**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a therapeutic diet was provided as ordered for 1 of 3 residents (Resident 1), reviewed for therapeutic diets. This failure had the potential to cause unwanted weight gain, a decline in medical condition, and a diminished quality of life. Findings included . Review of a Resident Information Sheet (face sheet) in the electronic health record printed on 06/11/2025, showed Resident 1 was readmitted to the facility from the hospital on [DATE] and had a diagnosis of [NAME] Syndrome (a rare disease that causes excessive appetite and overeating). Review of weight records dated 06/06/2025 showed Resident 1's weight was 268 pounds (lbs. -a unit of measurement); on 06/07/2025, 270 lbs.; and on 06/11/2025, 274 lbs. Review of Resident 1's dietary card on their lunch tray dated 06/11/2025 showed, diabetic diet (limits unhealthy fats and added sugars), small portions-sub [substitute] fruit for dessert. Observation on 06/11/2025 at 12:40 PM, showed Resident 1's lunch tray had a cherry tart desert with topping and a mixed fruit cup. Further observation during that time showed Resident 1 consumed both the dessert and the mixed fruit cup. In an interview on 06/11/2025 at 1:19 PM, Staff C, Dietary Manager, stated that Resident 1 was on a diabetic diet and should only eat 2,000 calories a day. Staff C stated, I try to redirect Resident 1 when they request extra portions of food or items that were not on their diet, but over the past couple of months it has been hard to redirect them. When they see other residents with certain foods, they want to have [them] too. Staff C further stated that Resident 1 should not have had the cherry tart on their lunch tray but should have only had the mixed fruit cup for dessert. A joint record review and interview on 06/11/2025 at 1:26 PM with Staff C showed Resident 1's planned diabetic menu items dated 06/11/2025 for breakfast, lunch, and dinner's calories totaled 2,200. Staff C stated that Resident 1's planned diabetic diet list of food items was 220 calories over the 2000 calories limit. In an interview on 06/11/2025 at 1:43 PM, Resident 1 stated, I ate the cherry dessert and the fruit cup. They were on my tray, so I ate them. I usually get both a dessert and some fruit on my tray at lunch time in the dining room and I eat them both. I have been trying to lose weight, but it is so hard to do. In an interview on 06/11/2025 at 5:23 PM, Staff D, Assistant Director of Nursing, stated that Resident 1 should have received the fruit cup on their lunch tray, but not the cherry tart desert. In an Interview on 06/11/2025 at 5: 25 PM, Staff E, Quality Assurance Nurse, stated that Resident 1 was on a diabetic diet and should not have received the cherry tart dessert on their lunch tray, that the mixed fruit was the only desert that should have been on the lunch tray. Reference (WAC): 388-97-1200(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff provided care and services in a manner that maintained and promoted dignity while providing meal assistance for 1 of 2 residents (Resident 70), reviewed for meal observations. This failure placed the resident at risk for a diminished self-worth and overall well-being. Findings included . Review of the facility's undated document titled, Resident Handbook included the resident bill of rights which showed that residents had the right to be treated with respect and dignity. Resident 70 admitted to the facility on [DATE]. Observation and interview on 03/28/2025 at 1:00 PM, showed Staff Z, Certified Nursing Assistant (CNA) was standing while assisting Resident 70 with their lunch who was sitting in their wheelchair. Staff Z stated that they usually do not sit while they assisted residents with their meals. Staff Z stated that sitting when feeding a resident would be better because then the residents would not feel they are rushed. Staff Z further stated that they were trained to provide meal assistance for residents at eye level. Observation and interview on 03/31/2025 at 2:02 PM, Staff AA, CNA, showed Resident 70 in bed with their lunch in front of them. Further observation showed Staff AA standing next to Resident 70's bed while they assisted them with their meal. Staff AA stated they were standing while assisting Resident 70 with their meal because [Resident 70's] bed was too high. In an interview on 04/02/2025 at 4:12 PM, Staff B, Director of Nursing, stated that they expected staff to be seated next to the resident while assisting with their meals. In an interview on 04/02/2025 at 4:39 PM, Staff A, Administrator, stated that staff [Staff Z and Staff AA] should be seated and at eye level when assisting residents with their meals. Reference: (WAC) 388-97-0180(1)(2)(3) .

