I stated they had mentioned to try to monitor Resident 2's behaviors. Staff I stated Resident 2 would call out, sometimes would undress, their cognition was really off. Staff I stated as soon as Resident 2 would sit up, the resident would say they had enough for the day and decline the rest of therapy. Staff I stated they would try again another day and try different things with Resident 2 but Resident 2 would decline. Staff I stated Resident 2 would vomit just seeing the medication prior to taking their medication. Staff I stated Resident 2 had been independent in the community before they fractured their hip. Staff I stated maybe Resident 2 had a reaction to the anesthesia when they had their hip surgery. In an observation on 04/26/2024 at 4:53 PM, Resident 2's door was open, and the resident was visible from the hallway. Resident 2 was lying in bed uncovered and undressed. In an observation and interview on 04/29/2024 at 11:27 AM, Resident 2 was lying in bed uncovered with only an incontinent brief. Resident 2 stated they were sick to their stomach. Resident 2 stated they were nauseated over the weekend. Resident 2 stated the staff wanted them to do things they were not capable of doing. Resident 2 stated they were unable to sit up in a chair for over an hour. Resident 2 stated the staff wanted them to eat their meals in the dining room but when they would ask the staff to take them back to their room the staff would tell them they did not have time to do that. Resident 2 stated that they did not participate with therapy because it was uncomfortable and hurt. Resident 2 stated they were not a wuss, but the staff wanted them to do things that were very painful. Resident 2 stated they had cancer, and they were supposed to go to the cancer center but had not. Resident 2 sated they were left to use their incontinent brief to go to the bathroom and had to wait for the staff to come clean them up. Resident 2 stated half the time they did not sleep, the other night a NAC came into their room around 2:00 AM and asked them what they were doing. Resident 2 stated they told them they were lying there, and the NAC told them to go to sleep. Resident 2 stated they used to be happy and in a good mood ready to do things, wanted to go places and was nothing like that now. In an interview on 04/29/2024 at 1:13 PM, Staff B, Director of Nursing Services, stated Resident 2 had post anesthesia delirium. Staff B stated Resident 2 had some refusals and periods where they would be hot, then would be cold and would take off their clothes. Staff B stated they had been working with Resident 2's provider and had notified the resident's power of attorney. Staff B stated they had identified Resident 2's refusals and they had been combative with care. Staff B stated Resident 2's behavioral interventions were to give them space and to reapproach which was the most effective. Staff B stated they had notified Resident 2's providers of the resident's delirium, and the providers were on the same page of reapproaching the resident. Staff B stated they had been monitoring Resident 2's behaviors and using their approaches. Staff B stated they recognized Resident 2 needed more behavioral support. Refer to WAC 388-97 1060 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure pharmacy services were provided to meet the residents needs for 3 of 4 residents (Resident 1, 2, and 3) reviewed for new admissions. The facility's failure to ensure medications were acquired and administered as ordered on the day of admission and the facility's failure to follow their process for when medications were not available placed residents at risk of diminished quality of health and diminished quality of life. Findings included . Review of the facility's in-service titled, Education: admission Medications, initiated on 03/18/2024, showed when a resident admitted to the facility, make sure to go through all the proper channels to ensure delivery of the resident's medication. 1) Fax new orders to the pharmacy, 2) If orders have not yet arrived, pull the medication from the Cubex (modular medication dispensing machine), 3) If the medication was unavailable in the Cubex, call the pharmacy to have the medications satellited to the facility, 4) Always give over the counter medications. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE], with diagnoses to include aftercare for heart bypass surgery, anxiety, and depression. Review of a faxed prescription for tramadol (opiate narcotic pain medication) 50 mg (milligram) three times daily was signed by the discharging hospital provider for Resident 1. The fax was scanned and noted to be received by the facility on 04/17/2024 at 12:57 PM. Review of Resident 1's discharge summary orders, dated 04/17/2024, showed tramadol HCI 50 mg was to be given three times daily. Review of admission Summary progress note, dated 04/17/2024 at 1:22 PM, showed Resident 1 was admitted to the facility. Review of the care plan dated 04/17/2024 showed Resident 1 had acute pain related to their incision after their bypass heart surgery. The interventions included to give medication as ordered. Review of Resident 1's Medication Administration Record (MAR), dated 04/17/2024 through 04/26/2024, showed the following information: - On 04/17/2024 evening shift their pain was rated at an eight on a zero (no pain) to 10 (Severe pain) pain scale. - There was no tramadol administered on 04/17/2024 to treat the resident's reported pain. - Tramadol 50 mg three times daily was started on 04/18/2024 at 9:00 AM. In a co-interview on 04/26/2024 at 2:40 PM, Collateral Contact 1, Resident 1's family member, stated on the first day Resident 1 was admitted to the facility there was a problem with Resident1's medication, tramadol. Resident 1 stated they were supposed to get their medications and the nursing staff stated the order was not on the chart, then they said they had to call the doctor. Resident 1 stated finally at 3:00 AM, they received their tramadol. Resident 1 stated it was pretty painful to not receive their pain medication. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnoses to include diabetes (serious condition where your blood glucose level is too high) and leukemia (a cancer of the blood). Review of Resident 2's MAR, from 04/03/2024 through 04/25/2024, showed an order for Steglatro for diabetes to start on 04/04/2024. The documentation for the administration of the Steglatro was blank on 04/04/2024 and 04/05/2024 for the scheduled 8:00 AM dose. Resident 2's MAR, from 04/03/2024 through 04/25/2024, showed an order for Imatinib Mesylate, one time a day related to leukemia, to start on 04/04/2024. On 04/04/2024 the 8:00 AM dose was coded NN. The key at the end of the MAR showed NN was a code for Other / See Nurse Notes. Review of Resident 2's progress note, dated 04/04/2024, showed, Held Imatinib this A.M. r/t (related to) pharmacy needed prior authorization r/t high cost. Medication approved by CEO (Chief Executive Officer) today. <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with a diagnosis to include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of Resident 3's MAR, dated 04/11/2024 through 04/29/2024, showed an order for carbidopa-levodopa (a medication for Parkinson's disease) three times daily. The MAR showed the carbidopa-levodopa medication was not administered until the morning of 04/12/2024. In an interview on 04/26/2024 at 4:05 PM, Staff A, Licensed Practical Nurse/ Staff Development Coordinator, stated when they received a new resident admission, the orders were faxed over from the admitting facility and then they were faxed to the pharmacy. Staff A stated two nurses checked the orders and the orders were activated after the two nurses have completed the medication checks. Staff A stated they faxed the orders to their contracted pharmacy and would receive the medication either at 6:00 PM or 3:00 AM, depending on when they faxed the orders to the pharmacy. In an interview on 04/29/2024 at 12:16 PM, Staff A , stated Resident 1's tramadol was given on 04/18/2024 but was not documented as administered on the electronic medical record (EMR). Staff A stated they were starting education with the nurses on ensuring there was documentation on the EMR of medication administration. Staff A stated Resident 1's medication arrived at the facility at 3:00 AM, and Resident 1 was given their tramadol at 3:20 AM on 04/18/2024. Staff A stated they had started education with the nurses on 03/18/2024 on a lot of different things including on medication training after they had notice the residents needed to get their medication in a better fashion. In an interview on 04/29/2024 at 1:13 PM, Staff B, Registered Nurse/Director of Nursing Services, stated they were not 100% sure why Resident 1 and Resident 2 medications were not administered timely. Staff B stated they provided education to the staff each time a resident does not receive their medication on admission. Staff B stated that when they received information on an admission, they processed the resident's orders super-fast, and it could have been that they were Refer to WAC 387-97-1300(1)(b)(i)(ii)

Based on observation, and interview, the facility failed to provide a clean and sanitary environment for 1 of 1 residents' shower room. This failed practice decreased Resident 4's desire to bathe, did not promote a clean and comfortable environment for the residents to be bathed and placed the residents at risk of a diminished quality of life. Findings included . In an interview on 04/29/2024 at 11:43 AM, Resident 4, stated the shower room was filthy. Resident 4 stated the grout was black and the tub was filthy. Resident 4 stated it was just awful and they did not like to take a shower. Resident 4 stated if the shower room was cleaned, they would like to take a shower every three days but as it was, they would rather have a bed bath than take a shower in the shower room. In an observation and interview on 04/29/2024 at 11:37 AM, Staff C, Nursing Assistant Certified, stated they wiped the shower stall down with sanitizer wipes after each resident was showered. Staff C asked about the observed black debris on the threshold directly in front of the shower stall and the black debris on the north wall of the shower room next to the shower stall. Staff C stated the black debris just stayed there. Staff C stated housekeeping cleaned the shower room weekly. Staff C stated the tub did not work when asked about the debris in the tub. In an observation and interview on 04/29/2024 at 1:06 PM, Staff D, Housekeeping, stated they sanitize the surfaces in the shower room. Staff D stated they thought the building was old when asked about the dark debris in front of the shower stall. Staff D stated the dark debris on the threshold of the shower stall was built up grime. Refer to WAC 388-97-3220(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 1) reviewed for respiratory care and services was provided care consistent with professional standards of practice. The facility failed to ensure there was a physician order in place prior to administering a continuous positive airway pressure (CPAP) machine (a medical device that provides pressurized air) was set to the ordered flow rate. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs, diminished quality of life and negative outcomes. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include congestive heart failure (condition when the heart does not pump enough blood), cardiac arrest (heart attack), and chronic obstructive pulmonary disease (inflammatory lung disease). Review of hospital Discharge summary, dated [DATE], showed no orders or treatments for a CPAP machine. Review of Resident 1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), for 02/09/2024 through 02/12/2024, showed no orders to administer the CPAP machine. Review of Resident 1's care plan, dated 02/10/2024, showed Resident 1 had a potential for alteration in respiratory status and with an intervention to use a CPAP machine and referred to the administration record for when to use the machine. Review of Resident 1's progress note, dated 02/12/2024 at 4:55 AM, showed Resident 1 used a CPAP machine. In an interview on 03/11/2024 at 3:38 PM, Staff B, Director of Nursing Services, stated the nursing staff monitored Resident 1's oxygen saturation (how much oxygen is traveling through the body in the red blood cells). Staff B stated there should have been a physician's order for Resident 1 to have the CPAP machine used. Reference WAC 388-97-1060 (3)(j)(vi) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a dignified existence was maintained for 1 of 1 sampled resident (Resident 1) reviewed for resident rights. The facility failed to ensure Resident 1 was dressed appropriately when they were sent out on public transportation to their dialysis treatment for up to 6 hours. This failure placed the resident at risk for a diminished self-worth and a diminished quality of life when they felt exposed at a public appointment. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include amputation of a toe to right foot, end stage kidney disease, and peripheral vascular disease (circulatory condition of narrowed blood vessels that reduces blood flow). Review of Resident 1's admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/28/2023, showed the resident had moderate impaired cognition and no history of refusal of care. The resident required two staff with extensive physical assistance for transfers, dressing and bed mobility. The assessment showed the resident used a wheelchair and primary mode of mobility. In an electronic communication on 10/02/2023 at 1:26 PM, Collateral Contact 1 (CC1), Resident 1's family member, stated on 09/20/2023 the resident was sent to their dialysis appointment on a public transportation bus only in a hospital gown, and a blanket while it was raining outside. In an interview on 10/03/2023 at 1:38 PM, Staff E, Registered Nurse/Resident Care Manager (RCM), stated Resident 1 had personal clothes, as the family had brought them in the day they admitted to the facility. Staff E stated all residents should be dressed appropriately for outings and appointments. In a phone interview on 10/13/2023 at 9:38 AM, CC2, clinical coordinator at dialysis center, stated on 09/20/2023 Resident 1 arrived for dialysis in a hospital gown, and a blanket on their lap. CC2 stated the resident had to be transferred from their wheelchair to the dialysis chair with the use of a mechanical lift. CC2 stated the resident was upset and distraught as they felt exposed, since they were dressed inappropriately, and there were others who were receiving dialysis treatment that could see the resident. CC2 stated the dialysis area was an open area with multiple chairs where multiple people received treatments at the same time. CC2 stated we did the best we could to cover them up, but they [Resident 1] were really upset. Review of a facility provided document on 10/18/2023, titled personal belonging inventory, showed the resident had a blouse, a coat, and a phone. The bottom of the document stated it was for Resident 1. The section of the document where the resident or authorized representative was to sign, and staff member signed to verify the document was accurate was left blank. In a follow up electronic communication on 10/19/2023, CC1 stated they had brought three outfits to the facility for Resident 1 on 09/18/2023 about an hour after they arrived at the facility. They brought three shirts, three pairs of pants, underwear and an extra bra and shoes. In a joint interview on 10/19/2023 at 12:56 PM, Staff A, Administrator, and Staff B, Director of Nursing Services, Staff B stated their expectation was resident's inventory sheet were completed accurately and signed. Staff A agreed that Resident 1's inventory sheet was not completed accurately, and the expectation was residents would not be sent to appointments in hospital gowns. Reference (WAC) 388-97-0180(1)(2)(3) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure pneumococcal vaccines (a vaccine that protects against pneumococcal infections that can lead to serious infections such as pneumonia and blood infections) were offered to 1 of 5 residents (Resident 2) reviewed for immunizations and infection control. This failed practice placed the residents at risk for illness, spread of a communicable disease and a diminished quality of life. Findings included . Review of the facility policy titled, Pneumococcal Program, revised 05/31/2023, showed all residents and family members receive education regarding the benefits, potential side effects and general safety of receiving the of pneumococcal immunization. Residents are then offered and given the pneumococcal vaccine in accordance with physicians' orders unless contraindicated, resident had already received, or refused. The facility will provide a copy of the vaccine information sheet (VIS) statement. Residents who have previously received only Pneumococcal conjugate vaccine (PCV)13: 1 dose PCV20 at least 1 year after the PCV13 dose OR complete the recommended PPSV23 series. Resident 2 admitted to the facility on [DATE] with diagnoses to include heart disease, and history of stroke. The Quarterly minimum data set (MDS - an assessment tool) assessment, dated 07/21/2023, showed the resident had moderate impaired cognition. Review of Resident 2's immunization record, showed the resident had a historical immunization record for the PCV13 on 10/15/2015. The residents medical record did not show the resident or residents representative were educated on the benefits, potential side effects of the vaccine. The residents medical record did not show the resident was offered a PCV to complete the series. In an interview on 10/03/2023 at 2:18 PM, Staff H, License Practical Nurse/Staff Development Coordinator (SDC), stated residents were screened on admission for their vaccines. The admission nurse would usually obtain a consent or a refusal at the time of admission, and Staff H would review a few days later. Staff H stated the facility had missed Resident 2, and had not educated and offered the pneumococcal vaccine to the resident or their representative. Reference (WAC) 388-97-1340(2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan, based on the activity assessment, for two of seven residents (Resident 2 and 23) reviewed for comprehensive care plans. This failure created the potential to negatively impact the residents' quality of life. Findings included . Review of the facility's policy titled, Activity Programs, dated 11/28/2017, showed care plans addressed recreation programs that are appropriate for each resident based on the resident's skills, abilities, needs, and preferences. The care plan would address issues, concerns, problems, or needs affecting the resident's involvement and engagement in activities. <RESIDENT 2> Review of the Clinical Census, found in Resident 2's electronic medical record (EMR) under the Clinical tab, revealed resident was admitted to the facility on [DATE]. Review of the Activities Evaluation, dated 10/10/2022, revealed Resident 2 would like to spend their day walking, gardening, watching TV, flower arrangements, arts and crafts, and going to church. Review of Resident 2's Comprehensive care plan, updated 06/13/2023, revealed there was not a care plan to address the resident's activity interests. In an interview on 07/25/2023 at 10:09 AM, Resident 2 stated they liked to take care of others and religion was very important to them. <RESIDENT 23> Review of the Clinical Census, found in Resident 23's EMR under the Clinical tab, revealed the resident was admitted to the facility on [DATE]. Review of the Activity Assessment on the Minimum Data Set (MDS - an assessment tool), dated 02/06/2023, revealed Resident 23 liked group activities. Review of Resident 23's Comprehensive care plan, updated 06/13/2023, revealed there was not a care plan to address the resident's activity interests. In an interview on 07/25/2023 at 12:14 PM, Resident 23 stated they liked group activities like Bingo, coloring pictures on canvas, and sitting at the nurse's station. In an interview on 07/27/2023 at 3:00 PM, Staff C, Activity Manager, revealed they were not aware that a care plan had not been developed for Resident 2 or Resident 23. WAC Reference 388-97-1020 (1), (2)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** WAC Reference 388-97-0940 (1) (2) Based on observation, interview, and record review, the facility failed to provide a consistent activity program to meet the needs of 5 of 7 seven (Resident 2, 23, 13, 16, and 18) residents reviewed for activities. This failure created the potential for residents to miss out on opportunities of interest to maintain a meaningful life. Findings included . Review of the facility's policy titled, Activity Programs, dated 11/28/2017, indicated the facility provided facility-sponsored group and individual activities, designed to meet the interests of each resident based on the comprehensive assessment and the preferences of each resident. The activities will support the physical, mental, and psychosocial well-being of each resident. <RESIDENT 2> Review of the Clinical Census, found in Resident 2's electronic medical record (EMR), showed the resident was admitted to the facility on [DATE]. Review of the Activities Evaluation, dated 10/10/2022, revealed Resident 2 was a visiting nurse for 23 years and would like to spend their day walking, gardening, watching TV, flower arrangements, arts and crafts, and going to church. In an interview on 07/25/2023 at 10:09 AM, Resident 2 stated they liked to take care of others, and religion was very important to them. In an interview on 07/26/2023 at 2:00PM, Resident 2 stated no activities had occurred on 07/25/2023. Resident 2 stated they would like more activities such as movies, Bingo, and religious activities. <RESIDENT 23> Review of the Clinical Census, found in Resident 23's EMR, showed Resident 23 was admitted to the facility on [DATE]. Review of the Activity section on the Minimum Data Set (MDS - an assessment tool) assessment, dated 02/06/2023, revealed Resident 23 liked group activities. In an interview on 07/25/2023 at 12:14 PM, Resident 23 stated they liked Bingo, coloring pictures on canvas, and sitting at the nurse's station. In an interview on 07/26/2023 at 2:00 PM, Resident 23 stated they would like more activities such as group activities and activities on the weekend. <RESIDENT 13> Review of the Clinical Census, found in Resident 13's EMR, showed the resident was admitted to the facility on [DATE]. Review of the Activities Evaluation, dated 10/27/2022, showed Resident 13 worked on Naval ships, enjoyed documentaries, and painting. The evaluation showed Resident 13 would like to watch documentaries and their own DVDs. The evaluation showed activities staff would ensure Resident 13 had the tools they needed to enjoy their preferred individual activities. In an interview on 07/25/2023 at 1:35 PM, Resident 13 said a friend brought them CD's that they would like to listen to on their stereo. Resident 13 said staff were to help them with the CDs but did not know who that was. The resident had a stack of CD's approximately 12 inches high as well as a stack of DVD's approximately six inches high on the bookshelf above the CD/DVD player which was located above the television. Observations of Resident 13 on 07/25/2023 at 10:56 AM, 07/25/2023 at 1:35 PM, 07/26/2023 at 1:24 PM, and 07/27/2023 at 8:32 AM, identified Resident 13 in their room on their bed. The CD player, DVD, audio book, and television were not on during any of the observations. <RESIDENT 16> Review of the Clinical Census, found in Resident 16's EMR, showed the resident was admitted to the facility on [DATE]. Review of the Activities Evaluation, dated 08/05/2022, revealed Resident 16 preferred to spend time in their room but wanted to attend Resident Council and Bingo games. Additionally, the evaluation noted Resident 16 would be supported by activities staff so they may attend out-of-room activities they preferred, and activity staff would provide one to one visits. Review of the Care Plan, dated 07/19/2023, revealed Resident 16 did not like to leave their room except for live musical events. The care plan approaches listed to assist resident with out-of-room activities such as Bingo, Resident Council Meeting and Music; and activity staff would offer frequent one to one visits. Review of the Resident Council minutes for January 2023, February 2023, March 2023, April 2023, May 2023, and July 2023, showed Resident 16 did not attend the Resident Council meeting. In an interview on 07/25/2023 at 10:56 AM, Resident 16 stated they did not receive one on one visits but would like to. <RESIDENT 18> Review of the Clinical Census, found in Resident 18's EMR, showed the resident was admitted to the facility on [DATE]. Review of the Activities Evaluation, dated 08/04/2022, revealed Resident 18 enjoyed group activities and games. Review of the care plan, dated 04/24/2023, revealed Resident 18 was a devote Catholic and communion was very important. Activity Staff would inform and encourage to out of room activities, such as Bingo, birthday socials, resident council, root beer floats, fresh flower arranging, group games, tea party, worship service, watching movies, and art. In an interview on 07/27/2023 at 8:35 AM, Resident 18 stated they were not invited to the Resident Group Interview on 07/26/2023 at 2:00 PM with the surveyor. When asked if they attended group activities, Resident 18 said not as much lately. Review of the July 2023 Activity Calendar provided by Staff A, Chief Executive Officer, on 07/25/2023, was for the week of the survey, not the month, showed the following activities listed: -no activities were identified for Monday 07/24/2023 or for Tuesday 07/25/2023. -Wednesday (07/26/2023): 10:00 AM Ball Group; 1:00 PM one - one visits; 2:30 PM Bingo. - Thursday (07/27/2023): 10:00 AM Balloon Bop; 1:00 PM Resident Council; 2:30 PM Reading outside. - Friday (07/28/2023): 10:00 Ball Group; 1:00 1-1 visits; 3:00 gardening Observations during the survey from 07/25/2023 to 07/28/2023, revealed no activities on Tuesday and only Bingo on Wednesday. In attendance at Bingo was only Resident 2 and Resident 23, both who were already in the dining room following the Resident Group Meeting, held by the surveyor. The Staff C, Activity Manager (AM), was not in the facility on 07/25/2023. In an interview on 07/27/2023 at 3:00 PM, Staff C stated they had worked for the facility for only one month before they had to personal leave. Staff C stated they had just returned on 07/26/2023 and was working part time. Staff C could not state who conducted the activities while they were on leave. Staff C confirmed the activities did not occur on Tuesday and only the Bingo occurred on Wednesday. In an interview on 07/28/2023 at 10:30 AM, Staff A stated they and the Social Service Director were supposed to have carried out the activities while the Staff C was on leave. Staff A stated the facility was lacking in the activity department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address required documentation and communication for Advance Directives to reflect resident desires for one of one resident (11) reviewed for advance directives. This failed practice placed residents at risk of losing their right to have their desired wishes and intervention followed in the event of a healthcare emergency. Findings included . Review of the facility's policy titled, Advanced Care Planning dated [DATE], directed staff to identify, clarify, and periodically review at least quarterly, after a life altering event, and after return from a hospitalization, as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions . lf a resident determines to change their advanced directives the facility records have a progress note that explains the update and current care decisions. The resident record communication process is updated so staff are aware of the changes. The retired documents are thinned from the chart and placed into overflow with a progress note that explains the changes in code status. Physician Orders for Life-Sustaining Treatment (POLST), is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. (A POLST paradigm form is not an advance directive.) Resident 11 was a long-term care resident who admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, and multiple cardiac conditions. Upon admission, the resident's POLST dated [DATE] was provided. The POLST, directed staff to perform CPR (cardiopulmonary resuscitation) with limited additional interventions if they were found to have no pulse and were not breathing. Review of the resident's medical record included a document titled, Advanced Directive Document, dated [DATE] and indicated the resident had a Power of Attorney and a POLST. The resident discharged to the hospital on [DATE] with a gastrointestinal bleed and readmitted to the facility on [DATE]. The Discharge Minimum Data Set, an assessment tool, dated [DATE], documented the resident had significant cognitive impairment. A physician's advanced care planning note from the hospital, dated [DATE], documented an advance care planning discussion with Resident 11's son/Power of Attorney (POA) for healthcare decision and physician occurred via the phone. The POA and physician discussed personal goals of care with the resident's guarded prognosis. The note showed that the family had decided to change the resident's code status to DNR (do not resuscitate) and to continue to opt for limited interventions for treatable conditions like infections, stroke, heart attack etc. The resident's medical record on [DATE], showed the POLST with the resident's wishes from [DATE]. The electronic medical record directed staff that the resident was DNR-Selective treatment-SEE POLST. There was no revised POLST in the clinical record. In an interview on [DATE] at 11:18 AM, the Chief Nursing Officer (CNO)/Director of Nursing Services (DNS), brought in Resident 11's revised POLST. The CNO/DNS said the POSLT was recently updated and provided the hospital dictation of the discussion. The CNO/DNS said the son would sign the POLST soon and then it would be scanned into the medical record. In an interview on [DATE] at 3:40 PM, Staff C, Medical Records, stated there were behind in scanning and was currently scanning records in from the middle of May. In an interview on [DATE] at 10:23 AM, Staff H, Registered Nurse, stated upon admission they ask if they have a DPOA (Durable Power of Attorney) or advanced directives in place. They said they do a new POLST if they do not have one then, get it signed by the POA and provider. Staff H stated they did not manage the advanced directive process, but social services did. Staff H stated Resident 11 had been a full code. They stated at the hospital, the resident was changed to a no code/DNR, but the hospital did not send the updated POLST when the resident readmitted . Staff H said they had the POA wishes verbally, and it was put into the orders. Staff H stated the nurses look for current code status in the computer. In a follow up interview on [DATE] at 12:11 PM, the CNO/DNS showed that the revised POLST was now signed by the son. The CNO/DNS stated that the most recent POLST document was not in the chart, but the DNR order had been updated in the chart. The CNO/DNS agreed if a nurse checked the order in an emergency, it would say DNR but if they went to confirm the residents wishes with the POLST scanned in, it would show the desire for a full code. The CNO/DNS acknowledged this could be an issue had the resident coded. Reference WAC 388-97-0280 (3)(C)(i-ii)(d)(ii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure a resident was free from abuse for one of one resident's (20) reviewed for abuse prevention procedures. The facility failed to implement interventions to prevent potential psycho-social harm for a resident that placed them at risk for sexual abuse when a known family member was allowed private visits in the resident's room. Findings included . Review of the facility policy titled, Abuse, revised 07/23/2019, stated their procedure was to develop intervention strategies to prevent and/or reduce occurrence of abuse . a component was to prevent and identify concerns/problems and take corrective action to assist in preventing re-occurrences, actions may include .having a staff member observe the visits with a visitor who had inappropriate behavior in the past. Resident 20 was admitted [DATE] with diagnosis to include Dementia, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had moderate cognition impairment, and required one person assistance with transfers, dressing, personal hygiene, and toileting. In an observation on 06/13/2022 at 11:22 AM, the door to the resident's room was closed, upon entrance to the room, the resident's husband was observed to be sitting in the chair next to the resident who was lying in the bed. In an observation on 06/13/2022 at 11:45 AM, the resident's husband opened the door to the room, exited the room and left the facility. Review of the resident's care plan on 06/14/2022, showed the resident had a focus for potential psycho-social harm due to inability to give consent for sexual encounters due to dementia dated 02/05/2020. Goal of care was the resident would be free from psycho-social harm related to being a vulnerable cognitively impaired adult. Interventions included that the resident's husband must visit with the resident in a public are or if in the room the door must always remain open. In an observation on 06/15/2022 at 10:43 AM, the door to the resident's room was closed, upon entrance the resident's husband was observed to be sitting in the chair next to the resident lying in the bed. In an interview on 06/15/2022 at 10:44 AM, the Chief Nursing Officer (CNO)/Director of Nursing Services (DNS), was located around the corner from the resident's room. The CNO/DNS stated that the daughter/power of attorney (POA) had requested the residents husband visit in public area or door to be open during their visits because of a past protective service investigation. The CNO/DNS confirmed the door should be open when the resident's husband was visiting. The CNO/DNS was unaware that the resident's husband was in the facility at that time and was unaware that the door was closed. The CNO/DNS left the interview to go ensure the door was open. In an observation on 06/15/2022 at 11:23 AM, the door to the resident's room was open and the resident's husband was sitting in chair next to bed. In an interview on 06/15/2022 at 12:12 PM, Staff O, Registered Nurse (RN), stated the door to the resident's room was to be open every time the husband had a visit. Staff O was unaware that the husband had been in the room with the door closed. In an interview on 06/15/2022 at 12:30 PM, Staff E, Nursing Assistant Certified (NAC), stated they were unsure if the door to the room was to be open while the husband visited the resident. In an interview on 06/17/2022 at 1:18 PM, Staff D, Social Services (SS), stated the husband was to have visits with the resident in a public space or with the door open to the resident room. In an interview on 06/17/2022 at 3:28 PM, the CNO/DNS stated the husband was to check in at the front so the staff were aware that they were in the facility, then the floor nurse would supervise that the door to the room was open or delegate that task to the NAC's on the floor. The CNO/DNS confirmed the staff had been unaware the husband had visited with the door to the resident's room closed for two days. WAC 388-97-0640 (1)(2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to implement a comprehensive person-centered care plan for two of three sampled residents (2 and 20) reviewed for comprehensive care planning. The facility failed to ensure staff implemented interventions for a resident at risk for falls, and a resident with a swallow precaution was supervised during meal intake. Findings included . Review of the facility policy titled, Care Plans, revised 11/28/2019, The facility will develop and implement a person-centered comprehensive care plan for each resident. RESIDENT 20 Resident 20 was admitted to the facility 02/10/2021 with diagnosis to include malnutrition, dysphagia (difficulty with swallowing), dementia, and general weakness. The Quarterly MDS dated [DATE] showed the resident had moderate cognition impairment, required supervision with meals, and had no history of refusal of care. Review of the resident care plan on 06/13/2022 showed the resident had a focus of Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance and dementia. Interventions to include aspiration (choking) precautions as followed: - resident is to sit upright for meals and all intake through oral consumption - encourage small bites and sips - reminder to swallow - if voice is wet, instruct resident to cough to clear throat - encourage resident to sit up for 20-30 minutes after meals intake - no straws - oral care after every meal Review of the speech Discharge summary dated [DATE] - 03/25/2022 stated to facility safety and efficiency, it is recommended the resident use the following strategies .upright posture during meals and upright posture 30 minutes after meals and supervision for oral intake. In an observation on 06/13/2022 at 11:43 AM, resident was lying flat on their back in the bed, staff entered the room and delivered the lunch tray to the resident, exited the room, and closed the door. The resident was not supervised and was not sitting upright in the bed. In a continuous observation and interview on 06/14/2022 at 12:05 PM, the door to the resident's room was closed, upon entering the room the resident was observed to be lying flat on their back in the bed. The lunch tray was sitting on the over the bed table, and the resident stated they are going to eat now. At 12:33 PM no staff had entered the resident room to supervise the meal; the resident's door was closed. Upon entering the resident was observed to by lying flat on their back eating a container of yogurt, the white food on the plate is gone off the plate. At 12:43 PM, no staff had entered the resident room to supervise the meal. In an observation on 06/16/2022 at 8:45 AM, the door to the resident's room was closed, the resident was observed to be lying flat on their back in the bed eating a bowl of hot cereal that was sitting on their chest. The resident was not supervised or sitting upright in the bed. In a continuous observation on 06/16/2022 at 12:04 PM, Staff P, Hospitality Aide, entered the resident room and delivered their lunch tray to the resident. The resident was observed to be lying flat on their back in the bed. Staff P exited the room and closed the door behind them. The resident was not supervised or sitting upright in the bed. At 12:18 PM, no staff had entered the resident room to supervise the meal; the resident's door was closed. At 12:24 PM the resident's door was opened by a visitor, the resident was observed to be lying flat on their back in the bed, the lunch tray was sitting on the over the bed table and 25% of the meal was missing. RESIDENT 2 Resident 2 was admitted to the facility 02/04/2019 with diagnosis to include Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and pain. The Annual MDS, dated [DATE], showed that the resident had intact cognition, required extensive assistance with two staff members for transfers and one staff member for bed mobility, toilet use, personal hygiene, and dressing. The resident had no history of refusal of care and had a history of falls. Review of the facility fall assessment completed on 06/02/2022 showed the resident was at risk for falls. Review of the resident's care plan on 06/13/2022 showed the resident had a focus for falls as the resident was a high risk for falls related to their Parkinson Disease, and unsteady gait. The goal of care was the resident would not sustain serious injury. Interventions to include for staff to ensure the blue Dycem (rubber gripper) was in the resident's recliner dated 12/18/2021. In an observation on 06/14/2022 at 9:02 AM the resident was lying in their recliner in their room there is no Dycem on the recliner. In an observation on 06/14/2022 at 11:20 AM the resident was assisted from their recliner to the wheelchair. When resident stood up there was no Dycem in the recliner. In an observation on 06/15/2022 at 9:11 AM, the resident was lying in their recliner in their room there is no Dycem on the recliner. In an interview on 06/15/2022 at 12:12 PM, Staff O, Registered Nurse (RN) stated that the resident should have the blue Dycem under them while they are in their recliner. In an interview on 06/15/2022 at 12:30 PM, Staff E, Nursing Assistant Certified (NAC) stated the resident should have the blue Dycem under them while they are in their recliner. In an observation on 06/16/2022 at 8:43 AM, the resident is lying in the bed, there is no Dycem in the recliner. In an interview on 06/16/2022 at 9:55 AM, Staff Q NAC, stated the resident should have the blue Dycem under them while they are in their recliner. In an interview on 06/16/2022 at 11:18 AM, Staff H, RN stated the resident should have the blue Dycem under them while they are in their recliner. In an interview on 06/16/2022 at 11:32 AM, Staff G, Licensed Practical Nurse (LPN) stated they were responsible for the MDS, and they updated the care plan accordingly. Staff G stated that they participated in daily morning clinical meetings and would also update the care plan based on the information that was discussed in those meetings, such as interventions for falls or therapy recommendations. In an observation on 06/17/2022 at 9:01 AM, the resident is lying in the bed, there is no Dycem in the recliner. In an interview on 06/17/2022 at 1:57 PM, Staff J, Staff Development stated they were responsible for educating the staff on policy and procedures. WAC 388-97-1020 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 17 Resident 17 admitted to the facility on [DATE] with diagnosis to include Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and dementia. The Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had severe cognition impairment and required one-person extensive assist for personal hygiene. Review of the resident's