**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 1 of 5 sampled residents (Resident 59) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life. Findings included .Review of the facility's policy titled, Psychotropic Medications [drugs that affect a person's thoughts, emotions, and behaviors], updated 01/01/2023, showed, .If a resident is on antipsychotic medications when they are admitted to the facility, an AIMS test will be performed upon admit, every 6 months, and PRN [as needed].Resident 59 was admitted to the facility on [DATE] with multiple diagnosis to include dementia with agitation and delirium (a condition that causes cognitive decline with a severe state of confusion known as delirium, often manifesting as agitation, hallucinations, and/or delusions).Record review of Resident 59's BIMS (Brief Interview for Mental Status, a screening tool used to evaluate a resident's cognitive function and identify the presence and severity of cognitive impairment), dated 08/27/2025, showed Resident 59 was severely cognitively impaired.Record review of Resident 59's physician orders, dated 08/26/2025, showed Resident 59 was prescribed Olanzapine (an antipsychotic medication) 2.5 mg (milligrams) at bedtime. The August 2025 and September 2025 Electronic Medication Administration Record showed Resident 59 was receiving Olanzapine 2.5 mg at bedtime. Review of Resident 59's Electronic Health Record did not show documentation of an AIMS test completed for the administration of Olanzapine. In an interview on 09/10/2025 at 2:50 PM, Staff C, Resident Care Manager/Registered Nurse (RN), said an AIMS test should be completed for residents receiving antipsychotic medications upon admission and when a new antipsychotic medication was started. Staff C said she could not find an AIMS test completed on Resident 59, stating, It got missed upon admission, it should have been done. In an interview on 09/10/2025 at 3:09 PM Staff B, Director of Nursing/RN, said he expected an AIMS test to be completed on residents taking an antipsychotic medication upon admission and upon starting a new antipsychotic medication. Reference WAC 388-97-1060 (3)(k)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident admission Minimum Data Set (MDS, an assessment tool) was completed within the required timeframe for 1 of 10 sampled residents (Resident 59) reviewed for resident admission assessments. Failure to complete the admission MDS within the required timeframe placed residents at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide to facilitate accurate and effective resident assessment practices in long-term care facilities), Version 1.19.1, effective October 1, 2024, showed the admission MDS assessment must be completed no later than the 14th calendar day of the resident's admission (admission date plus 13 calendar days). Resident 59 was admitted to the facility on [DATE]. Record review of Resident 59's Electronic Health Record, on 09/10/2025 at 2:09 PM, showed Resident 59's admission MDS was still In Progress, 16 calendar days after admission. In a joint interview on 09/10/2025 at 2:22 PM, with Staff B, Director of Nursing/Registered Nurse (RN), and Staff E, MDS Nurse/RN, Staff B said Staff E scheduled the MDS assessments. Staff E said she would schedule the admission MDS when a new resident was admitted . Staff E said the MDS ARD (assessment reference date) was usually scheduled for seven days after admission, sometimes sooner. Staff E said the MDS needed to be completed one week after the ARD. Staff E said she did not have Resident 59's MDS done yet because she went on vacation and it should have been completed 2 days ago. In an interview on 09/10/2025 at 2:29 PM, Staff B said he expected the admission MDS was completed by the 14th day of admission. Reference WAC 388-97-1000 (1)(b)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Pre-admission and Resident Review (PASRR) assessment was reviewed, completed and submitted for 2 of 5 residents (Resident 16 and Resident 4) reviewed for PASRR. This failure had the potential to place residents at risk of not receiving the necessary mental health services and a diminished quality of life. Findings included… 1. Resident 16 was admitted to the facility on [DATE] with multiple diagnoses to include anxiety (a common emotional state characterized by feelings of unease) and depression (a common mental health condition characterized by persistent of low mood or sadness). The quarterly Minimum Data Set (MDS, an assessment tool), dated 06/17/2025, indicated Resident 16 was moderately cognitively impaired. Review of Resident 16's PASRR, dated 07/23/2024, indicated Resident 16 had a Mood Disorder (a mental health condition that primarily affects a person's emotional state); however, “No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur.” No other PASRR was completed or transmitted. During an interview on 09/10/2025 at 1:08 PM, Staff H, Social Service Director, said the exemption meant a resident did not need a PASRR evaluation unless the resident was in the facility beyond 30 days and had not discharged . While reviewing Resident 16’s PASRR, Staff H said that one was missed, it should have been reviewed. 2. Resident 4 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 4 was alert and oriented and admitted with diagnoses including major depressive disorder (a persistent mood disorder that affects how you feel, think, and handle daily activities. It is not just temporary sadness but serious mental illness that requires treatment.) Record review of Resident 4's PASRR Level 1 assessment, dated 08/04/2025, documented Resident 4 had a Serious Mental Health Indicator of a Mood Disorder: Depression. The assessment documented that Resident 4 qualified for an Exempted Hospital Discharge because the individual was likely to require fewer than 30 days of nursing facility services. The assessment also documented that a PASRR Level 2 for resident 4 must be completed if the scheduled discharge (of less than 30 days) does not occur. Record review of Resident 4’s Electronic Health Records (EHR) showed no documentation of a new PASRR Level one or Level 2 was completed. In an interview on 09/10/2025 at 1:08 PM Staff H, said she was responsible for making the referrals to the PASRR Coordinator. When asked what an Exempted Hospital Discharge meant on the PASRR Level 1 evaluation, Staff H said it meant the resident didn’t need a PASRR unless they were at the facility longer than 30 days. Staff H said she had not sent in a new the referral to the PASRR Coordinator for Resident 4 requesting a PASRR Level 2 evaluation, and that she hadn’t realized Resident 4 had been at the facility longer than 30 days. Reference WAC 388-97-1915 (1)(2)(c

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 3) reviewed for accidents related to falls. This failure placed residents at risk for subsequent falls, injuries, unmet care needs, and a diminished quality of life.Findings included.Resident 3 was admitted to the facility on [DATE] with multiple diagnosis to include repeated falls. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 06/16/2025, documented Resident 3 was cognitively intact.Record review of the facility's Resident Incident Log, dated August 2025, showed Resident 3 had a fall on 08/12/2025 and 08/24/2025. Record review of Resident 3's fall investigation, dated 08/12/2025, Notes documented, .The Care Plan has been updated: Cue and encourage him to use call light and wait for help.Record review of CONCLUSION FALLS: [Resident 3] 08/12/2025 0530 AM, undated, documented, .The Care Plan has been updated: Cue and encourage him to use call light and wait for help.Record review of Resident 3's fall investigation, dated 08/24/2025, showed Notes dated 08/28/2025, documented, .Care Plan has been updated: Cue and encourage to use call light and wait for help.Record review of CONCLUSION FALLS: [Resident 3] 08/24/2025 @ [at] 11:25 AM, undated, documented, .Care Plan has been updated: Cue and encourage to use call light and wait for help.Record review of Resident 3's At risk for falls related to history of falls care plan, revised 08/14/2025, showed Resident 3 had a fall on 08/12/2025. The fall care plan further showed an intervention, date initiated 08/14/2025, Cue and encourage him to use call light and wait for help.Record review of Resident 3's fall care plan, revised 08/14/2025, did not document a fall and/or a new revision or intervention for a fall on 08/24/2025.In an interview on 09/11/2025 at 11:57 AM, Staff G, Resident Care Manager/Licensed Practical Nurse, said after a resident had a fall, the nurse would do an incident report at the time of the fall. Staff G said she would follow up after the fall and form a conclusion, write a summary of the fall, and update the care plan with a new intervention. When asked about a new fall intervention in the care plan for Resident 3 after the fall on 08/24/2025, Staff G said normally she would have changed the care plan with a new intervention, stating, I must have missed it. In an interview on 09/11/2025 at 12:17 PM, Staff B, Director of Nursing/Registered Nurse, said he expected the care plan was updated to include a new intervention after a resident had a fall. Reference WAC 388-97-1020 (2)(a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain daily weights per physician's orders for 1 of 5 residents (Resident 5) reviewed for quality of care. The facility also failed to check for PICC (peripherally inserted central catheter line used for long-term intravenous (IV) access to administer medications) line blood return for 1 of 1 resident (Resident 23) reviewed for medication administration. This failure placed residents at risk of unmet care needs, potential complications and a diminished quality of life.Weights Resident 5 was admitted to the facility on [DATE] with multiple diagnoses to include congestive heart failure. The admission /Medicare - 5 Day Minimum Data Set (an assessment tool), dated 06/20/2025, documented Resident 5 was severely cognitively impaired.Record review of Resident 5's physician's order, dated 06/14/2025, documented, Daily Weights for one week and the weights once per week unless ordered otherwise by provider every day shift for Weight until 06/19/2025 18:00 AND every day shift every 7 day(s) for Weight.Record review of Resident 5's electronic health record (EHR) did not show documentation of weights on: 06/15/2025, 06/16/2025, 06/17/2025, 06/18/2025 and 06/19/2025.Record review of Resident 5's physician's order, dated 06/23/2025, documented, Daily Weights for one week and the weights once per week unless ordered otherwise by provider.Record review of Resident 5's EHR did not show documentation of weights on: 06/24/2025, 06/25/2025, 06/26/2025, 06/28/2025, 06/29/2025 and 07/01/2025.In an interview on 09/10/2025 at 1:25 PM, when asked to review Resident 5's weights based on physician's orders, Staff C, Resident Care Manager/Registered Nurse (RN), said some weights were missed. Medication AdministrationResident 23 was admitted to the facility on [DATE] with multiple diagnoses including Endocarditis (an inflammation of the inner lining of the heart caused by a bacterial or fungal infection).Record review of Resident 23's physician's order, dated 08/24/2025, documented PICC: Flush with 5ml [milliliters] Before & After each medication during your shift. Check for blood return prior to flush. If no blood return, notify MD [doctor] EBP [enhanced barrier precautions] for IV Line every shift EBP for IV terapy [sic]. During a medication administration observation on 09/10/2025 at 1:45 PM, Staff F, RN, was observed to flush Resident 23's right arm PICC line and start IV antibiotic administration. Staff F did not check the PICC line for blood return as per physician's order. When asked if it was a requirement that Resident 23's PICC line be checked for blood return, Staff F said blood return was checked the previous day during blood draws (procedure where a small amount of blood was removed from the body for laboratory testing).