Based on interview and record review, the facility failed to inform the resident and/or their representative before administering psychotropic (mind altering) medications for 1 of 5 residents (Resident 34), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about their medications. Findings included . Review of the facility's undated document titled, admission Agreement, showed, Consent for Medical Treatment: The resident has the right to make health care decisions, including consenting to or refusing treatment. Review of the facility's undated document titled, Resident Handbook, showed, Residents have the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Review of the psychiatric progress note dated 04/17/2024 showed Resident 34 had diagnoses of Parkinson's psychosis (symptom of losing touch with reality), delusions (fixed false belief about something), and visual hallucination (the experience of seeing, hearing, feeling, or smelling something that does not exist). Further review showed Resident 34 started on Nuplazid (an antipsychotic -mind altering) medication on 09/21/2023. Review of the Electronic Health Record (EHR) showed Resident 34 did not have consent for Nuplazid when it was initiated on 09/21/2023. Further review of the EHR showed Resident 34 had a consent for Nuplazid a year later dated 10/09/2024. In an interview and joint record review on 04/02/2025 at 3:28 PM with Staff E, Resident Care Manager, stated that Resident 34 was given the first dose of Nuplazid on 09/22/2023. A joint record review of Resident 34's EHR did not show consent for Nuplazid when it was initiated on 09/21/2023. Staff E stated that Resident 34 had a consent for Nuplazid dated 10/09/2024 and that there was no consent that was completed in 2023. Reference: (WAC) 388-97-0300(3)(a)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained and completed for 1 of 3 residents (Resident 70), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility's undated document titled, admission Agreement, showed that Residents/Legal Representatives have been given written materials about resident's right to accept to or refuse medical treatments as provided by state law and has been informed of resident's right to formulate Advance Directives. Review of Resident 70's Social Service History & Initial assessment dated [DATE], showed Resident 70 made their own decisions with support from daughters when needed. It further showed the assessment did not indicate whether Resident 70 had a DPOA for health care or if they chose not to execute an Advance Directive document at that time. Review of Resident 70's comprehensive care plan printed on 03/30/2025, did not show an advance directive care plan. In an interview on 03/28/2025 at 8:51 AM Resident 70 stated that they had advance directive and that their relative was their DPOA. In a joint record review and interview on 03/28/2025 at 10:15 AM with Staff M, Social Services Assistant, did not show Resident 70 had an advance directive document in their Electronic Health Records (EHR). Staff M stated that they did not see Resident 70's advance directive or anyone listed as DPOA in their EHR. In an interview and joint record review on 03/28/2025 at 10:33 AM, Staff BB, Unit Manager, stated that a copy of resident's advance directive would be uploaded into the resident's EHR, and that they would keep a copy in the three-ring binder in the nursing station. Staff BB stated they did not find a copy of Resident 70's advance directive in a three-ring binder kept at the nursing station. In an interview and joint record review on 04/01/2025 at 1:07 PM, Staff N, Social Services Director, stated that the resident's advance directive would be obtained on admission and would be part of the Social Service Assessment. A joint record review with Staff N did not show Resident 70 had an advance directive document in their EHR. Staff N stated that Resident 70 did not have one [advance directive]. In an interview on 04/02/2025 at 5:26 PM, Staff A, Administrator, stated that they expected residents to have them [advance directive]. Reference: (WAC) 388-97-0280(3)(c) (i-ii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN) and Notification of Medicare (federal health insurance program for people age [AGE] or older) Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 2 of 3 residents (Resident 25 & 73), reviewed for beneficiary notification. These failures placed the residents and/or their representatives at risk of not being fully informed and losing their right to an appeals process. Findings included . Review of the facility's undated document titled, Resident Handbook, showed that the residents have the right to receive notices in writing. Further review of the document showed that the resident has the right to be informed about Medicare eligibility and coverage. Review of the undated NOMNC Form from the Centers for Medicare and Medicaid Services (CMS) -10123, showed the NOMNC must be delivered at least two calendar days before Medicare covered services end. Review of the SNF ABN Form CMS-10055, dated 2024, showed the SNF required to issue the SNF ABN to Medicare residents prior to providing services that Medicare may not cover. Further review of the document showed the SNF ABN provided information to the residents so that they could decide whether to get the care that may not be paid for by Medicare and assume financial responsibility. RESIDENT 25 Review of the SNF Beneficiary Notification Review form dated 04/02/2025 showed Resident 25 received Medicare Part A Skilled Services from 01/20/2025 to 02/22/2025. Further review of the document did not show that an ABN and/or a NOMNC were provided to Resident 25. There was no explanation written to explain why either one of these was not given. Review of Resident 25's Electronic Health Record (EHR) did not show documentation that an SNF ABN and/or a NOMNC were provided to Resident 25, two days before their last covered day. RESIDENT 73 Review of the face sheet printed on 03/25/2025, showed Resident 73 admitted to the facility on [DATE]. Review of the SNF Beneficiary Notification Review showed that Resident 73 received Medicare Part A skilled services from 11/14/2024 to 02/25/2025 and remained in the facility after skilled services ended. Further review of the document showed that SNF ABN was not issued to Resident 73. Review of Resident 73's EHR did not show documentation that an SNF ABN was provided to Resident 73 two days before their last covered day. In an interview on 04/01/2025 at 2:15 PM, Staff M, Social Services Assistant, stated that the SNF ABN were not provided for Resident 25 and 73. Staff M further stated that NOMNC was not provided for Resident 25. In an interview on 04/02/2025 at 4:39 PM, Staff A, Administrator, stated that they expected Residents 25 and 73 to be provided with their SNF ABN and/or NOMNC before the end of their last day of Medicare Coverage. Reference: (WAC) 388-97-0300 (1)(e) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit the resident Minimum Data Set (MDS - an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 1 of 22 residents (Resident 69), reviewed for transmitting MDS assessments. This failure placed the residents at risk for unmet care needs and diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11, revised in October 2024, showed all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. For submission, the MDS data must be in record and file formats that conform to standard record layouts and data dictionaries, and pass standardized edits defined by CMS and the State. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. Review of the electronic health record showed Resident 69 was admitted to the facility on [DATE] and discharged on 11/10/2024. Review of Resident 69's discharge MDS dated [DATE] showed it was completed on 11/18/2024 and was not submitted/transmitted to the CMS. In a joint record review and interview on 03/28/2025 at 1:56 PM with Staff H, MDS Nurse, showed Resident 69's discharge MDS dated [DATE] was completed on 11/18/2025 and not transmitted/submitted. Staff H stated that the MDS was completed but not transmitted and it should have been. Staff H further stated that Resident 69's MDS should have been transmitted by 12/02/2024, 14 days after completion of the MDS. In an interview on 04/02/2025 at 11:45 AM, Staff B, Director of Nursing, stated they expected MDS to be completed and transmitted in a timely manner. Staff B further stated that Resident 69's discharge MDS should have been transmitted after completion. Reference: (WAC) 388-97-1000(5)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 2 Resident 2 admitted to the facility on [DATE] with diagnoses that included affective mood disorder (affects a person's emotional state) and anxiety disorder (having excessive/persistent worry and fear). Review of Level I PASARR form dated 01/24/2025 showed Resident 2 had an exempted hospital discharge and had no Level I PASARR screening completed prior to admission to the facility. Review of Resident 2's Electronic Health Record (EHR-census) dated 03/31/2025 showed Resident 2 remained in the facility for 50 days from day of admission until Resident 2 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident 2's EHR (documents) did not show a Level I PASARR screening was completed when Resident 2 had remained in the facility for more than 30 days. In an interview and joint record review on 03/31/2025 at 10:38 AM, Staff M, Social Services Assistant, stated that if a resident came with an exempted hospital discharge PASARR, they would send a fax to the PASARR coordinator and would inform them that a resident was expected to stay in the facility greater than 30 days. When asked, when do they determine that a resident would stay beyond 30 days in the facility, Staff M stated, Me and [Staff N] would usually talk about it, and we make sure to send the completed [Level I] PASARR screening before the 30th day. A joint record review of Resident 2's EHR did not show a Level I PASARR screening was completed prior to Resident 2's hospital discharged on 03/15/2025. Staff M stated that they had sent an email to the PASARR coordinator about it (Level I PASARR screening). In another interview on 04/01/2025 at 10:38 AM, Staff M stated that they had emailed the PASARR coordinator about Resident 2's Level I PASARR screening and referral for Level II PASARR. When asked for a copy of the correspondence to the PASARR coordinator, Staff M stated, I will check my files. At 3:38 PM, Staff M stated that there was no Level I PASARR screening completed and no PASARR level II referral sent to the PASARR coordinator prior to Resident 2's hospital discharged on 03/15/2025. In an interview on 04/01/2025 at 4:11 PM, Staff A stated that they expected Level I PASARR screening should have been done for [Resident 2] who remained more than 30 days in the facility and that if there was a need for a Level II then a referral should have been sent [to the PASARR Coordinator]. Reference: (WAC) 388-97-1975(1-5) Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 2 of 5 residents (Residents 55 & 34), reviewed for PASARR screening. In addition, the facility failed to complete Level I PASARR screening form for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 5 residents (Resident 2). These failures placed the residents at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities. Findings included . Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, revised in September 2024, showed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy showed all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with States's Medicaid rules for screening. The policy show A record of the prescreened shall be maintained in the resident's medical record. The policy further showed If a resident who was not screened due to an exception .and the resident remains in the facility longer than 30 days, the facility must screen the individual using the State's Level I screening process and refer a resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. RESIDENT 55 Review of the face sheet printed on 03/28/2025 showed Resident 55 initially admitted to the facility on [DATE] with diagnosis that included depression (feeling of loneliness, sadness). Further review of the face sheet showed Resident 55 had a diagnosis of delusional (fixed false belief about something) disorder on 02/19/2025. Review of Resident 55's Level I PASARR dated 08/24/2022, showed the diagnosis of depression was not marked in Section I (SMI/ID/RC). In a joint record review and interview on 04/01/2025 at 12:25 PM with Staff N, Social Services Director, showed the diagnosis of depression was not marked in Resident 55's Level I PASARR in Section I. A joint record review of Resident 55's face sheet showed the diagnosis of delusional disorder on 02/19/2025. Staff N stated that depression should have been marked in Resident 55's Level I PASARR in Section I. Staff N stated Resident 55's Level I PASARR should have been updated to reflect the new diagnosis of delusional disorder. Staff N further stated that Resident 55's Level I PASARR should have been correctly completed from the initial admission, updated to reflect the new diagnosis, and followed by a Level II PASARR referral. In an interview on 04/01/2025 at 2:17 PM, Staff A, Administrator, stated they expected the PASARR forms to be accurate. Staff A further stated that Resident 55's most current Level I PASARR form should have had a diagnosis of depression and delusional disorder marked in the SMI section and that it should have been sent to a PASARR level II evaluation upon completion. RESIDENT 34 Review of Resident 34's PASARR showed Level I was completed on 01/28/2022 and no referral for Level II was indicated. Review of the psychiatric progress note dated 04/17/2024 showed Resident 34 had diagnoses of Parkinson's (a movement disorder of the nervous system that worsens over time) psychosis (symptom of losing touch with reality), delusions, and visual hallucination (the experience of seeing, hearing, feeling, or smelling something that does not exist). It further showed Resident 34 started on Nuplazid (an antipsychotic [mind altering] medication used to treat hallucinations and delusions related to Parkinson's disease) on 09/21/2023. Review of Resident 34's Electronic Health Record (EHR) did not show a new Level I PASARR screening and referral for Level II were completed. In an interview and joint record review on 04/01/2025 at 2:15 PM, Staff M, Social Services Assistant, stated that upon admission, they would review the resident's PASARR, their diagnoses, and their medications to see if a PASARR Level II evaluation was needed. Staff M further stated that if Resident 34 was exhibiting new behaviors then they would do a referral for Level II evaluation. A joint record review of Resident 34's PASARR, Staff M stated that Resident 34 doesn't experience any hallucinations and did not think [Resident 34] would qualify for a PASARR Level II. Staff M further stated they did not complete a new Level I PASARR and referral for Level II evaluation for Resident 34. In an interview on 04/02/2025 at 4:39 PM, Staff A stated that Resident 34 did not have any suicidal ideations, therefore they did not expect to complete a new Level I PASARR with a Level II PASARR referral for Resident 34.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident centered discharge plan was in place for 1 of 1 resident (Resident 96), reviewed for discharge planning. The failure to begin the discharge planning process at admission placed the resident at risk for delayed discharge, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharge Planning Process, revised in May 2024, showed, If discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented in the electronic medical record. An active individualized discharge care plan will address .discharge destination .identified needs, such as medical, nursing, equipment, educational, or psychosocial needs. Resident 96 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool) dated 12/26/2024 showed discharge goal for Resident 96 was to be discharged back to community (home). Review of Resident 96's comprehensive care plan printed on 03/31/2025 did not show a discharge care plan. In an interview and joint record review on 03/31/2025 at 10:16 AM, Staff M, Social Services Assistant, stated they discussed discharge planning with the residents and/or their representatives. Staff M stated, we write a care plan to show their discharge goal whether to home or ALF [assisted living facility]. A joint record review of Resident 96's comprehensive care plan initiated on 12/20/2025 did not show a discharge care plan. When asked if a discharge care plan had been developed for Resident 96, Staff M stated no. Staff M further stated, For sure, everybody should have one [discharge care plan]. In an interview on 03/31/2025 at 3:44 PM, Staff A, Administrator, stated they expected a discharge care plan had been developed for Resident 96. Staff M further stated, I expect that they [residents] should have a discharge care plan in the beginning [residents' admission]. Reference: (WAC) 388-97-0080 (2)(a)(d)(e) (i-iv) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the discharge summary was completed and included a recapitulation (overview) of the resident's stay for 1 of 1 resident (Resident 96), reviewed for discharge summary. This failure placed the resident at risk for unsafe discharge, complications and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharge Planning Process, revised in May 2024, showed, The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record. The results of the evaluation and the final discharge plan will be discussed with the resident or resident's representative. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer . Resident 96 admitted to the facility on [DATE]. Review of the discharge Minimum Data Set (an assessment tool) dated 02/07/2025 showed Resident 96 was discharged to the community on 02/07/2025. Review of the IDT [Interdisciplinary Team] Skilled Meeting Note, dated 02/05/2025, showed Resident 96 was independent with their activities of daily living and was walking more than 500 feet using a four-wheeled walker. The IDT skilled meeting note showed Resident 96 would be discharged to their home. Review of the electronic health record (EHR) did not show a discharge summary was completed for Resident 96. In an interview on 03/31/2025 at 8:30 AM, Resident 96's collateral contact stated that Resident 96 left the faciity on [DATE] because [Resident 96] was ready to leave and go back home. In an interview on 03/31/2025 at 10:16 AM, Staff M, Social Services Assistant, stated that Resident 96 was planned to be discharged on the weekend and that Resident 96 had been asked to sign an AMA [against medical advice-when a resident leaves the facility against the advice of their doctor] form on 02/07/2025. Staff M stated that there was a miscommunication about Resident 96's discharge date . When asked if a discharge summary was completed for Resident 96, Staff M stated, You would have to ask the nurse about it. In an interview on 03/31/2025 at 11:15 AM, Staff D, Resident Care Manager, stated that they would complete a discharge summary before a resident's discharge. When asked if a discharge summary had been completed for Resident 96, Staff D stated, I don't [do not] see anything on [Resident 96's] EHR. In an interview and joint record review on 03/31/2025 at 1:52 PM, Staff B, Director of Nursing, stated that they would start to complete a discharge summary for residents who were determined by the IDT for discharge. A joint record review of Resident 96's EHR did not show a discharge summary had been completed for Resident 96. Staff B stated Resident 96 did not have a discharge summary. In an interview on 03/31/2025 at 3:50 PM, Staff A, Administrator, stated, We complete and provide discharge summary whether they [residents] are discharged AMA or discharged to home or other nursing facility. Staff A further stated that Resident 96 had an anticipated discharge and that a discharge summary should have been completed. Reference: (WAC) 388-97-0080(7)(a)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and/or provide activity plan for 1 of 1 resident (Resident 45), reviewed for activities. This failure placed the resident at risk of boredom, decreased mood, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities, revised in February 2025, showed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Resident 45 was admitted to the facility on [DATE] with a diagnosis that included Dementia (a medical condition affecting memory, thinking and social abilities). Review of the quarterly Minimum Data Set (an assessment tool) dated 02/20/2025, showed Resident 45's preferred language was Mandarin (Chinese language) and activity preferences that included reading and keeping up with the news. Review of the activity care plan initiated on 12/28/2024, showed Resident 45 enjoyed independent activities that included reading and watching TV/ Chinese news programs. The activity care plan further showed that staff should offer opportunities for engagement that align with [their] cultural background and interests, providing access to Chinese-language media, reading materials . Observation on 03/27/2025 at 10:58 AM, showed Resident 45 on their wheelchair with their relative at bedside. It further showed Resident 45's TV was not on and there were no reading materials in Resident 45's room that were related to their Chinese culture or ethnicity. Observations on 03/28/2025 at 10:30 AM did not show Resident 45 had been offered or provided activities that aligned with their cultural background and interests. Another observation at 2:50 PM, showed Resident 45 was audibly speaking by themselves in their native language while looking out their window. It further showed Resident 45's TV was not on while their roommate's TV was on in an English-speaking channel with its volume audibly set. In an interview on 03/27/2025 at 10:59 AM, Resident 45's relative stated that they come every day at 10 in the morning up to 1 [one o'clock PM]. When asked if Resident 45 had been provided activities other than performing exercises in the rehabilitation gym, Resident 45's relative stated no. In an interview on 03/28/2025 at 12:47 PM, Staff Y, Certified Nursing Assistant, stated that they speak Mandarin and helped staff to communicate with Resident 45. When asked if they provided activities to Resident 45 that included Chinese reading materials or setting their TV on Chinese channel or programs, Staff Y stated, The family is always here every day. In an interview and joint record review on 03/28/2025 at 4:02 PM, Staff P, Activity Director, stated they provided Resident 45 Mandarin newspaper from another resident in the facility and that was about two weeks ago. A joint record review of Resident 45's activity care plan showed Resident 45 enjoyed watching TV/Chinese news programs and it further showed intervention about providing access to Chinese-language media, reading materials . When asked if Resident 45 had been provided with activities as stated in their care plan, Staff P stated, The family is always there. Staff P further stated, To tell you I have not done it [providing activities to Resident 45] lately since this COVID [a respiratory infectious disease] thing. In an interview on 03/31/2025 at 3:47 PM, Staff A, Administrator, stated that they expected staff to have implemented their care plan and provided activities to Resident 45. Reference: (WAC) 388-97-0940(1)(2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 1 resident (Resident 15), reviewed for hospice services. This failure placed the resident at risk of not receiving the necessary hospice care services, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Coordination of Hospice Services, revised in September 2024, showed the facility will maintain communication with hospice and identify, communicate, follow, and document all interventions put into place by hospice and the facility. Review of the face sheet printed on 04/01/2025 showed Resident 15 admitted to the facility on [DATE]. Review of the hospice order dated 01/30/2025, showed that Resident 15's hospice referral was made. Review of Resident 15's medical records (electronic and paper charting) did not show documentation of hospice care visit notes. In an interview on 03/28/2025 at 12:44 PM, Staff X, Licensed Practical Nurse, stated that the hospice nurse communicated to them before or after meeting with Resident 15. Staff X stated that communication with hospice staff was mainly verbal or by phone. Staff X further stated they did not see the hospice visit notes for Resident 15 on their medical records. In an interview and joint record review on 03/28/2025 at 12:52 PM with Staff G, Resident Care Manager, stated that Resident 15 had been receiving hospice services since January 2025. A joint record review of the Electronic Health Record (EHR) showed no documentation of hospice visit notes. Staff G stated the hospice notes should have been uploaded into Resident 15's EHR. In an interview on 04/01/2025 at 1:33 PM, Staff B, Director of Nursing, stated that there was verbal communication between the facility and hospice agency staff. Staff B stated that there should have been both verbal and written communication to coordinate care between the facility and hospice. Staff B further stated that the hospice visit notes should have been uploaded to Resident 15's EHR and were made accessible for the facility staff. Reference: (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 residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received trauma informed care, trigger assessment, and trauma-informed care assessment in accordance with professional standards of practice for 3 of 4 residents (Residents 8, 34 & 76), reviewed for mood/behavior. These failures placed residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . Review of the facility's policy titled, Trauma Informed Care, revised in May 2024, showed that it was the policy of the facility to ensure residents who are trauma survivors received culturally competent, trauma informed care in accordance with professional standards of practice. The policy showed, Each resident will be screened for a history of trauma upon admission. The policy further stated that if the screening indicates that the resident has a history of trauma and/or trauma related symptoms, the facility will identify triggers which may re-traumatize residents with a history of trauma. RESIDENT 8 Review of the face sheet printed on 03/25/2025 showed Resident 8 admitted to the facility on [DATE] with a diagnosis that included PTSD. Review of the comprehensive care plan printed on 03/25/2025, showed no documentation that Resident 8 had history of trauma and/or identified triggers. During a joint record review and interview on 04/01/2025 at 12:25 PM with Staff N, Social Service Director, showed Resident 8's face sheet listed a diagnosis of PTSD. A joint record review of the trauma informed care assessment dated [DATE] showed Resident 8 had a history of PTSD. Staff N stated that if the resident's trauma assessment results showed positive for PTSD, the facility should assess triggers and include it in the resident's care plan. Staff N stated that Resident 8's trauma informed care assessment came positive for PTSD, the trigger assessment was not completed, and the care plan did not reflect what Resident 8's triggers were. Staff N stated that trauma triggers for Resident 8 should have been identified, their care plan should have been updated to incorporate strategies for managing PTSD and address the identified triggers. In an interview on 04/01/2025 at 2:17 PM, Staff A, Administrator, stated that their expectation was for trauma informed care assessment to be completed for any resident with the history of PTSD. Staff A further stated that if Resident 8 had a history of trauma, a trigger assessment should have been completed, and the care plan should have been developed to address it. RESIDENT 34 Review of the psychiatric progress note dated 04/17/2024 showed Resident 34 had diagnoses of Parkinson's (a movement disorder of the nervous system that worsens over time) psychosis (symptom of losing touch with reality), delusions (fixed false belief about something), and visual hallucination (the experience of seeing, hearing, feeling, or smelling something that does not exist). It further review showed Resident 34 started on Nuplazid (an antipsychotic -mind altering) medication on 09/21/2023. In a joint record review and interview on 04/01/2025 at 2:15 PM with Staff M, Social Services Assistant, Resident 34's Electronic Health Record (EHR) did not show a trauma informed care assessment. Staff M stated that Resident 34 was a retired police officer [worked in law enforcement] and that there was no indication of PTSD. In an interview on 04/02/2025 at 4:39 PM, Staff A stated they could not find a Trauma Informed Care Assessment for Resident 34. RESIDENT 76 Review of care plan printed on 03/30/2025, showed Resident 76 had a diagnosis of malignant neoplasm of the frontal lobe (a cancerous tumor that can significantly affect brain function including behavioral and emotional changes). In an interview on 04/02/2025 at 8:37 AM, Staff N, Social Services Director, stated that they would complete a trauma informed consent care assessment for new residents and that if there has been a traumatic event, they would assess the need for mental health services. Staff N further stated that they had a conversation with Resident 76's relatives and that they did not have knowledge of past traumas for Resident 76. In a joint record review with Staff N, Resident 76's EHR did not show a record of a trauma informed care assessment. Staff N stated, I don't see one [trauma informed care assessment] here. In an interview on 04/02/2025 at 4:39 PM, Staff A stated that they expected the trauma informed care assessments done for the residents. Reference: (WAC) 388-97-1060(3)(e) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 45 Review of the physician progress note dated 12/09/2024 showed Resident 45 had apixaban five mg to be given twice a day for A-Fib. Review of March 2025 MAR did not show Resident 45 was monitored for the anticoagulant use. In an interview on 03/31/2025 at 1:14 PM, Staff L, Registered Nurse, stated that they monitored residents for side effects of anticoagulant. When asked about Resident 45's monitoring for anticoagulant use, Staff L stated that Resident 45 was on apixaban. Staff L further stated, If we see symptoms then that's [that is] the only time we document. If we don't [do not] see anything then we don't [do not] chart. In an interview and joint record review on 03/31/2025 at 1:26 PM, Staff F, RCM, stated that they monitored residents on anticoagulant for its side effects. Staff F stated, We monitor for bleeding, bruising and we also monitor their stool. When asked how they monitored for side effects of anticoagulant, Staff F stated, there is a prompt that tells us to monitor and document. A joint record review of the March 2025 physician orders and MAR did not show Resident 45 was monitored for anticoagulant use. Staff F stated Resident 45 was not monitored for side effects of anticoagulant. In an interview and joint record review on 03/31/2025 at 2:15 PM, Staff B stated, Monitoring entails documentation. If it is not documented, it is not done. Staff B stated that they monitored residents for side effects of anticoagulant. A joint record review of the physician orders showed Resident 45 was on an anticoagulant and a physician order for anticoagulant side effects monitoring was started on 03/31/2025. Staff B stated that there had been an order for monitoring of side effects of anticoagulant but it was discontinued. Staff B further stated, there should have been continuous monitoring for side effects of anticoagulant for [Resident 45]. Reference: (WAC) 388-97-1060 (3)(k)(i)(4) Based on interview and record review, the facility failed to ensure adequate monitoring was conducted for use of anticoagulants (medication that prevent blood clot) for 2 of 5 residents (Residents 55 & 45), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and related complications. Findings included . Review of the facility's policy titled, Medication Monitoring, revised in January 2025, showed, the facility takes a collaborative, systemic approach to medication management, including the monitoring of medications for efficacy and adverse side consequences. The policy further showed licensed nurses with periodic oversight by nurse managers shall adhere to facility policies and current standards of practice for administration and monitoring of medications. RESIDENT 55 Review of the face sheet printed on 03/28/2025 showed Resident 55 initially admitted to the facility on [DATE]. Review of the January 2025 to March 2025 Medication Administration Record (MAR) showed Resident 55 had an order for apixaban (anticoagulant medication) 5 milligrams (mg-a unit of measurement) to be given twice a day to treat atrial fibrillation (A-Fib - an irregular and often very rapid heart rhythm). Review of the nursing progress notes from 01/07/2025 to 03/31/2025 did not show Resident 55's anticoagulant use was adequately monitored. In a joint record review and interview on 04/01/2025 at 9:15 AM with Staff G, Resident Care Manager (RCM), showed the January 2025 to March 2025 MAR did not show Resident 55 was being monitored for anticoagulant use. Staff G stated that residents on anticoagulant medication needed to be monitored for adverse side effects. Staff G further stated monitoring for adverse side effects of anticoagulant medication for Resident 55 should have been started when they started the medication. In an interview on 04/01/2025 at 1:57 PM, Staff B, Director of Nursing, stated that monitoring for side effects of anticoagulant medication use was required to ensure residents safety and appropriate intervention if complications arose. Staff B stated that Resident 55's anticoagulant side effects monitoring should have been started when it was first ordered by the physician.

Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 refrigerators (Medication Storage A), reviewed for medication storage. This failure placed the residents at risk of receiving compromised and ineffective medications. Findings included . Review of the facility's policy titled, Medication Storage, revised in May 2024, showed that the facility would ensure all medications housed on the premises would be stored in the medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of the undated package insert document for Tubersol (tuberculin - purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis [a serious illness caused by a type of bacteria that mainly affects the lungs]) showed an open multi-dose vial of Tubersol which has been opened and in use for 30 days should be discarded. In a joint observation and interview on 04/01/2025 at 9:39 AM with Staff G, Resident Care Manager, showed the refrigerator in Medication Storage A had one multi-dose vial of tuberculin that was a quarter full. Further observation showed the multi-dose vial had no open date. Staff G stated that the tuberculin multi-dose vial had no open date and that it should have been discarded. In an interview on 04/01/2025 at 3:34 PM with Staff B, Director of Nursing, stated that when the multi-dose vial of tuberculin was not marked with the open date, then we cannot be certain of the date it was open. Reference: (WAC) 388-97-1300 (2) .