dental visit on 03/08/2022 showed the resident had moderate amounts of food, plaque (sticky film of bacteria) and calculus (hardened plaque) on the resident's teeth with recommendations to have staff assist with teeth brushing. Review of the resident's care plan on 06/13/2022 showed a focus for Activities of Daily Living (ADL) of self-care performance deficit related to dementia, and Parkinson's with an intervention that the resident was a set-up assist for oral care, staff were directed to hand the equipment to the resident and tell her to complete the task. The care plan did not reflect the updated recommendations from the dentist. In an interview on 06/15/2022 at 12:12 PM, Staff O, Registered Nurse (RN) stated the Nursing Assistant Certified (NAC) are responsible for assisting the resident to brush their teeth. In an interview on 06/15/2022 at 12:30 PM, Staff E, NAC stated they just set up the resident to brush their teeth. If there are changes to the plan of care the resident will go on alert and it shows on the tablets when they log into the POC system. In an interview on 06/16/2022 at 10:12 AM, Staff F, NAC stated they do not always do oral care in the morning but try at bedtime. In an interview on 06/16/2022 at 11:32 AM, Staff G, Licensed Practical Nurse (LPN) stated they were responsible for the MDS, and they updated the care plan accordingly. Staff G stated if they notice there had been an update, they will update the care plan accordingly. Staff G stated there are times the DNS or Staff J, Staff Development may update the care plan as well. In an interview on 06/16/2022 at 2:39 PM, with the Administrator and Chief Nursing Officer (CNO)/Director of Nursing Services (DNS); CNO/DNS stated that Staff G was the driver of the care plan, but that it was a clinical team discussion in the morning meeting. The Administrator stated ultimately, they are responsible to ensure the care plans are updated accordingly. Reference (WAC) 388-97-1020 2(a)(d)(f), 4(b), 5(b) RESIDENT 11 Resident 11 was initially admitted to the facility on [DATE] and most recently re-admitted on [DATE] after a hospitalization. Review of a Physician Assistant - Certified note on 05/03/2022 showed an order for Resident 11 to not wear any shoes because of a new wound on their foot. Review of Resident 11's care plan, print date 06/14/2022, did not show that Resident 11 was not to wear shoes. During an interview on 06/15/2022 at 9:29 AM, the Director of Nursing/Chief Nursing Officer (DSN/CNO) stated that they could not find any documentation that the care plan was updated for Resident 11 to show that they should not wear shoes. Review of Resident 11's [NAME] (directions for providing resident's care that comes from the care plan), dated 06/14/2022, showed that • Resident 11 required two staff assist to transfer (get on and off toilet) and to assist to toilet every two hours. • Resident 11 required one-two staff extensive assist with sit to stand lift (machine that assists with transfers) in and out of their wheelchair. During an observation and interview on 06/15/2022 at 1:31 PM, Staff E, Nursing Assistant Certified (NAC) and Staff I, Nursing Assistant (NA), were observed to assist Resident 11 to lay down. The staff used a hoyer lift (machine lifts person and suspends in air to move from one surface to another) to move resident from the wheelchair and onto the bed. The resident was then provided incontinent care and positioned for a rest. Staff I stated that Resident 11 can no longer stand and assist with the transfer, so staff have been using the hoyer lift for the last month per the recommendation of the therapy department. Staff I stated that they can no longer assist resident onto the toilet because of the hoyer lift. Staff I acknowledged that Resident 11's care needs did not match the directions provided on the [NAME]. During an interview on 06/15/2022 at 2:49 PM, the DNS/CEO stated that resident's care plans should be updated at the morning clinical meeting when there has been a change in the resident's condition. The DNS/CNO reported that Resident 11 had a change in their mobility due to a wound on their toe and a recent hospitalization. The DNS/CEO stated that that Resident 11's care plan should have been updated when they readmitted from the hospital to reflect their changes in mobility. Based on observation, interview and record review, the facility failed to review and revise care plans for three of 11 residents (3, 11, and 17) reviewed for care planning. These failures placed the residents at risk for unmet care needs, adverse health effects and a diminished quality of life. Findings included . Review of the facility policy titled, Care Plans, dated 11/28/2019, showed that the care plan is revised as needed based upon: • changes in resident condition, cognition or behavior symptoms. • to achieve deside outcome • Resident's inability to participate in a program to attain highest practicable level of well being RESIDENT 3 Resident 3 admitted [DATE] with diagnoses which included infection and history of stroke. Review of the resident's admission orders dated 03/08/2022 showed the resident admitted with orders for skilled therapies and an anticoagulant medication. Review of the resident's care plan on 06/15/2022 showed care plan problems and interventions had been created related to skilled therapies and anticoagulant therapy. Review of the resident's current orders showed the resident was no longer receiving skilled therapies or anticoagulant therapy. The resident's care plan had not been revised to remove the care plan problems that no longer pertained to the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 17 Resident 17 admitted to the facility on [DATE] with diagnosis to include Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), chronic pain. The Annual MDS dated [DATE] showed the resident had severe cognition impairment, and one-person extensive assist for personal hygiene. Review of the resident's dental visit on 03/08/2022 showed the resident had moderate amounts of food, plaque (sticky film of bacteria) and calculus (hardened plaque) on the resident's teeth. In an observation on 06/13/2022 at 9:25 AM, the resident had visible particles in between teeth and gums in their mouth. There was no toothbrush visible in the room. In an observation on 06/14/2022 at 12:41 PM, the resident was observed lying in the bed there were visible particles in between teeth and gums in their mouth. There was no toothbrush visible in the room. In an observation on 06/15/2022 at 10:47 AM, the resident stated they had not brushed their teeth that day, there was visible red stain on lips and around mouth. In an interview on 06/15/2022 at 12:12 PM, Staff O, RN stated the NAC's were responsible for assisting the resident to brush their teeth. In an interview on 06/15/2022 at 12:30 PM, Staff E, NAC stated they just set up the resident to brush their teeth. Staff E was asked where the toothbrush was kept, they dug through the top shelf in the resident's closet under briefs and other toiletries and retrieved bag with a dry toothbrush at the bottom. In an observation on 06/16/2022 at 9:49 AM, the resident was observed lying in their recliner in their room, with visible particles in between teeth and gums in their mouth. The resident was unsure if they brushed their teeth that day. In an interview on 06/16/2022 at 10:12 AM, Staff F, NAC stated they do not always do oral care in the morning but try at bedtime. Staff F was asked where the toothbrush for the resident was kept, was retrieved from the top shelf in the resident's closet under briefs and other toiletries and retrieved bag with a dry toothbrush at the bottom. In an interview on 06/17/2022 at 10:02 AM, Staff R, NAC stated they were assigned to care for the resident for that shift. Staff R stated they did not offer oral care to the resident that day and was unaware if oral was offered when the resident was assisted out of bed for the day early that morning. WAC 388-97-1060 (2)(c) Based on observation, interview, and record review, the facility failed to provide necessary activities of daily living (ADLs) care and services for two of two dependent residents (11 and 17) reviewed for ADLs. The facility failed to ensure hand hygiene was provided before and after meals, nail care, shaving and oral care. This failure left the residents with unmet, but necessary care and services. Findings included . Review of the facility policy titled, Activities of Daily Living, revised 02/28/2019 showed assistance is provided to residents who need assistance with nutrition, grooming, oral hygiene, toiletings, and other personal care. RESIDENT 11 Resident 11 most recently re-admitted on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment of care needs), dated 4/19/2022, showed that Resident 11 needed extensive assistance with grooming, one staff assist with eating and that they required physical assistance with bathing. The MDS showed that Resident 11 had severe cognitive impairment. During an observation and interview on 06/13/2022 at 12:57 PM, Resident 11 was noted to have whiskers 1/8th inch long on his face and there was brown material under all fingernails on their right hand. Resident 11 stated that they did not want to grow a beard. During a phone interview on 06/13/2022 at 2:05 PM, Resident 11's Collateral Contact (CC1), stated that having clean fingernails was important and that resident had always been shaved when they visited. During an observation and interview on 06/14/2022 at 9:27 AM, Resident 11 was noted to have 1/8th inch whiskers on their face. Staff Q, Nursing Assistant Certified (NAC), acknowledged that Resident 11's whiskers were long. Staff Q stated that Resident 11was to be shaved with their showers and that they were scheduled for a shower that day. During an observation and interview on 06/14/2022 at 11:09 AM, Resident 11 was noted to have brown matter under all of their fingernails. Staff H, Registered Nurse (RN), observed Resident 11's fingernails with the surveyor and reported that resident feeds self with their hands. Staff H stated that staff should clean resident's nails during showers and as needed. During an observation and interview on 06/15/2022 at 7:41 AM, Resident 11 was noted to have brown matter under all fingernails and long whiskers on their face. Staff J, Staff development Nurse, stated that Resident should have had nail care done with their shower on 6/14/2022 and that the aides should be cleaning them as needed. Staff J stated that Resident 11 should have been shaved during their shower. Review of Resident 11's bathing documentation showed that they received a shower on 06/14/2022 and 06/10/2022. Review of the [NAME], print date 06/14/2022, showed that Resident 11 was to have hand hygiene before and after meals and that nail care was to be done on shower days and as needed. Resident 11 was to have two showers a week. There was no documentation to show how often Resident 11 was to be shaved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of four residents (2) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure appropriate indication and provide documented evidence of clinical rationale for the administration of psychotropic medications. This failure placed the resident at risk for potential medication related side effects. Findings include . Resident 2 was admitted to the facility 02/04/2019 with diagnosis to include Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), hallucinations, communication deficit, and anxiety. The Annual Minimum Data Set (MDS) assessment dated [DATE], showed that the resident had intact cognition, with no history of refusal of care. Review of the facility Consultant Pharmacist's Medication Regimen Review document dated 02/16/2022, showed that the resident had an order for Hydroxyzine (a medication used to treat anxiety) every six hours as needed for anxiety. The document from the pharmacist showed the resident had used the medication 11 times in the last 30 days, and to continue the medication, the physician would need to provide a clinical rationale. The document provided had a note that stated patient/family request medication stay in place. There was no clinical rationale provided for the as needed anxiety medication, and the document was not signed by a physician. In an interview on 06/17/2022 at 11:32 AM, the Chief Nursing Officer (CNO)/Director of Nursing Services (DNS), stated the process for review of the pharmacy recommendations was completed monthly. The CNO/DNS stated they only allow an as needed anxiety medication for 14 days, if required longer than 14 days, they had the physician assess the resident for clinical rational and would document that in the medical record. The CNO/DNS confirmed the rational for use on the 02/16/2022 Pharmacy Recommendation document was not an appropriate clinical rational for indication of use of the medication, they confirmed it was unsigned and that there was no documentation in the resident's medical record for the rationale. WAC 388-97-1060(3)(k)(i) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appetizing, palatable foods for three of five (24, 30, and 27) residents reviewed for nutrition services. Failure to provide palatable foods placed residents at risk of diminished dining experience and inadequate nutritional intake which could lead to weight loss and a decreased quality of life. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE]. During an interview on 06/13/2022 at 1:03 PM, Resident 24 stated that the food was often lukewarm when it arrived and that there was no variation to the menu. Resident 24 stated that they were given broccoli on their lunch tray and that just the sight of broccoli caused them to lose their appetite. Resident 24 stated that their meal card showed that they do not like broccoli or onions, but they still have these foods served on their meal tray. During a conversation on 06/14/2022 at 1:34 PM, the Consultant Dietician was notified that Resident 24 did not like broccoli. The dietician reported that broccoli was listed as a dislike on Resident 24's meal card. Review of the Diet History & Food Preferences assessment, dated 05/24/2022, confirmed broccoli was listed as a food the resident dislike. During an observation and interview on 6/15/2022 at 1:03 PM, Resident 24 stated, it seems like they serve me broccoli every day. Resident 24 stated that the smell and look of broccoli made them sick to their stomach. The lunch tray was still at bedside and had broccoli in the mixed vegetables. The meal card on the tray showed broccoli listed under the dislikes section. On 06/15/2022 at 1:25 PM, Staff H, Registered Nurse, was shown the tray card and was notified that Resident 24 had received broccoli on their meal tray today and on Monday (06/13/2022). RESIDENT 30 In an interview on 06/13/2022 at 1:47 PM, Resident 30 stated they did not like the food, and it was not good. They stated the facility served too much barbeque sauce, teriyaki, and sausage. They stated the bacon was greasy and not crisp. They stated the menu was very repetitive. They stated their spouse brought them lunch every day. They said they had shared their complaints with the Staff A, Dietary Manager. RESIDENT 27 In an interview on 06/13/2022 at 9:26 AM, Resident 27 stated, sometimes the food was very good, other days not so [NAME]. The resident stated they overcook the vegetables. Reference WAC 388-97-1100 (1)(2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe, clean, comfortable and homelike environment on 2 of 2 units and in the main dining room. Failure to ensure consistent housekeeping services and ensuring a dignified and homelike dining experience placed residents at risk for decreased quality of life. Findings included . CLEAN BUILDING In an observation on 06/13/2022 at 9:46 in room [ROOM NUMBER] for Resident 28 had brown matter on the floor next to the bed, there was scattered trash under the bed. In an observation on 06/13/2022 at 10:25 AM in room [ROOM NUMBER] for Resident 28, continued to have the same brown substance on the floor next to the bed, the toilet bowl was full of yellow liquid, there was a visible dark ring around bowl of toilet, a razor was lying in the bottom of the sink with white substance on it. In an observation on 06/13/2022 at 12:00 PM in the dining room two of the dining tables on the right had smears, with visible crumbs and appeared unclean. In an observation on 06/13/2022 at 1:55 PM, Resident 30 admitted [DATE], their admission Minimum Data Set (MDS) Assessment completed on 06/06/2022 showed the resident had intact cognition. Resident 30 stated there was no housekeeping the weekends. In an interview on 06/13/2022 at 2:24 PM, Staff S, contracted housekeeping and laundry manager stated there had been weekends when there are no housekeepers available to work. Staff S stated they try to cover, but sometimes they are a no call no show, and if they come in then they would not have a day off. Staff S stated they do not have a on call list. In an observation on 06/14/2022 at 8:50 AM in room [ROOM NUMBER] for Resident 28 there was visible grey non-skid socks lying on the floor near the entrance. There was a granola bar wrapper on the floor, there was a plant on the floor by their toilet. Bathroom had brown debris on the floor. In an observation on 06/14/2022 at 9:01 AM in room [ROOM NUMBER] for Resident 17, there was cracks in corner of the base board, a piece of base board was lying on the ground, and there was dust and debris next to piece. In an observation on 06/14/2022 at 9:02 AM in room [ROOM NUMBER] for Resident 2, the floor was sticky, the bathroom floor was sticky, trash was full, toilet has riser had brown speckled matter all over the seat of the riser and on toilet base, there was yellow liquid in the toilet, and there were stains visible in the toilet bowl. In an observation on 06/14/2022 at 10:05 AM the Room's 21 and 23 had a shared bathroom, there was brown matter on toilet and down the base of the toilet. In an observation on 06/14/2022 at 11:31 AM the floor in room [ROOM NUMBER] was sticky. In an observation on 06/14/2022 at 12:46 PM the Room's 21 and 23 had a shared bathroom continued to have brown matter on toilet and down the base of the toilet. In an observation on 06/14/2022 at 12:45 PM in room [ROOM NUMBER] for Resident 17, there was cracks in corner of the base board, a piece of base board was lying on the ground, and there was dust and debris next to piece. In an observation on 06/14/2022 at 1:10 PM in room [ROOM NUMBER] for Resident 28, continued to have the same brown substance on the floor next to the bed, there was multiple pieces of trash, and dust visible under the bed. A washcloth was sitting on floor under head of bed, in the bathroom the floor had visible dirt with pieces of paper on ground, the toilet water was clear with visible dark stain around the bowel above the water line. In an observation on 06/14/2022 at 1:14 PM in room [ROOM NUMBER] for Resident 9 the room had visible pieces of paper, and a glucometer strip lying on ground, the bathroom floor had brown stains near shower entrance. In an observation on 06/14/2022 at 2:26 PM in room [ROOM NUMBER] for Resident 17 the room continued to have a cracked broken base board with same piece lying on the ground next to crack. In an observation on 06/14/2022 at 3:17 PM in room [ROOM NUMBER] for Resident 17 the room continued to have a cracked broken base board with same piece lying on the ground next to crack. In an observation on 06/14/2022 at 3:18 PM, in room [ROOM NUMBER] for Resident 28 the floor continued to have brown substance on the floor by the bed, there was multiple pieces of trash, and dust under the bed. The washcloth was still on floor under head of bed, the bathroom floor had visible dirt with pieces of paper on ground, the toilet water was clear with the dark visible stain around the bowel above the water line. In an observation on 06/15/2022 at 9:37 AM in room [ROOM NUMBER] for Resident 28, had more brown substance on the floor by the bed, there was multiple pieces of trash, and dust under the bed. The washcloth was still on floor under head of bed, bathroom floor had visible dirt with pieces of paper on ground, the toilet water was clear with visible dark stain around the bowel above the water line. The linen sheet under resident were stained with brown matter. In an observation on 06/15/2022 at 9:39 AM room [ROOM NUMBER] for Resident 2 room the floor was sticky. In an observation on 06/15/2022 01:48 PM in room [ROOM NUMBER] for Resident 28 the floor continued to have brown substance on floor by the bed, there continued to be more pieces of trash, and dust under the bed. A washcloth continued to be on the floor under head of bed, the bathroom floor had visible dirt with pieces of paper on ground, the toilet water was clear with visible dark stain around the bowel above the water line. Bed linens under the resident were stained with brown matter. The over the bed table had large, dried beige material on top. In an observation and interview on 06/16/2022 at 8:52 AM in room [ROOM NUMBER] for Resident 28, the floor continued to have brown substance on floor by the bed, there continued to be more pieces of trash, and dust under the bed. There was a box of under ware on the floor. There was washcloth and clothes lying on the floor under the head of bed, the bathroom floor was visible with dirt and pieces of paper on ground, the toilet water was clear with visible dark stain around the bowel above the water line, there was wipes lying on the floor by the toilet, and the plant was on the ground near the toilet. The linens under the resident were stained with brown matter. There was a pile of straw wrappers on the floor. Resident 28 stated that they would allow housekeeping to enter their room to clean their room, they prefer it occur after lunch please. In an interview on 06/16/2022 at 9:55 AM, Staff Q, Nursing Assistant Certified (NAC), stated that Resident 28 had refused care at times, but usually with some reproach they would allow them to assist with personal care and change linens. Staff Q stated that on 06/13/2022 they did not want assistance with cleaning but after lunch they were ok, and they were able to shower the resident and change the bed linens. In an interview on 06/16/2022 at 10:37 AM, Staff S, Housekeeping Manager stated they had a five-step process for all resident rooms daily, that included to dust, sweep and mop, clean the mirrors and side tables, empty the trash and then they clean the restroom, by cleaning the toilet and restock the room as needed. Staff S stated they deep clean one room a day, with goal to have all rooms completed once monthly. Staff S was shown room [ROOM NUMBER] and confirmed that the room [ROOM NUMBER] was not cleaned the day before. Staff S stated the housekeeping staff are not going into that room the resident was aggressive towards them, they stated they had a staff member quit their job, due to how scared they were to go into that room. Staff S stated management was aware of the situation and the NAC's do what they can to clean the room. In an observation on 06/16/2022 at 12:47 PM in room [ROOM NUMBER] for Resident 28, the floor continued to have brown substance on floor by the bed, there continued to be more pieces of trash, and dust under the bed. There was a box of under ware on the floor. There was washcloth and clothes lying on the floor under the head of bed, the bathroom floor was visible with dirt and pieces of paper on ground, the toilet water was clear with visible dark stain around the bowel above the water line, there was wipes lying on the floor by the toilet, and the plant was on the ground near the toilet. The linens under the resident were stained with brown matter. There was a pile of straw wrappers on the floor. In an interview on 06/16/2022 at 12:48 PM, Staff T, Housekeeper stated they had been employed at the facility for three years. Staff T stated they clean all the resident rooms daily and do one deep clean a day. Staff T stated they do not clean room [ROOM NUMBER]; they do not go in there. Staff T stated occasionally they will go in to change trash or swap out the towels, they confirmed management was aware they were not cleaning room [ROOM NUMBER]. In an observation on 06/17/2022 at 9:02 AM, room [ROOM NUMBER] for Resident 20 the floor was sticky. In an observation on 06/17/2022 at 9:04 AM PM, in room [ROOM NUMBER] for Resident 28, the floor had more brown substance by the bed, there was multiple pieces of trash, and dust under the bed and debris, the box of under ware was still on the floor, and the over the bed table had dried white substance on top of it. There were washcloths and clothes sitting on the floor under head of bed, the bathroom floor had visible dirt, with pieces of paper on the ground, the toilet water was clear with visible dark stain around the bowel above the water line, there were wipes lying on the floor by the toilet, and the plant was on ground near the toilet. The bed linens under the resident were stained with brown matter. In an observation on 06/17/2022 at 1:41 PM, in room [ROOM NUMBER] for Resident 28, the floor had more brown substance by the bed, there was multiple pieces of trash, and dust under the bed and debris, the box of under ware was still on the floor, and the over the bed table had dried white substance on top of it. There were washcloths and clothes sitting on the floor under head of bed, the bathroom floor had visible dirt, with pieces of paper on the ground, the toilet water was clear with visible dark stain around the bowel above the water line, there were wipes lying on the floor by the toilet, and the plant was on ground near the toilet. The bed linens under the resident were stained with brown matter. In an interview on 06/17/2022 at 2:34 PM, Administrator stated they were unaware that the room had not been cleaned. Administrator stated they were aware there was a problem in the past and was unclear if housekeeping or nursing had been cleaning room [ROOM NUMBER]. They stated that they were told the room used to look worse than it did now. No other information was provided. DINING In an observation on 06/13/2022 at 12:02 PM, the lunch meal was observed to be delivered to residents in the main dining room with the meal left on institutional style trays. Staff were observed to remove the plate warmer from beneath the plate and the lid, but left the dishes and other items on the trays for the entire meal which is not homelike. Additionally, meals were not delivered to residents at the same table together: In an observation on 06/13/2022 at 12:10 PM, Resident 9 was served his meal and began to eat independently. Resident 11 at the same table was observed to intently stare at Resident 9's plate while he began to eat. Resident 9 had been the 5th meal served overall. Residents 9 and 11 were the only two residents at their table. Resident 11 was the 8th meal served at 12:13 PM and when his tray was delivered he stated oh bless you! Amen. Staff C stated that Resident 11 loves to eat. In observations on 06/13/2022, 06/14/2022, and 06/15/2022 at the lunch dining room meals, the dining tables were observed to all be at the same height. One resident (Resident 6) was observed to sit at the same place at the end of one of the tables. The table was too tall for her. Resident 6 was observed to barely see over the table, the meal sitting at eye level and they were observed to have to reach up at an awkward angle to eat. In an interview on 06/13/2022 at 12:22 PM, Staff I stated they deliver the trays in the order on the cart unless someone is not in the dining room yet, then they skip that one. In an observation on 06/16/2022 at 12:18 PM, Resident 6 was observed to now have a separate overbed table placed in front of her with her meal on it. Staff C, Nursing Assistant stated it was because the other table was too tall for her so they were going to try this as of today. In an interview 06/14/2022 at 1:56 PM with Staff N, Resident Dietician, they stated they reviewed the clinical pieces of dining as it related to nutrition at risk review. They stated they had not been aware of any specific preference or homelike issues. WAC 