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 complete pain assessments every shift for 1 of 5 residents (Resident 6) reviewed for pain. This failure placed residents at risk for unmet care needs and a diminished quality of life.Resident 6 was admitted to the facility on [DATE], with multiple diagnoses to include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), fibromyalgia (chronic condition characterized by widespread muscle pain) and chronic pain syndrome. The Quarterly Minimum Data Set (an assessment tool), dated 05/02/2025, documented Resident 6 was severely cognitively impaired.Record review of Resident 6's Nightingale Pain Assessment: Verbal & Non-verbal, dated 08/25/2025, documented Resident 6 occasionally experienced pain and staff assessment for pain should have been conducted.Record review of Resident 6's Nightingale Pain Assessment: Verbal & Non-verbal dated 07/18/2025, documented Resident 6 was unable to verbalize if she had pain and documented indicators for pain which included non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements or postures related to right heel deep tissue injury.Record review of Resident 6's care plan, initiated on 03/28/2023, documented Resident 6 had chronic pain related to fibromyalgia and interventions included to monitor, record and report complaints of pain.Record review of Resident 6's Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report, dated 08/19/2025, documented G: PAIN WILL REMAIN AT OR BELOW GOAL OF 4/10 THROUGH 9/1/25. I: SN -ASSESS PT'S [patients] PAIN USING APPROPRIATE SCALE.Record review of Resident 6's nursing progress note, dated 06/27/2025 at 6:29 AM, documented, Notified by CNA [certified nurses assistant] that res [resident] has a skin issue oh R [right] heel. Upon assessment noted res R heel was black 4.7 cm [centimeters] x 5.2cm. no discharge noted. No open areas noted. Third L [left] toe 0.5 cm spot on knuckle. Res reports it is painful.09/08/2025 at 10:09 AM, Resident 6 was observed lying in bed. When asked if Resident 6 was in pain, Resident 6 said she had pain all over and the pain medication she had received earlier in the morning did not help.In an interview on 09/10/2025 at 1:00 PM, Staff C, Resident Care Manager/Registered Nurse, when asked how Resident 6's pain was assessed Staff C stated, She is supposed to be assessed for pain every shift. When asked to review Resident 6's medication administration record for pain documentation Staff C stated, Pain assessment is normally a separate order, and it should be added.In an interview on 09/11/2025 at 1:19 PM, Staff D, Nursing Assistant, was asked if Resident 6 complained or was observed to be in pain. Staff C stated, she hollers out during care. Staff C said Resident 6 sometimes verbalizes generalized discomfort when receiving care.Reference WAC 388-97-1060 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment was maintained for 2 of 7 rooms (rooms [ROOM NUMBERS]) reviewed for environment, when sharps containers (a puncture-resistant, leak-proof container designed to safely collect and dispose of sharp medical instruments that can puncture or cut skin, like needles, syringes, and lancets) were observed above the full line. This failure placed residents, visitors, and staff at risk for injury, potential exposure to diseases, and a diminished quality of life. Findings Included . In an observation on 09/08/2025 at 11:07 AM, the red sharps container mounted on the wall inside of room [ROOM NUMBER], date written on container 09/16/24, showed sharps instruments inside of the container above the fill line that said, do not fill above this line. The top lid, where the sharps instruments were placed in the container for disposal, was observed to not open all the way as sharps instruments in the full container would catch on the lid and pop up and out to the opening of the lid. In an observation on 09/08/2025 at 11:21 AM, the red sharps container mounted on the wall inside of room [ROOM NUMBER] near the sink, undated, showed sharps instruments inside of the container above the fill line that said, do not fill above this line. Syringes were observed inside the sharps container obstructing the top lid, where the sharps instruments were placed in the container for disposal, from opening and closing all the way. In an interview on 09/08/2025 at 2:23 PM, Staff J, Registered Nurse (RN), said either environmental services and/or nursing staff would empty full sharps containers, just whoever noticed it needed to be done. Staff J said he considered it needed to be done when the sharps instruments inside the container were at the fill line. In a joint observation and interview on 09/08/2025 at 2:34 PM with Staff J, the sharps container in room [ROOM NUMBER] was observed over the fill line. Staff J locked the sharps container lid stating, It's high enough that it should be emptied, it is at the fill line for sure. In a continued joint observation with Staff J, the sharps container in room [ROOM NUMBER] was observed over the fill line. Staff J said it should be locked too and locked the lid on the sharps container. In an interview on 09/08/2025 at 2:36, Staff K, Environmental Services Supervisor, said if she saw a sharps container at the full line she would empty it. Staff K said it was not mandated to any specific department for checking the sharps containers. Staff K said they did not have a process for checking the sharps containers, stating, I suppose we should make it a certain department. In an interview on 09/09/2025 at 11:20 AM, Staff B, Director of Nursing and RN, said he expected staff would change the sharps containers when they reached the full line. Reference WAC 388-97-3220 (1)

Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 3 kitchen refrigerators, and in 1 of 2 nourishment refrigerators (East Hall) reviewed for food storage. The facility also failed to keep an accurate temperature log for 1 of 2 nourishment refrigerators (East Hall). These failures placed residents at risk for food borne illness, and a diminished quality of life.Findings included . During an observation on 09/08/2025 at 9:12 AM, the kitchen refrigerator on the left, was observed with the following expired, opened items: 1. Plastic Tupperware container of Parmesan Cheese- labeled with use by date of 09/02/20252. Plastic Tupperware container of Jam - labeled with ineligible use by date During an observation on 09/09/2025 at 9:23 AM, the nourishment refrigerator on East Hall, was observed with the following expired, opened items: 1. Fruit cup- labeled with use by date of 09/03/2025 2. Six undated fruit cups During an observation on 09/09/2025 at 9:25 AM, the nourishment refrigerator on East Hall was observed with the latest temperature taken on 09/04/2025. Review of the temperature log did not show documentation for the following dates:09/05/2025, 09/06/2025, 09/07/2025, 09/08/2025, and 09/10/2025. In an interview on 09/08/2025 at 9:19 AM, Staff L, Dietary Manager, said the kitchen staff were responsible for restocking, cleaning, and monitoring temperatures in the nourishment refrigerators. Staff L said the items going into the food storage areas should be labeled right away, should be kept until the use by date, and then disposed of by the third day. Staff L stated, We keep it in the fridge for three days. Staff L proceeded to throw away the expired items. In an interview on 09/10/2025 at 11:38 AM, Staff B, Director of Nursing/Registered Nurse, said he expected food items in the refrigerators to be labeled accurately and discarded by the use by date. Reference WAC 388-97-1100 (3) & 2980

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 288 was admitted to the facility on [DATE]. The admission MDS assessment, dated 09/04/2024, documented Resident 288 was alert and oriented. On 09/09/2024 at 10:03 AM, Resident 288 was observed sitting in her wheelchair next to her bed. Resident's 288 bed was observed to have quarter length bed rails to the left and right sides of the bed. Review of Resident 288's EHR did not show a physician's order related to the use of bed rails. On 09/10/24 at 3:10 PM, Resident 288 was observed sitting in her wheelchair next to her bed. Resident's 288 bed was observed to have quarter length bed rails to the left and right sides of her bed. On 09/13/24 at 8:57 AM, Resident 288 was observed lying in bed watching her television. Resident 288's bed had quarter length bed rails to the left and right side of her bed. Reference WAC 388-97-0620 (1)(a)(b) Based on observation, interview, and record review, the facility failed to obtain a physician's order for 2 of 4 sampled residents (3 & 288) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included . Record review of the facility's undated policy entitled, Devices/Enablers Policy and Procedure, documented .Nursing Staff will also obtain a physician order for the device/enabler. 1) Resident 3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 08/05/2024, documented Resident 3 was moderately cognitively impaired. On 09/09/2024 at 10:50 AM, Resident 3 was observed lying in bed on their left side with quarter length bed rails on left and right sides of the bed. At 3:17 PM, Resident 3 was observed lying in bed on their back with quarter length bed rails on left and right sides of the bed. Review of Resident 3's Electronic Health Record (EHR) did not show a physician's order related to bed rails. On 09/10/2024 at 1:32 PM, Resident 3 was observed lying in bed on their back with quarter length bed rails on left and right sides of the bed. On 09/11/2024 at 8:51 AM, Resident 3 was observed sitting up in bed eating breakfast with quarter length bed rails on left and right sides of the bed. At 10:34 AM, Resident 3 was observed in bed on their back with quarter length bed rails on left and right sides of the bed. At 3:02 PM, Staff C, Resident Care Manager (RCM) and Registered Nurse (RN), said enablers such as positioning/mobility bars or quarter rails require a doctor's order. Staff C said she could not find an order for Resident 3's quarter bed rails and indicated there should have been one. At 3:18 PM, Staff B, Director of Nursing Services (DNS) and RN, said it was his expectation residents had physician orders for use of enablers such as quarter bed rails or mobility bars.