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required dementia (memory loss) management training upon hire for 2 of 5 staff (Staff U & Staff V), reviewed for sufficient and competent Nurse staffing. This failure placed the residents at risk for potential negative outcomes and unmet care needs. Findings included . Review of the facility's policy titled, Required Training, Certification and Continuing Education of Nurse Aides, revised in September 2024, showed, It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. STAFF U Review of the undated facility's employee record showed Staff U, CNA, was hired on 07/09/2024. It further showed no documentation that Staff U received the required dementia management training. STAFF V Review of the undated facility's employee record showed Staff V, CNA, was hired on 04/23/2024. It further showed no documentation that Staff V received the required dementia management training. In an interview and joint record review on 04/02/2025 at 10:16 AM, Staff C, Infection Preventionist/Staff Development Coordinator, stated that they provided dementia management training for staff upon hire and annually through Relias (online training). A joint record review of the online training with Staff C did not show Staff U and Staff V had completed their dementia management training. When asked if Staff U and Staff V had received the dementia management training, Staff C stated, It does not look like they had completed it [dementia training] upon hire. In an interview on 04/02/2025 at 10:31 AM, Staff B, Director of Nursing, stated they expected Staff U and Staff V to complete their dementia management training upon their hire. Reference: (WAC) 388-97-1680 (2)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were evaluated, assessed, received physician orders for self-medication administration, and educated to keep medications in a lockable storage for 4 of 15 residents (Residents 50, 7, 76 & 90), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment and store medications in a lockable unit placed the residents at risk for medication errors, adverse reactions, and related complications. Findings included . Review of the facility's policy titled, Medication Storage, revised in May 2024, showed that this facility would ensure all medications housed on our premises would be stored in the medication rooms to ensure security. The general guidelines included all drugs and biologicals would be stored in locked compartments. RESIDENT 50 A review of Resident 50's April 2025 Medication Administration Record (MAR) showed they were admitted to the facility on [DATE] and had an order for albuterol sulfate (an inhaler used to open the airways to increase air flow to the lungs). The MAR did not include a self-medication order. An observation and interview on 03/31/2025 at 9:12 AM, showed Resident 50 had an albuterol inhaler sitting on the shelf next to the sink in the resident's room. Resident 50 stated that they used the inhaler every day. A joint record review and interview on 04/02/2025 at 8:54 AM with Staff E, Resident Care Manager (RCM), showed that Resident 50 did not have a self-administration assessment. Staff E stated that they did not find a self-administration medication assessment for Resident 50. RESIDENT 7 Review of Resident 7's physician orders, printed on 04/01/2025, showed there were orders for nine oral medications and three eye drop medications. Review of Resident 7's Self-Administration of Medications assessment dated [DATE] did not show an assessment for oral medications. An observation and interview on 03/27/2025 at 1:13 PM showed a medication organizer was on Resident 7's bedside table. It further showed that there were seven different pills in the medication organizer and there were three different bottles of prescription eye drops in Resident 7's nightstand drawer. Resident 7 stated that Staff E would be working with them [on learning on how to manage their own medications] in the morning. Resident 7 further stated that nightstand drawer remained unlocked. Another observation and interview on 04/02/2025 at 8:31 AM, showed Resident 7 was sitting up in their recliner with the bedside table in front of them and their medication organizer contained seven different pills and three different prescription eye drops on the bedside table. Resident 7 stated that they had taken [their] morning medications before eating [breakfast] and without supervision. In a joint record review and interview on 04/02/2025 at 8:40 AM with Staff E, did not show a self-medication assessment for Resident 7's oral medications. Staff E stated that residents on a self-medication plan store their medications in a locked drawer in their room. Staff E stated that getting a key for the locked drawer was optional and that Resident 7 did not have one. RESIDENT 76 In an observation and interview on 03/25/2025 at 3:15 PM showed a brown bottle with a handwritten label with Chinese characters was on the shelf in Resident 76's room and the bottle was half full of oblong shaped pills. Resident 76 stated that the pills from the bottle were Chinese herbs and would take them once in a while. Further observation showed a red box on the shelf by the sink, containing an opened tube of cream with Chinese characters written. Resident 76 stated that they used this cream to treat itching. In an interview and joint record review on 04/02/2025 at 8:40 AM, Staff E stated that they would complete a self-medication assessment for residents on the self-medication program. In a joint record review of Resident 76's EHR did not show a self-medication assessment was completed. Staff E stated that a self-medication assessment was not done. In a joint observation and interview on 04/02/2025 at 8:57 AM Staff E showed Resident 76 had a brown bottle of pills sitting on their shelf and a red box with a tube of cream in them. Staff E stated that Resident 76 was not on a self-medication administration program. RESIDENT 90 A review of Resident 90's March 2025 MAR showed they were admitted to the facility on [DATE]. Further review of the MAR did not include an order for the Afrin (brand name-treats nasal congestion) nasal spray and hydrocortisone cream (a topical cream that treats inflamed or itchy skin). In an observation on 03/26/2025 at 8:51 AM, showed a bottle of Afrin nasal spray on a shelf by the sink in Resident 90's room. Resident 90 stated they administered the nasal spray on their own. Further observation showed a half-used tube of hydrocortisone cream was observed on their nightstand. Resident 90 stated that they used hydrocortisone cream on their feet to treat itching. A review of Resident 90's EHR did not show a self-medication assessment or a physician's order for self-medication administration. In a joint record review and interview on 04/02/2025 at 3:18 PM with Staff E showed Resident 90 did not have a self-medication assessment or a physician's order for self-medication administration in their EHR. Staff E stated that they have not initiated a self-medication assessment with Resident 90. In an interview on 04/02/2024 at 4:12 PM, Staff B, Director of Nursing, stated their expectations included that residents on self-medication administration would start with a self-medication assessment and that their medications should be in a locked drawer. Reference: (WAC) 388-97-0440, 1060 (3)(k)(l) .

Based on observation, interview, and record review, the facility failed to provide the website address of the Washington State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) on the posted contact information in 4 of 4 facility areas (100-Wing, 400-Wing, across the conference room, and the library), reviewed for residents' rights. This failure placed the residents at risk of not being able to report their concerns online to the State Long-Term Care Ombudsman. Findings included . Review of the facility's undated document titled, admission Agreement, showed Residents had the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. Review of the facility's undated document titled, Resident Handbook, showed information and contact information for State and local advocacy organizations, including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program and the protection and advocacy system. Further review of the handbook showed that the resident has the right to receive notices in writing including addresses (mailing and email) of all pertinent State regulatory and informational agencies, such as Long-Term Care Ombudsman. Multiple observations on 03/31/2025 at 11:59 AM of the 400-Wing Nurses Station, on 04/20/2025 at 4:00 PM of the 100-Wing Nurses Station, at 4:02 PM of the hallway across the conference room, and at 4:04 PM of the library did not show the Long-Term Care Ombudsman information posted included the website address. In an interview on 04/02/2025 at 5:26 PM, Staff A, Administrator, stated that the ombudsman information posting did not include the website address. Reference: (WAC) 388-97-0300(7)(c) .

Based on observation, interview, and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 2 of 2 residents (Residents 34 & 70) and signage of medical information were posted in residents' rooms for 2 of 15 residents (Residents 70 & 301), reviewed for homelike environment. These failures placed the residents at risk for a less than homelike environment and a diminished quality of life. Findings included . Review of the facility's undated document titled, Resident Handbook, showed that residents have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. ROOM TRAYS In an observation on 3/27/2025 at 12:33 PM, showed Resident 34 was eating their lunch off a serving tray. In an observation on 03/31/2025 at 2:25 PM, showed Resident 70 was eating their lunch off a serving tray. In an interview on 03/28/2025 at 12:28 PM, Staff BB, Unit Coordinator, stated that they did not think leaving meals on the serving tray was homelike. Staff BB further stated that they remove the meals off the tray when serving in the dining room. In an interview on 04/02/2025 at 9:30 AM, Staff E, Resident Care Manager, stated that they leave meals on the tray when residents were served in their rooms. Staff E further stated, I don't think it makes a difference with or without the tray unless they had a preference. In an interview on 04/02/2025 at 4:12 PM, Staff B, Director of Nursing, stated that when they deliver room trays, they leave the meals on the tray. Staff B further stated that the meals are removed off the tray when they serve in the dining room. In an interview on 04/02/2025 at 4:39 PM, Staff A, Administrator, stated that they expected that resident room trays to be served on the trays and that meals served in the dining room would be removed off the trays. SIGNAGE RESIDENT 70 In an observation on 3/26/2025 at 4:07 PM, a sign that read, No blood pressure or lab draws on the right arm was posted behind Resident 70's bed. In an interview on 03/28/2025 at 4:07 PM, Resident 70 stated that they would like the sign that was posted behind his bed to be removed since blood can be drawn on the left arm. RESIDENT 301 An observation and interview on 03/30/2025 at 3:03 PM, Resident 301 showed a sign behind their bed that reads, No BP [blood pressure]/IV [intravenous-in the vein] on L [left] arm. Resident 301 stated they did not know anything about it [the sign] then stated it was there because they had lymphedema (a condition that results in swelling of the leg or arm) and staff needed to know to avoid using Resident 301's left arm to check for their blood pressure. In an interview on 04/02/2025 at 9:30 AM, Staff E stated that the sign on the wall in residents' rooms make a good visual as in reminders for staff. When asked if the signs created a homelike environment, Staff E stated that they did not think it made a difference since the signs were short and sweet. In an interview on 04/02/2025 at 4:12 PM, Staff B stated that the signs were posted for safety and that residents were aware of the signage before they were implemented. Staff B further stated that residents would say whether they would like the sign to be posted or not. In an interview on 04/02/2025 at 4:39 PM, Staff A stated they did not feel the signs posted on the wall would take away from a homelike environment. Reference: (WAC) 388-97-0880 .

Based on observation, interview, and record review, the facility failed to ensure staff document medications in accordance with professional standards of practice for 3 of 10 residents (Residents 148, 28 & 8), failed to ensure medications were not handled with bare hands for 1 of 10 residents (Resident 2), and failed to ensure insulin (medication that works by lowering levels of sugar in the blood) pens were wiped with alcohol pads before use and the skin was pinched prior to insulin administration for 2 of 2 residents (Residents 20 & 19), reviewed for medication administrations. In addition, the facility failed to ensure feeding tube (enteral tube - a medical device used to provide nutrition to people who cannot obtain nutrition by mouth or need nutritional supplementation) was checked for placement or patency prior to administering medications for 1 of 1 resident (Resident 16). These failures placed the residents at risk for medication errors, unmet care needs and other negative outcomes. Findings included . Review of the facility's policy titled, Medication Administration, revised in May 2024, showed that medications were administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy further showed that medications were not to be touched with bare hands and that staff should sign the MAR after medications were administered. Review of the facility's policy titled, Insulin Pen, revised in May 2024, showed that the insulin pens' rubber seal should be wiped with an alcohol pad after the insulin pen cap was removed from the insulin pen and prior connecting the pen needle onto the insulin pen. The policy further showed to gently pinch up the skin at the injection site and hold, and to inject the needle straight at a 90-degree angle to the skin. Review of the facility's policy titled, Verifying Placement of Feeding Tube, revised in September 2024, showed, It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube. The policy further showed, For gastrostomy [a flexible tube used for feeding] tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube . Check and record the length of the tube prior to feeding as per facility policy. Notify supervisor and/or practitioner if abnormal finding . If unable to confirm placement, notify supervisor and/or physician. Do not proceed with feeding, flush, or medication administration until tube placement is verified. SIGNING BEFORE MEDICATION ADMINISTRATION RESIDENT 148 Observation on 03/31/2025 at 9:31 AM, showed Staff L, Registered Nurse (RN), signed Resident 148's March 2025 Medication Administration Record (MAR) as given prior to administering their four medications. RESIDENT 28 Observation on 03/31/2025 at 10:13 AM, showed Staff L had already signed Resident 28's MAR as given prior to administering their 11 medications. Staff L took a medication cup with medications in it from the medication cart and gave them to Resident 28. Staff L stated that Resident 28 was not in their room earlier that day when they tried to give their medications. RESIDENT 8 Observation on 03/31/2025 at 10:18 AM, showed Staff L had already signed Resident 8's MAR as given prior to administering their seven medications. Staff L took a medication cup with medications in it from the medication cart and a pain patch and took them to Resident 8. In an interview on 03/31/2025 at 10:37 AM, Staff L stated that they knew the residents usually took their medications and that was why they signed the MAR for Residents 148, 28 & 8 prior to administering their medications. Staff L further stated that they should have waited for Residents 148, 28 & 8 to take their medications prior to signing their MAR. In an interview on 04/02/2025 at 12:31 PM, Staff D, Resident Care Manager (RCM), stated they expected staff to sign the MAR after the medications were administered to the residents. Staff D further stated that Staff L should not have signed the MAR for Residents 148, 28 & 8 prior to administering their medications. TOUCHING MEDICATIONS WITH BARE HANDS Review of the March 2025 MAR showed Resident 148 had an order for Vitamin D (supplement) to take one tablet a day by mouth. Observation on 03/31/2025 at 9:39 AM, showed Staff L dropped one of Resident 2's Vitamin D tablet on the flat surface of the medication cart, Staff L then picked it up with bare hands and placed it in a medication cup. Observation further showed Resident 2 took their Vitamin D tablet. Staff L stated that they should have disposed the Vitamin D as they touched it with their bare hands. In an interview on 03/31/2025 at 12:31 PM, Staff D stated they expected medications to be disposed of if they fall on the medication cart surface. Staff D further stated that Staff L should not have touched Resident 2's Vitamin D with their bare hands and should have given Resident 2 a new Vitamin D tablet. INSULIN ADMINISTRATION RESIDENT 20 Review of the March 2025 MAR showed that Resident 20 had an order for insulin Lispro to be injected subcutaneously (placed under the skin) before lunch. Observation on 03/28/2025 at 11:57 AM, showed Staff K, RN, prepared Resident 20's insulin dose. Staff K removed the cap from Resident 20's insulin pen, screwed a new insulin needle in, and administered it to Resident 20's abdominal (belly) area. Staff K did not clean Resident 20's insulin pen rubber seal prior to connecting the insulin pen needle and did not pinch their skin site prior to administering their insulin. RESIDENT 19 Review of the March 2025 MAR showed Resident 19 had an order for insulin Lispro to be injected subcutaneously before lunch. Observation on 03/28/2025 at 12:12 PM, showed Staff K prepared Resident 19's insulin dose. Staff K removed the cap from Resident 19's insulin pen, screwed a new insulin needle in, and administered it to Resident 19's abdominal area. Staff K did not clean Resident 19's insulin pen rubber seal prior to connecting the insulin pen needle and did not pinch their skin site prior to administering their insulin. In an interview on 03/28/2025 at 12:42 PM, Staff K stated that they did not clean the insulin pen rubber seals for Residents 20 & 19 and that they did not know if they should have. In an interview on 04/02/2025 at 12:02 PM, Staff D stated that they expected staff to clean the insulin pen rubber seals with alcohol wipes prior to attaching the needles. Staff D stated that Staff K should have cleaned the insulin pen rubber seals for Residents 20 & 19 with alcohol wipes prior to connecting the pen needles. Staff D further stated that Staff K should have pinched the skin site areas for Resident 20 & 19 prior to injecting their insulin. VERIFYING FEEDING TUBE PLACEMENT Observation and interview on 04/02/2025 at 8:43 AM, showed Staff G, RCM, was administering medications to Resident 16 via feeding tube. Staff G did not check the feeding tube for placement prior to administering Resident 16's medications. Staff G stated that they do not need to check for feeding tube placement prior to administering medications and that it was done by a staff who placed the feeding tube supplement. Staff G further stated that they did not check Resident 16's feeding tube placement prior to administering their medications. In an interview on 04/02/2025 at 2:40 PM, Staff C, Infection Preventionist, stated they expected staff to verify feeding tube placement by checking the mark on the feeding tube to make sure that the tube had not moved prior to administering medications. In an interview on 04/02/2025 at 3:01 PM, Staff B, Director of Nursing, stated they expected nurses to sign the MAR after administering medications to the residents. Staff B stated that Staff L should not have signed the MAR for Residents 148, 28 and 8 prior to administering their medications. Staff B stated they expected staff to wipe insulin pen rubber seals with alcohol wipes prior to attaching the needle and to pinch the resident's skin area prior to injecting insulin. Staff B stated that Staff K should have cleaned the insulin pen rubber seals with alcohol wipes prior to connecting the needle and should have pinched the skin areas for Residents 20 and 19 prior to injecting their insulin. Staff B stated they expected staff to check for feeding tube placement by checking the red mark on the feeding tube to make sure it has not moved. Staff B further stated that Staff G should have checked feeding tube placement for Resident 16. Reference: (WAC) 388-97-1620 (2)(b)(i)(ii) .

Based on observation, interview, and record review, the facility failed to ensure foods items were handled appropriately in accordance with professional standards of food safety for 1 of 3 refrigerators (Walk-In Refrigerator) and 1 of 1 Shelf (Shelf below steamer table), reviewed for food services. Additionally, the facility failed to ensure 1 of 5 kitchen staff (Staff W) was wearing a beard net. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Date Marking for Food Safety, revised in November 2022, showed, the facility adheres to a date marking system to ensure the safety of ready to eat time/temperature control for safety food. The policy further showed, the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The marking system shall consist of the day/time of opening, and the day/time the item must be consumed or discarded. FOOD ITEMS IN THE WALK-IN REFRIGERATOR During a joint observation and interview on 03/25/2025 at 8:33 AM with Staff O, Dietary Manager, showed a half package of cheese with a use by date of 03/31/2025 without an open date, a package of provolone cheese with an open date of 03/18/2025 without a use by date, and an opened bag of iceberg lettuce that had brownish leaves. Staff O stated the iceberg lettuce was unusable, and it should have been discarded. Staff O further stated that a half package of cheese should have had an open date and the provolone cheese should have had a use by date. FOOD ITEMS ON THE SHELF BELOW THE STEAMER TABLE During a joint observation and interview on 03/31/2025 at 8:13 AM, Staff O showed a container of baking powder with an unreadable open date and with an expiration date of 03/26/2025, four jugs of opened honey and three -quarter bottle of red wine vinegar without open and/or use by date. Staff O stated the baking powder should have had a clear and readable open date. Staff O further stated the jugs of honey, and the red wine vinegar should have had an open and use by date. WEARING A BEARD NET IN THE KITCHEN During a joint observation and interview on 03/31/2025 at 8:13 AM with Staff O showed Staff W, Dishwasher, was washing dishes in the kitchen. Staff W was wearing a surgical mask that did not completely cover their beard. Staff O stated that the facility had no specific policy regarding beard net requirement and was unaware that wearing a beard net in the kitchen was required. In an interview on 04/01/2025 at 2:17 PM, Staff A, Administrator, stated that they expected the kitchen staff to regularly inspect food items, label and date them upon opening, and to discard unusable food items. Staff A stated that they expected the facility staff to wear beard nets if they have long beards. Staff A further stated Staff W should have worn a beard net. Reference: (WAC) 388-97-1100 (3) .

