**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for choices, was afforded the right to choose their own attending physician. This failure placed the resident at risk for a diminished quality of care. Findings included Review of Resident 1's electronic medical record showed they admitted to the facility on [DATE] from a hospital with diagnoses including repair of right upper leg fracture with revision of a total hip replacement after a fall. The resident had a large surgical incision (about 16 inches long) related to the fracture repair. In a telephone interview on 02/18/2025 at 12:16 PM with Collateral Contact 1 (CC1), they stated that they had requested the facility to contact Resident 1's Primary Care Physician (PCP) for orders and a history of the resident as they were familiar with the resident and their history, and were told by a facility nurse that they had to use the facility Physician, Staff D. CC 1 stated that they were not happy with this decision as they did not feel the facility Physician understood Resident 1's complex medical history. Record review showed a progress note dated 01/25/2025 at 7:30 PM where Staff C, Registered Nurse wrote that Collateral Contact 1 had requested Resident 1's PCP be called to get orders and resident history, it was explained that [their] PCP within this facility upon admission to this facility was Staff D, Physician. During an interview on 12/18/2025 at 1:57 PM, with Staff B, Director of Nursing, they stated that residents could only use the three physicians that were approved by the facility, as their physican while they were admitted to the facility for treatment. During an interview on 12/18/2025 at 3:43 PM with Staff A, Administrator, they stated that they had trouble finding physicians to see residents in the facility in the past related to their rural location. They further stated that they had not had a resident request to use their own PCP and would work on the process. Reference: WAC 388-97-0200 (1)

Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures when they failed to report an allegation of abuse to the State Agency (SA) within the required timeframe and failed to complete a thorough investigation for 1 of 2 sampled residents (Resident 23) reviewed for abuse. This failure placed the resident and other residents at risk for repeated abuse. Findings included . The 10/2022 revised facility policy titled Abuse/Neglect/Misappropriation/Exploitation documented the facility protected residents from abuse and neglect by implementing procedures designed to prevent, identify, report, and investigate allegations of abuse and neglect. The policy instructed staff to report immediately to the Abuse Hotline (a SA), but no later than 2 hours after an allegation of abuse or neglect was made if the events that caused the allegation resulted in serious bodily injury, and no later than 24 hours if the events that caused the allegation did not involve abuse or result in serious bodily injury. The policy documented that all alleged incidents of abuse or neglect were thoroughly investigated to determine what occurred and to make necessary changes to the provision of care and services to prevent recurrence. The policy documented a thorough investigation included but was not limited to an interview with the alleged resident victim, the assigned caregiver and caregivers in the immediate area, and a physical examination of the resident. This policy defined sexual abuse as any form of non-consensual contact including but not limited to unwanted or inappropriate touching. The policy instructed staff to evaluate whether the resident had the capacity to consent to sexual activity when determining if the incident met the definition for an allegation of sexual abuse. Appendix D of the October 2015 Nursing Home Guidelines The Purple Book, instructed a facility to report sexual abuse/assault to the SA, log the incident in the facility's Incident Log within 5 days of discovery and notify the police. <Resident 23> A review of the 08/01/2024 significant change assessment documented Resident 23 had medically complex conditions, was cognitively intact, used a wheelchair and was independent with mobility throughout the facility. A 01/19/2024 Social Services progress note documented Resident 23 and an unnamed resident were witnessed by staff kissing on the lips while in the dining room. The unnamed resident had severe cognitive impairment and was unable to give consent. The note further documented staff met with Resident 23, who stated they were not aware the unnamed resident was cognitively impaired. Resident 23 stated they understood that any further physical contact would not be appropriate. Resident 23 was assigned to a different table in the dining room, and the unnamed resident was moved to a room closer to the nurse's station to allow closer supervision. Staff A, Administrator, and Staff B, Director of Nursing, were notified of the incident. The January 2024 Incident Log was reviewed and there was no entry on the log that documented the 01/19/2024 observation of a potential sexual abuse incident, that the incident was reported to the SA, investigated, or reported to law enforcement as instructed by The Purple Book. During an interview on 09/09/24 at 8:39 AM, Staff A confirmed the resident observed kissing with Resident 23 currently resided in the facility on the same hall as Resident 23. Staff A acknowledged the 01/19/2024 allegation of sexual abuse had not been logged on the incident log, reported to the SA, and investigated as required and should have been. Staff A agreed an investigation would have allowed the facility to determine the extent of any nonconsensual contact between Resident 23 and other residents, if any. Staff A also confirmed the incident had not been reported to law enforcement. Reference: WAC 388-97-0640(2)