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a copy of the Notice Before Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 for 1 sampled resident (26) reviewed for transfer notice requirements. This failure placed residents at risk of loss of added protection from being inappropriately transferred or discharged from the facility. Findings included . Resident 26 was admitted to the facility on [DATE] with diagnoses including congestive heart failure exacerbation and physical deconditioning. The admission Minimum Data Set assessment, dated 07/24/2024, documented Resident 26 was alert and oriented. Record review of resident's electronic health records documented Resident 26 was transferred to and admitted to a local hospital on [DATE]. On 09/11/2024 at 2:01 PM, when asked if a Notice of Transfer for Resident 26 was sent to the Office of the State Long-Term Care Ombudsman, Staff A, Administrator, said he would check whether the notice was sent. On 09/13/2024 at 12:28 PM, Staff A stated .I just found out about when to send a copy of the Notice of Transfer . to the Office of the State Long-Term Care Ombudsman. Staff A said he sent out the Notice of Transfer for the months of June, July and August on 09/11/2024. Reference WAC 388-97-0120 (5)(b)(i) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's oral/dental status for 1 of 1 sampled resident (21) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 21 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 07/30/2024, documented Resident 21 was severely cognitively impaired, did not have tooth fragments or broken natural teeth, had no mouth pain, and was able to be examined. Record review of the Dietitian Consulting Services - Nutrition Assessment, dated 07/29/2024, documented, natural teeth in poor shape. Record review of a Nutrition/Dietary progress note, dated 07/30/2024, documented, .teeth in poor shape. On 09/09/2024 at 10:19 AM, Resident 21's mouth was observed to have missing upper teeth, and lower teeth had sharp edges and dark tan in color. Resident 21 said he had mouth pain. On 09/10/2024 at 1:17 PM, Resident 21's upper teeth were observed mostly missing on upper gums with pointed short tooth fragments present. Resident 21's lower teeth were observed to be dark tan in color with multiple sharp jagged points. Resident 21 said his tooth pain was on his bottom teeth. Resident 21 said staff had not talked to him about dental concerns or asked about dental pain. On 09/12/2024 at 2:44 PM, after observing Resident 21's teeth, Staff C, Resident Care Manager and Registered Nurse (RN), talked to Resident 21 and stated, It looks like you're missing teeth. Do your teeth hurt? Resident 21 stated, It hurts all the time. Staff C stated, Yes. [Resident 21] does have some missing or broken teeth. Whatever was left on the bottom are broken teeth. [Resident 21] obviously needs dental care. At 3:05 PM, Staff E, MDS Nurse and RN, said she gathered information for the MDS by looking at the resident's medical records, asked staff, and would talk to the resident about pain. When asked about the oral/dental status of the MDS assessment, Staff E stated, If I don't go and see the resident myself ., she would look at the admission assessment, care conference assessment, or skilled care review. When asked about looking at Resident 21 to assess his oral/dental status or gathering information in the medical record, Staff E stated, That's a good question . I don't remember. At 3:26 PM, after observing Resident 21's teeth, Staff B, Director of Nursing Services and RN, said Resident 21 had broken natural teeth. Staff B indicated the MDS oral/dental status was inaccurate and stated, We need to do a correction on this. Staff B indicated there should be a visual assessment completed for the oral/dental status on the MDS. At 3:50 PM, Staff E said she had looked where she got the information for the oral/dental status on Resident 21's MDS, and stated, I probably did not look at [Resident 21's teeth] myself. Reference WAC 388-97-1000 (1)(b), (2)(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed for 1 of 4 sampled residents (6) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Record review of the facility's undated policy entitled, Devices/Enablers Policy and Procedure, documented Use of the device/enabler will be appropriately care planned and added to the resident's [NAME]. Resident 6 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 06/12/2024, documented Resident 6 was severely cognitively impaired. On 09/09/2024 at 10:39 AM, Resident 6's bed was observed with the left side against the wall and a mat on the floor the full length of the bed along the right side. At 11:38 AM, Resident 6 was observed sitting up in a wheelchair in her room with the left side of the bed against the wall. Review of Resident 6's Electronic Health Record comprehensive care plan, did not address the left side of bed against the wall and a mat on the floor along the right side of the bed. On 09/10/2024 at 1:11 PM, Resident 6's bed was observed with the left side against the wall and a mat leaning up against a wall away from the bed. On 09/11/2024 at 10:36 AM, Resident 6's was observed lying on the bed on her left side with the left side of the bed against the wall and a mat on the floor the full length of the bed along the right side. At 1:45 PM, Resident 6 was observed sitting up in a wheelchair in her room with the left side of the bed against the wall. At 2:30 PM, when asked how they knew the care needs of a resident, Staff D, Certified Nursing Assistant, stated, We look at the [resident's] care plan. At 3:02 PM, Staff C, Resident Care Manager and Registered Nurse (RN), said residents with their bed placed against the wall and a mat on the floor should have it care planned. Staff C said she could not find a care plan for Resident 6's bed against the wall and mats on the floor. Staff C stated, It should be in the care plan. At 3:18 PM, Staff B, Director of Nursing Services and RN, said it was his expectation care plans were in place for residents with their bed against the wall and mats on the floor. Reference WAC 388-97-1020 (1), (2)(a)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure activities of (ADLs) care was provided for dependent residents including nail care for 1 of 2 sampled residents (5) reviewed for ADLs. This failure placed residents at risk of not receiving the care and assistance needed for which they were unable to perform themselves. Findings included . The facility's policy entitled, Nail Care, dated 01/01/2024, indicated I. Nail care which we considered a part of personal hygiene/grooming and is provided by the certified nursing assistant if the resident is not diabetic, and the nails are not severe or complicated. II. If the resident is diabetic the nail care will be done by the licensed nurse due to being higher risk. III. The resident nails are checked for cleanliness and length as a standard of care in grooming/hygiene for the certified nursing assistant and cleaned as needed and nail care is offered. Resident 5 was admitted on [DATE]. The annual Minimum Data Set assessment, dated 08/14/2024, indicated Resident 5 was severely cognitively impaired and needed substantial/maximal assistance with personal hygiene. The ADLs care plan, initiated 08/09/2024, documented check nail length and trim and clean on bath day and as necessary. The Tub/Shower task, dated 09/10/2024, documented Resident 5's last bath or shower was on 08/31/2024. On 09/09/2024 at 12:06 PM, Resident 5 said he would like to have assistance getting his nails trimmed. On 09/10/2024 at 2:14 PM, Resident 5's fingernails were about a 1/3 inch long. Resident 5 said he mentioned to the bath aid he would like his nails done but was told they were not able to do them. Resident 5 said the nails have not been done for about a month. At 2:50 PM, Staff I, Nursing Assistant (NA), said they checked resident nails when they did baths or showers. Staff I said resident nail care was done by the the NA unless the resident was diabetic, for which they would report to the nurse. At 2:59 PM, Staff B, Director of Nursing Services and Registered Nurse, said shower aid would do finger nail care at the time of the resident's baths but the nurse would do the nail care if the resident was diabetic. After observing Resident 5's fingernails, Staff B said it looked like they had not been trimmed for about two weeks. 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 explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a manner of which the resident and/or representative understood for 1 of 3 sampled residents (25) reviewed for arbitration agreement. This failure placed residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life. Findings included . Review of the facility's Optional Voluntary Arbitration Agreement documented, 5. Right to Rescind this Agreement. You may rescind this Agreement to arbitrate within thirty (30) days after signing it by giving written notice of your withdrawal to the Facility . Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 08/13/2024, documented Resident 25 was alert and oriented. Review of Resident 25's Nursing Note, dated 08/17/2024, documented, .resident believed she was in a hotel and wanted to speak with the manager about her bill . Review of Resident 25's Nursing Note, dated 08/18/2024, documented, .some confusion prior to sleep. Review of Resident 25's Daily Skilled Nursing Charting progress note, dated 08/28/2024, documented, .res [resident] is alert and oriented [A&O] x2 [when someone knows who they are and where they are, but not what time it is], reoriented to time of day . Review of Resident 25's Daily Skilled Nursing Charting progress note, dated 08/30/2024, documented, .A&O x2, some confusion . Review of Resident 25's Daily Skilled Nursing Charting progress note, dated 09/01/2024, documented, .Res alert with some confusion/forgetfulness . Record review of Resident 25's Optional Voluntary Arbitration Agreement, dated 08/29/2024, showed the arbitration agreement was signed by Resident 25 and Staff J, Admissions Coordinator. On 09/13/2024 at 11:25 AM, when asked if Resident 25 recalled signing a binding arbitration agreement, or if staff reviewed a binding arbitration agreement with her, Resident 25 stated, I was under pain with a broken hip. I can't remember any paperwork. Maybe my sister signed it. When asked if Resident 25 knew what a binding arbitration agreement meant, Resident 25 shook her head no and said she was kinda unsure. At 11:41 AM, Staff J said to determine if a resident was capable to sign an arbitration agreement, she would ask them cognitive questions such as, what was the day, month, and the resident's name. Staff J said she would also ask the social services department if a resident could sign their own paperwork. When asked what was explained to residents and/or their representative regarding their right to rescind an arbitration agreement, Staff J said she would tell them if they changed their mind, the facility could change it at any time. Staff J stated, I can't imagine there ever being a time they can't change their mind. After looking at the facility's arbitration agreement, Staff J said she was not aware they had only 30 days to change their mind. When asked if it was explained to a resident and/or their representative they had 30 days to change their mind, Staff J stated, No. I didn't tell them they have only 30 days to change their mind . It bothers me that I didn't know that. At 11:59 AM, Staff A, Administrator, said he did not know for how long after signing an arbitration agreement it could be rescinded, and stated, They have as much time as they like. I don't know. No WAC Reference .