Based on observation, interview, and record review, the facility failed to ensure glucometer (device that measures the concentration of sugar in the blood) control testing reading numbers were documented accurately for 5 of 5 residents (Residents 20, 19, 92, 24 & 47), reviewed for resident records. This failure placed the residents at risk of medical complications, unmet care needs, and diminished quality of life. Findings included . Review of the facility's policy titled, Glucometer Cleaning, revised in April 2025, showed that glucometers should be cleaned after each use with Mycolio [brand name] disinfectant wipes. The document showed that glucometers and glucometer bins were cleaned weekly using Mycolio disinfectant wipes and that glucometer control testing was done in the EMAR [Electronic Medication Administration Record] by performing both low and high testing, comparing the readings to the range printed on the test strip bottle. Document (+) [plus] accurate reading (-) [minus] inaccurate reading, repeat the test, if still inaccurate, replace with a new glucometer. Further review of the document did not show the exact reading numbers for the low and high solution control test. RESIDENT 20 Review of January 2025 to March 2025 Medication Administration Record (MAR) showed an order for Glucometer Control Testing: perform both low and high testing every night shift. Compare reading to the range printed in the container. The document further showed Resident 20's January 2025 to March 2025 MAR had a check mark, which per the MAR meant administered, and did not show the exact reading numbers for low and high control testing of their glucometer. RESIDENT 19 Review of January 2025 to March 2025 MAR showed Resident 19 had orders for Glucometer Control Testing: perform both low and high testing every night shift. Compare reading to the range printed in the bottle. Doc [document] (+) accurate reading (-) inaccurate reading, repeat the test, if still inaccurate, replace with a new glucometer. Further review of Resident 19's January 2025 to March 2025 MAR showed a + were documented daily, and the MARs did not show the exact reading numbers for low and high control testing of their glucometer. RESIDENT 92 Review of March 2025 MAR showed Resident 92 had an order for Glucometer Control Testing: perform both low and high testing every night shift Compare reading to the range printed in the bottle. Doc (+) accurate reading (-) inaccurate reading, repeat the test, if still inaccurate, replace with a new glucometer. Further review of Resident 92's March 2025 MAR showed a + were documented daily for the glucometer control testing check and the MAR did not show the exact reading numbers for low and high control testing of their glucometer. RESIDENT 24 Review of January 2025 to March 2025 MAR showed Resident 24 had an order for Glucometer Control Testing: perform both low and high testing every night shift. Compare reading to the range printed in the bottle. Doc (+) accurate reading (-) inaccurate reading, repeat the test, if still inaccurate, replace with a new glucometer. Further review of Resident 24's January 2025 to March 2025 MAR showed a + were documented daily for the glucometer control testing check and the MAR did not show the exact reading numbers for low and high control testing of their glucometer. RESIDENT 47 Review of February 2025 and March 2025 MAR showed Resident 47 had an order for Glucometer Control Testing: perform both low and high testing every night shift. Compare reading to the range printed in the bottle. Doc [document] (+) accurate reading (-) inaccurate reading, repeat the test, if still inaccurate, replace with a new glucometer. Further review of Resident 47's February 2025 and March 2025 MAR showed a + were documented daily for the glucometer control testing check and the MAR did not show the exact reading numbers for low and high control testing of their glucometer. In an interview and joint observation on 04/02/2025 at 5:30 PM, Staff B, Director of Nursing, stated they checked the residents' glucometer for control testing every night and that they documented it in the residents' MAR. Joint observation of the Evencare G2 (brand name -glucometer system) high and low testing bottle solutions for glucometers showed that the reading numbers from 35 to 65 were for low range and the reading numbers from 160 to 216 were for high range. Staff B stated that staff checks the control testing for residents' glucometers and if the results were within the ranges of the low- and high-level solutions, staff would document with a plus symbol to note that the results were within range. Staff B further stated that the results of the low- and high-level reading numbers were not documented in the residents' MAR. A joint record review and interview with Staff B showed that the multiple MARs for Residents 20, 19, 92, 24 and 47 did not have the reading numbers for low and high level tests documented. Staff B stated that the facility did not document the reading numbers for the low and high test solution of control testing in the MAR for Residents 20, 19, 92, 24 and 47. Reference: WAC 388-97-1720(1)(a)(ii) .

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases by: 1. Not having a water management program that assessed the potential growth of Legionella (a waterborne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease) was completed for the decorative water fountain. 2. Touching medications with bare hands during medication administration for 1 of 10 residents (Resident 2), reviewed medication administration. 3. Not performing hand hygiene and disinfection of glucometers (device used to check blood sugar levels) for 3 of 3 residents (Residents 20, 92 & 19), reviewed for blood glucose (blood sugar) monitoring. 4. Not cleaning insulin (a hormone that helps regulate blood sugar levels) pens (administration device) prior to medication administration for 2 of 2 residents (Residents 20 & 19), reviewed for insulin administration. 5. Not following Enhanced Barrier Precautions (EBP- precaution to protect the spread of infectious organisms for 1 of 1 resident (Resident 16), reviewed for EBP. 6. Not performing hand hygiene and proper use of Personal Protective Equipment (PPE-use of gown, gloves, face shield, N95 masks for 4 of 4 residents (Residents 31, 150, 83 & 38), reviewed for transmission based precautions (TBP-to help stop the spread of germs from one person to another). 7. Not discarding full sharp containers (limited capacity puncture-resistant, leak-proof container designed to dispose of needles/sharps) for 2 of 16 sharps containers for (Resident 7 & Medication Storage A), reviewed for use of sharps containers. These failures placed the residents, visitors, and staff at an increased risk of acquiring infection, related complications, and personal injury. Findings included . Review of the facility's policy titled, Legionella Surveillance, revised in May 2024, showed that Legionella surveillance was one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens (organisms that normally do not harm their host but can cause disease when the host's resistance is low) in the facility's water systems. Review of the facility's policy titled, Water Management Program, revised in May 2024, showed that a risk assessment would be conducted annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The policy further showed that a variety of measures would be used, including physical control, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. Review of the facility's policy titled, Medication Administration, revised in May 2024, showed that medications were administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Further review of the policy showed that medications were not to be touched with bare hands. Review of the facility's policy titled, Hand Hygiene, revised in May 2024, showed that staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy further showed that hand hygiene should be performed between residents; before applying and after removing PPE including gloves; before performing resident care procedures; before and after providing care to residents in isolation; and after handling items potentially contaminated with blood, body fluids, secretions, or excretions. Review of the facility's policy titled, Glucometer Disinfection, revised in May 2024, showed that glucometers were disinfected to prevent transmission of blood borne diseases to residents and employees. The policy further showed that the facility would ensure that glucometers were cleaned and disinfected after each use and according to the manufacturer's instructions. The glucometers should be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA - a federal agency that protects human and environmental health by regulating pollutants and enforcing laws) - registered healthcare disinfectants that were effective against viruses that were transmitted by blood and other fluids. Review of the facility's policy titled, Insulin Pen, revised in May 2024, showed that the insulin pens' rubber seal should be wiped with an alcohol pad after the insulin pen cap was removed from the insulin pen and prior to placing the pen needle onto the insulin pen. Review of the facility's policy titled, Transmission-Based (Isolation) Precautions, revised in May 2024, showed the facility would follows Centers for Disease Control (CDC) guidance. The policy further showed that Aerosol Contact Precautions (prevent transmission of infectious pathogens through droplets and very small particles containing the virus) was used for conditions that included COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) where it instructed staff to wear a fit-tested N95 or higher-level [mask] or respirator [air-purifying respirator certified by the National Institute for Occupational Safety and Health (NIOSH)/ filter/fitted masks that fit over the nose and mouth, and when properly fitted, can filter 95% of smoke particles]) and other appropriate PPE while delivering care to the residents. The policy further showed that the facility used Quarantine Precautions [to reduce/prevent transmission of potential or suspected infectious agents spread through droplets and very small particles that contain the virus] that is used with asymptomatic residents with known exposure to COVID-19 for an extended period of time, and instructed staff to wear a fit-tested N95 or higher-level respirator and other appropriate PPE while delivering care to the resident. WATER MANAGEMENT Review of the facility's water management program updated on 11/29/2024, showed that the water temperature of the outdoor decorative water fountain would be checked weekly. Further review of the document showed that if the water fountain temperature was over 70 degrees Fahrenheit (°F), the facility would add chlorine [chemical element used as a bleach, oxidizing agent, and a disinfectant in water purification] until 0.5 milligrams (a unit of measurement) per liter of free chlorine was measured. Review of the facility provided document titled, Legionella Risk Assessment, dated 03/29/2021, 05/02/2022 and 06/26/2023. Further review of the document showed that it included the assessment of the facility's decorative [water] fountain and did not show that an assessment risk for Legionella was completed for 2024. In a joint record review and interview on 04/02/2025 at 1:34 PM with Staff A, Administrator, showed the legionella risk assessment was last dated 06/26/2023. Staff A stated the facility used the same legionella risk assessment form and added the dates when the assessments were completed on the same sheet and use a different sheet if there were changes. Staff A stated they completed the legionella risk assessments annually [and it was not done for 2024]. In another joint record review and interview on 04/02/2025 at 1:39 PM with Staff A, did not show a control test documentation for the facility's decorative water fountain in the water management program binder. Staff A stated that the facility water fountain runs only in the summertime and that the facility performed weekly temperature checks and PH [a measure of how acidic or basic a substance is] testing of the water during that time. Staff A further stated that there was no documentation to show control testing of the water fountain was done after year 2020. TOUCHING MEDICATIONS WITH BARE HANDS Review of the March 2025 Medication Administration Record (MAR) showed Resident 2 had an order for Vitamin D (supplement) to take one tablet a day by mouth. Observation on 03/31/2025 at 9:39 AM, showed Staff L, Registered Nurse (RN), dropped Resident 2's Vitamin D tablet on the flat surface of the medication cart and then picked it up with their bare hands into a medication cup. Further observation showed Resident 2 took their Vitamin D tablet. In an interview on 03/31/2025 at 12:31 PM, Staff D, Resident Care Manager (RCM), stated they expected medications to be disposed of if they fell on the medication cart and should not be touched with bare hands. Staff D further stated that Staff L should not have touched Resident 2's Vitamin D tablet with their bare hands and should have given Resident 2 a new Vitamin D tablet. HAND HYGIENE AND GLUCOMETER DISINFECTION Review of the facility's provided document titled, EVENCARE G2 [brand name] Blood Glucose [sugar] Monitoring System, dated 2018, showed glucometers would be disinfected and cleaned with one of the validated EPA-registered disinfecting wipes. RESIDENT 20 Observation on 03/28/2025 at 11:43 AM, showed Staff K, RN, entered Resident 20's room and put on clean gloves without performing hand hygiene. Staff K then used a glucometer to check Resident 20's blood sugar level, removed their soiled gloves, and proceeded to put a pair of new gloves on. Staff K then used an alcohol wipe to clean Resident 20's glucometer. Staff K did not do hand hygiene in between glove change. RESIDENT 92 Observation on 03/28/2025 at 11:46 AM, showed Staff K removed their soiled gloves and put on a clean pair of gloves after they checked Resident 92's blood sugar. Staff K then used an alcohol wipe to clean Resident 92's glucometer. Staff K did not do hand hygiene in between glove change. RESIDENT19 Observation on 03/28/2025 at 11:50 AM, showed Staff K entered Resident 19's room and put on clean gloves without performing hand hygiene. Staff K then used a glucometer to check Resident 19's blood sugar level, removed their soiled gloves, and proceeded to put a new pair of gloves. Staff K then used an alcohol wipe to clean Resident 19's glucometer. Staff K did not do hand hygiene in between glove change. In an interview on 03/28/2025 at 12:08 PM, Staff K stated their practice was to clean the resident's glucometer with alcohol wipes. Staff K stated that they cleaned Residents 20, 92, and 19's glucometers with alcohol wipes. In another interview on 03/28/2025 at 12:42 PM, Staff K stated that they would do hand hygiene between glove change. Staff K further stated that they should have performed hand hygiene prior to entering Resident 20 and 19's rooms and/or in between glove change for Residents 20, 19 and 92. CLEANING OF INSULIN PENS RESIDENT 20 Observation on 03/28/2025 at 11:57 AM, showed Staff K was preparing for Resident 20's insulin dose. Staff K removed the cap from Resident 20's insulin pen, placed a new pen needle in and administered it to Resident 20. Staff K did not clean Resident 20's insulin pen rubber seal [with alcohol pads] before placing the new needle onto the insulin pen. RESIDENT19 Observation on 03/28/2025 at 12:12 PM, showed Staff K was preparing Resident 19's insulin dose. Staff K removed the cap from Resident 19's insulin pen, placed a new pen needle in, and administered it to Resident 19. Staff K did not clean Resident 19's insulin pen rubber seal before placing the needle onto the insulin pen. In an interview on 03/28/2025 at 12:42 PM, Staff K stated they did not clean the insulin pen rubber seals for Residents 20 and 19 prior to insulin administration. In an interview on 04/02/2025 at 12:02 PM, Staff D stated they expected staff to do hand hygiene before entering and after leaving residents' rooms, before putting on PPE and after removing PPE, and in between glove change. Staff D stated that Staff K should have done hand hygiene before entering Residents 20 and 19's rooms, and in between glove change during Residents 20, 92 and 19's blood sugar checks. Staff D stated they expected staff to disinfect residents' glucometers using two Mycolio sanitizing wipes and that Staff K should have used the sanitizing wipes to clean Residents 20, 92, and 19's glucometers. Staff D further stated that Staff K should have cleaned Residents 20 and 19's insulin pen rubber seals with alcohol wipes prior to connecting the pen needles. EBP Review of the undated facility provided signage titled, Enhanced Barrier Precautions, showed that providers and staff must wear gloves and a gown for high contact resident care activities that included feeding tube (flexible tube that delivers nutrients directly to the stomach) care or use. Observation on 04/02/2025 at 8:27 AM, showed an EBP signage outside Resident 16's room. Observation on 04/02/2025 at 8:43 AM, showed Staff G, RCM, was administering medications to Resident 16 via feeding tube without wearing a gown. Joint record review and interview showed Resident 16 had an EBP signage outside their room that instructed staff to wear a gown for high contact care including feeding tube care. Staff G stated that they did not wear a gown prior to administering Resident 16 their medications and they should have since [Resident 16] has a feeding tube. HAND HYGIENE AND PUTTING ON AND REMOVING PPE FOR TBP AND EBP Review of the facility provided signage titled, Aerosol Contact Precautions, dated 08/14/2024, showed that providers and staff should wash or gel hands, wear a gown and gloves, use an N95, and wear eye protection. Other requirements included the use of resident dedicated or disposable equipment; and to clean and disinfect shared equipment per manufacturer instructions. The signage further showed that staff should perform hand hygiene prior to putting on PPE and after removing PPE. RESIDENT 31 Review of the physician orders printed on 03/26/2025 showed Resident 31 was on aerosol contact precautions due to positive COVID-19 and that their door should remain closed. Observation on 03/26/2025 at 2:29 PM showed Resident 31's room was open and had an Aerosol Contact Precaution signage outside their door. Further observation showed Resident 31 was outside their room and not wearing their mask. Observation on 03/26/2025 at 2:38 PM, showed Staff I, Certified Nursing Assistant (CNA), wearing an N95 respirator, entered Resident 31's room holding a blood pressure cuff and a pair of gloves. Further observation showed Staff I exited Resident 31's room with the blood pressure cuff under their left arm and entered Resident 150's room (an EBP room). Staff I did not perform hand hygiene prior to entering Resident 150's room. Staff I then exited Resident 150's room, donned a gown and gloves without doing hand hygiene, and went back to provide care to Resident 150. A joint record review and interview on 03/26/2025 at 2:50 PM with Staff I showed an aerosol contact precaution signage outside of Resident 31's room. Staff I stated that Resident 31 had COVID-19 and that they did not perform hand hygiene before entering and after exiting Resident 31's room. Staff I further stated that they should have worn a gown, face shield, and/or gloves prior to entering Resident 31's room. Staff I stated they should have removed their soiled N95 and put a new one on after exiting Resident 31's room. Staff I further stated that they should have sanitized the blood pressure cuff after they used it for Resident 31 and that they should have done hand hygiene prior to entering Resident 150's room. In an interview on 04/02/2025 at 12:19 PM Staff D stated that prior to entering Resident 31's room, Staff I should have performed hand hygiene and put on their gown, gloves, and face shield. Staff D stated that Staff I should have removed their soiled N95 after exiting Resident 31's room and put a new N95. Staff D stated that Staff I should have sanitized the blood pressure cuff after they used it for Resident 31. Staff D stated that Staff I should have done hand hygiene prior to entering Resident 150's room. Staff D further stated that Resident 31 should have remained closed. In an interview on 04/02/2025 at 2:35 PM, Staff C, Infection Preventionist, stated that Staff K should have used a blue top sanitizing wipes to clean the glucometers for Residents 20, 92, and 19. Staff C stated Staff K should have performed hand hygiene before entering Resident 20 and 19 rooms and between glove change. Staff C stated that Staff K should have wiped Residents 20 and 19's insulin pen rubber seals prior to placing the pen needles. Staff C stated that Staff G should have worn a gown prior to administering Resident 16's medications via feeding tube. Staff C stated that Staff L should not have touched Resident 2's Vitamin D tablet with their bare hands. Staff C stated that Staff I should have performed hand hygiene before entering and after exiting Resident 31 and 150's room. Staff C stated that Staff I should have put on PPE prior to entering Resident 31's room and should have changed their soiled N95. Staff C further stated that Resident 31's room should not have been open. In an interview on 04/02/2025 at 3:01 PM, Staff B, Director of Nursing, stated that they expected staff to follow infection control protocol regarding hand hygiene, putting on and removing PPE, medication administration, disinfection of glucometers, cleaning of insulin pen rubber seals, and EBP/TBP precautions. RESIDENT 83 An observation on 03/27/2025 at 12:54 PM showed Staff R, CNA, went out of Resident 83's room (a TBP/COVID-19 room) wearing their N95 and face shield. Staff R removed their face shield, placed it in the trash bin outside Resident 83's room and performed hand hygiene. Staff R then walked towards the unit nurses' station. Staff R did not remove and/or change their N95. In an interview on 03/27/2025 at 12:57 PM, Staff R stated that they were expected to remove and change their N95 after exiting a TBP/COVID room. When asked if they had removed and changed their N95 after they exited Resident 83's room, Staff R stated, No, I did not. Staff R further stated that they should have changed their N95 when exiting Resident 83's room. RESIDENT 38 An observation on 03/27/2025 at 1:35 PM, Staff S, RN, went out of Resident 38's room (a quarantine precaution room) wearing their N95 and face shield. Staff S removed their face shield and their N95 then threw them in the trash bin. Staff S then opened the clean PPE bin and put on new N95. Staff S did not perform hand hygiene after removing their soiled face shield and N95. In an interview on 03/27/2025 at 1:37 PM, Staff S stated that Resident 38 had COVID exposure due to COVID positive roommate who had been transferred to another unit. When asked about hand hygiene after removing their soiled face shield and N95 and before putting on a new N95, Staff S stated, I was in a hurry, and I think I forgot that [perform hand hygiene]. In an interview on 03/28/2025 at 9:08 AM, Staff F, RCM, stated they expected staff to remove and change their soiled N95 after they exited a TBP/COVID room and to perform hand hygiene. In an interview on 04/01/2025 at 4:15 PM, Staff C stated they expected staff to remove and change their N95 after wearing them in a TBP/COVID room and to perform hand hygiene after removing their soiled PPE. In an interview on 04/01/2025 at 4:34 PM, Staff B stated they expected staff to follow infection control practices such as changing N95 and performing hand hygiene. RESIDENT 7 In an observation on 03/25/2025 at 8:53 AM showed that the sharps container in Resident 7's bathroom was filled to the fill line. MEDICATION STORAGE A In a joint observation and interview on 04/01/2025 at 9:39 AM with Staff G, showed that the sharps container in Medication Storage A was filled above the fill line. Staff G stated that they would have the sharps container replaced. Staff G further stated that the housekeepers were responsible for emptying the sharps container in the medication room. In an interview on 04/01/2025 at 3:34 PM, Staff B stated that they expected sharps containers to be replaced when they were three-quarters full. Staff B stated that the housekeepers were responsible for replacing sharps containers in the residents' rooms. Staff B further stated that the nurses were responsible for sharps containers on the medication carts and in the medication rooms. Reference: (WAC) 388-97- 1320 (1)(a)(c) .