Based on interview and record review, the facility failed to assess, identify triggers that might prompt a recall of previous traumatic events, and develop care planned goals and interventions for a resident who was a trauma survivor for 1 of 2 sampled residents (Resident 7) reviewed for trauma informed care. This failure placed the resident at risk for re-traumatization, psychological harm and a diminished quality of life. Findings included . The 10/2022 revised facility policy titled Trauma Informed Care described a traumatic event as either a single or enduring repeated or multiple experiences that completely overwhelmed a resident's ability to cope or integrate ideas and emotions involved in that experience. Trauma-Informed Care promoted an environment of healing and recovery rather than practices that might inadvertently re-traumatize a resident. Staff were instructed to screen residents for trauma-informed care needs upon admission and identify the triggers and history of trauma in residents, with the help of family/friends/responsible parties. A care plan was to be developed that aimed to reduce re-traumatization, provide interventions for de-escalation, and provide a safe and secure environment. <Resident 7> A review of the 08/14/2024 annual assessment documented Resident 7 had diagnoses including post-traumatic stress disorder (PTSD, a disorder that developed when a person experienced or witnessed a scary, shocking, terrifying, or dangerous event that usually included a threat to life or a severe injury.) The assessment documented Resident 7 had severe cognitive impairment, was mildly depression, experienced delusions (a false belief or judgment about external reality, held despite undeniable evidence to the contrary), and occasionally rejected care and wandered. Their behavior had worsened compared to the prior assessment. Review of the 09/18/2020 Psychosocial History and Discharge Plan confirmed Resident 7 had a history of traumatic events that might include abuse/neglect, war, assault, PTSD, or natural disasters, for example. The resident also had sleep disturbances and adjustment/mood/behavior problems. A Trauma-informed Care Plan was initiated in this section of the electronic medical record that carried over to the electronic version of the care plan. It documented Resident 7 had a potential alteration in psychosocial well-being related to survivor of traumatic event. The goal was that the resident verbalized feeling safe and secure in their living environment through the next review period. There was no documentation to show what type of traumatic event Resident 7 had experienced, any triggers that could re-traumatize the resident, and what measures the staff needed to take to prevent or de-escalate re-traumatization. A 09/03/2024 revised care plan documented Resident 7's PTSD was related to having served in the military during war time. The goal developed was that triggers of the traumatic event would be minimized. The care plan did not include what the triggers for re-traumatization were. Additionally, there were no interventions to instruct the staff how to minimize or prevent the triggers or de-escalate episodes of re-traumatization. During an interview on 09/09/24 at 8:20 AM, Staff D, Social Services Director, stated Resident 7 had a diagnosis of PTSD because of the war. They stated Resident 7's diagnosis was there, but the resident had never displayed any behaviors related to it. Staff D was unable to state what Resident 7's triggers were because the resident had not had any episodes of PTSD, it was just a diagnosis. Staff D acknowledged Resident 7's plan of care lacked clarity and guidance on how the diagnosis of PTSD impacted the resident, what triggers might re-traumatize the resident, what signs or symptoms the resident could exhibit, and what staff were to do to prevent or de-escalate re-traumatization. Staff D stated they needed to do more research to determine what events might trigger Resident 7. During an interview on 09/09/24 at 8:29 AM, Staff E, Nursing Assistant-Registered, stated PTSD was a behavior that came about from previous situations. Staff E stated they were familiar with Resident 7, but they were unsure if Resident 7 had PTSD. During an interview on 09/09/2024 after breakfast hours, Staff F, Nursing Assistant (NAC), described PTSD as people being really stressed and frustrated. Staff F stated they were familiar with Resident 7, but they were unsure if Resident 7 had PTSD. During an interview on 09/09/24 at 1:19 PM, Staff G, NAC, stated that they had heard of PTSD, it stood for post-traumatic stress disorder, but they did not know what that meant. Staff G thought they had received training about PTSD. Staff G was unsure if Resident 7 had PTSD. No Associated WAC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately date food items and ensure expired food items were disposed of when indicated during 1 of 1 inspections in the main