388-97-0880 (1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 6 Resident 6 has been a resident of the facility since 10/03/2021. Review of the Quarterly MDS dated [DATE], showed that resident 6 had moderate hearing difficulty and required extensive assistance from staff to walk or to move in their wheelchair. In an observation on 06/13/2022 at 10:18 AM, Resident 6 was sitting in their wheelchair in their room. No TV or music was on in the room. In an observation on 06/13/2022 at 11:00 AM, Resident 6 was sitting in their room and there was no TV or music on in the room. In an observation on 06/13/2022 at 11:34 AM, Resident 6 was in the dining room sitting at a table. There was a TV playing music videos, but the sound was quiet, and surveyor had difficulty hearing the sound. Review of Resident 6's activity assessment, dated 10/05/2021, showed that residents current activity interests were: animal/pets, movies, TV, sports, music ([NAME], 40's, 50's), radio, reading, and word games. Review of the Care plan, print date 06/16/2022, showed Resident 6's activity goals were to participate in one-two individual activities per week, participate in one-two independent leisure activities daily, participate in one-two group activities weekly, and participate in daily issue of the daily doings. Review of the May 2020 V2 report (document of care and services received) showed that Resident 6 participated in two group activities during the month, had individual (1:1) activities 15 days of the month, and participated in self-directed activities (music, TV or visited with other residents) 11 days of the month. The V2 report showed that there was no activity participation of any kind on May 1st, 4th, 5th, 7th, 8th, 10th, 13th, 15th, 21st, 22nd, 24th, 25th, 26th, 28th, 29th, 30th. (16 of the 31 days) Review of the June 2020 V2 report from, 06/01 - 06/15/2021, showed that Resident 6 participated in individual activities four days of the month, and participated in self-directed activities three days of the month. There was no documentation that a group activity was attended. The V2 report showed that there was no activity participation of any kind on June 2nd, 3rd , 4th, 5th, 7th, 9th, 10th, 11th, 12th, 13th, 15th. (11 of the 15 days) In an interview on 06/15/2022 at 10:10 AM, Staff H, Registered Nurse, Stated the social services staff and Staff P, hospitality aid were doing activities. Staff H stated We have no activities director right now. There are just a couple of folks who help with some of it. In an interview on 06/16/2022 at 2:14 PM, the Administrator confirmed there was no current Activity Program Director stating we don't have a director, they quit and we are recruiting. Reference WAC 388-97-0940 (1)(2)(3) RESIDENT 19 Resident 19 admitted [DATE] with diagnoses which included dementia. The resident was able to communicate some basic needs but required staff to anticipate needs which would include offering and assisting the resident to participate in meaningful activities. Review of an annual activities evaluation dated 04/23/2022 showed detail regarding the resident's known interests stating that the resident enjoyed pet visits, all musical events, watching the staff water their plant, coffee social, armchair travel, bowling, flower deliveries, aroma therapy listening to easy listening music, watching musicals on television, birdwatching, being read to and spending time with their spouse. Review of the most recent annual MDS assessment dated [DATE] showed the resident activity preference interview was completed by the resident representative and identifed music, groups, favorite activities, time outside and religious events as somewhat or very important to the resident. Review of the care plan on 06/15/2022 showed no person centered detailed activity interventions had been developed based on the resident's stated preferences. The available choices were the generic system generated choices. Documentation showed the only activities marked for the resident were listed as conversation or friends and family. There was no documentation of any other resident preferred meaningful activities. In observations on 06/13/2022 at 12:50 PM, 06/14/22 09:45 AM , 06/14/22 01:04 PM, 06/14/22 02:28 PM, the resident was sitting in their room in a tilt in space wheelchair with the TV playing sitcom re-runs which on the same channel as the room mate's TV (Resident 26). There was a doll on her lap or on the bed during each observation. There is a CD player/radio noted to be on the bedside table in the resident's room with dust on it. On 06/14/2022 at 10:03 AM, Staff I, Nursing Assistant was asked what type of activities Resident 19 liked and they stated they used to like to go to coffee hour and church. When asked if they still do those things, Staff I stated they did not know because they have not been having them. Staff I stated that the resident's spouse visits. On 06/14/2022 at 10:26 AM, several facility staff were observed attempting to organize a coffee social. Resident 19 was not observed to be invited or assisted to attend. This was one of only a handful of group activities observed to occur during the six days on site. On 06/15/2022 at 10:02 AM, the resident was in their room in their wheelchair with a doll across their lap, both their TV and their room mate's TV (Resident 26) again both on the same channel with volume very loud. There were no observations of the resident engaged in any meaningful activities as identified by their comprehensive assessment. RESIDENT 26 Resident 26 admitted [DATE] with diagnoses which included dementia. Review of the resident's activities care plan dated 04/13/2020 showed staff were to inform, invite and encourge the resident to attend activities and identified activities the resident enjoyed as coffee, exercise, live music and pets. In observations on 06/13/2022 at 12:50 PM, 06/14/22 09:45 AM , 06/14/22 01:04 PM, 06/14/22 02:28 PM, the resident was sitting in their room in a standard wheelchair with the TV playing sitcom re-runs which on the same channel as the room mate's TV (Resident 19). The facility activities calendar included events the resident would enjoy; however, observations on all days of the survey showed the scheduled activities were not occuring due to lack of activity staff. Based on observation, interview, and record review, the facility failed to provide meaningful and engaging activities to residents with cognitive impairments for five of six residents (1, 6, 8, 19 and 26) reviewed for activity concerns. This failure placed residents at risk of feelings of boredom, depression and decreased quality of life. Findings included . Review of the facility's Resident Handbook revised January 2019 showed short- and long-term residents enjoy a wide range of ongoing activities and events, tailor-made to amuse, entertain, and inform. The handbook showed the following types of activities offered: Physical Activities We promote stronger bodies, bones and coordination, and muscles, through a variety of exercises and activity programs designed to improve or maintain physical wellbeing. Spiritual Activities Our spiritual and religious services focus on needs that are important to many of our residents and promote spiritual well-being and religious fulfillment Social Activities We host numerous social programs that are designed to encourage human connection and interaction. Parties, games, musical entertainment, and exciting outings are just some of the many social events held here. Intellectual Activities A number of programs focus on challenging you mind. Our goal is to keep you involved and stimulated with group activities, such as: political discussions, brain teasers, word and math challenge games, current event discussions, etc. Emotional Programs Our emotionally inspired programs include personal visits, reminisce groups, holiday, and birthday celebrations, and more The handbook showed if an activity was cancelled for any reason, a replacement activity will be scheduled. RESIDENT 1 Resident 1 admitted [DATE] with diagnosis to include dementia and major depressive disorder. According to the Quarterly Minimum Data Set (MDS) assessment on 06/03/2022 showed during an interview about activities, Resident 1 stated going their favorite activities was very important to them including, group activities, music, pet visits and news. Review of an activity note dated 04/21/2022 at 9:44 AM written by Staff D, Social Services showed Activities Evaluation completed. Additional Notes and Summary: (Resident 1) continues to come out of their room for all the meals in the dining room. They enjoy talking with other residents and staff members. The resident is always in cheerful mood and liked to participate in the activities. Refer to evaluation for details. Review of the activity care plan for Resident 1 directed activity staff to inform, invite, encourage, and assist the resident to participate in scheduled out of room activities, including their interest of Men's Coffee Social, bowling, live musical events, and seated stretch class. The care plan showed they enjoyed participating in both large and small group activities as well as independent activities and 1:1 room visit. The care plan showed they would be provided with a daily issue of the facility's Daily Doings and be notified of any change made to the activity's agenda. In observations on 06/13/2022 at 9:16 AM, 10:16 AM, Resident 1 was up in their wheelchair in their room looking down with their hand on their head. The TV was on in their room. At 11:23 AM, the resident was in the same location and asleep. At 11:59 AM, 1:12 PM and 2:30 PM they remained in their room with the TV on. In an observation on 06/14/2022 at 12:57 PM and 2:29 PM, Resident 1 was in bed with his TV on. At 3:17 PM, the resident remained in bed asleep. In an observation on 06/15/2022 at 8:42 AM., Resident 1 was in their room in their wheelchair watching CBC news. At 1:43 PM and 2:39 PM the resident remained in bed with no meaningful activities. In an observation on 06/16/2022 at 9:38 AM, Resident 1 in their room in their wheelchair. The TV was on home shopping network featuring high heeled shoes. At 11:01 AM, the resident remained in bed with the TV on. In an observation on 06/17/2022 at 9:48 AM and 11:14 AM, the resident was sitting by nurses' station with no meaningful activity occurring. In an interview on 06/16/2022 at 2:32 PM, The Director of Nursing Services/Chief Nursing Officer stated Resident one did like to be in their room but knowing the resident, the staff should be encouraging them to attend activities RESIDENT 8 Resident 8 admitted on [DATE] with diagnoses to include a stroke with one sided paralysis, major depressive disorder, panic disorder, insomnia, and anxiety disorder. According to the Annual MDS assessment on 04/06/2022, they were interviewed, and stated activities were very important to them. They did not refuse care. Review of the activity care plan for Resident 8 directed activity staff to inform, invite, encourage, and assist the resident to participate in scheduled out of room activities, including their interest of Bingo, men's coffee social, happy hour, and live musical events The care plan showed the staff would inform, invite, and encourage out of room activities they enjoyed. The care plan showed they would be provided with a daily issue of the facility's Daily Doings and be notified of any change made to the activity's agenda. Review of a psychotropic meeting note dated 03/29/2022, The resident engaged in conversation with staff and behavior monitor shows no depressive statements, but the resident had been coming out of their room for activities less. The plan was to encourage the resident to join group activities and offer in room activities with a review next quarter. Review of an activity note dated 04/13/2022 at 8:16 PM, written by Staff D, Social Services showed Activities Evaluation completed. Resident preferences are in room activities and likes sports on the TV. They come out to some room activities Men's coffee, music events. The family and friends take them out on family events. In an observation on 06/13/2022 at 9:16 AM, 10:14 AM, 11:24 AM, 12:33 PM, 1:13 PM, the resident was observed to be in bed with the TV on. In an interview on 06/13/2022 at 10:17 AM, Staff H, Registered Nurse stated the resident was alert and oriented but withdrawn. In an observation on 06/14/2022 at 10:04 AM, 11:30 AM, 12:03 PM, 1:03 PM, 2:25 PM they were observed to be in bed with their TV on. The resident did not attend men's coffee, one of their listed favorite activities. In observations on 06/15/2022 at 8:44 AM, 10:04 AM, 11:52 AM, 1:39 PM, the resident was observed to be in bed with the TV on. In observations on 06/16/2022 at 8:30 AM,9:36 AM, 10:35 AM, 10:58 AM, 11:50 AM, 1:00 PM and 2:02 PM, the resident was observed to be in bed with the TV on. In a follow up interview on 06/16/2022 at 10:12 AM, Staff H, RN was asked about the lack of meaningful activities for Resident 8. Staff H stated the resident was a recluse and stayed in bed. They stated the daughter and Power of Attorney visit. In an interview on 06/17/2022 at 9:17 AM, Resident 8 was in bed watching the Price is Right. The resident said they had not been getting up for activities because they do not have them anymore. There is not much going on. During multiple observations all days of survey, the resident was not observed in a meaningful activity. The facility failed to provide the residents with meaningful activities in accordance with their culture, current preferences, and mental and physical abilities.

Based on interview and record review, the facility failed to ensure the Activity Director had the appropriate qualifications to assess and care plan activities for facility residents. This failure placed residents at risk for decreased quality of life related to lack of a qualified Activity Director. Findings included . Review of facility employee roster on 06/14/2022 showed no facility staff currently employed as an Activity Director. In an interview on 06/16/2022 at 2:14 PM, the Administrator stated there was no current Activity Director in the facility. The Administrator stated the prior Director had resigned and the facility was recruiting for the position. Social Services and Nursing were filling in to provide activities, but no current staff held the proper credential to serve as Activity Director. Reference WAC 388-97-0940 (3)(a-c) .