Based on observation, interview, and record review, the facility failed to maintain glucometer (a device for measuring the concentration of sugar in the blood) disinfection per manufacturers' recommendations for 4 of 4 glucometers in Wing 300, reviewed for safe operating condition. This failure placed residents at risk of inaccurate blood sugar readings and potential negative outcomes. Findings included . Review of the facility's policy titled, Glucometer Disinfection, revised in May 2024, showed that glucometers were disinfected to prevent transmission of blood borne (can be spread through contamination by blood and other body fluids) diseases to residents and employees. The policy further showed that the facility would ensure that glucometers were cleaned and disinfected after each use and according to the manufacturer's instructions. The glucometers should be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA - a federal agency that protects human and environmental health by regulating pollutants and enforcing laws) - registered healthcare disinfectants that were effective against viruses that were transmitted by blood and other fluids. Review of the facility's provided document titled, EVENCARE G2 [brand name] Blood Glucose [sugar] Monitoring System, dated 2018, showed glucometers would be disinfected and cleaned with one of the validated EPA-registered disinfecting wipes: - Dispatch Hospital Cleaner Disinfectant towels with Bleach - Medline Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol - Clorox Healthcare Bleach Germicidal and Disinfectant Wipes - Medline Micro-Kill Bleach Germicidal Bleach Wipes Further review of the document showed, Other EPA registered wipes may be used for disinfecting the EVENCARE G2 system, however these other wipes [Mycolio disinfecting wipes] have not been validated and could affect the performance of the meter [glucometer]. Review of the facility's policy titled, Glucometer Cleaning, revised in April 2025, showed that glucometers should be cleaned after each use with Mycolio [brand name] disinfectant wipes. Review of the undated facility's document titled, Weekly Glucometer Cleaning, showed the Wing 300's glucometers and glucometer bin were cleaned weekly using Medline Micro Kill [brand name] (red top) disinfectant wipes. Further review of the document showed glucometers and glucometer bins were cleaned weekly from 07/03/2024 to 04/02/2025. Observation on 03/28/2025 at 11:43 AM, showed Staff K, Registered Nurse, cleaned the glucometer with an alcohol wipe after they used it to check Resident 20's blood sugar. Observation on 03/28/2025 at 11:46 AM, showed Staff K cleaned the glucometer with an alcohol wipe after they used it to check Resident 92's blood sugar. Observation on 03/28/2025 at 11:50 AM, showed Staff K cleaned the glucometer with an alcohol wipe after they used it to check Resident 19's blood sugar. Observation on 04/01/2025 11:50 AM, showed in Wing 300 an unknown staff was cleaning a glucometer using Mycolio [not validated to sanitize EVENCARE G2 glucometers] disinfectant wipes. In an interview on 03/28/2025 at 12:08 PM, Staff K stated their practice was to clean residents' glucometers with alcohol wipes. Staff K stated that they cleaned Residents 20, 92, and 19's glucometers with alcohol wipes. In an interview and joint record review on 03/28/2025 at 3:54 PM, Staff C, Infection Preventionist, stated that glucometers were cleaned with the blue top disinfectant wipes Mycolio (brand name) and expected staff to use two wipes. Staff C stated that cleaning glucometers with alcohol wipes were not appropriate as they would not kill bloodborne pathogens (organisms that cause diseases). Staff C stated that the facility used EVENCARE G2 glucometers. A joint record review showed that the EVENCARE G2 glucometers manufacturers' user guide did not include Mycolio as a validated EPA product for disinfecting the glucometers. Staff C stated that the manufacturer's guide did not list Mycolio as a product to disinfect EVENCARE G2 glucometers. In an interview on 04/02/2025 at 12:02 PM, Staff D, Resident Care Manager, stated they expected staff to disinfect residents' glucometers using two Mycolio sanitizing wipes. Staff D further stated that Staff K should have used the sanitizing wipes to clean Residents 20, 19 and 92's glucometer after checking their blood sugar levels. A joint record review and interview on 04/02/2025 at 4:37 PM with Staff B, Director of Nursing, showed the EVENCARE G2 glucometer manufacturer's guide did not include Mycolio as a validated EPA product to disinfect the glucometers. Staff B stated that the residents' glucometers have not had any discrepancies with the readings [blood sugar levels] and that the facility does a glucometer control test every night. In a follow up interview and joint observation on 04/02/2025 at 5:30 PM, Staff B stated that residents' glucometers control testing results were documented in their MAR. Joint observation of the EVENCARE G2 low-and high-testing solutions for glucometers showed the reading numbers from 35 to 65 were for low range and reading numbers from 160 to 216 were for high range. Staff B stated that the reading number results were not documented in the residents' MARs and that if the results were within the ranges of the low- and high-level, staff would document + with a plus symbol to show that the results were within range. A joint record review did not show that the MARs for Residents 20, 19, 92, 24 and 47 had the reading numbers. Staff B stated that Residents 20, 19, 92, 24, and 47 MARs did not have documentation of the reading numbers of their glucometers. Reference: (WAC) 388-97- 2100(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely information about medical appointment for 1 of 1 resident (Resident 1), reviewed for planning and implementation of care. The failure to notify the resident's representative of Resident 1's medical appointment led to the cancellation of the medical procedure and prevented the resident's representative the ability to exercise their right to make an informed decision. Findings included . Review of the face sheet showed Resident 1 was admitted to the facility on [DATE] with a diagnosis that included dementia (a group of symptoms affecting memory, thinking and social abilities). Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 09/05/2024 showed that Resident 1 had moderate cognitive impairment. Review of the nursing progress notes dated 09/15/2024 showed that Resident 1 was on alert for increased confusion. Review of the communication care plan initiated on 09/09/2024 showed Resident 1 required supervision in all decision making. Further review of the communication care plan showed staff was directed to provide necessary cues as Resident 1 understands consistent, simple, and directive sentences. Review of the nursing progress notes dated 09/18/2024 showed Resident 1 was scheduled for an appointment on 09/17/2024 for a fistula gram procedure (to look for abnormal areas in dialysis [treatment that removes waste and excess fluid from the blood when the kidneys are no longer working properly] fistula or graft that may be causing problems with dialysis]). The nursing progress notes further showed that resident attended the appointment, but the procedure was cancelled because the clinic could not get a hold of Resident 1's Durable Power of Attorney (DPOA). In an interview on 09/24/2024 at 8:17 AM, Collateral Contact 1 (CC1), stated that Resident 1 had a medical appointment for a fistula gram procedure. CC1 stated that Resident 1 was confused about their whereabouts and the purpose of the appointment. The clinic then tried to contact Resident 1's DPOA to get the consent for the medical procedure but was not successful. CC1 further stated that the appointment was cancelled because Resident 1 was unable to answer the questions about their medical appointment. In an interview on 09/24/2024 at 12:45 PM, Collateral Contact 2 (CC2), stated that the facility did not communicate that their presence (either in person or by phone) was necessary for Resident 1's medical appointment. CC2 stated that they were not informed that their consent would be required for Resident 1's procedure. In an interview on 10/01/2024 at 3:22 PM, Staff D, Unit Coordinator, stated that it was their responsibility to coordinate resident appointments. Staff D stated that they had contacted the DPOA to inform them about the appointment, but they did not inform them to be available for the appointment. In an interview and joint record review on 10/02/2024 at 10:26 AM with Staff C, Resident Care Manager, stated that Resident 1 had a medical appointment for fistula gram procedure. A joint record review of the care plan showed that the resident required supervision for all decision making. Review of the quarterly MDS dated [DATE] showed that Resident 1 had moderate cognitive impairment. Staff C stated that the medical appointment was canceled because the clinic was unable to get a hold of Resident 1's DPOA. Staff C further stated that the resident was sent to the medical appointment without their representative or escort. In an interview and joint record review on 10/02/2024 at 10:50 AM with Staff B, Director of Nursing Services, stated that the resident was alert and capable of making independent decisions. Joint record review of the communication care plan showed that the resident required supervision for all decision making. Staff B stated that had they known consent was necessary for fistula gram procedure, they would have confirmed it with the DPOA. In an interview on 10/07/2024 at 10:30 AM, Staff A, Administrator, stated that it was their expectation that the facility would work together with the resident's representative or the DPOA to arrange medical appointments. Staff A further stated, I would be guessing, as Resident 1 attends dialysis three times a week on her own, the Unit Coordinator may not have addressed the consent aspect of this appointment with [the] DPOA. Reference: (WAC) 388-97-0260 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident's personal clothing were kept safe from loss/theft and failed to follow their process for missing/lost items for 1 of 1 resident (Resident 18), reviewed for personal property. This failure placed the resident at risk for decreased sense of security and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Personal Belongings, revised in May 2023, showed that the facility will exercise reasonable care for the protection of the resident's property from loss or theft. If an item is on the inventory sheet (the list that has resident's belongings) and is lost the facility will reimburse the resident. Review of the facility's policy titled, Resident and Family Grievances, revised on 10/31/2023, showed that all staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the grievance official. Prompt efforts include acknowledgement of complaint/grievance and actively working toward resolution of that complaint/grievance. Resident 18 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool), dated 11/09/2023, showed the resident was cognitively intact. On 01/17/2024 at 9:12 AM, Resident 18 stated that they had lost two white hoody shirts, one [NAME] shirt, and one Seattle Mariners t-shirt a few months ago. Resident 18 stated that an unknown staff put their clothes in a bag, and they did not see their clothes after that. Resident 18 further stated that they reported it to the facility, but the facility did not respond to them. Review of facility's form titled, Concern and Comment Form, dated 08/21/2023, showed Resident 18 reported missing four clothing items. Further review of the form showed that a house wide search was conducted but were unable to locate the clothing items. The form also showed that Resident 18 was notified of the outcome, and the facility would reimburse them for replacement cost of the missing items. Review of Resident 18's clinical records (hard copy and electronic health) showed no personal belonging inventory list form in their file. During a joint record review and interview on 01/18/2024 at 2:06 PM with Staff A, Administrator, showed no documentation that the missing clothing were replaced or reimbursed. Staff A stated that the facility was aware of the grievance, but they did not find the documentation that the items were replaced or reimbursed. Staff A also stated that they spoke to Resident 18's representative, and they confirmed that the items missing were not replaced/reimbursed. Staff A further stated that they should have offered or replaced the resident's missing clothes. Reference: (WAC) 388-97-0560 (1)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency within the required time frame for 1 of 1 resident (Resident 44), reviewed for abuse allegation. This failure placed the resident at risk for potential unidentified mistreatment and lack of protection due to unrecognized abuse. Findings included . According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), required the nursing home employee (or other mandated reporter) to make a report if they had reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. It also showed, Federal law requires the facility to report all allegations of abuse or neglect. This would include taking seriously any allegation from residents or others with a history of making allegations. Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse, Neglect and Exploitation, revised in May 2023, showed that the facility were to report all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property were to be reported immediately to the Administrator and to other appropriate agencies in accordance with current state and federal regulations within the prescribed timeframes. Resident 44 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 01/04/2024, showed Resident 44 had moderately impaired cognition. The MDS also showed that Resident 44 had functional limitations to both upper and lower extremities (hands, arms, legs, and feet) and required dependent (helper does all the effort) assistance with toileting hygiene. Review of the incident report log for August 2023, showed no documentation that Resident 44's allegation of abuse was reported to the State Agency within the required time frame. On 01/16/2024 at 8:29 AM, Resident 44 stated that an [unknown] nursing aide dragged me off the bed by pulling the pad under them during toileting care in bed. Resident 44 also stated that it made them feel afraid and I was screaming, then Staff N, Activities/Recreation Assistant, heard them and came in their room to ask what happened. Resident 44 then reported the incident to Staff N. On 01/17/2024 at 8:58 AM, Staff N stated that they were unable to recall when the incident happened. Staff N stated that during the incident, they heard someone screaming from Resident 44's room. Staff N entered the room and observed the [unknown] staff providing toileting care to the resident and that Resident 44 informed them that the staff was pulling them off the bed. Staff N then told the staff to stop what they were doing, and then the staff left the resident's room. Staff N further stated that they informed Resident 44's nurse, the Activity Director, and the Administrator about the incident. On 01/17/2024 at 9:44 AM, Staff A, Administrator, was notified by the surveyor about Resident 44's allegation regarding feeling afraid of a nursing aide during care. Staff A stated that the incident happened on 08/07/2023, and that the incident was not reported to the state agency. On 01/19/2024 at 8:18 AM, Staff L, Registered Nurse, stated that sometime in August 2023, Staff N reported that Resident 44 was screaming during toileting care. Staff L stated that the staff (Staff O, Nursing Assistant Registered) left Resident 44's room and reported to them that Resident 44 was being difficult. Staff L then completed the toileting care for Resident 44 and asked the resident if they were okay, Resident 44 replied that they did not want Staff O to provide their care. When asked about the incident, Staff L stated that they did not report the incident to the Resident Care Manager, Director of Nursing, and/or the Administrator. On 01/19/2024 at 9:35 AM, Staff B, Director of Nursing Services, stated that they were not informed of the allegation made by Resident 44. Staff B also stated that the facility's process would have been to interview Resident 44 and ensure their safety and report the incident to the state agency when appropriate. In another interview on 01/19/2024 at 1:20 PM, with Staff A, stated that the allegation should have been reported to the state agency. Reference: (WAC) 388-97-0640 (5)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure allegation of abuse was thoroughly investigated for 1 of 1 resident (Resident 44), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised in May 2023, showed that when a suspicion of abuse, neglect or exploitation, or reports of neglect or exploitation occur, an immediate investigation was warranted. Investigations includes identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, exploitation, and/or mistreatment had occurred, the extent, and cause and providing complete and thorough documentation of the investigation. Resident 44 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 01/04/2024, showed Resident 44 had moderately impaired cognition. The MDS also showed that Resident 44 had functional limitations to both upper and lower extremities (hands, arms, legs, and feet) and required dependent (helper does all the effort) assistance with toileting hygiene. Review of the incident report log for August 2023, showed no documentation that Resident 44's allegation of abuse was reported and/or investigated. On 01/16/2024 at 8:29 AM, Resident 44 stated that an [unknown] nursing aide dragged me off the bed by pulling the pad under them during toileting care in bed. Resident 44 also stated that it made them feel afraid and I was screaming, then Staff N, Activities/Recreation Assistant, heard them and came in their room to ask what happened. Resident 44 then reported the incident to Staff N. On 01/17/2024 at 8:58 AM, Staff N stated that they were unable to recall when the incident happened. Staff N stated that during the incident, they heard someone screaming from Resident 44's room. Staff N entered the room and observed the [unknown] staff providing toileting care to the resident and that Resident 44 informed them that the staff was pulling them off the bed. Staff N then told the staff to stop what they were doing, and then the staff left the resident's room. Staff N further stated that they informed Resident 44's nurse, the Activity Director, and the Administrator about the incident. On 01/17/2024 at 9:44 AM, Staff A, Administrator, was notified by the surveyor about Resident 44's allegation regarding feeling afraid of a nursing aide during care. Staff A stated that the incident happened on 08/07/2023, and that the incident was not investigated by the facility. On 01/19/2024 at 8:18 AM, Staff L, Registered Nurse, stated that sometime in August 2023, Staff N reported that Resident 44 was screaming during toileting care. Staff L stated that the staff (Staff O, Nursing Assistant Registered) left Resident 44's room and reported to them that Resident 44 was being difficult. Staff L then completed the toileting care for Resident 44 and asked the resident if they were okay, Resident 44 replied that they did not want Staff O to provide their care. When asked about the incident, Staff L stated that they did not report the incident to the Resident Care Manager, Director of Nursing, and/or the Administrator. On 01/19/2024 at 9:35 AM, Staff B, Director of Nursing Services, stated that they were not informed of the allegation made by Resident 44. Staff B also stated that the facility's process would have been to interview Resident 44 and ensure their safety and report the incident to the state agency when appropriate and complete an investigation. In another interview on 01/19/2024 at 1:20 PM, Staff A, Administrator, stated that the allegation should have been reported and investigated thoroughly. Reference: (WAC) 388-97-0640 (6)(a)(b)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the residents/representatives describing the reason for transfers for 2 of 5 residents (Residents 63 & 21), reviewed for hospitalization. This failure placed the residents at risk for not having an opportunity to make informed decision about transfers/discharge. Findings included . Review of the facility's policy titled, Transfer and Discharge [including discharge Against Medical Advice], revised in May 2023, showed that for emergency transfers/discharges, the facility should provide transfer notice as soon as practicable to resident and representative. The policy further showed that the facility should document assessment findings and other relevant information regarding the transfer in the medical record. RESIDENT 63 Resident 63 admitted to the facility on [DATE]. Review of the progress note dated 02/04/2023, showed Resident 63's representative had requested that Resident 63 be transferred to the hospital after they were informed of Resident 63's changes of mental status. Review of the Electronic Health Record (EHR) did not show documentation that a written notice of transfer/discharge was provided to Resident 63 and/or their representative. Further review of the progress note dated 10/18/2023, showed Resident 63 was sent to hospital due to confusion/altered mental status. Review of Resident 63's EHR did not show documentation that a written notice of transfer/discharge was provided to Resident 63 and/or their representative. On 01/19/2024 at 8:36 AM, Staff D, Resident Care Manager, stated that they provided Resident 63 and/ or their representative a written notice when Resident 63 was transferred/discharged to the hospital on [DATE] and on 10/18/2023. Staff D further stated that Resident 63's written notice should be in their medical records. During a joint record review and interview with Staff T, Medical Records Manager, on 01/19/2024 at 9:26 AM, did not show that a written notice of transfer/discharge was provided to Resident 63 and/or their representative. Staff T stated they did not find it. During a joint record review and interview on 01/20/2024 at 3:35 PM with Staff A, Administrator, did not show that a written notice of transfer/discharge was provided to Resident 63 and/or their representative. Staff A stated that they could not find the written notice document. Staff A further stated that the written notice should have been given and documented in Resident 63's file. RESIDENT 21 Resident 21 readmitted to the facility on [DATE]. Review of the progress note dated 11/07/2023, showed Resident 21 was transferred to the hospital for evaluation. The EHR did not show that a written notice of transfer/discharge was provided to Resident 21 and/or their representative. On 01/18/2024 at 1:23 PM, Staff F, Social Service Assistant, stated that they did not provide a notice of transfer/discharge to the residents and/or their representatives. Staff F stated that nursing may have provided it to the residents, but their social service department did not. On 01/20/2024 at 4:01 PM, Staff A, stated that they were not able to find the written notice of transfer/discharge for Resident 21 and that it should have been done. Reference: (WAC) 388-97-0120 (2)(a)(b)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 2 of 5 residents (Residents 63 & 21), reviewed for hospitalization. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed Hold, revised in May 2023, showed that prior to and at the time of transfer for hospitalization or therapeutic leave the facility will provide to the resident and/or the representative written notice, which specifies the duration of the bed hold policy. RESIDENT 63 Resident 63 admitted to the facility on [DATE]. Review of the progress note dated 02/04/2023, showed Resident 63 was sent to the hospital for altered mental status. Review of Resident 63's clinical record did not show that a bed-hold notice was provided to Resident 63 and/or their representative. During a joint record review and interview on 01/19/2024 at 8:36 AM with Staff D, Resident Care Manager, showed that a bed hold notice was not provided to Resident 63 and/or their representative. Staff D stated that they believed there was a verbal bed hold discussion with Resident 63, but it was not documented. Staff D further stated that the bed hold discussion with Resident 63 should have been documented. RESIDENT 21 Resident 21 readmitted to the facility on [DATE]. Review of the progress note dated 11/07/2023, showed Resident 21 was transferred to the hospital for evaluation. Further review of the electronic health record (EHR) did not show documentation that Resident 21 was notified of a bed hold. On 01/18/2024 at 12:49 PM, Resident 21 stated that they did not remember if they or their representative was notified of a bed hold. On 01/18/2024 at 1:23 PM, Staff F, Social Service Assistant, stated that Social Services and nursing provided bed hold notices and that they would call the resident's representative if they wanted to do a bed hold. Staff F reviewed the EHR and stated that they did not see a progress note for a bed hold for Resident 21. On 01/20/2024 at 12:09 PM, Staff B, Director of Nursing, stated that they expected the Resident Care Manager, Social Services, and Business Office to give bed hold notices and document it in the progress notes. On 01/20/2024 at 12:38 PM, Staff A, Administrator, stated that they expected the nurse to call the residents' representatives and inform them of the bed hold. Staff A stated that the bed hold notice should be completed and documented in the progress note. Staff A further stated that they were not able to find bed hold notices for Resident 63 and 21. Reference: (WAC) 388-97-0120 (4)(a)(b)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 53 Resident 53 admitted to the facility on [DATE]. Review of the significant change of status MDS dated [DATE] showed Resident 53 was dependent with oral hygiene (the ability to use suitable items to clean teeth, ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment). Review of the ADL care plan intervention revised on 09/07/2022, showed Resident 53 had upper and lower dentures and required assistance with oral care. Review of the personal hygiene Point of Care History report for December 2023 and January 2024, showed Resident 53 did not decline personal hygiene care from staff. On 01/16/2024 at 10:27 AM, Resident 53's representative stated that Resident 53 used upper and lower dentures and when they visited Resident 53, it appeared that they did not have their lower dentures on as Resident 53 was having a hard time chewing the garlic bread. Observations on 01/18/2024 at 1:39 PM and on 01/19/2024 at 8:44 AM, showed one denture in a denture cup on the sink labeled with Resident 53's name. Further observation on 01/19/2024 at 8:51 AM, showed Resident 53 had their upper dentures on and was not wearing their lower dentures. During a joint observation and interview on 01/19/2024 at 8:53 AM with Staff J, CNA, showed one denture in a denture cup on the sink labeled with Resident 53's name. Staff J stated that they looked at the care guide and care plan for guidance to care for residents. Staff J stated that they did not know Resident 53 wore dentures and that assistance was not provided with their dentures. On 01/19/2024 at 9:33 AM, Staff G, Registered Nurse, stated that they did not get report that Resident 53 declined to wear their dentures. On 01/19/2024 at 12:13 PM, Staff H stated they expected the CNA to follow the care plans. Staff H also stated that if the care plans directed staff to assist with denture care, they expected staff to follow that. Staff H further stated that they were not aware and/or received report that Resident 53 declined to wear their dentures. On 01/19/2024 at 4:19 PM, Staff B stated they expected staff to follow Resident 53's care plans. Reference: (WAC) 388-97-1020 (1)(2)(a) Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 2 of 17 residents (Residents 23 & 53), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for dental care, dentures, and incontinence care placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, revised in May 2023, showed that the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan policy also showed, Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. RESIDENT 23 DENTAL Resident 23 readmitted to the facility on [DATE]. Review of the significant change in status Minimum Data Set (MDS-an assessment tool) dated 11/13/2023, showed that Resident 23 had obvious or likely cavity or broken natural teeth. Review of Resident 23's January 2024 Medication Administration Record, showed an order for Acetaminophen (a medication for pain) 500 milligrams (a unit of measurement) TID (three times a day) given for tooth pain, started on 12/01/2023. Review of a provider progress note dated 01/16/2024, showed that Resident 23 had dental pain-had dental f/u [follow up] 12/6, recommend replacing filling. Review of Resident 23's Activities of Daily Living (ADL) care plan, revised on 11/10/2023, showed an intervention of Dental/oral care: one assist, own teeth. There was no care plan to address the dental concerns or dental pain. On 01/16/2024 at 8:31 AM, Resident 23 stated they have a cavity and it hurts when I bite down on the left side bottom and it sometimes affects my eating. On 01/17/2024 at 1:40 PM, Staff X, Licensed Practical Nurse, asked Resident 23 if they were having any pain, Resident 23 stated, only my tooth. On 01/19/2024 at 10:27 AM, Staff X stated that Resident 23 complained of tooth pain and had been for a couple months. Staff X also stated they would expect to have a care plan that addressed Resident 23's tooth pain. Joint record review of Resident 23's care plan with Staff X, did not show a care plan addressing the tooth concern or tooth pain. On 01/19/2024 at 11:35 AM, Staff H, Resident Care Manager, stated they would expect to have a care plan for Resident 23's dental concern/pain. Joint record review of Resident 23's care plan did not show their dental problem/pain was addressed. On 01/20/2024 at 1:03 PM, Staff B, Director of Nursing, stated if a resident was having tooth pain, taking pain medications routinely for it, and had a documented cavity, they would expect a care plan for dental problem/pain. INCONTINENCE CARE Review of the significant change in status MDS dated [DATE], showed Resident 23 was dependent for toileting and was always incontinent of urine. Review of Resident 23's urinary incontinence care plan, revised on 11/26/2023, showed an intervention to offer urinal upon raising, before, and after meals and at bedtime and in between. On 01/18/2024 at 1:15 PM, Staff W, Certified Nursing Assistant (CNA), stated they used to offer the urinal to Resident 23 but he doesn't like it. On 01/19/2024 at 9:04 AM, Resident 23 stated that the staff stopped offering a urinal because I refused it. On 01/19/2024 at 10:07 AM, joint record review and interview with Staff X, showed that Resident 23's urinary incontinence care plan directed staff to offer a urinal. Staff X stated, I don't think he uses it and we use to offer a urinal, but he refuses it. During a joint record review and interview on 01/20/2024 at 1:14 PM with Staff B, showed Resident 23's urinary incontinence care plan directed staff to offer a urinal. Staff B stated that staff should be doing that because you never know when they might say that they want to use it. Staff B also stated that if a resident refused care, they would care plan that but I didn't know that he refuses to use the urinal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DENTURE CARE RESIDENT 53 Resident 53 admitted to the facility on [DATE]. Review of the significant change of status MDS dated [DATE] showed Resident 53 was dependent with oral hygiene (the ability to use suitable items to clean teeth, ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment). Review of the ADL functional care plan intervention revised on 09/07/2022, showed Resident 53 wore upper and lower dentures and required assistance with oral care. Review of the personal hygiene Point of Care History for December 2023 and January 2024, showed Resident 53 did not decline personal hygiene care from staff. On 01/16/2024 at 10:27 AM, Resident 53's representative stated that Resident 53 wore upper and lower dentures, and when they visited Resident 53 it appeared that they were not wearing their lower dentures as Resident 53 was having a hard time chewing the garlic bread. Observations on 01/18/2024 at 1:39 PM and on 01/19/2024 at 8:44 AM, showed one denture in a denture cup on the sink labeled with Resident 53's name. Further observation on 01/19/2024 at 8:51 AM, showed Resident 53 had their upper dentures on and was not wearing their bottom dentures. On 01/19/2024 at 8:53 AM, joint observation and interview with Staff J, CNA, showed one denture in a denture cup on the sink labeled with Resident 53's name. Staff J stated that they looked at the care guide and care plan for residents' care guidance. Staff J stated that they did not know Resident 53 wore dentures and that assistance was not provided with their dentures. On 01/19/2024 at 9:33 AM, Staff G, RN, stated that they did not get report that Resident 53 declined to wear their dentures. On 01/19/2024 at 12:13 PM, Staff H, RCM, stated that they expected the CNA to follow the care plan. Staff H stated that if the care plan directed them to assist with denture care, they expected staff to follow that. Staff H further stated that they were not aware and/or received report that Resident 53 declined to wear their dentures. On 01/19/2024 at 4:19 PM, Staff B, Director of Nursing, stated that they expected staff to provide Resident 53 ADL assistance per their care plan. Reference: (WAC) 388-97-1060 (1)(2)(b)(c) Based on observation, interview, and record review, the facility failed to consistently provide nail care and denture care for 2 of 3 residents (Residents 44 & 53), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised in May 2023, showed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy titled, Providing Nail Care, revised in May 2023, showed that routine cleaning and inspection of nails will be provided during scheduled showers and as needed. RESIDENT 44 Resident 44 admitted to the facility on [DATE] with a diagnosis that included left hemiplegia (left sided weakness). Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 01/04/2024, showed Resident 44 had functional limitations to both upper and lower extremities (arms, hands, legs, and feet) and required maximal assistance (helper does more than half the effort) for personal hygiene. On 01/16/2024 at 11:51 AM and on 01/18/2024 at 1:41 PM, showed Resident 44's right foot toenails were long and discolored. Resident 44 stated they would like their toenails trimmed. Review of the ADL care plan initiated on 11/15/2023, showed Resident 44 was at risk for complications and needed assistance with their ADLs due to weakness, impaired mobility, left above the knee amputation (removal of the limb), and left-hand contractures (permanent shortening [muscle, tendon, or scar tissue] producing deformity). Further review of the ADL care plan did not show ongoing podiatry (foot treatment) services were received and/or toenail care was refused by Resident 44. Joint record review and interview on 01/18/2024 at 2:00 PM with Staff K, Certified Nursing Assistant (CNA), showed that Resident 44's care guide directed the nursing aides to trim Resident 44's fingernails. Staff K stated that the nurses were responsible to trim the resident's toenails. Joint observation and interview on 01/18/2024 at 2:03 PM with Staff L, Registered Nurse (RN), showed Resident 44's right toenails were long and discolored. Staff L stated that toenails were to be trimmed by evening nurses weekly on their shower days, and that Resident 44 was scheduled for a shower every Monday on evening shift. Joint record review and interview on 01/19/2024 at 8:55 AM with Staff D, Resident Care Manager (RCM), showed no documentation that Resident 44 refused toenail care. Staff D also stated that the nail care on the Monday Spa Schedule form dated 01/15/2024 for Resident 44 indicated N for not given. On 01/19/2024 at 9:41 AM, Staff B, Director of Nursing, stated that Resident 44 was last seen by the podiatrist (foot doctor) on 10/05/2023 and that Resident 44 should have received nailcare weekly and thereafter unless Resident 44 refused nailcare. Staff B stated there were no documentation for nailcare refusal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and provide risks and benefits for bed rail/side rail use to meet the needs of 1 of 4 residents (Resident 5), reviewed for accident hazards. This failure placed the resident at risk for injury and a diminished quality of life. Findings included . Review of the facility's policy titled, Proper Use of Side Rails, revised in May 2023, showed that the facility shall assess the resident for .risks associated with the use of side/bed rails. The side rail policy also showed that the facility shall obtain informed consent from the resident, or the resident representative for the use of bed rails, prior to installation/use. Resident 5 readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 01/02/2024 showed Resident 5 required partial/moderate assistance for rolling left and right in bed, and for lying to sitting in bed. Observations on 01/16/2024 AM at 10:16 AM and on 01/18/2024 AM at 8:46 AM, showed Resident 5's right side rail was loose. In an interview and joint observation on 01/18/2024 at 1:10 PM with Staff W, Certified Nursing Assistant, stated that Resident 5 required limited to extensive assist with bed mobility (moving in bed). Staff F also stated that Resident 5 used the side rails for turning and to pull themself up in bed. Joint observation of the right side rail showed it was loose. Staff W stated, I can tell the difference between the left and right one and the right one needs to be tightened. On 01/19/2024 at 10:07 AM, Staff X, Licensed Practical Nurse, stated that there should be an assessment and they need to sign a waiver before the side rails were installed on the resident's bed. On 01/19/2024 at 11:06 AM, Staff Y, Nurse Manager, stated they looked and could not find any assessment or consent explaining risks/benefits of side rails use for Resident 5. Staff Y also stated that when they asked Resident 5 about the side rails, Resident 5 stated that the side rails were just there. On 01/19/2024 at 12:03 PM, Staff H, Resident Care Manager, stated that their expectation prior to installing side rails was that therapy would do an assessment and a consent form explaining the risks/benefits for side rail use, signed by the resident and/or their representative. On 01/20/2024 at 12:54 PM, Staff B, Director of Nursing, stated they expected an assessment to be done prior to installing the side rails but was unsure what the policy said regarding the risks/benefits for side rail use. Staff B also stated that Resident 5 used their side rails for mobility and that they would expect to have an assessment done prior to installing the side rails. On 01/20/2024 at 1:26 PM, Staff A, Administrator, stated that prior to using the side rails, there needed to be consent from the resident and/or their representative, an assessment completed, and a physician order. Staff A further stated they could not find an assessment or documentation that risks/benefits were provided to Resident 5 prior to using the side rails. Reference: (WAC) 388-97-1060 (3)(g), 388-97-0260 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate services for 1 of 2 residents (Resident 23) who had identified dental needs. The failure to follow through and coordinate dental services placed the resident at risk for dental pain, dental complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Dental Services, revised in May 2023, showed, It is the policy of this facility . to assist residents in obtaining routine . and emergency dental care. The dental policy also showed that the emergency dental services includes services needed to treat any problem of the oral cavity that required immediate attention by a dentist. Resident 23 readmitted to the facility on [DATE]. Review of the significant change in status Minimum Data Set (an assessment tool) dated 11/13/2023, showed Resident 23 had obvious or likely cavity or broken natural teeth. Review of Resident 23's January 2024 Medication Administration Record, showed an order for Acetaminophen (a medication used for pain) 500 milligrams (mg-a unit of measurement), 1000 mg TID (three times a day) for tooth pain, started on 12/01/2023. Review of a dental note dated 12/06/2023, showed the dentist recommended that Resident 23 have a filling on tooth #20 to resolve the pain. The dental note also showed, This is a conservative treatment designed to potentially save the tooth if possible. However, this may not take care of the issue at which point he would need an extraction. This is the most pressing issue and the only one [the dentist] feels needs to be addressed immediately. The note also stated that the dental office could not accommodate Resident 23 due to being in a wheelchair and that they would need to be treated somewhere else. Review of a provider progress notes dated 12/19/2023, showed Resident 23 was seen by an outside dentist on 12/06/2023, and it was recommended to replace the filling on tooth #20, but Resident 23 will need to be rescheduled with dentist who can accommodate wheelchair patients [residents using wheelchair for mobility]. This was again discussed with the staff today and will be followed up on. On 01/16/2024 at 8:31 AM, Resident 23 stated that they had a cavity and it hurts when I bite down on the left side bottom and it sometimes affects my eating. On 01/17/2024 at 1:40 PM, Staff X, Licensed Practical Nurse, asked Resident 23 if they were having any pain and Resident 23 stated, only my tooth. In another interview on 01/19/2024 at 10:27 AM with Staff X, stated that Resident 23 complained of tooth pain and had been for a couple months. Staff X also stated that they had told the Resident Care Manager (RCM) about Resident 23's tooth pain but was unsure if there was a plan for Resident 23 to see a dentist. On 01/19/2024 at 11:35 AM, Staff H, RCM, stated that if a resident had tooth pain, they would assess them and then would ask Social Services or the Unit Coordinator to help make dental appointments. Staff H further stated that they were unaware Resident 23 had tooth pain. On 01/19/2024 at 12:15 PM, Staff Z, Unit Coordinator, stated that they send out referrals if dental appointments were needed outside of the facility. Staff Z also stated that if a resident was having pain, they would write urgent on the referral. Staff Z stated, I know he [Resident 23] has pain and that they were waiting for Staff F, Social Services Assistant, to give them more information, but they haven't sent the referral yet. Staff Z further stated that they were waiting for a referral from the doctor to send the resident for an outside dentist. Staff Z acknowledged that it had been since 12/06/2023 when Resident 23 had the recommendation to get dental care from an outside dentist. On 01/20/2024 at 11:06 AM, Staff F stated they heard that Resident 23 needed to see a dentist and had given that information to Staff Z. Staff F stated they could not remember when they gave that information and that they did not know the status for getting Resident 23 scheduled with an outside dentist. On 01/20/2024 at 1:03 PM, Staff B, Director of Nursing, stated that if a resident complained of dental pain, they would have a provider assess them and then make an appointment as soon as possible. Staff B further stated that it was hard to find a place [dental office] that would accept wheelchair bound residents. On 01/20/2024 at 1:26 PM, Staff A, Administrator, stated that they have had issues finding a dental office that accommodates wheelchairs, but I think we found one. Staff A also stated that they thought Resident 23 was getting set up with an appointment and that a referral was not necessary to get a resident scheduled. Reference: WAC 388-97-1060 (3)(j)(vii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate use of antibiotic medication (used to treat infection) was followed for 1 of 4 residents (Resident 280), and failed to ensure standardized tools and criteria were utilized for antibiotic stewardship program (such as Loeb Minimum Criteria [minimum set of signs/symptoms used to determine whether to treat an infection with antibiotics] and/or SBAR [Situation, Background, Assessment, and Recommendation - a toolkit that helps staff/prescribing clinicians communicate about suspected UTIs [Urinary Tract Infections-bladder infection] and facilitates appropriate antibiotic prescribing) to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of adverse side effects and antibiotic resistance. These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility's policy titled, Antibiotic Stewardship, revised in May 2023, showed the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. It also showed that the program included antibiotic use protocols and a system to monitor antibiotic use. The facility uses the McGeer Criteria (an assessment tool used to determine if an event met the definition of an infection) to define infections and determine whether to treat an infection with antibiotics. Resident 280 admitted to the facility on [DATE]. Review of the progress notes dated 09/11/2023, showed Resident 280 complained of mild dysuria (pain with urination) and urinary frequency. The provider was notified and ordered a urine analysis (laboratory test of the urine). Further review of the progress notes dated 09/13/2023, showed the provider prescribed Keflex (antibiotic to treat infections) 250 milligrams (unit of measurement) four times a day for five days for Resident 280. Review of the September 2023 medication administration record showed Resident 280 received Keflex from 09/13/2023 to 09/18/2023 for dysuria. Review of Resident 280's urine culture laboratory report dated on 09/12/2023, showed it was pending. Review of the facility's form titled, Revised McGeer Criteria for Infection Surveillance Checklist, dated 09/13/2023, showed Resident 280 was marked for UTI criteria NOT met [did not meet the criteria/no urine culture (a test to find germs that can cause an infection)/sensitivity test (checks to see what kind of medicine will work best to treat the infection) result]. Further review of the Revised McGeer Criteria for Infection Surveillance Checklist form showed that the facility did not use the standardized tools and criteria to assess their residents for any infections. On 01/20/2024 at 2:09 PM, Staff C, Infection Preventionist, stated that they used the McGeer Criteria for monitoring of UTIs. Staff C stated that they did not use an SBAR communication tool or Loebs Minimum Criteria. Staff C also stated that they tracked antibiotic use and urinalysis results, and that if the laboratory/culture results came in, I follow up on it. Staff C further stated that they missed following up on Resident 280's culture result. On 01/20/2024 at 2:42 PM, Staff B, Director of Nursing, stated that the tool they used for antibiotic stewardship program was the McGeer Criteria. Staff B also stated that Staff C checked if they met the criteria and looked at urinalysis and culture/sensitivity result as they came. Staff B further stated that they expected Staff C to follow up on Resident 280's missing culture/sensitivity report. No Associated WAC. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 32 Resident 32 admitted to the facility on [DATE]. On 01/19/2024 at 11:19 AM, Resident 32 stated that the facility gave them some papers but did not recall whether it was a summary of a completed baseline care plan or not. On 01/19/2024 at 12:21 PM, Resident 32's representative stated that they did not recall if a copy of the summary of the baseline care plan was provided. During a joint record review and interview on 01/19/2024 at 10:22 AM with Staff I, showed no documentation that a summary of the baseline care plan was provided to Resident 32. Staff I stated that RCMs were responsible for doing the baseline care plan. Based on interview and record review, the facility failed to provide a summary/copy of the baseline care plan to the residents and/or their representatives for 4 of 4 residents (Residents 334, 32, 57 & 183), reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Baseline Care Plan, revised in May 2023, showed that a written summary of the baseline care plan shall be provided to the resident and their representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: the initial goals of the resident, a summary of the resident's medications and dietary instructions and any services and treatments to be administered by the facility and personnel acting on behalf of the facility. RESIDENT 334 Resident 334 admitted to the facility on [DATE]. On 01/18/2024 at 9:19 AM, Resident 334 stated, I don't remember any care plans. During a joint record review and interview on 01/19/2024 at 10:22 AM with Staff I, admission Nurse, showed no documentation that a summary of the baseline care plan was provided to Resident 334. Staff I stated, The RCM (Resident Care Manager) does it.RESIDENT 57 Resident 57 admitted to the facility on [DATE]. Review of Resident 57's clinical record, showed no documentation that the care plan was reviewed and/or a summary was given to the resident and/or their representative within 48 hours of admission. On 01/16/2024 at 8:36 AM, Resident 57 stated that they did not recall receiving a summary of the care plan within two days of admission. RESIDENT 183 Resident 183 admitted to the facility on [DATE]. Review of Resident 183's clinical record showed no documentation that the care plan was reviewed and/or a summary was given to the resident and/or their representative within 48 hours of admission. On 01/17/2024 at 12:36 PM, Resident 183's representative stated that they did not receive a summary of the baseline care plan from the facility at that time. On 01/18/2024 at 3:59 PM, Staff I stated that the summary of the baseline care plan would only be given to the resident and/or their representative upon request and not on a regular basis. Staff I further stated that the baseline care plan would be discussed at care conferences. During a joint record review and interview on 01/19/2024 at 1:20 PM with Staff F, Social Service Assistant, showed care conferences were held past 48 hours of admission. Staff F also stated that they did not provide and/or offer the summary of the baseline care plan during care conferences for Resident 334, Resident 32, Resident 57, and Resident 183. On 01/19/2024 at 1:25 PM, Staff B, Director of Nursing Services, stated that the facility had not been providing a summary of the baseline care plan to residents and/or their representatives within 48 hours of admission. Reference (WAC) 388-97-1020(3) .