kitchen. This failure placed the residents at risk for food-borne illnesses. Findings included . Review of the undated facility guideline titled Dry, Refrigerated and Freezer Storage Chart documented proper storage times for opened and unopened dry, refrigerated and frozen food items. The guideline instructed the staff to follow manufacturer's directions and expiration dates and those expiration dates superseded the guidelines. The guideline instructed that once a food item was opened it was not to be stored longer than the total unopened time. An observation and interview in the facility's kitchen on 09/03/24 at 11:15 AM was completed with Staff C, Dietary Services Manager with the following findings: <REFRIGERATED GOODS> 1. A bag of Caesar salad was dated 08/27 but had no clear indication if that was the date the food item was received by the facility, or the discard or expiration date. 2. 16 to 20 margarine blocks were undated. 3. Four bags of romaine lettuce had no discard by or expiration date. Staff C stated the staff repackaged the romaine lettuce and did not usually date them. Staff C stated they would find out when the lettuce was to be discarded. 4. One opened bag of celery heads had no discard by or expiration date. The storage chart recommended celery had a storage time of one week. <DRY STORAGE> 1. Five unopened and undated loaves of sliced bread and one opened and undated loaf of bread with about 1/3 of the loaf inside the bag were in the storage area. Staff C stated they did not date the bread; it was used up quickly. The storage chart documented unopened bread was to be stored for four to five days. Opened and unrefrigerated bread was to be stored for 1 day. 2. A jar of basil leaves had no opened or expiration date. The storage chart documented herbs were to be stored for six months, whether opened or unopened. 3. A jar of bay leaves had a handwritten opened date of 11/07/2018. Staff C acknowledged the food item expired six years ago and disposed of it. The storage chart recommended a storage time for whole spices of one to two years. 4. A plastic tub with the word cocoa, 11/1, and 11/23 handwritten on it had no actual manufacturer label. Staff C confirmed the tub contained cocoa powder, but stated they did not know how long it had been sitting there. 5. Two large cans of chunky light tuna had no discard by or expiration date. The storage chart recommended unopened canned foods, specifically fish and seafood, were to be discarded within one year of receipt by the facility. 6. A gallon bag of opened dry cereal had no opened or expiration date on it. 7. A bottle of [NAME] cooking wine had two dates written on it, 1/4 as the date received, and 4/25 as the date opened. No year was identified for either date. The storage chart recommended opened [NAME] wine was to be discarded within six to nine months. 8. A bottle of olive oil had an opened date of 7/17 and no expiration date. The storage chart provided no guidance for the recommended storage time. 9. Eight large bins contained different dry pastas that included spaghetti, macaroni, penne, and lasagna. The pastas were not labeled with an opened date or discard by date. When interviewed on 09/10/2024 at 11:26 AM, Staff C acknowledged that adequate dates had not been documented on the foods identified. Staff C agreed that dating foods allowed staff to know when food items needed to be discarded and how long foods could be stored. Reference: WAC 388-97-1100(3), -2980

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was appropriately maintained and changed regularly, according to professional standards of practice for 1 of 2 sampled residents (Resident 38) These failures placed the residents at risk for contact with contaminated care equipment, potential respiratory infections, and respiratory distress. Findings included . Per the 12/09/2022 admission assessment, Resident 38 admitted to the facility with heart failure and chronic obstructive pulmonary disease (a group of lung diseases that block airflow, making it difficult to breathe) and required oxygen due to those conditions. Review of the physician orders showed on 12/09/2022, the resident had been prescribed oxygen to be used continuously due to the diagnoses listed. The most recent physician order dated 06/20/2023 directed nursing staff to change the oxygen tubing weekly and as needed. On 10/11/2023 at 11:48 AM, Resident 38's oxygen tubing on their walker was dated 08/02/2023. On 10/12/2023 at 8:58 AM, Resident 38 was observed lying in bed, wearing oxygen that was connected to their concentrator. The tubing attached to their walker was dated 08/02/2023. On 10/12/2023 at 11:50 AM, Resident 38's oxygen tubing that was connected to their concentrator was dated 08/02/2023. Subsequent observations of the oxygen tubing being dated 08/02/2023 were on 10/12/2023 at 2:29 PM, 10/13/2023 at 8:01 AM, 10/13/2023 at 10:04 AM and 10/13/2023 at 12:17 PM. During an observation on 10/16/2023 at 8:51 AM, Resident 38 stated their oxygen tubing was changed that morning (1 month and 2 weeks since the last time the oxygen had been changed). During an interview on 10/16/2023 at 11:57 AM, Staff B, Director of Nursing (DNS) stated oxygen tubing is to be changed weekly and needed to be dated. Staff B stated if the oxygen tubing is not changed timely, it could cause an infection. Staff B, DNS, approached surveyor on 10/16/2023 at 1:57 PM and stated the oxygen tubing had not been changed on 10/14/2023, although the treatment administration record was signed saying it had been. Staff B stated the oxygen was changed two days later on 10/16/2023. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review the facility failed to appropriately label, and store refrigerated controlled substances in a permanently affixed compartment as required in 1 of 1 medication rooms observed for medication storage. In addition, the facility failed to maintain records to reconcile refrigerated emergency kit controlled medications in 1 of 1 medication rooms. This failure placed the facility at risk of controlled drug diversion. Findings included . Review of pharmacy policy titled, Inventory Control of Controlled Substances, dated 01/2022, showed the facility should maintain a written record of all controlled substance medications transferred from the pharmacy to the facility's emergency medication kit. The policy further showed facility staff should count all medications with risk for abuse or diversion at each change of shift or at least once daily and document on a controlled substance count sheet. During observation of the medication room refrigerator on 10/13/2023 at 10:42 AM with Staff C, Resident Care Manager (RCM), a locked black metal box was removed from the refrigerator and opened by Staff C. The contents of the black metal box consisted of three resident specific containers of Ativan (a controlled medication used to treat anxiety or seizures), a brown semitransparent unlabeled prescription bottle that contained a sealed vial of injectable Ativan, and a prescription bottle labeled as the facility's emergency medication kit that contained a sealed vial of injectable Ativan. In an interview on 10/13/2023 at 10:54 AM, Staff D, Registered Nurse (RN), stated the brown unlabeled prescription bottle that contained a vial of injectable Ativan was part of the facility's emergency kit. Staff D further stated the emergency kit Ativan was counted in the electronic medication dispensing machine and not in a controlled substance medication book. Staff D attempted to log into the medication dispensing machine to verify the controlled medication count but was unsuccessful. In an interview on 10/13/2023 at 10:55 AM, Staff C, RCM, stated the emergency kit Ativan was not counted in a controlled substance medication book but was counted in the electronic medication dispensing machine by pharmacy staff once a month. Staff C attempted to log into the medication dispensing machine to verify the controlled medication count but was also unsuccessful. Staff C acknowledged the emergency kit Ativan should be counted in a controlled substance medication book by facility staff. In an interview on 10/13/2023 at 11:58 AM, Staff A, Administrator, acknowledged the Ativan in the facility's emergency kit was not being counted and there was no system in place to track it. Staff A also acknowledged the Ativan should be stored in an affixed compartment. In an interview on 10/13/2023 at 12:25 PM, Staff B, Director of Nursing, stated the facility followed the pharmacy's policy for controlled substances. Staff B acknowledged Ativan from the facility's emergency medication kit was only counted by the pharmacy technician once a month and not routinely counted or tracked by facility staff. Staff B also acknowledged the Ativan was not stored in a permanently affixed compartment. Reference WAC: 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to consistently maintain dish machine temperatures which placed all residents at increased risk for foodborne illness. Findings included . During an observation of the kitchen on 10/17/2023 at 12:21, Staff E, Dietary Manager, stated the dishwasher was a low temperature dishwasher, which must sanitize the dishes at 120 degrees or above. The temperature logs for October 2023 showed the temperatures were below 120 degrees on 16 different occasions. Staff E stated that maintenance was informed each time the dishwasher was below 120 degrees, and the temperature was fixed. Staff E was unable to provide documentation showing the temperature had been fixed and what the new temperature was afterward. During an interview on 10/17/2023 at 1:35 PM, Staff F, Maintenance Assistant, stated they are notified when the temperature of the dishwasher was low. When Staff F looked at the temperature log for October 2023, they stated they were unaware that the temperature had dropped below 120 degrees that often. Staff F stated that the dishwasher is connected to the laundry and when the temperature of the dishwasher goes below 120 degrees, they shut down a washer and the temperature of the dishwasher increases. When Staff F was asked for documentation showing the temperatures were rechecked after the dishwasher was fixed, they stated they did not have any because they did not know they needed the documentation. During an interview on 10/18/2023 at 8:56 AM, Staff A, Administrator, stated the dishwasher had to be ran a few times before the temperature would rise to the appropriate temperature. Staff A added the temperature of the dishwasher should have been 120 degrees or above and there had not been any foodborne illnesses. Reference: WAC 388-97-1100 (3) and 388-97-2980