. Based on observation, interview and record review, the facility failed to ensure infection prevention practices are being maintained including proper use of personal protective equipment (PPE) and hand hygiene for 2 of 8 sampled residents (26 & 30) reviewed for infection prevention and control. These failures placed residents at risk of communicable infections and a decreased quality of life. Findings included . Record review of the facility's Employee Training on Infection Prevention and Control policy, dated 11/01/2018, documented staff trainings and education regarding infection prevention and control included hand hygiene and use of PPE. 1) On 09/10/2024 at 1:58 PM, Staff F, Certified Nurse Assistant (CNA), was observed providing care for Resident 26. Staff F took off her gloves, opened Resident 26's door and proceed to retrieve gloves from the isolation cart located outside the room. Staff F then returned into the room, put on the new pair of gloves and continued to provide resident care. When asked about the process for doffing PPE between care, Staff F said she should have washed her hands in between changing gloves. 2) On 09/10/2024 at 3:37 PM, Resident 30's room was observed with an enhanced barrier precautions sign on the door and an isolation cart outside the room. At 3:38 PM, Staff G, CNA, and Staff H, CNA, went into Resident 30's room to provide incontinence care for Resident 30. Staff G and Staff H did not put on isolation gowns. At 3:58 PM, Staff G was observed taking trash out of the Resident 30's room with the same gloves used to provide incontinence care for Resident 30. Staff G then went to the dirty utility room door, entered the code on the door using the contaminated gloves, opened the door and threw the trash away. Staff G then took her gloves off, returned to Resident 30's room and sanitized her hands. While in Resident 30's room, Staff G put on gloves and collected dirty linen, bagged the linen in a plastic bag, left the room with the gloves on both her hands. Staff G then went to the dirty utility room door, entered the code on the door using the contaminated gloves and discarded the dirty linen. At 4:03 PM, when asked if Resident 30 was on isolation precautions, Staff G stated, Right now I am not sure. When asked how she would know what kind of isolation precautions a resident was on, Staff G stated, We are informed by the charge nurse or the sign outside of the door. When asked about the use of contaminated gloves outside of Resident 30's room, Staff G stated Yes, I had gloves on. On 09/11/2024 at 11:46 AM, Staff B, Director of Nursing Services and Registered Nurse, said infection control trainings were provided on hire date and during staff meetings. Staff B said it was the expectation staff would use the isolation precaution signs outside of resident's doors to identify the appropriate PPE to use during care. Staff B said it was the expectation staff removed contaminated gloves and perform hand hygiene before leaving the resident's room. Reference WAC 388-97-1320 (1)(c)(2)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 4 of 9 sampled residents (1, 24, 26 & 30) reviewed for ADs. This failure place residents at risk for losing their right to have healthcare preferences and decisions honored and a diminished quality of life. Findings included . The facility's policy entitled, Advanced Directives, dated 08/01/2018, indicated, I. Upon admission, we will determine whether a resident has an advance directive, if they do not have and advance directive we will determine whether the residents or resident representative wishes to formulate and advanced directive. II. Information will be provided to the residents or resident representative about the right to refuse medical and surgical treatment and formulate an advanced directive. Including the facility policy on advance directive and applicable state law regarding advanced directives. 1) Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 07/01/2024, showed Resident 1 was severely cognitively impaired. Resident 1's electronic health record (EHR) did not show an AD or documentation an AD was reviewed since admission. 2) Resident 24 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 24 was moderately cognitively impaired. Resident 24's EHR did not show an AD or documentation an AD was reviewed since admission. 3) Resident 26 was admitted to the facility on [DATE]. The 5-day MDS, dated [DATE], showed Resident 26 was alert and oriented. Resident 26's EHR did not show an AD or documentation an AD was reviewed since admission. 4) Resident 30 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the Resident 30 was alert and oriented. Resident 30's EHR did not show an AD or documentation an AD was reviewed since admission. On 09/11/2024 at 12:23 PM, Staff K, Social Services Director, said Advance Directives were addressed in the initial admission care conference, and if residents decline, I typically make a note in the care conference. I Follow up. I reach out. If they don't have it, I give them a form to fill out. Staff K said there had been gaps in documentation. Staff K stated, I could probably be better with follow up. It should be documented. At 1:07 PM, Staff A, Administrator, said ADs should be reviewed and addressed at the initial care conference. Staff A stated, Yes. We know there were issues. Reference WAC 388-97-0280 (3)(c)(i) .

**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 and a physician order was obtained for safe self-administration of medications for 1 of 1 sampled residents (24) reviewed for clinically appropriate self administration of medications. This failure placed residents at risk for medication errors, adverse medication interactions, and a diminished quality of life. Findings included . The facility policy entitled, Self-Medication Administration, undated, documented, Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. The policy documented, An assessment shall be done on the resident that will demonstrate the knowledge of indications for use and appropriate dose of this medication. The resident will also demonstrate the ability to safely store this medication in the bedside drawer in a locked box for safety . a written order to keep the medication at the bedside must be in the chart. Resident 24 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/28/2023, documented Resident 24 was moderately cognitively impaired. On 07/18/2023 at 9:10 AM, a jar of vaporizing rub (a medication used to manage cold symptoms) was observed on the bedside table. When asked who applied the medication to the resident, Resident 24 said she puts it on herself. On 07/19/2023 at 5:09 AM, Resident 24 was observed lying in bed with eyes closed. A jar of vaporizing rub was on the bedside table. At 2:36 PM, a jar of vaporizing rub was observed on the bedside table. Resident 24 was not in the room. At 2:38 PM, Staff J, Registered Nurse (RN), was observed entering Resident 24's room. Staff J stated, [Resident 24] probably should have an order for that [medication] to be there. That should not be there. Staff J picked up the jar of vaporizing rub and took it back to her med cart and stated, Let's go check on that. After reviewing Resident 24's electronic health record, Staff J stated, I don't see an order. I'm going to keep this [the vapor rub] with me . I don't see a self-med assessment. At 2:42 PM, Staff K, Residential Care Manager and Licensed Practical Nurse, said the process for residents to self-administer medications was to get an order from the physician to keep the medication at the bedside and do a self-medication assessment. When asked if the vaporizing rub in Resident 24's room should have had an order and self-medication assessment, Staff K stated, Yes. I will get an order for this right away. The family sometimes sneaks in medications for her. On 07/20/2023 at 3:20 PM, Staff B, Director of Nursing Services and RN, said it was his expectation medications at the bedside have a physician's order for the medication and for it to be kept at the bedside, and a self-medication administration assessment be completed. Reference WAC 388-97-0440 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to obtain, provide, and/or assist with completing Advance Directives (AD) for 1 of 6 sampled residents (7) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 05/25/2023, documented Resident 7 was cognitively intact. A review of the Resident 7's medical record did not show documentation of an AD. On 07/21/2023 at 11:43 AM, Staff F, Social Services, said they only request an AD when a resident was admitted . Staff F said Resident 7 had been in the facility a while. Staff F said they reviewed the AD at every care conference. Staff F said there was not an AD in Resident's 7 medical record and was unsure if they requested Resident 7's AD. At 11:46 AM, Staff B, Registered Nurse and Director of Nursing Services, said the facility did not have an AD on file for Resident 7. Staff B said the facility should determine if the resident has an AD, and if so, place a copy in the medical record. Reference WAC 388-97-0300 (1)(b), (3)(a-c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and/or a Notice of Medicare Non-Coverage (NOMNC) was issued timely, at least two calendar days before Medicare services ended, for 1 of 3 sampled residents (33) reviewed for SNF ABN and NOMNC notification. This failure placed residents and their representatives at risk for not having adequate information to make financial decisions related to a continued stay in the facility and a diminished quality of life. Findings included . Resident 33 was admitted to the facility on [DATE]. A medical record review showed Resident 33 had a Medicare Part A Skilled Services episode start date of 05/23/2023, and a last covered day of Part A service on 06/23/2023. After 06/23/2023, Resident 33 remained as a resident in the facility. Record review of Resident 33's SNF ABN documented Resident 33 was provided and signed the SNF ABN on 06/23/2023, the same as the last covered day of Part A services. Record review of Resident 33's NOMNC documented Resident 33 was provided and signed the NOMNC on 06/23/2023, the same as the last covered day of Part A services. Resident 33's Electronic Health Record, dated 06/23/2023, documented, LCD [last covered day] 06/23/2023 for therapies and nursing. Resident is pending Medicaid application process. Contacted family and notified them of current status. On 07/19/2023 at 8:06 AM, Staff I, Social Services Director, said social services would notify the resident or the resident's family when their Medicare Part A coverage was ending. If social services was out, medical records or nursing staff would do it. When asked how many days in advance the resident or resident's representative was notified when coverage was ending, Staff I stated, Two days in advance they are notified for NOMNC/ABN, sometimes earlier if they need discharge planning. When asked about Resident 33's Medicare Part A coverage change, Staff I stated, [Resident 33] was a different scenario, he signed his on the 23rd, the last day of coverage . The NOMNC was delayed, so that was a facility error. Same with the ABN. It should have been signed two days ahead of time. At 8:26 AM, Staff A, Administrator, said when they got notice the resident was coming off Medicare Part A, the social services team notified the family and completed the NOMNC and/or SNF ABN at least 48 hours in advance with the resident and/or the resident's representative. Staff A said it was her expectation the resident and/or resident representative was notified at least two days in advance. Reference WAC 388-97-0300 (1)(e) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure there was a system in place to resolve grievances (a resident concern or complaint) promptly for 1 of 2 sampled residents (7) reviewed for grievances. This failure paced residents at risk for unmet care needs, not being heard and a diminished quality of life. Findings included . Resident 7 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 05/25/2023, documented the resident was cognitively intact, required extensive assistance with activities of daily living, and did not have a plan to return to the community. Resident 7's comprehensive care plan, dated 05/24/2023, documented Resident 7 would like to stay at the facility long-term. Interventions included the facility would periodically check with Resident 7 to verify no change in the discharge plan, and staff would encourage Resident 7 to decorate her room to make it more homelike. On 07/17/2023 at 2:14 PM, Resident 7 said she had asked many times about getting a private room. Resident 7 said she was led to believed she could not have a private room because she was on Medicaid. Resident 7 said they did not take the time to explain why she could not have a private room. Resident 