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with the census, actual number of staff and the hours worked for each shift for 4 of 5 days reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's form titled, Report of Nursing Staff Directly Responsible for Resident Care, showed that the forms had no actual number of staff and the hours worked on the nurse staffing form on 01/17/2024, 01/18/2024, 01/19/2024 and 01/20/2024. Further review of the forms showed the census was not written on the form on 01/18/2024, 01/19/2024 and 01/20/2024. Observations on 01/17/2024 at 8:44 AM, on 01/18/2024 at 8:49 AM, on 01/19/2024 at 12:28 PM and on 01/20/2024 at 11:05 AM, showed the facility's daily nursing staffing form posted on the wall by Director of Nursing Service's (DNS) office did not display the actual number of nursing staff and hours worked for the shift. Observations on 01/18/2024 at 8:49 AM, on 01/19/2024 at 12:28 PM and on 01/20/2024 at 11:05 AM, showed the facility's daily nursing staffing form posted on the wall by DNS's office did not include the census. On 01/20/2024 at 9:44 AM, Staff V, Payroll Specialist, stated that they were responsible to fill the census, actual number of staff, and hours worked. Staff V stated the actual number of staff and hours worked would be filled out on the following day after the facility checked who worked the previous day. Staff V further stated that they did not post the actual number of staff and hours worked because it was hard to know the actual number of staff and hours worked till the next day. Staff V further stated that the census should have been included in the daily posting. On 01/20/2024 at 10:05 AM, Staff A, Administrator, stated that they did not know that posting the actual number of nursing staff and hours worked were required. Staff A further stated that the census should have been included in the daily nurse staffing post. No associated WAC .

Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) and failed to ensure expired medications were disposed of timely in accordance with current accepted professional standards for 2 of 4 medication carts (300 & 400 Hall Medication Carts), reviewed for medication storage. In addition, the facility failed to maintain proper temperature for 2 of 2 refrigerators in the medication storage room (Medication Storage Room Refrigerator A & B). These failures placed the residents at risk for receiving compromised, ineffective, and expired medications. Findings included . Review of the facility's policy titled, Labeling of Medications and Biologicals, revised in May 2023, showed, All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. Review of the facility's policy titled, Medication Storage, revised in May 2023, showed the temperatures are maintained within 36-46 degrees Fahrenheit (°F - scale of temperature). The temperature logs are kept with each refrigerator and temperature levels are recorded twice daily. It also showed, In the event that a refrigerator is malfunctioning, the person discovering the malfunction is to notify the Director of Nursing or Administrator for guidance. 300 HALL MEDICATION CART Joint observation and interview on 01/19/2024 at 10:51 AM with Staff L, Registered Nurse (RN), showed that the 300 Hall Medication Cart contained three packs of lemon glycerin swab stick with an expiration date of 08/2023. Staff L stated that those packs of glycerin swab stick should not be in the cart if they were expired and that they would discard them. 400 HALL MEDICATION CART Joint observation and interview on 01/19/2024 at 12:55 PM with Staff U, RN, showed that the 400 Hall Medication Cart had one Lispro (fast-acting) Insulin (medication to lower blood sugar) pen, not labeled with the resident's name and with no open date, and one Degludec (long-acting) Insulin pen, labeled with Resident 59's name with no open date. Staff U stated that the Lispro Insulin pen belonged to Resident 18 and should have been labeled with the resident's name and an open date. Staff U further stated that Resident 59's Degludec insulin pen should have been dated. MEDICATION STORAGE ROOM A REFRIGERATOR Observation of the Medication Storage Room A Refrigerator on 01/19/2024 at 9:32 AM showed the following: - 19 Insulin (various types) pens - Two boxes of Glatiramer injection (medication used to treat Multiple Sclerosis [a disease that impacts the central nervous system] relapses) - One pneumococcal (pneumonia - lung infection) vaccine - Two boxes of house stock flu vaccines - One box of Bisacodyl (medication for constipation) suppository - One box of Tylenol suppository - Four vials of multi-dose Tuberculin Purified Protein Derivatives Mantoux test (a prescription solution to test for Tuberculosis [potentially serious infectious disease that mainly affect the lungs]) - One Victoza injection (medication used to help lower blood sugar levels) - One Repatha injection (helps the liver reduce bad levels of cholesterol [fat-like substance that the body needs in the right amount] levels in the blood, also used to lower risk of stroke, heart attack, or other heart complications). Joint observation and interview on 01/19/2024 at 9:32 AM with Staff H, Resident Care Manager (RCM), showed that the Medication Storage Room A refrigerator temperature was at 50 °F. Staff H, stated that they were supposed to follow the process as listed in the refrigerator temperature log, check 2x [twice]/day (36-45 degrees) and to report temperatures that are out of range. MEDICATION STORAGE ROOM A REFRIGERATOR TEMPERATURE Review of the Medication Storage Room A Refrigerator temperature log for August 2023, September 2023, and January 2024, showed an instruction to check the refrigerator temperature two times a day (day and evening). Furrher review of the refrigerator temperature log showed the following: - On 08/01/2023, evening, 50° F. - On 08/07/2023, evening, 51° F. - On 08/26/2023, evening, 50° F. - On 09/04/2023, evening documented as mm [sic], no temperature was recorded. - On 01/13/2024, evening, was blank/no documentation. - On 01/14/2024, evening, was blank/no documentation. MEDICATION STORAGE ROOM B REFRIGERATOR TEMPERATURE Review of the Medication Storage Room B temperature log for September 2023 and November 2023, showed an instruction to check the refrigerator temperature two times a day (day/evening). Further review of the refrigerator temperature log showed the following: - On 09/07/2023, day, 48° F. - On 11/30/2023, evening, -5° F. Joint record review and interview on 01/20/2024 at 2:05 PM with Staff B, Director of Nursing, showed that the Medication Storage Room A and B Refrigerator temperature logs had temperatures outside the parameters and had missing documentations. Staff B stated that the medication refrigerator temperatures were to be checked twice a day. Staff B also stated that the missing documentations in the temperature log meant that they were not checked and that they were not made aware of these. Staff B further stated that it was their expectation that nursing staff labeled/dated Insulin pens and that nursing staff should follow facility procedures for proper labeling of medications. Additionally, Staff B stated that Resident 18 and 59's Insulin pen should have been labeled/dated if they were in the medication cart and that the expired medication should have not been in the medication cart. Reference: (WAC) 388-97-1300 (2) .