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity during dining for one of one sample residents (6), reviewed for dignity. This failure placed the resident at risk for embarrassment and a decreased quality of life. Findings included . Per the quarterly assessment dated [DATE], Resident 6 had diagnoses which included dementia, was significantly cognitively impaired, and required total, one person physical assistance to eat. A dietary note dated 02/18/2022 showed the resident was on a modified liquid diet. In an observation on 05/24/2022 at 12:50 PM, the resident was in their room in a wheelchair, with lunch on a tray table in front of them. Staff M, Nursing Assistant, stood over the resident while feeding them. Staff M quickly spooned the liquified food into the resident's mouth, without telling them which food they were being fed, or asking the resident for their preference. During the same observation on 05/24/2022 at 12:54 PM, Staff K, Nursing Assistant, came into the room and took over feeding the resident from Staff M. Staff K also stood over the resident to feed them for the rest of the meal. Again, staff didn't let the resident know which food they were being fed, prior to spooning food into the resident's mouth. In a follow-up interview on 05/27/2022 at 12:22 PM, Staff K stated it was facility policy for staff to sit with residents who required assistance with eating, and acknowledged they had not done that. Staff M was not available for an interview. Reference: WAC 388-97- 0180 (1-4)

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sample residents (33), reviewed for range of motion/mobility, received appropriate monitoring and consistent treatment for identified range of motion limitations. This failure placed the resident at risk for further avoidable range of motion declines. Findings included . Review of the resident's record showed a diagnosis of a cerebral infarction (loss of blood flow to part of the brain, resulting in an area of cellular death), along with left sided hemiplegia (paralysis on one side of the body). Per the record, the resident required two people to extensively assist with bed mobility, transfers, toileting, dressing, and personal hygiene. Contracture assessments (a contracture is an abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching, which could cause a permanent decrease in range of motion), completed on 01/17/2022 and 04/18/2022, showed the resident did not have a contracture in their left hand. The resident's care plan, dated 08/21/2019, addressed a deficit with the resident's ability to perform activities of daily living. The care plan included an intervention for a positioning splint (a medical device to hold a joint in a neutral position, to prevent loss in range of motion) as needed for the resident's left hand, with direction to be placed on in the morning when the resident was dressing, and to be removed when the resident was ready for bed. In an observation on 05/24/2022 at 9:08 AM, Resident 33 was observed lying in bed with their left arm dependent at their side, and their left fingers and thumb curled into their palm. At that time, the resident reported they recognized it was getting harder to completely straighten their left fingers and thumb. Review of the facility's restorative program showed the resident was to participate in an active range of motion program (resident participation with movement), five to six times weekly, starting in January of 2022. There was no specific direction found in the resident's record related to maintaining range of motion in the resident's left hand, arm or shoulder, or assistance with placement of the left-hand positioning splint. On 05/25/2022 at 2:01 PM Staff E, Restorative Aide, confirmed that Resident 33 had a range of motion program in place. Staff E explained that the range of motion program did not include working with the left-hand positioning splint, as the resident had to ask for the splint to be put on their left hand. Staff E added the resident did not always participate in range of motion, and they worked with the resident when they were out of bed and willing to participate. In an observation of Resident 33 on 05/24/2022 at 11:46 AM, they had the left-hand positioning splint on with their left fingers and thumb curled into their palm, and not positioned correctly. The resident tried to move their hand in the splint, and was unable to place their left fingers flat in the splint. During the above observation Staff F, Nursing Assistant, entered the room and was asked how the splint worked. Staff F stated that they worked as a restorative assistant part-time, and would occasionally help the resident put on the brace if the resident requested. Staff F was able to place the resident's thumb in the correct position, but was not able to straighten the 1st, 2nd and 3rd fingers to fit fully straightened into the positioning splint. On 05/25/2022 at 11:28 AM Staff C, Physical Therapist, was asked how the facility monitored the resident's range of motion to ensure it was not declining. Staff C stated that physical therapy would receive a communication from restorative or nursing staff if a resident's range of motion was declining. Staff C stated that they had not received any kind of communication from nursing or restorative that Resident 33's left-hand positioning splint was not fitting properly, or a report from the resident or staff of worsening of a left-hand contracture. Staff C reported not having worked with the