7 said the facility tried to avoid giving the resident a roommate, but it could happen. Resident 7 said she planned on staying at the facility forever. Resident 7 said she valued her privacy and having a private room was particularly important. The resident said she required a larger wheelchair and mechanical lift. The resident's room was observed to be fully decorated with pictures and collectibles. Resident 7 said she knew some rooms were too small to accommodate her, but she felt there was a solution. On 07/20/2023 at 12:45 PM, Resident 7 said she would go by the staff offices and say Hey, do you have a private room. Resident 7 said the facility did not give her an adequate response, so it had become a bit of a joke. Resident 7 stated, This is my forever home. On 07/21/2023 at 10:32 AM, Staff F, Social Services, said she was aware Resident 7 would like a private room and its importance to the resident. Staff F said there were no private rooms that would accommodate the resident. Staff F said during the last care conference they discussed Resident 7's room arrangement and as a result, they sent a referral to the neighboring assisted living. Staff F said she did not document discussions regarding the private room. Staff F said she had not followed up with the resident on the referral to the assisted living side and did not know the status. Staff F said typically they would not update the resident on the status of their request. Staff F said she was aware the resident wanted to stay at the facility forever but they did not have a room that met Resident 7's needs. At 11:46 AM, Staff B, Registered Nurse and Director of Nursing Services, said he was aware Resident 7 wanted a private room. Staff B said Resident 7 liked to have time alone and had large equipment used for her care. Staff B said he was unaware of a referral to the assisted living side of the facility. Staff B said Resident 7 was here long-term and the resident's concerns should be addressed. Reference WAC 388-97-0460 (2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure physician orders and consents were obtained for 2 of 7 sampled residents (1 & 36) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . The facility's policy, Devices/Enablers Policy and Procedure, undated, documented, The nursing staff will then inform the resident and responsible party of the risks/benefits of the device and will obtain an informed consent for the device. If the resident or responsible party are not in agreement with the device/enabler, the device/enabler will not be placed . Nursing Staff will also obtain a physician order for the device/enabler. 1) Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The Medicare/5 day Minimum Data Set (MDS), an assessment tool, dated 07/06/2023, documented Resident 1 was moderately cognitively impaired. Record review of Resident 1's Electronic Medical Record (EMR) showed no physician's orders related to a bed against the wall, a fall mat, bilateral bed mobility bars, or a high/low bed in the low position. On 07/17/2023 at 10:07 AM, Resident 1 was observed in bed with the bed against the wall, a fall mat on the floor beside the bed, and bilateral mobility bars to the head of the bed. On 07/18/2023 at 9:18 AM, Resident 1 was observed in bed with the bed against the wall, a fall mat on the floor beside the bed, bilateral mobility bars to the head of the bed, and the high/low bed was in low position. 2) Resident 36 was admitted to the facility on [DATE]. The admission/Medicare/5 day MDS, dated [DATE], documented Resident 36 was moderately cognitively impaired. Record review of Resident 36's EMR showed no physician's order or a consent related to the right side of the bed against the wall. On 07/17/2023 at 10:13 AM, Resident 36 was observed in bed with the bed against the wall on the right side of the bed. On 07/19/2023 at 12:57 PM, Resident 36 was observed sitting up in bed eating lunch. The bed was against wall to the right side of Resident 36. On 7/20/2023 at 9:41 AM, Resident 36 was observed in bed. The bed was observed to be against wall to the right side of Resident 36. At 12:49 PM, Staff J, Registered Nurse (RN), said if a resident used quarter rails, fall mats, hi/low beds, or had a bed against the wall, a consent and a physician's order was needed. At 1:04 PM, Staff K, Resident Care Manager and Licensed Practical Nurse, said a physician's order and consent should have been obtained if a resident used bed mobility bars, fall mats, a hi/low bed, or a bed against the wall. Staff K was not able to locate a physician's order for Resident 1's bed against the wall, fall mat, bilateral bed mobility bars, or a hi/low bed. Staff K was not able to locate a physician's order or consent for Resident 36's bed against the wall. At 3:15 PM, Staff B, Director of Nursing Services and RN, said it was his expectation a physician's order and consent was completed for the use of enablers and/or devices such as mobility bars, hi/low beds, fall mats, and a bed against wall. Reference WAC 388-97-0620 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 1 of 3 sampled residents (8) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/30/2023, documented Resident 8 was cognitively intact. Resident 8's electronic medical record documented a transfer to the hospital on [DATE] with a readmission on [DATE]. The electronic medical record did not show a documentation of a bed-hold notice for the transfer. On 07/20/2023 at 10:41 AM, Staff D, Resident Care Manger and Registered Nurse, said a bed-hold notice was sent with the resident at the time of discharge to the hospital. Staff D said if the bed-hold was not addressed at this time, social services would follow up with the resident or resident representative on the next business day. Staff D stated, I don't see a bed-hold for Resident 8's transfer to the hospital on [DATE]. At 11:07 AM, Staff I, Social Services Director, said if a bed-hold was not obtained at the time of a transfer to the hospital then she would follow up with the resident or resident representative the next day. Staff I stated, There is only a blank bed-hold form dated for 05/30/2023 for Resident 8. The bed-hold was not completed for Resident 8. Reference WAC 388-97-0120 (4) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure resident assessment data was encoded and transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for 1 of 2 sampled residents (30) reviewed for resident assessments. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 30 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 05/25/2023, documented the resident was cognitively intact. Resident 30's progress notes, dated 04/25/2023, documented Resident 30 was discharged to home. Resident 30's discharge MDS assessment showed the MDS was not submitted. On 07/21/2023 at 9:19 AM, Staff G, Licensed Practical Nurse and MDS Coordinator, said the Registered Nurse (RN) did not sign off Resident 30's discharge MDS. The MDS did not get submitted as a result. Staff G said they have no formal process to ensure the facility was submitting the MDS. Staff G said this MDS should have been submitted. At 12:03 PM, Staff B, Director of Nursing Services and RN, said Resident 30's MDS was not submitted as required. Staff B said they had no system in place to catch missed MDS submissions. Reference WAC 388-97-1000 (4)(b), (5)(a), (e)(i-iii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE]. The significant change MDS, dated [DATE], documented the resident was moderately cognitively impaired and did not have a pressure area or a deep tissue injury. <Fluid Restriction> Resident 32's general information care plan, dated 05/21/2023 and updated 06/04/2023, documented an intervention for Resident 32 for 1,200 ML (milliliters) fluid restriction, 240cc (cubic centimeter) all meal trays, 240 nurses supplements and med pass, 120cc at bedside. NO EXTRA FLUIDS AT BEDSIDE, TALK WITH NURSE. A physician's order, dated 06/04/2023, documented, FLUID RESTRICTION 1,200ml (milliliters) in 24 hours. The fluid restriction order was discontinued on 07/16/2023. A progress note, dated 7/16/2023, documented, On alert d/c [discontinue] fluid restriction. Will let resident know new orders. Resident 32's Electronic Medical Record (EMR) did not show documentation of Resident 32's care plan updated after the fluid restriction was discontinued. <Skin Condition> Resident 32's skin integrity care plan, dated 05/21/2023, documented, [Resident 32] has actual impairment to skin integrity of the Coccyx [bone at the base of the spinal column] DTI [deep tissue injury, a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] r/t [related to] recent weight loss and hospitalization. Resident 32's progress note, dated 05/24/2023, documented, No DTI noted. Record review of Resident 32's CAA (care area assessment) Worksheet, dated 07/11/2023, documented, Boney prominence to coccyx not open blanches [able to make redness go away by pressing on it] . Will care plan for prevention of development of pressure ulcer. The EMR did not show documentation of Resident 32's care plan updated to reflect current skin condition. On 07/18/2023 at 2:19 PM, Resident 32's skin on her coccyx was observed with Resident 32's permission and Staff P, RN, being present. Resident 32's skin was intact, pink, and blanchable. Resident 32 said the skin was never open. Staff P said the skin on Resident 32's coccyx was never open or a DTI. Just a red area they put the dressing on for more protection on her coccyx. On 07/19/2023 at 3:10 PM, Staff J said the care plan should be updated with a change in resident's condition, including skin changes, or new physician's orders if needed. At 3:21 PM, Staff G, MDS Coordinator and Licensed Practical Nurse (LPN), said she updated the care plans when she did the MDS. When asked about Resident 32's significant change MDS, dated [DATE], Staff G stated, I haven't updated this one yet . I haven't gotten to it. It's hard to get to everything. Staff G said it should have been updated. At 3:37 PM, Staff K, Residential Care Manager and LPN, said the MDS coordinator and the RCMs usually updated the care plans. Staff K said the care plans were updated quarterly with the MDS and as needed for skin changes, intervention changes, an incident, and with a physician's order change. Staff K was unable to find where Resident 32's care plan had been updated when the fluid restriction was discontinued and stated, Yes. That should have been updated. Staff K said Resident 32's care plan should have been updated to reflect current skin conditions. On 07/20/2023 at 3:17 PM, Staff B said it was his expectation the care plan was updated to reflect residents' current skin conditions and with physician order changes. Reference WAC 388-97-1020 (2)(c)(d) Based on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 14 sampled residents (10 & 32) reviewed for care plan revisions. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life. Findings included . 