Based on observation, interview, and record review, the facility failed to ensure infection control practices for hand hygiene and/or proper use of gloves were followed during peri-care (cleaning of private areas), wound care, and medication administration for 3 of 3 residents (Residents 42, 23 & 48), and failed to do hand hygiene during meal observations for 2 of 2 staff (Staff M & T), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings Included . Review of the facility's policy titled, Hand Hygiene, revised in May 2023, showed that the use of towelettes (antimicrobial-impregnated wipes) are not a substitute for using an Alcohol-Based Hand Rub (ABHR) or antimicrobial soap. It also showed that the use of gloves does not replace hand washing and if the task required gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. HAND HYGIENE AND GLOVE USE RESIDENT 42 Observation and interview on 01/18/2024 at 1:49 PM, showed Staff S, Certified Nursing Assistant (CNA), did hand hygiene, put on gloves, removed Resident 42's soiled brief, and provided peri-care. Staff S wiped a small amount of stool/feces from Resident 42's bottom. Using the same gloves, Staff S applied barrier cream (skin protectant) to Resident 42's bottom, put on a clean brief, placed pillows under Resident 42's arms, positioned the bedside table, and placed the call light within Resident 42's reach. Staff S then removed their gloves, put a blanket on the resident, and sanitized their hands prior to leaving Resident 42's room. Staff S provided peri-care assistance without changing their gloves and/or performing hand hygiene when going from a dirty to a clean task. When asked about their hand hygiene and glove use practice, Staff S stated they performed hand hygiene before putting on and after taking off their gloves and that they would continue using the same gloves as long as their gloves were not visibly soiled. On 01/19/2024 at 12:28 PM, Staff H, Resident Care Manager (RCM), stated they expected Staff S to remove their gloves after they provided peri-care, perform hand hygiene, and put on clean gloves prior to applying barrier cream and/or new brief. On 01/19/2024 at 3:07 PM, Staff C, Infection Preventionist, stated that their process was to perform hand hygiene before entering/after leaving the residents' room, between passing trays, between resident care, before donning and taking off gloves, and going from a dirty to a clean task. Staff C further stated that Staff S should have removed their gloves and performed hand hygiene after providing peri-care to Resident 42. On 01/19/2024 at 4:18 PM, Staff B, Director of Nursing, stated that they expected staff to perform hand hygiene and apply new gloves when going from a dirty to a clean task. RESIDENT 48 Review of the facility's policy titled, Administration of Injections, revised in May 2023, showed that gloves are required for administering medications that might involve contact with blood or body fluids. Review of the facility's document titled, Injectable Medication Administration Procedure, revised in January 2018, showed to administer medications via subcutaneous (just below the skin) route in a safe, accurate, and effective manner, staff should perform hand hygiene, and put on gloves prior to administering injections. Observation on 01/19/2024 at 12:02 PM with Staff G, Registered Nurse, showed they were administering Insulin (medication that works by lowering levels of sugar in the blood) injection to Resident 48 without wearing gloves. On 01/19/2024 at 12:17 PM, Staff G stated that they did not use gloves to administer the Insulin injection to Resident 48 and that they should have used them since there was a possibility of touching bodily fluids. On 01/19/2024 at 12:37 PM, Staff H stated that their expectation was for the nurses to wear gloves prior to administering Insulin injections to the residents. On 01/20/2024 at 9:32 AM, Staff B stated that they expected the nurses to follow facility policy when administering Insulin injections. Staff B further stated that staff [Staff G] should have worn gloves prior to administering Insulin injection to Resident 48.HAND HYGIENE DURING MEALS STAFF M On 01/16/2024 at 7:22 AM, Staff M, CNA, was observed pushing a meal cart to the hallway, then went back to the Main Dining Room at 7:31 AM, grabbed a meal tray, and assisted a resident with their bread and butter using a bread knife without performing hand hygiene. On 01/16/2024 at 7:42 AM, Staff M returned to the dining room, did not perform hand hygiene before assisting another resident with their meal tray. When finished assisting the resident with their meal tray, Staff M cleaned their hands using a towelette. On 01/16/2024 at 7:48 AM, Staff M stated they used towelettes to clean their hands just now. Staff M also stated that they should have performed hand hygiene before assisting residents with their meals using the hand sanitizer. STAFF T Observation on 01/16/2024 at 12:33 PM, showed Staff T touched a resident's arm to let them know the meal tray was on the table, Staff T then walked to the kitchen to get gloves and donned the gloves on without performing hand hygiene. On 01/16/2024 at 12:41 PM, Staff T stated that they should have performed hand hygiene before wearing their gloves. On 01/19/2024 at 9:43 AM, Staff B stated that staff were trained to perform hand hygiene in the dining room. Staff B also stated that if the policy said towelettes were not a substitute for using hand sanitizer or antimicrobial soap then staff should have used the hand sanitizer and/or performed hand hygiene using soap and water before assisting residents with their meals. Staff B further stated that staff were expected to perform hand hygiene before putting on their gloves and after removing them. Reference: (WAC) 388-97-1320 (1)(a)(c) RESIDENT 23 Review of Resident 23's January 2024 Medication Administration Record, showed an order for wound care on their left medial (toward the middle) foot. Observation on 01/17/2024 at 1:45 PM, showed Staff X, Licensed Practical Nurse, was performing wound care for Resident 23. Staff X applied a dressing and kerlix (a type of bandage) on the resident's left foot wound and removed their used gloves. Staff X did not perform hand hygiene after removing their used gloves. With bare hands, Staff X taped the kerlix, and placed the soiled dressing materials in the garbage can. Staff X proceeded to put a sock back on Resident 23's left foot and performed hand hygiene. On 01/17/2024 at 2:02 PM, Staff X stated that after taking their gloves off, they should have washed their hands right away. Staff X also stated that they did not perform hand hygiene after taking off their gloves/or after touching the items in Resident 23's room. On 01/19/2024 at 12:06 PM, Staff H stated their expectation for hand hygiene during wound care was that when nurses were done with the task, they would take off their gloves and perform hand hygiene right away. On 01/20/2024 at 10:47 AM, Staff C stated that there should be hand hygiene performed right after taking [their] gloves off during wound care/dressing changes. On 01/20/2024 at 1:00 PM, Staff B stated they expected staff to perform hand hygiene immediately after removing their gloves during wound care/dressing changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct routine maintenance to ensure bed rails/side rails were safe to use for 4 of 4 residents (Residents 42, 47, 5 & 1), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment. Findings included . Review of the facility's policy titled, Proper Use of Side Rails, revised in May 2023, showed the facility was to check the rails regularly to make sure they are still installed correctly and have not shifted or loosened over time. RESIDENT 42 Resident 42 admitted to the facility on [DATE] with a diagnosis that included aftercare following joint replacement surgery and muscle weakness. Review of the admission Minimum Data Set (MDS- an assessment tool) dated 12/28/2023, showed Resident 42 was cognitively intact. Review of the Activities of Daily Living (ADL) care plan intervention, revised on 01/02/2024, showed Resident 42 required two-person extensive assist for bed mobility (moving in bed), and used side rails to assist with turning and repositioning. Joint observation and interview with Resident 42 on 01/16/2024 at 9:14 AM, showed their left side rail was loose. Resident 42 stated they used the side rails daily and that they were aware the left side rail was loose. Resident 42 also stated that staff [unknown] had looked at it and told them, It's as good as it can get. Further observation and interview on 01/17/2024 at 1:44 PM and on 01/18/2024 at 3:05 PM, showed Resident 42's side rail was loose and moved when pulled or pushed forward. Resident 42 stated it scared them and that it was not safe for other people to use who did not know the condition of the side rail. RESIDENT 47 Resident 47 admitted to the facility on [DATE] with a diagnosis that included muscle weakness. Review of the quarterly MDS dated [DATE] showed Resident 47 was cognitively intact. Review of the ADL care plan intervention revised on 10/24/2023, showed Resident 47 required two-person assist for bed mobility and used a bariatric (relating to or specializing in the treatment of obesity) bed with right and left quarter side rails for side-to-side mobility. Observations on 01/16/2024 at 12:24 PM and on 01/17/2024 at 1:41 PM, showed Resident 47's right side rail was loose. Resident 47 stated that they used the side rails daily for bed mobility, but they did not know if staff checked their side rails for looseness or if they worked properly. On 01/18/2024 at 3:05 PM, Staff P, Certified Nursing Assistant (CNA), confirmed that Resident 42's left side rail and Resident 47's right side rail was loose. Staff P stated that if the side rails were loose, they would fill out a maintenance referral form and maintenance would fix them right away. On 01/18/2024 at 3:19 PM, Staff Q, Maintenance Director, stated they did not know they had to check the side rails regularly and that they were developing a process. Staff Q also stated that residents were evaluated by therapy before the side rails were installed and that they did not check the side rails after that. Staff Q further stated, They're all going to wiggle. On 01/19/2024 at 12:22 PM, Staff H, Resident Care Manager (RCM), stated they expected staff to fill out the maintenance referral form when side rails needed maintenance. Staff H also stated that if the side rails wiggled or were loose, they expected the CNAs to report it for maintenance. On 01/19/2024 at 4:09 PM, Staff B, Director of Nursing, stated if the side rails needed maintenance, they expected staff to complete a maintenance referral form and notify the nurse. RESIDENT 5 Resident 5 readmitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] showed Resident 5 required partial/moderate assist for rolling left and right in bed, and from lying to sitting on the side of the bed. Observations on 01/16/2024 at 10:16 AM and on 01/18/2024 at 8:46 AM, showed Resident 5's right side rail was loose. During an interview and joint observation on 01/18/2024 at 1:10 PM with Staff W, CNA, stated that Resident 5 required limited to extensive assist with bed mobility and that they used the side rails for turning and to pull themself up in bed. Observation of the right side rail showed it was loose, Staff W stated, I can tell the difference between the left and right one, and the right one needs to be tightened. RESIDENT 1 Resident 1 readmitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] showed Resident 1 was dependent for rolling left and right in bed, and for lying to sitting on the side of the bed. Observations on 01/16/2024 at 1:02 PM and on 01/18/2024 at 8:40 AM showed, Resident 1's right and left side rails were loose. On 01/18/2024 at 1:10 PM, Staff W stated that Resident 1 required total assistance for bed mobility and when they were turned in bed, Resident 1 held on to the side rails. On 01/18/2024 at 1:33 PM, Staff Q stated that when they moved the residents' bed, they would check the side rails but there hasn't been a schedule or a routine check. Staff Q also stated that they had a log for checking the medical equipment in the resident rooms, but it did not show that the side rails were checked, and there is no record of which bed is in which room. Staff Q further stated they would start doing audits of side rails monthly and plan to develop a log for checking them. On 01/20/2024 at 1:26 PM, Staff A, Administrator, stated they expected maintenance to do a bed check that included checking the side rails. Staff A also stated that they had a policy for how often bed checks were done, but the facility did not provide this policy. Reference: (WAC) 388-97-2100 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain nursing records in accordance with accepted professional standards and practice for 1 of 1 resident (Resident 1) reviewed for accuracy, completion, presence of sufficient information describing resident condition, and documentation. This failure had the potential risk for healthcare providers to rely on inadequate information when making treatment decisions for residents and a potential risk for not receiving quality care. Findings included . INSUFFICIENT DOCUMENTATION Information about Resident 1's clinical condition was not documented at the time of a change in condition occurring during 10/10/2022 and 10/11/2022. Resident 1 admitted to the facility on [DATE] with diagnoses to include dementia (memory loss) without behaviors, chronic congestive heart failure, atrial fibrillation (abnormal heart rhythm) with history of pulmonary embolism (blood clots in lungs) and history of deep vein thrombosis (blood clot in deep vein) in the lower leg. Review of the medication administration record for 10/11/2022 for night shift (10 PM to 6 AM) showed that Resident 1 received as needed pain medication at 4:45 AM for severe pain [8 out of 10]. There was no pain assessment completed at that time. Review of the nursing progress notes showed Resident 1 did not have any documentation regarding the resident's condition for the night shift on 10/10/2022 to 10/11/2022. The resident had complaints of severe sudden onset of pain in their legs, which was 8 out of 10. There was no documentation of any assessment being completed or notification made to the doctor. Further review of the progress note dated 10/10/2022 at 3:34 PM, identified that Staff A, Registered Nurse, did not document any assessments related to Resident 1's complaints of right leg pain during their shift, requiring pain medication. There was no documentation that the residents' legs and/or skin had been assessed. During a joint interview and record review on 12/05/2022 at 4:09 PM, the Director of Nursing (DNS) acknowledged that they had not documented in Resident 1's clinical record on 10/11/2022 when the resident had sudden onset of severe complaints pain, in which the DNS gave as needed pain medication. The DNS also confirmed that Staff A did not document in the clinical record regarding multiple complaints of pain or if skin assessments were completed during their shift on 10/11/2022. Reference: (WAC) 388-97-1720 (1)(a) (i-iv) .

Based on observation, interview, and record review, the facility failed to ensure the oxygen (O2) nasal canula (a thin tube inserted into the nose to deliver O2) was dated and in a plastic bag when not in use for 1 of 1 resident (Resident 66) reviewed for respiratory care. This failure placed the resident at risk for infection and related complications. Findings included . Review of the facility's policy titled, Oxygen Concentrator, dated 05/2022, revealed, Care of the resident-Cannulas should be changed weekly and dated .Document in the resident's clinical record to change tubing/bag weekly and date the tubing. Observation on 10/10/2022 at 10:44 AM, revealed Resident 66's O2 tubing that was connected to the concentrator by his bedside was not dated. The tubing was also not dated or bagged that was on his wheelchair. Observation on 10/10/2022 at 4:21 PM revealed that Resident 66's O2 tubing that was connected to the concentrator by his bedside was not dated. The oxygen tank located on the resident's wheelchair, had tubing that was also not dated, and the tubing was lying across the wheelchair and not bagged. Observation on 10/11/2022 at 2:14 PM, revealed that Resident 66's O2 tubing that was on his wheelchair was not dated or bagged. The tubing on the concentrator was also not dated. Interview and observation on 10/11/2022 at 3:15 PM with Licensed Practical Nurse, Staff H, confirmed the tubing on the concentrator and wheelchair had no date on them. Staff H further confirmed the O2 tubing on the wheelchair was not bagged. Staff H stated, This should all be dated and the tubing not in use, should be bagged. On 10/13/2022 at 12:52 PM, interview with the Administrator, Staff A, revealed that, My expectations are that O2 tubing should be changed and dated weekly and also bagged when not in use. Interview on 10/13/2022 at 2:37 PM with the Director of Nursing, Staff B, revealed that if the tubing gets changed by anyone, it should be dated. Reference: (WAC) 388-97-1060 (3)(j)(vi) .

Based on observation and interview, the facility failed to ensure expired medications and laboratory supplies were properly discarded to prevent the potential use of the medications and supplies in 1 of 2 medication storage rooms observed. This failure placed the residents at risk to receive ineffective medications, use compromised laboratory supplies, and possibly experience adverse side effects. Findings included . Observation of Station B Medication Room on 10/11/2022 at 2:48 PM, revealed the following expired medications: - One bottle of Gabapentin (for nerve pain) Sol [solution] 250/5 ml [milliliter] 300 cc [cubic centimeters] bottle, 250 cc left in bottle, with an expiration date of 05/2022. - Two bottles of Loperamide Hydrochloride (for diarrhea) Oral solution 1 mg [milligrams] per 7.5 ml (4 fl. oz. - 120 ml) with an expiration date of 05/2022. - One Combivent Respimat inhalation spray 20 mcg [micrograms]/100 mcg per actuation 120 metered doses with an expiration date of 08/2022. - Four bottles of Docusate Sodium (for constipation) 200 mg capsules one with 30 tablets with an expiration date of 08/02/2022, one with 60 tablets with an expiration date of 08/12/2022, one with 13 tablets with an expiration date of 08/02/2022, and one with 15 tablets with an expiration date of 08/26/2022. - Three bottles of Zinc (supplement) 50 mg, 100 tablets with an expiration date of 05/2022. - One bottle of Aspirin 325 mg, 100 tablets with an expiration date of 09/2022. Continued observation of the medication room revealed the following expired biologicals: - One bottle of H-Chlor 12 0.125% sodium hypochlorite solution (most found in cleaning products) 473 ml (16 fluid oz.) with an expiration date of 04/21/2022. - Three bottles of 50 Blood glucose Test Strips (to test for high blood sugar) with an expiration date of 09/29/2018. - One bottle of Hemoccult Sensa (rapid test to detect blood in the stool) Developer/15 ml with an expiration date of 05/01/2021. - One 3 ml vial of True Control Glucose Control Level (used for quality control testing) with an expiration date of 04/30/2018. - One vial of BD Swab transport system (collection transport system to collect laboratory specimen) with an expiration date of 07/31/2022. - Forty purple top laboratory [blood collection] tubes 3 ml, with an expiration dates of 05/01/2021. - Two green top laboratory tubes 3 ml tube, with an expiration date of 06/06/2021. - Two red top laboratory tubes 3 ml, with an expiration date of 07/03/2022. During an interview with Registered Nurse, Staff G, on 10/11/2022 at 3:19 PM, stated I always look at the expiration date of every medicine I get out of the refrigerator before I give it to a resident, I don't know about checking for expired medications routinely, somebody else must do that. She revealed that all the expired medications were prescribed to residents who were no longer in the facility. During an interview with the Director of Nursing, Staff B on 10/11/2022 at 4:30 PM, revealed it was the responsibility of the night nurse to check the medication room out daily for any expired medication, biologicals, and medical equipment and dispose of the equipment in the proper way. During an interview with the Administrator, Staff A on 10/11/2022 at 4:04 PM, revealed it was her expectation the night nurse would notify Staff B and the Pharmacy of expired medications. Reference: (WAC) 388-97-1300 (2) .

Based on observation, interview, and record review, the facility failed to ensure foods stored in the refrigerator, freezer, and dry storage, were labeled, dated when opened, and closed shut. The facility also failed to separate clean work areas from soiled work areas and keep the kitchen clean from debris and garbage. These failures had the potential to affect all 81 residents in the facility who consumed food from the kitchen. Findings included . Review of the facility's policy titled, Monitoring of Cooler/Freezer Temperature, dated 11/2022, documented Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded. On 10/10/2022 at 8:23 AM, the following observations in the kitchen were made with, and verified by the Dietary Manager, Staff C: 1. The dry storage room contained one bag of pasta that was not labeled and dated. It also contained one bag of cake mix that was not labeled, dated, or closed shut. 2. The walk-in refrigerator contained one bag of salmon, teriyaki chicken, beef, ham, a container of soup and a block of cheese that were not sealed shut. 3. The walk-in freezer contained one bag of bacon bits, beef crumbles, black bean burgers, green beans, corn meal, panko (breadcrumbs) and two boxes of pork sausage patties that were not sealed shut. The green beans were frozen in a block of ice from the bag not being sealed. 4. Located in the kitchen under a cabinet was a plastic bin with oatmeal in it that was not labeled and dated. There was also a plastic bin that contained sugar and the lid was cracked open. Both containers were dirty with dried food particles on them and what appeared to be dried grease. 5. The floor in the kitchen was wet and dirty. The entire kitchen was dirty with food on the counter tops, and water flying everywhere from the dirty tray line. There were clean dishes coming out of the dishwasher that was beside the dirty sinks. The oven was dirty with food particles and grease. All plates went into the warming cart wet. There was no space to air dry dishes or trays, and they were all stacked wet except for the bowls that were stacked in layers. The dirty dish tray pushed the clean dish tray out of the dishwasher due to not having a conveyor belt that moved dishes through the dishwasher. Staff C agreed that the kitchen was dirty. Observation and interview on 10/11/2022 at 8:30 AM with the Administrator, Staff A, revealed the same issues as noted above. Staff A stated, This is such a small space, I am not sure how we could change the layout. The floor was being replaced. We were waiting on a contractor to complete the work. Reference: (WAC) 388-97-1100 (3) .