resident for more than six months, and stated that occupational therapy had last worked with the resident in January 2022. On 05/25/2022 at 2:10 PM, Resident 33 was observed in the hallway outside the dining room with their left fingers held fully extended in the splint with a velcro strap, and their left thumb held fully extended with another velcro strap. In an interview on 05/25/2022 at 1:26 PM, Staff C stated that the resident's hand was flaccid today, and Staff E was able to place the resident's hand in the splint with their fingers extended. Staff C also stated they had worked with the resident for several years, and the resident was not always able to focus on one task, and it may not be fair to rely on the resident to ask to have the splint put on as they may lose focus and forget to ask staff to put the splint on. Reference: (WAC) 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to serve food at palatable temperatures for 1 of 6 sample residents (33), reviewed for in-room dining. This failure placed the resident at risk for inadequate nutritional intake, and a reduced quality of life. Findings included . In an interview on 05/23/2022 at 3:05 PM, Resident 33 stated that when food was delivered to their room it was cold. In an interview on 05/25/2022 at 8:42 AM, Resident 33 was observed sitting at the edge of their bed eating breakfast. When asked how breakfast tasted the resident replied, the eggs are cold. Staff F, Nursing Assistant, was in the room when the resident made the comment, and did not offer to warm the eggs up, or get warm ones. An observation of the lunch service was completed on 05/26/2022 at 11:36 AM. At 12:02 PM Staff G, Cook, was asked to take the temperature of the hot food as it was placed in Styrofoam clamshell containers, to be delivered to isolation residents eating in their rooms. The lasagna was 184 degrees Fahrenheit (F) at that time. The resident hall trays were then placed into a thin aluminum sided cart with the door left open, and were transported from the kitchen area to the hallway outside of room two. At 12:40 PM, staff prepared to deliver the last tray on the cart to a resident in room fifteen. The temperature of the lasagna was taken, and was 128.7 degrees F. According to the Washington State Retail Food Code (page 44, section 03525), holding temperature for hot foods was to be 135 degrees F. Per the document, food not at that temperature must be re-heated to an internal temperature of 165 F or above for 15 seconds, in order to limit the possible growth of organisms harmful to humans. In an interview on 05/26/2022 at 2:14 PM Staff D, Kitchen Manager, acknowledged a temperature of 128.7 degrees Fahrenheit was not a proper holding temperature for hot food. They further stated the Styrofoam containers had been used for the last three days for residents under isolation precautions (precautions that create barriers between people and germs to prevent spread), and were not designed to hold heat. Staff D stated they were not aware it was taking an extended period to deliver trays to those residents. In an interview on 05/26/2022 at 2:17 PM Staff A, Administrator, and Staff B, Director of Nursing, stated that they did not recognize there was a problem with isolation trays being delivered with food below palatable and safe holding temperatures. Reference: (WAC) 388-97-1100 (1), (2)

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines. This failure placed residents and staff at risk for contracting COVID-19. Findings included According to the Center for Disease Control document, How to use Your N95 Respirator, dated 03/16/2022, showed N95 masks must form a seal to the face to work properly. The N95 should be placed under the chin, with the nose piece bar at the top. The top strap should be pulled over the head and placed near the crown, and the bottom strap should be placed at the back of the neck, below the ears. The straps should lay flat, untwisted and not be crisscrossed. On 05/23/2022 at 11:33 AM, Staff B, Director of Nursing, was observed in the lobby area of the facility wearing an N95 with both mask straps placed behind the neck. At 1:02 PM Staff H, Activity Director, was also observed wearing an N95 with both mask straps placed behind the neck. Additional observations of Staff B wearing the mask straps behind the neck were made at 1:57 PM and 4:24 PM that same day. On 05/25/2022 at 10:10 AM, Staff H was observed on the East Unit speaking with a resident to inquire if they wanted to attend the activity. Staff H's N95 mask had both straps behind the neck and under the ears. At 11:59 AM on the same day, Staff J, Staffing Coordinator, was observed to have both the N95 mask straps placed behind the neck. At 11:25 AM on 05/27/2022, Staff I, Charge Nurse, was observed walking down the East Unit hallway with both N95 straps placed behind the neck. During an interview at 11:28 AM, when asked how the N95 mask straps should be positioned, Staff I readjusted the top strap to place it on the top of the head and stated the strap probably fell down earlier when they had adjusted their earpiece. In an interview on 05/27/22 at 11:38 AM with Staff A, Administrator and Staff B, when asked about the positioning of the straps for the N95, Staff B confirmed the bottom strap should be around the base of the neck and the top strap should be above the ears. Reference (WAC): 388-97-1320 (1)(a)