Based on interview and record review, the facility failed to ensure the facility wide assessment included all the required components. The assessment lacked information concerning information about running day to day operations versus emergency operations. This failure had the potential to place all residents in the facility at risk for inadequate care, lack inadequate outside services and inadequate response during an emergency or disaster. Findings Included . A Review of the facility assessment, dated 06/13/2022, showed that the facility assessed staffing by reviewing resident acuity and PPD (Per Patient Day). The assessment did not report what the acuity of the facility had been or what the PPD was to help determine if the facility had adequate staff in place. The assessment indicated that the facility had adequate staff, although the facility had open positions for the activity director, restorative nurse and restorative aides and the dietary manager did not have adequate credentials per regulation. A Review of the facility assessment found there was no information on what specific training or competencies were needed to care for their resident population. A review of the facility assessment found that there was no information listed for what outside resources were being used and if those services were adequate to serve the resident population. A review of the facility assessment found it lacked information about the cultural and religious preferences of the residents and how that affected the operation of the facility. A review of the facility assessment showed the section for All Hazards Risk Assessment was blank and it lacked a facility and community based all hazards risk assessment. During an interview on 06/17/2022 at 11:46 AM, the Administrator stated that they had completed the facility assessment from a template on the first day of survey and that there was not a facility assessment in place since the ownership of the facility changed in February 2022. The administrator acknowledged that the assessment was missing key components. No Associated WAC .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 2 Resident 2 was admitted to the facility [DATE] with diagnosis to include Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), and pain. The Annual Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition. Review of the resident's medical record on [DATE], showed the last physical therapy evaluation and discharge summary were not located in the electronic medical record, and there were no paper medical records available. In an interview on [DATE] at 3:40 PM, Staff C stated that the physical therapy notes were with the company that they were no longer with. Staff C stated when the new company took over, they switched therapy providers. Staff C stated they called the main office to the previous therapy provider and requested the records and was hopeful they would be there on [DATE] but they were not sure. In an interview on [DATE] at 10:25 AM, Staff C stated they were able to get the therapy notes, if more were required, they could request again. Staff C confirmed the therapy records from the previous provider were not readily accessible. RESIDENT 17 Resident 17 admitted to the facility on [DATE] with diagnosis to include Parkinson's Disease and dementia. The MDS assessment dated [DATE] showed the resident had severe cognition impairment. Review of the resident's medical record on [DATE] showed the consent for use and treatment for an antianxiety medication were not located in the electronic medical record, and there were no paper medical records available. On [DATE] at 4:15 PM a request for the consent for use and treatment for an antianxiety medication were requested as they were not in the electronic medical record. In an interview on [DATE] at 9:48 AM, the CNO/DNS stated they located the consent form. The CNO/DNS was unable to explain why the medical records were not readily accessible. In an interview on [DATE] at 3:40 PM, Staff C stated that they had been behind in scanning information into the medical record and that they were caught up to the middle of [DATE]. In an interview on [DATE] at 10:25 AM, Staff C stated they are also the central supply for the facility, and they assist with care giving on the floor in the mornings, as they are a Nursing Assistant Certified (NAC) as well as medical records. 388-97-1720(1)(a)(i)(ii)(iii)(iv) Based on interview and record review, the facility failed to ensure complete and accurate medical records were maintained and readily accessible for four of seven residents (2, 6, 11 and 17) reviewed for accuracy of medical records. This failure included psychotropic (a medication that affects a person's mental state) consent form, therapy evaluations, Preadmission Screening and Resident Review (PASRR) evaluations (a required admission assessment for psychological support needs) and wishes for CPR (cardiopulmonary resuscitation) that were not readily accessible to staff. This placed residents at risk for unmet needs, condition deterioration, unrecognized changes in condition and adverse outcomes. Findings included . Review of the facility policy titled, Resident Medical Record, revised [DATE], medical records are maintained on each resident in accordance with accepted professional standards; they are complete, accurate, readily accessible, and systematically organized. RESIDENT 6 Resident 6 admitted on [DATE] with diagnoses to include Alzheimer's, depression, and anxiety, Review of the clinical record on [DATE], showed the preadmission PASRR was not in the clinical record. At 12:39 PM, the PASRR was requested from Staff C, Medical Records. In a joint interview on [DATE] at 12:48 PM, Staff C provided the PASRR and stated it had not been scanned into the medical record. Staff C stated when the change of ownership occurred not all of the prior medical records had been scanned in. They stated they were caught up to filing in May. The Administrator stated that if the nurses needed to locate medical records, they had a key to get into the medical records office. They stated all records were located on site, they just needed to be located. RESIDENT 11 Resident 11 admitted on [DATE]. Review of the resident's code status on the resident's [NAME] (tool to show nursing aides how to provide care), located in the electronic medical record showed the resident's Code Status (wishes shall they be found with no pulse or respirations) was DNR - (do not resuscitate) and SELECTIVE TREATMENT - SEE POLST (Physician Orders for Life-Sustaining Treatment). Review of the POLST scanned into the chart said the resident wished to be a full code. In an interview on [DATE] at 11:18 AM, Chief Nursing Officer (CNO)/Director of Nursing Services (DNS) brought in the revised POLST and said was recently updated. They said the son would sign the POLST soon and then scanned into his medical record. In an interview on [DATE] at 3:40 PM, Staff C stated they were behind in scanning items into the medical record. In an interview on [DATE] at 10:23 AM, Staff H, Registered Nurse, stated Resident 11, was a full code when they sent them out. They stated that the resident was changed to a no code/DNR at the hospital, but the hospital did not send the updated POLST to the facility. Staff H said they had the Power of Attorney (POA) wishes verbally and put that into the orders, so it was updated on the [NAME] and face sheet. Staff H stated if a resident coded (heart would stop), they looked in the medical record for the residents wishes. In an interview on [DATE] at 12:11 PM, the CNO/DNS had the resident's POLST which was now signed by the son. They stated they were not sure what happened but acknowledged that the correct POLST was not in the medical record, but the order had been updated. The CNO/DNS acknowledged this could be an issue had the resident coded. Review of the clinical record on [DATE] at 9:00 AM, showed the current POLST had not been scanned into the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 2 Resident 2 was admitted to the facility 02/04/2019 with diagnosis to include Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), and pain. The Annual Minimum Data Set (MDS) assessment dated [DATE] showed that the resident had intact cognition, with no history of refusal of care. Review of the Restorative Program Referral Form dated 12/17/2021, directed staff to perform: - BUE and BLE AROM exercises three - five times a week. - Ambulate with front wheeled walker with one person assist Review of the resident's care plan with a focus dated 02/23/2021 showed that the resident had decline in mobility due to Parkinson Disease progression with a goal to increase muscle strength and coordination to maintain independence with eating and improve gate quality. Interventions to include Nursing Restorative Program with AROM exercises for their upper and lower extremities, and a walking program. Review of the Documentation Survey Report dated 03/01/2022 through 06/14/2022 showed that there was no restorative nursing program documented for the resident. In an interview on 06/13/2022 at 1:15 PM, the resident stated, I'm deteriorating, I have Parkinson's and it's a slow ride downhill, I could use some exercises. RESIDENT 20 Resident 20 was admitted to the facility 02/10/2021 with diagnosis to include malnutrition, abnormal gait and mobility, and general weakness. The Quarterly MDS dated [DATE] showed the resident had moderate cognition impairment, with no history of refusal of care. Review of the Restorative Program Referral Form dated 09/08/2021, directed staff to perform: - AROM to all major joints with 10 repetitions and two sets each - Ambulation 150 feet with a front wheel walker - Practice with toilet transfers using front wheel walker Review of the resident's care plan with a focus dated 09/20/2021 showed that the resident had impaired mobility related to gait abnormalities, and osteoarthritis with a goal to maintain range of motion to all extremities and toilet transfers. Interventions to include a Nursing Restorative Program with AROM exercises for their upper and lower extremities, and a walking program. Review of the Documentation Survey Report dated 03/01/2022 through 06/14/2022 showed that there was no restorative nursing program documented for the resident. In an interview on 06/16/2022 at 8:30 AM, The Administrator stated the facility had five residents with contractures. The list included the names of residents (25, 16, 4, 8 and 2). In an interview on 06/16/2022 at 10:12 AM, Staff H, Registered Nurse (RN), stated the facility had no restorative services in place. Staff H was informed the resident had not had their splint on and there was no direction for who places it, for how long etc. They stated they would look into the order and that nursing or OT could put the splint on. In a joint interview on 06/16/2022 at 2:15 PM, The Administrator stated they had not had a restorative program in several months but could not recall exactly when RA stopped. They stated all our RA certified aides left in February or March with the company change. They said they would look at using residents part B benefits for those that could benefit from therapy. They said they would add lack of restorative services to their Quality Assurance Performance Improvement (QAPI) plan and were looking at which nurse could oversee the program. The Director of Nursing Services (DNS)/Certified Nurse Officer (CNO) stated staffing was a challenge and they would move forward to provide the restorative program with urgency and as a top priority. They stated they were having therapists re-screen residents for services. In an interview on 06/17/2022 at 2:34 PM, the Administrator stated they did not have a back up plan for the lack of restorative staff. The stated they did not have enough staff to take care of the residents so there wasn't staff to complete restorative tasks. In an interview on 06/17/2022 at 3:45 PM, a list of therapy evaluations for residents who the facility stated would benefit from restorative nursing was requested to the DNS/CNO. Review of the staff roster showed there were no restorative aides or nurses to interview. Reference: (WAC) 388-97-1060 (1)(2)(b)(3)(d) RESIDENT 19 Resident 19 admitted on [DATE] and was a long term care resident with diagnoses which included osteoarthritis, dementia, Review of skilled occupational therapy discharge recommendations dated 08/25/2021 showed Resident 19 had impaired range of motion to the right shoulder and had restorative nursing recommendations for bilateral upper extremity range of motion recommendations to maintain range of motion necessary for activities of daily living (ADLs) and reduce risk for contractures. The recommendation was for BUE AAROM (active assist range of motion)/PROM 3-5 days a week. The resident also had physical therapy recommendations for bilateral lower extremity range of motion 3-5 days a week. Review of care plan and [NAME] (instructions to nursing assistants) showed both programs identified under the restorative nursing section of the care plan. Review of the resident's record on 06/17/2022 for the months of March, April, May, and June of 2022 showed no place for documentation of the resident's restorative programs and no evidence to show it had ever been completed. In an interview on 06/16/2022 at 10:14 AM, Staff F, Nursing Assistant (NA) stated the staff used a sit to stand transfer machine with the resident. Staff F stated they could bear some weight, but the staff had to do most everything for them. Staff stated the resident could not help much with upper body dressing because their arms are pretty stiff, and had never seen them raise their arms above their head. Staff F did not know if the resident had an exercise program and stated it was not something they did