1) Resident 10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 07/18/2023, documented the resident was moderately cognitively impaired, required extensive assistance from two staff with activities of daily living, and used an indwelling urinary catheter. Resident 10's urinary care plan, dated 05/23/2023, documented Resident 10 required a foley catheter (flexible tube that is inserted into the bladder to drain urine) for retention issues. Resident 10's urinary care plan documented catheter care would be performed according to facility protocol. Resident 10's progress notes documented the resident was admitted to the hospital from [DATE] to 03/17/2023 for a urinary tract infection (UTI). Resident 10's progress notes documented the resident was admitted to the hospital from [DATE] to 05/05/2023 with severe urinary retention. A foley catheter was placed due to the urinary retention. Resident 10 returned to the facility on [DATE] with the catheter. Resident 10's progress notes documented the resident was admitted to the hospital from [DATE] to 05/24/2023 with a UTI and severe hydronephrosis (urine accumulates in the kidneys causing swelling) with likely ongoing urinary issues. On 07/20/2023 at 3:04 PM, Staff J, Registered Nurse (RN), said they would expect the care plan to be updated when a resident's condition changed. Staff J said Resident 10's care plan should be specific with the care of the catheter. On 07/21/2023 at 9:30 AM, Staff M, Certified Nursing Assistant, said she had training in caring for a catheter. Staff M said the care plan did not give direction on how to care for Resident 10's catheter. Staff M said the newer staff would benefit from these details on the care plan. At 10:49 AM, Staff E, Infection Preventionist and RN, said she previously worked in a hospital setting and did not know the care plans needed more specific interventions. Staff E said Resident 10 had several UTIs resulting in a urinary catheter. Staff E said she did not revise the care plan to include this diagnosis. At 11:58 AM, Staff B, Director of Nursing Services and RN, said he expected the care plan to be revised when a resident had a change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the bowel protocol was initiated per physician's orders and when needed for 1 of 7 sampled residents (12) reviewed for quality of care related to bowel management. This failure placed residents at risk for medical complications, change in health status, increased pain and a decreased quality of life. Findings included . Resident 12 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated 05/02/2023, documented Resident 12 was cognitively intact. Resident 12's physician's order, dated 01/24/2023, documented Milk of Magnesium (MOM, a laxative) 1200 MG (milligram)/15 ML (milliliter) by mouth every 24 hours as needed for constipation if no BM (bowel movement) x 3 days or at resident's request. Resident 12's physician order, dated 01/24/2023, documented, Dulcolax (a laxative) Suppository 10 MG insert 1 suppository rectally every 96 hours as needed for constipation every 4 days if MOM not effective. Resident 12's physician's order, dated 01/26/2023, documented, Bisacodyl (a laxative) EC Oral Tablet Delayed Release 5 MG every 24 hours as needed for constipation. May use instead of MOM to initiate BM protocol. Resident 12's bowel record documented Resident 12 had a bowel movement on 06/22/2023 and did not have another BM until 06/29/2023, six days between BMs. Resident 12's July 2023 Medication Administration Record documented the bowel protocol was not initiated during the 06/22/2023 to 06/29/2023 time period. On 07/20/2023 at 2:00 PM, Staff I, Licensed Practical Nurse, stated, At the beginning of the shift we are supposed to look at the clinical dashboard to see the clinical alerts for the bowel list. At 2:08 PM, Staff D, Residential Care Manager and Registered Nurse, said residents with no BM approaching the 72-hour mark were triggered on the dashboard so the bowel protocol could be initiated. Staff D stated, [Resident 12] should have had the bowel protocol started on 06/24/2023 and did not. Reference WAC 388-97-1060 (1), (3)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents with an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) had a valid medical diagnosis and a complete provider order for 1 of 5 sampled residents (8) reviewed for catheter use. This failure placed residents at risk of acquiring potentially preventable catheter associated urinary tract complications and a diminished quality of life. Findings included . Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/30/2023, documented Resident 8 was cognitively intact. A physician's order, dated 06/06/2023, documented Resident 8 was ordered, foley cath (catheter) care with soap and water q (every) shift, cath care wipes done on night three times a day. A physician's order, dated 07/14/2023, documented Resident 8 was ordered, foley care per protocol every 30 days, change prn [as needed] if dislodged, occluded [closed up], or otherwise indicated every night shift every 30 days(s). Resident 8's catheter care plan, initiated on 03/24/2023, documented, [Resident 8] has catheter at this time, empty drainage bag every shift and document output. The care plan included one intervention, dated 03/24/2023, Provide catheter care every shift, empty drainage bag every shift. Review of Resident 8's medical records did not show documentation of provider orders for the indwelling catheter with justification/appropriate diagnosis and size of catheter. On 07/20/2023 at 10:46 AM, Staff D, Resident Care Manager and Registered Nurse (RN), stated, All catheter orders should indicate what type of catheter is being used, the catheter size, the balloon size, and an appropriate diagnosis. Staff D said there should be orders for scheduled changes and cleaning. Staff D said the catheter care plan should be specific indicating what type of catheter was being used including the catheter size, balloon size, and the diagnosis. Staff D said the care plan should also have the changing and cleaning schedule listed. Staff D said Resident 8's physician orders did not indicate the size or diagnosis for the foley catheter. Staff D said Resident 8's care plan was not resident specific and complete. Staff D said the infection preventionist monitored and tracked all catheters. On 11:03 AM, Staff E, Infection Preventionist and RN, said she did not think catheter orders were needed for Resident 8 since the resident was admitted to the facility with the foley catheter already in place related to wound healing. Reference WAC 388-97-1060 (3)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure an anticoagulant (blood thinner) medication related complications were monitored for 1 of 3 sampled residents (5) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects from anticoagulant medication use and a diminished quality of life. Findings included . Review of facility policy, Coumadin (Warfarin) and Other Anticoagulation Medication, undated, documented residents receiving any type of anticoagulation were monitored for signs and symptoms of bleeding to promote the safe and effective use of these medications. Resident 5 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 06/29/2023, documented Resident 5 was moderately cognitively impaired. A physician's order, dated 06/13/2023, documented Resident 5 was prescribed, Coumadin (an anticoagulant medication) Oral Tablet 4 MG (milligram) by mouth at bedtime for anticoagulation therapy. Resident 5's anticoagulant care plan, initiated and revised on 05/12/2023, documented the intervention to Monitor/document/report PRN [as needed] any [signs and symptoms] of CAD (coronary artery disease): chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema [swelling], changes in cap [capillary] refill, color/warmth of extremities. Resident 5's electronic medical record did not show documentation of monitoring for complications of anticoagulants. On 07/19/2023 at 2:59 PM, Staff D, Resident Care Manger and Registered Nurse, stated, All anticoagulation should have monitoring for adverse side effects. I don't see the adverse side effect monitoring for anticoagulation use for Resident 5. Reference WAC 388-97-1060 (3)(k)(i) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anxiety disorder (a mental health disorder characterized by feelings of worry or fear that interferes with daily life). The significant change MDS, dated [DATE], documented Resident 32 was moderately cognitively impaired. A physician's order, dated 06/04/2023, documented Resident 32 was prescribed Lorazepam (a medication used to treat anxiety). Resident 32's EMR did not show documentation of a consent from the resident or the resident's representative for the administration of lorazepam. On 07/21/2023 at 12:13 PM, Staff B, Director of Nursing Services and RN, said Resident 32 should have had a consent for the lorazepam. Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 4 of 6 sampled residents (5, 12, 32 & 39) reviewed for right to be informed and make treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life. Findings included . 1) Resident 5 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 06/29/2023, documented Resident 5 was moderately cognitively impaired. A physician's order, dated 01/25/2023, documented Resident 5 was prescribed Sertraline (an antidepressant). A physician's order, dated 06/10/2023, documented Resident 5 was prescribed Risperidone (an antipsychotic medication). Resident 5's Electronic Medical Record (EMR) did not show documentation of a consent from the resident or the resident's representative for the administration of risperidone and/or sertraline. 2) Resident 12 was admitted to the facility on [DATE]. The significant change MDS, dated [DATE], documented Resident 12 was cognitively intact. A physician's order, dated 05/23/2023, documented Resident 12 was prescribed Seroquel (an antipsychotic medication). Resident 12's EMR did not show documentation of a consent from the resident or the resident's representative for the administration of Seroquel. On 07/19/2023 at 2:03 PM, Staff D, Resident Care Manager (RCM) and Registered Nurse (RN), said the nurse receiving an order for a psychotropic medication needed to inform the resident or resident representative and obtain consent to administer the medication. Staff D stated, [I] could not find a consent for Resident 5's Risperidone or Sertraline nor Resident 12's Seroquel. 4) Resident 39 was admitted to the facility on [DATE] with diagnoses including anxiety and depression. The Medicare 5-day MDS, dated [DATE], documented the resident was cognitively intact. A physician's order, dated 06/22/2023, documented Resident 39 was ordered Trazodone, an antidepressant medication. A physician's order, dated 07/01/2023, documented Resident 39 was ordered Sertraline, an antidepressant medication. Resident 39's medical record did not show documentation of consents for the ordered psychotropic medications. On 07/19/2023 at 11:35 AM, Staff C, Licensed Practical Nurse, said psychotropic medications were medications that affected the mind. Staff C said nurses would talk to the resident about the risks and benefits to the psychotropic medication, and nurses would obtain written consent for the psychotropic medication at that time. Staff C said RCMs typically obtained consent for psychotropic medication, and the consent was sent to medical records and a copy uploaded to the resident's medical records. At 12:46 PM, Staff D said residents were educated on the risks and benefits of psychotropic medication, and at that time a psychotropic medication consent form was completed and signed by the resident or their representative. Staff D said Resident 39 was taking Sertraline and Trazodone. Staff D said she could not locate consents for the ordered psychotropic medications. Staff D said the medications were ordered directly by the provider, so the nurse on duty would not have known about the new prescription and could not obtain consent prior to administration of the medication. On 07/20/2023 at 10:52 AM, Staff B said consents should be obtained prior to starting psychotropic medications. Staff B said consents could be in the resident's assessment tab or the miscellaneous tab in their medical records. Staff B said there have been issues of providers inputting their orders directly, and when that happened nurses were unaware of the new orders and thus did not obtain consents for the ordered psychotropic medications. Reference WAC 388-97-0300 (3)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident 36 was admitted to the facility on [DATE]. The admission/Medicare/5 day MDS, dated [DATE], documented Resident 36 was moderately cognitively impaired. The facility policy, Devices/Enablers Policy and Procedure, undated, documented, Use of the device/enabler will be appropriately care planned and added to the resident's [NAME] (system of communication used to provide patient information). Resident 36's comprehensive care plan did not address the bed being placed against the wall. On 07/17/2023 at 10:13 AM, Resident 36 was observed in bed with the bed against the wall on the right side of the bed. At 4:02 PM, when asked about the bed being against the wall, Resident 36 stated, That's the way it's always been. On 07/19/2023 at 12:57 PM, Resident 36 was observed sitting up in bed eating lunch. The bed was observed to be against wall to the right side of Resident 36. On 7/20/2023 at 9:41 AM, Resident 36 was observed in bed. The bed was observed to be against wall to the right side of Resident 36. At 12:49 PM, Staff J, RN, said when a resident used enablers or devices such as quarter rails, fall mats, a high low bed, or a bed against the wall, it needed to be put in the care plan. At 1:04 PM, Staff K, RCM and Licensed Practical Nurse, said there should be a care plan implemented for a bed placement against the wall. Staff K said she could not locate a bed against the wall or a device/enabler care plan in place for Resident 36. Staff K said there should have been and stated, I'll take care of it right away. At 3:15 PM, Staff B said it was his expectation residents with a bed placed against the wall should have it care planned. Staff B stated, We didn't think about the small rooms with the bed against the wall. Reference WAC 388-97-1020 (1), (2)(a)(b)(c) 2) Resident 5 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's dementia. The significant change MDS, dated [DATE], documented Resident 5 was moderately cognitively impaired. Resident 5's Comprehensive Care Plan did not address the resident had non-Alzheimer's dementia. On 07/19/2023 at 2:59 PM, Staff D said medications and diagnoses would be care planned upon admission. Staff D said the care plan was updated with any new diagnosis or conditions. Staff D said she was unable to find where dementia was care planned for Resident 5. On 07/20/2023 at 1:38 PM, Staff B stated, Dementia is a diagnosis that should be care planned as with all active diagnoses. 3) Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE]. The quarterly MDS, dated [DATE], documented Resident 8 was cognitively intact. A physician order, dated 07/07/2023, documented Resident 8 was ordered Lasix (a diuretic) for 7 days related to edema. This order ended on 07/12/2023. Resident 8's July 2023 MAR documented, Lasix Oral tablet 20MG (Furosemide) Give 1 tablet by mouth one time a day for edema for 7 days. The MAR documented the medication was administered from 07/07/2023 to 07/12/2023. Resident 8's electronic medical record did not show edema monitoring in place. Resident 8's comprehensive care plan did not address the resident had edema. On 07/17/2023 at 9:33 AM, Resident 8 was observed with 3+ pitting edema (a swollen part of the body that dimples or pits when pressed) to both lower extremities. On 07/18/2023 at 9:49 AM, Resident 8 was observed with 3+ pitting edema to both lower extremities. On 07/19/2023 at 4:40 PM, Resident 8 was observed with 3+ pitting edema to both lower extremities. On 07/20/2023 at 10:08 AM, Resident 8 was observed with 3+ pitting edema to both lower extremities. At 10:25 AM, Staff D stated, All new and current health issues should be care planned. The person receiving the order should be updating the care plan. Staff D said she was unable to locate anything in Resident 8's care plan pertaining to edema. Staff D said edema should have been care planned. At 11:19 AM, Staff B said a diagnosis of edema was usually on the care plan. Staff B said Resident 8's care plan had not been updated to include edema Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 4 of 14 sampled residents (39, 5, 8 & 36) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 39 was admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 06/17/2023, documented the resident was cognitively intact. A physician's order, dated 07/12/2023, documented the resident was ordered Macrobid, an antibiotic medication used to treat UTI's. Resident 39's July 2023 Medication Administration Record (MAR) documented, Macrobid oral capsule . give 1 capsule by mouth two times a day for UTI for 7 days. The MAR documented the medication was administered from 07/12/2023 to 07/18/2023. Resident 39's Comprehensive Care Plan did not address the resident had a UTI. On 07/17/2023 at 10:24 AM, Resident 39 said she was currently being treated for a UTI (Urinary Tract Infection). On 07/19/2023 at 11:59 AM, Staff E, Infection Preventionist and Registered Nurse (RN), said when a resident was suspected of having a UTI, she expected floor nurses to complete a UTI-specific assessment called Loeb Criteria (a minimum set of signs and symptoms which, when met, indicate the resident likely has an infection and an antibiotic might be indicated, even if the infection has not been confirmed by diagnostic testing). Staff E said she was unable to locate the assessment for Resident 39. When asked if a resident should have a UTI-specific care plan, Staff E said she was not sure if she had seen a UTI-specific care plan, and Residential Care Managers (RCMs) may better answer the question. At 1:13 PM, Staff D, Residential Care Manager (RCM) and RN, said Resident 39 had a UTI. Staff D said Loeb Criteria should be completed, but Staff D was unable to locate the assessment. Staff D said she could not locate a UTI care plan in place for Resident 39. Staff D said there should be a care plan implemented for UTIs. Staff D said additional care plans can be added under custom focus to generate a new care plan for the UTI. On 07/20/2023 at 11:04 AM, Staff B, Director of Nursing Services and RN, said a resident with a UTI should have a UTI care plan, with interventions such as assess vitals, monitor for fever, and monitor for confusion. Staff B said the care plan process was kind of broken due to new staff members not knowing facility processes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview, the facility failed to ensure a safe environment was maintained and free from hazards related to unsecured and/or unsupervised chemicals and/or tools for 1 of 1 rooms under construction (Resident room [ROOM NUMBER]) and 1 of 2 shower rooms (West Hall) reviewed for accident hazards. This failure placed residents at risk for avoidable accidents and injuries, negative health outcome, and a diminished quality of life. Findings included . <Unsecured Tools> On 07/17/2023 at 10:05 AM, Resident room [ROOM NUMBER] was observed to have the carpet removed with no flooring on the floor, the window was cracked open, and a fan on the floor was running. Resident room [ROOM NUMBER] had a bucket of adhesive with the lid secured on the floor with a scraper tool/trowel spatula on top of the bucket with sharp edges. Resident room [ROOM NUMBER] had a wheeled work cart with tools on the cart including a box cutters with a blade in the tool, plyers, and an Ace brand sharp scraper in the room. Resident room [ROOM NUMBER] was unlocked with no signage on the door and no staff members present in or near the room. At 11:11 AM, Resident room [ROOM NUMBER] was observed to be unlocked with no signage on the door and no staff members present in or near the room. Resident room [ROOM NUMBER] had the same work cart and tools in the room, in the same location. On 07/18/2023 at 2:22 PM, Resident room [ROOM NUMBER] was observed to be unlocked with no signage on the door and no staff members present in or near the room. Resident room [ROOM NUMBER] had the same work cart and same tools in the room, in the same location. At 2:51 PM, Staff P, Registered Nurse (RN), said they have been remodeling the floors, taking the carpet out and putting vinyl in. At 3:05 PM, Staff Q, Maintenance Director, said they were replacing the flooring. Staff Q said he did not have a sign to put up to notify residents or families work was being done in the room. When asked how sharp objects or tools were stored while a room was being worked on and staff were not present, Staff Q stated, The door doesn't lock, I try to make sure all my tools are put away, especially the cutter tools are put away, so no resident can have access to them. After observing Resident room [ROOM NUMBER] with the box cutters, plyers and scrapers left unattended and accessible to residents, Staff Q stated, No, it should not be in here. It should be in my pocket. Staff Q was observed putting the box cutter tool in his pocket. At 3:32 PM, Staff B, Director of Nursing Services and RN, said it was his expectation tools were not left in an accessible room when staff were not present. <Unsecured Chemicals> On 07/17/2023 at 10:22 AM, the [NAME] Hall shower room, located across from resident room [ROOM NUMBER], was observed to be unlocked and unattended. A cabinet/cupboard located inside the [NAME] Hall shower room was unlocked with chemicals inside including peroxide multi-surface disinfectant and cleaner spray bottle, one-step disinfectant wipes, a jug of germicidal ultra bleach, and a tub of micro kill bleach germicidal wipes. At 2:07 PM, the [NAME] Hall shower room door and cupboard inside containing chemicals was observed unlocked and unattended. On 07/18/2023 at 9:05 AM, the west hall shower room door and cupboard inside containing chemicals was observed unlocked and unattended. At 1:35 PM, the [NAME] Hall shower room door and cupboard inside containing chemicals was observed unlocked and unattended. On 7/19/2023 at 5:08 AM, the [NAME] Hall shower room door and cupboard inside containing chemicals was observed unlocked and unattended. At 1:40 PM, Staff R, Certified Nursing Assistant, said she kept her cleaning supplies in the cabinet in the shower room. Staff R said she did not know where the key was for the cabinet, so it was kept unlocked. Staff R said the [NAME] Hall shower door was usually kept unlocked because she did not have a key until today. At 1:55 PM, when asked about the process for storing the cleaning supplies and chemicals in the shower room, Staff K, Resident Care Manager and Licensed Practical Nurse, stated, They are supposed to be under two locks and keys, the door locks and the cupboard locks. Staff K said Staff R just got her key to the door so it should be kept locked now. Staff K stated, We didn't know she didn't have a key. When asked to observe the [NAME] Hall shower room's cabinet, Staff K was observed opening the cupboard containing chemicals, without a key, and stated, Yes, that should have been locked. At 2:30 PM, Staff B said it was his expectation chemicals and cleaning supplies were kept behind locked doors and cabinets. Staff B said they just got a new cabinet in the [NAME] Hall shower room and thought it was kept locked. Reference WAC 388-97-3240 (1), -3260 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anxiety disorder. The significant change MDS, dated [DATE], documented Resident 32 was moderately cognitively impaired and received an antianxiety medication for seven of seven days during the assessment period. A physician's order, dated 06/04/2023, documented Resident 32 was ordered Lorazepam (an anti-anxiety medication) as needed for anxiety. Resident 32's behavior care plan, initiated and revised on 06/21/2023, documented, Resident is at risk for behavior symptoms r/t anxiety. An intervention, dated 06/21/2023, documented, Administer medications as ordered. Monitor effectiveness and side effects. Review of Resident 32's electronic medical record did not show documentation of monitoring of medication side effects. On 07/21/2023 at 12:13 PM, Staff B said Resident 32 should have been monitored for medication side effects for anti-anxiety medication. <Limit PRN Psychotropic Medications to 14 Days> A physician's order, dated 06/04/2023 and updated 06/29/2023, documented Resident 32 was ordered lorazepam as needed (PRN) without a stop date of 14 days. Resident 32's electronic medical record did not show documentation a physician assessed and indicated the PRN anti-anxiety medication was to be extended beyond 14 days. Resident 32's Psychotropic Med Review, dated 06/21/2023, documented need end date for PRN [lorazepam]. On 07/21/23 at 10:33 AM, Staff K, RCM and LPN, said PRN psychotropic medications needed to have a 14-day end date and be reviewed to see if the medication was being used and was effective. Staff K said it was expected the provider documented and assessed the PRN psychotropic medication use to see if should be changed to routine. At 12:15 PM, Staff B said all residents on PRN psychotropic medications should be reviewed after 14 days. Staff B said they would ask for a stop date after 14 days or the physician should assess them to see if the PRN medication was needed. Staff B was unable to provide documentation Resident 32 was re-evaluated after 14 days for the PRN psychotropic medication use. Reference WAC 388-97-1060 (3)(k)(i) 4) Resident 5 was admitted to the facility on [DATE] with diagnoses including delirium due to known physiological condition (a disturbed state of mind); delusional disorders (false beliefs about reality); insomnia due to other mental disorder (sleeplessness); anxiety disorder (excessive worry and/or fear); and major depressive disorder recurrent moderate (feelings of despondency and dejection). The significant change MDS, dated [DATE], documented Resident 5 was moderately cognitively impaired, received an antidepressant medication and an antipsychotic medication for seven of seven days during the assessment period. A physician's order, dated 01/25/2023, documented Resident 5 was prescribed Sertraline HCl (an antidepressant). A physician's order, dated 06/10/2023, documented Resident 5 was prescribed Risperidone (an antipsychotic medication). Resident 5's behavior care plan, initiated and revised on 02/08/2023, documented, [Resident 5] is at risk for behavior symptoms r/t depression and anxiety. History of behavior symptoms including delusions, hallucinations, and accusations. An intervention, dated 02/08/2023, documented, Administer medications as ordered. Monitor effectiveness and side effects. Review of Resident 5's electronic medical record did not show documentation of monitoring of medication side effects for the use of an antipsychotic and antidepressant medication. 