with the residents. In an observation of transfer on 06/16/2022 at 1:57 PM, Staff F and Staff H, Registered Nurse, were assisting the resident to transfer using the sit to stand. Staff F was observed to attempt to lift the resident's arm at the elbow area to allow for the sling to slide around and behind her and there was visible resistance from the resident. It was difficult during the observation to determine if the resistance was due to resident behavior or physical limitation. Staff F was asked if the resident was resisting the movement and Staff F stated no, it is more like stiffness. The resident was not able to give input due to dementia. RESIDENT 26 Resident 26 admitted [DATE] with diagnoses which included dementia, weakness and a history of falls. Review of a therapy referral form dated 11/24/2021 showed the resident had recommendations for AAROM of BUE/BLE x 15 repetitions; 2 sets 3-5 times per week with goal to maintain range of motion and balance. Review of the current care plan and [NAME] on 06/16/2022 showed no restorative nursing programs were set up for the resident and there was no further documentation found regarding any restorative programs for the resident. Based on observation, interview, and record review, the facility failed to ensure appropriate services were provided to maintain, increase and/or prevent a decrease in range of motion for nine of nine residents (1, 2, 4, 8, 9, 16, 19, 20 and 26) reviewed for range of motion. The facility placed residents at risk for a decline in range of motion (ROM), developing pain, and complications of immobility and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included . Review of the facility's policy titled, Restorative Nursing, dated 01/20/2020, showed the restorative program was a nursing directed program established to help the resident progress to a higher level of function and/or restore function. The program supplements and or reinforces gains made in therapy as part of normal recovery. The restorative program is to promote resident ability to adapt and adjust to living as independently and safely as possible. RESIDENT 1 Resident 1 admitted to the facility on [DATE] with diagnoses to include stroke and traumatic brain injury. According to the Quarterly Minimum Data Set (MDS) Assessment on 06/03/2022, the resident did not reject care. Review of the Occupational Therapy (OT) evaluation on 07/16/2021 revealed, the resident felt unsteady and was worried about falling. Their RUE (right upper extremity) and LUE (left upper extremity) strength were impaired and impacted the resident's activities of daily living (ADL's) from their prior level of function (PLOF). The restorative care plan intervention implemented on 03/16/2021, showed the resident was to receive a restorative nursing program (RNP) for bed mobility, rolling side to side while on the bed for five repetitions (reps) for 15 minutes for two to six days a week as tolerated. The resident was to be instructed to complete modified squats using a transfer pole from the bed or wheelchair (w/c) for ten reps, two to six times a week as tolerated. Review of the clinical record showed no place for the restorative aide charting. There was no prior documentation of restorative care. Review of the Physical Therapy (PT) evaluation on 06/15/2022, showed the resident demonstrated passive range of motion (PROM) of bilateral (both) upper extremities (BUE) and bilateral lower extremities (BLE) within functional limitations. The current restorative program was appropriate. Review of the restorative nursing referral dated 06/17/2022, showed new specific interventions from the 03/16/2021 restorative program. The recommendations showed a specific RNP that the resident was to receive for bed mobility, transferring, and active assisted ROM to their BUE and BLE. Resident 1 was not observed to receive any restorative services on 06/13/2022, 06/14/2022, 06/15/2022, 06/16/2022, 06/17/2022 or 06/21/2022. RESIDENT 4 Resident 4 admitted to the facility for rehabilitation on 08/05/2019, with diagnoses to include right shoulder nerve impingement, rheumatoid arthritis, knee and shoulder pain and muscle weakness. According to the resident's Annual MDS assessment, dated 03/14/2022, the resident had no cognitive impairment and did not reject care. They had upper and lower impairment on both sides of their body. Review of the PT evaluation on 07/22/2021, showed the resident had both left and right hip, knee, and ankle impaired ROM. The resident was unable to assist with rolling in bed due to hand/finger contracture's and was unable to flex their hips at all which limited their ability to sit in a chair. The plan of treatment was for restoration, compensation, and adaptation. Review of the OT evaluation on 07/27/2021 revealed, their RUE and LUE (left upper extremity) strength were impaired and impacted the resident's ADL's from PLOF. The left and right wrist and forearm were impaired in a severe swan neck (a deformity in which your fingers were bent abnormally) and multiple BUE joint contractures (stiffening and shortening of joints). Review of the restorative program referral dated 08/08/2021 included a goal of maintaining BUE ROM to both hands by positioning BUE in neutral with pillows, place wash rag roll in palm of hand to decrease risk for skin breakdown and complete Active Assisted Range of Motion (AAROM) to BUE joints within pain free ROM. Review of the resident's contracture and restorative care plan showed the resident had impaired mobility related to rheumatoid arthritis and exhibited hand contractures. The restorative staff were to perform active ROM to BUE joints two to six times a week as tolerated. Review of the clinical record showed no place for the restorative aide charting. There was no prior documentation of restorative care. Review of the ADL Care Area Assessment (CAA) on 03/14/2022, showed the residents hand contractures were present on admit and had worsened. The resident last worked with OT and PT in July of 2021. Review of a nursing progress note on 03/17/2022 at 2:49 PM showed the resident continued to need extensive assist with most ADL's due to hand contractures and pain/ The resident was able to thread utensils through their fingers to eat. Review of the undated OT evaluation and plan of treatment on 06/17/2022, showed the new referral was related to decline in range of motion of upper body with need for contracture management. The evaluation noted new stiffness to the left hand, right wrist, and right hand. OT noted dead skin build-up in the palm of the right hand with associated bad odor. The wrist crease had dead skin build up. A referral was sent to restorative nursing program for cleaning their hands after each meal and applying lotion to the unbroken skin. Palm guards were to be worn bilaterally while the resident sleeps. Review of the PT evaluation and plan of treatment on 06/20/2022, noted due to the documented physical impairment s and associated functional deficits, without skilled therapeutic intervention, the patient was at risk for depression and social isolation. Review of the restorative nursing referral on 06/20/2022, recommended passive ROM for both hips and ankles for 10-15 reps for 2 sets for 5-7 days a week and rolling both sides for 3 to 4 reps, 7 days a week. Resident 4 was not observed to receive any restorative services on 06/13/2022, 06/14/2022, 06/15/2022, 06/16/2022, 06/17/2022 or 06/21/2022. RESIDENT 8 Resident 8 admitted on [DATE] with diagnoses to include stroke and hemiplegia (weakness/paralysis) affecting their right side. According to the Annual MDS dated [DATE], the resident was cognitively intact and did not reject care. They had upper and lower range of motion impairment on one side. Review of the ADL CAA dated 04/06/2022, showed the resident needed limited to extensive assist with ADL's. Staff must assist and ensure that all needs were met. Not able to live in a lesser care setting. Review of the OT Discharge summary dated [DATE], showed the resident was to wear a left-hand wrist splint overnight to decrease the risk for contracture. Review of the OT evaluation and plan of treatment on 03/31/2021, showed that Resident 8 was referred to OT from the physician. The goal was to establish a RA program. Review of a physician facsimile dated 09/08/2021, showed a request from rehab for PT evaluation and treat for resident 8 related to a decline in bed mobility. The order was accepted on 10/08/2021. Review of the restorative program referral dated 12/23/2021, directed RA staff to perform PROM left upper and lower extremity for ten reps, AAROM to right UE and LE for ten reps and have resident perform stand pivot transfer with the transfer pole two to three times. Review of the contracture/mobility care plan dated 02/26/2021, restorative nursing staff were to provide active ROM to their right side of body 2-6 days a week, 10 reps per exercise, provide passive ROM to left side of body 2-6 days /week as tolerated, 10 reps per exercise, and assist with stand pivot transfer using the transfer pole from/to bed to/from wheelchair or bedside commode 3-5 x/week as tolerated. Review of the current PT evaluation and treatment plan showed the referral was to reassess limitation of range of motion of the left hand and review splint use. The PT noted the resident currently had a static hand splint and was able to tolerate wearing the splint. Current RA program was reviewed and passive ROM to fingers, thumb, and wrist in conjunction with a hand splint schedule was added to prevent worsening of limitation of joint movements of left hand and wrist due to cramps/spasms and hemiplegia. The PT included risk factors as further decline in function, immobility and DVT (blood clot in deep vein). Review of the current restorative nursing referral, recommended restorative staff assist the resident in active ROM to right side of their body two to six times a week with 10 reps, passive ROM to left side of body two to six times a week for 10 reps, stand pivot transfers with transfer pole from and to bed times 4 and left-hand splint as tolerated, Skin check was to be performed. PROM to all fingers, thumb, wrist of left UE, ten reps for two to three sets, five to six times a week. Review of the [NAME] (tool that directed nursing aides on how to perform care) showed a right arm splint but did not include when the splint was to be placed on, who was to place the splint on or how many hours the splint should be on the resident. Review of the clinical record showed no place for the restorative aide charting. There was no prior documentation of restorative care. In an interview and observation on 06/15/2022 at 1:39 PM, Resident 8 was lying in bed, without their splint on. They stated they did not mind wearing the splint. The resident stated they had not received any restorative or ROM to his hand in 8 months. In a follow up interview on 06/17/2022 at 9:17 AM, Resident 8 was lying in bed with their splint on their overbed table. The resident stated the staff had put the splint on for a bit last night and it helped alleviate some of the pain in their arm and hand. They commented their left shoulder was hurting as well. Resident 8 was not observed to receive any restorative services on 06/13/2022, 06/14/2022, 06/15/2022, 06/16/2022, 06/17/2022 or 06/21/2022. There were no observations of the left-hand splint on for all days of survey. RESIDENT 9 Resident 9 admitted on [DATE] with Alzheimer's disease, lack of coordination, muscle weakness, reduced mobility and a history of falls. According to the Annual MDS 04/11/2022, the resident had mild cognitive impairment and did not reject care. Review of the restorative referral dated 04/22/2021, directed restorative staff to complete the Nu Step machine (a type of an exercise machine). There were no specific time indications. The resident was to have an ambulation program and ambulate 150 ft with contact guard assistance for 150 feet. Review of a restorative nursing care plan dated 02/24/2022, showed the resident was to receive ROM to BUE and BLE for 10 reps, three to five times a week and ambulate in the parallel bars three to five times a week. The plan stated it was appropriate for the resident. On this care plan was a handwritten note that said not appropriate at this time will continue previous program. The handwritten note included a received date of 03/02/22. Review of a PT therapy plan dated 05/31/2022 showed the resident was unable to ambulate due to bilateral LE instability. Review of the clinical record showed no place for the restorative aide charting. There was no prior documentation of restorative care. Resident 9 was not observed to receive any restorative services on 06/13/2022, 06/14/2022, 06/15/2022, 06/16/2022, 06/17/2022 or 06/21/2022. RESIDENT 16 Resident 16 admitted on [DATE] with diagnoses to include stroke with right side hemiplegia and avascular necrosis (death of bone due to lack of blood supply) of both hips . According to the Annual MDS on 04/11/2022, they had mild cognitive impairment and did not reject care. There was upper and lower extremity ROM impairment on one side of their body. Review of the restorative program referral on 09/08/2021, the restorative staff were to assist with active assistive ROM to both LE for 10 reps for 2 sets to pain tolerance and assist with wheelchair to bed transfers 2 reps with wheelchair facing head of bead. Review the OT evaluation and treatment, showed the resident had right shoulder and elbow stiffness. The resident was referred to OT due to exacerbation of decrease in ROM in RUE, in order to evaluate the resident for possible contracture and skin integrity. The assessment showed there was joint tightness in residents right shoulder. The resident required skilled OT services to enhance the resident's quality of life with the least amount of supervision. Review of the clinical record showed no place for the restorative aide charting. There was no prior documentation of restorative care. Resident 16 was not observed to receive any restorative services on 06/13/2022, 06/14/2022, 06/15/2022, 06/16/2022, 06/17/2022 or 06/21/2022.