5) Resident 12 was admitted to the facility on [DATE] with diagnoses including depression, major depressive disorder, anxiety disorder, and adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life) with depressed mood. The significant change MDS, dated [DATE], documented Resident 12 was cognitively intact, and received an antidepressant medication and an antianxiety medication for seven of seven days during the assessment period. A physician's order, dated 01/24/2023, documented Resident 12 was prescribed Venlafaxine HCl ER (an antidepressant medication). A physician's order, dated 05/23/2023, documented Resident 12 was prescribed Seroquel (an antipsychotic medication). Resident 12's behavior care plan, initiated 02/02/2023 and revised 03/29/2023, documented, [Resident 12] is at risk for behavior symptoms/aggressive behaviors r/t history of depression. An intervention, dated 02/02/2023, documented, Administer medications as ordered. Monitor effectiveness and side effects. Review of Resident 12's electronic medical record did not show documentation of monitoring of medication side effects for the use of an antipsychotic and antidepressant medications. Review of Resident 12's electronic medical record did not show documentation of monitoring of target moods/behaviors related to antipsychotic use. Resident 12's Pharmacist's Medication Regimen Review, dated 06/06/2023 and 06/07/2023, documented, the antipsychotic agent Seroquel lacks an allowable diagnosis to support its use. Resident 12's electronic medical record did not show documentation to address the inappropriate diagnosis attached to the medication seroquel. On 07/19/2023 at 2:03 PM, Staff D said there should be behavior monitoring for all residents taking any psychotropic medications. Staff D said nurses do not chart specifically related to side effect monitoring. Staff D said any side effect monitoring would be done in the electronic chart under the progress notes and this charting would be as needed only. Staff D said there was no behavior monitoring for Resident 12's antipsychotic medication. Staff D said pharmacy recommendations were passed on to the provider and it is up to the provider to act on pharmacy recommendations. At 2:54 PM, Staff I, Social Services Director, said her position required that she add behavior monitoring for all psychotropics and nursing was supposed to place the side effect monitoring. Staff I was unable to locate behavior monitoring for Resident 12's antipsychotic. Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects, behaviors, and/or placing a stop date of 14 days for psychotropic as needed medications for 6 of 8 sampled residents (9, 15, 39, 5, 12 & 32) reviewed for unnecessary psychotropic medication. These failures placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life. Findings included . <Monitoring for Behavior/Medication Side Effects> 1) Resident 9 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a disorder that causes a persistent feeling of sadness and loss of interest) and post traumatic stress disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event). The quarterly Minimum Data Set (MDS), an assessment tool), dated 06/15/2023, documented the resident was cognitively intact, and received an antidepressant medication and an antipsychotic medication (medications used to treat symptoms of psychosis such as hearing voices, hallucinations, or paranoia) for seven of seven days during the assessment period. Resident 9's behavior care plan, initiated 02/03/2023 and revised 03/18/2023, documented, [Resident 9] is at risk for behavior symptoms r/t [related to] history of PTSD, anxiety, and depression. An intervention, dated 02/03/2023, documented, Administer medications as ordered. Monitor effectiveness and side effects. Review of Resident 9's electronic medical record did not show documentation of monitoring of medication side effects. 2) Resident 15 was admitted to the facility on [DATE] with diagnoses including anxiety and depression. The Medicare 5-day MDS, dated [DATE], documented the resident had disorganized thinking that did not fluctuate, received an antipsychotic six of seven days during the assessment period and received an antidepressant seven of seven days during the assessment period. A physician's order, dated 07/03/2023, documented Resident 9 was ordered Escitalopram, an antidepressant medication. A physician's order, dated 07/04/2023, documented Resident 9 was ordered Aripiprazole, an antipsychotic medication. A physician's order, dated 07/07/2023, documented Resident 9 was ordered Quetiapine, an antipsychotic medication. Resident 15's psychotropic medication care plan, initiated 07/07/2023, documented, [Resident 9] takes the following psychotropic medications: Abilify [Aripiprazole], Seroquel 25 mg BID [Quetiapine 25 milligrams twice a day], Lexapro [Escitalopram] For Diagnosis: OCD [Obsessive Compulsive Disorder, mental health disorder characterized by repetitive actions that seem impossible to stop], Depression. An intervention, dated 07/07/2023, documented, Monitor for adverse reactions to medications daily. Review of Resident 15's electronic medical record did not show documentation of monitoring of medication side effects. 3) Resident 39 was admitted to the facility on [DATE] with diagnoses including anxiety and depression. The Medicare 5-day MDS, dated [DATE], documented the resident was cognitively intact. A physician's order, dated 06/22/2023, documented Resident 39 was ordered Trazodone, an antidepressant medication. A physician's order, dated 07/01/2023, documented Resident 39 was ordered Sertraline, an antidepressant medication. Resident 39's behavior care plan, initiated 06/19/2023, documented, Resident is at risk for behavior symptoms r/t [related to] history of behavior symptoms of depression, anxiety, and insomnia. An intervention, dated 06/19/2023, documented, Administer medications as ordered. Monitor effectiveness and side effects. Review of Resident 39's electronic medical record did not show documentation of monitoring of medication side effects. On 07/19/2023 at 11:35 AM, Staff C, Licensed Practical Nurse (LPN), said psychotropic medications were any medication that would affect the mind. Staff C said the facility had an order on the Medication Administration Record (MAR) to monitor behaviors. Staff C said medication side effects would be documented in the resident's progress notes. Staff C reviewed Resident 9's, Resident 15's and Resident 39's medical records and was unable to find medication side effect monitoring. At 12:46 PM, Staff D, Residential Care Manager (RCM) and Registered Nurse (RN), said potential side effects of psychotropic medications included changes in mentation, changes in vital signs, or changes in behaviors. Staff D said residents should be monitored for medication side effects. Staff D reviewed the medical record for Resident 9, Resident 15, and Resident 39 and was unable to find medication side effect monitoring. When reviewing Resident 39's medical record, Staff D stated, Behavior monitoring is in place but not specific to side effect monitoring. We do not do side effect monitoring. On 07/20/2023 at 10:52 AM, Staff B, Director of Nursing Services and RN, said when a resident was ordered a psychotropic medication, the resident would be put on alert for side effects for 72 hours. Staff B said residents on psychotropic medications should be monitored for medication side effects. When asked about psychotropic medication side effect monitoring for Resident 9, Resident 15 and Resident 39; Staff B stated, If I find it I will let you know. The facility was not able to provide the medication side effect monitoring for the residents.

. Based on interview and record review, the facility failed to ensure mail delivery was provided on Saturdays for residents receiving mail via the US Postal Service for 4 of 5 sampled residents (7, 12, 19 & 246) reviewed for communication with privacy. This failure placed residents at risk of not receiving their mail in a timely manner and a diminished quality of life. Findings included . The Nursing Facility admission Agreement, dated 09/2013, documented, Each resident has a right to . send and promptly receive mail . On 07/19/2023 at 10:55 AM, during a Resident Council group interview, Resident 7 said there was activity staff that worked on Saturdays, but no mail was delivered on Saturday. The residents got Saturday's mail delivered on Monday. Resident 12, Resident 19 and Resident 246 also said there was no mail delivery on Saturdays. At 12:01 PM, Staff H, Activity Director, said mail delivered on Saturdays by the post office was taken by the post office to the assisted living side of the facility and put in a locked area until Monday. At 12:59 PM, Staff A, Administrator, said the post office delivered mail to the mailboxes on the assisted living side of the facility on Saturdays; but for the skilled nursing residents, it went to a secured area. Staff A said the receptionist picked up Saturday's mail on Monday and it was delivered to nursing home residents on Mondays. Staff A stated, I will have to figure out a process for them to get their mail on Saturdays . I will have to change that. Reference WAC 388-97-0500 (1) .

. Based on observation, interview and record review, the facility failed to ensure foods were prepared, stored, and served in a sanitary manner when the facility failed to ensure the kitchen was free from dust and debris, clean dishes and utensils were stored in a clean manner, and opened foods were not labeled and/or dated as required for all 42 facility residents who received meals from the facility kitchen. These failures placed all residents at risk for food-borne illness and a diminished quality of life. Findings included . On 07/17/2023 at 9:06 AM, during the initial kitchen tour, crumbs, grease, and debris were observed throughout the kitchen. In the dry food storage, a bag of stored food was on the floor. In the freezer, several eggrolls are noted on the floor. The hood had visible grease build-up and dust. A rack with clean dishes was in a high traffic area and had washcloths mixed in with the glasses. Several spices were noted without an open date. On 07/19/2023 at 2:10 PM, the kitchen was observed with Staff N, Dietary Manager. Four dented food cans were identified. Staff N, Dietary Manager, said these cans should be removed from use. Clean cups were stored on a stained and pitted cookie sheet. Staff N said the cups should not be stored on the cookie sheet. Several clean dishes were stored on a three-shelf rack near a high-traffic area. A heavily soiled step ladder was stored between the wall and rack, close to the clean dishes. A cloth was observed in one bin, mixed among the cups. Staff N said the cloth was supposed to be a cover to protect the clean cups. Staff N said staff were worried about the dishes getting contaminated. Staff N said they should find another way to store the dishes. Crumbs and debris were observed throughout the kitchen and appliances/equipment. A heavy layer of grease was observed under the steam table bottom shelf. Items were stored on the shelf. The hood was observed with visible grease, dust, and a cobweb on the sprinkler. A shelf next to the stove and directly across from the steam table, housed tools used to clean the stove top. A piece of cloth or paper next to the tools was stained yellow and black. Several employee water bottles were stored there. Staff N said they would have to look for another place to store the staff water bottles. The top of the stove was covered with grease and dust where oven mitts were stored. Staff O, Dietary Cook, was observed to use these oven mitts during observation of the tray line. Several opened spices were observed without open dates. Staff N said the staff should note the open date. Several clean knives were observed on a magnet hanging next to the three-compartment sink. The knives were not protected from possible splash when the sink was in use. The knives were nearly touching the sanitizer, covered in heavy dust, by the sink. Staff N said the knives could become contaminated and they will look for another solution. At 2:39 PM, Staff N said there had been a lot of turn-over and she had been required to cook. Staff N said she updated their cleaning schedule and will review it to ensure they were capturing the concerns identified. Reference WAC 388-97-2980 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 36 was admitted to the facility on [DATE]. The admission/Medicare/5 day MDS, dated [DATE], documented Resident 36 was moderately cognitively impaired. On 07/20/2023 at 9:41 AM, Resident 36's foley catheter drainage bag was observed on the floor lying to the left side of the bed. Staff J was observed in Resident 36's room stepping on the foley catheter drainage bag on the floor while providing care and bringing medications to Resident 36. At 9:47 AM, when asked where foley catheter drainage bags should be placed, Staff J said below the level of the bladder, hanging off the bed, and never on the floor. After observing Resident 36's foley catheter drainage bag on the floor, Staff J stated, Oh no. That shouldn't be there. Staff J was observed picking up the foley bag and hanging it off the side of bed. 3) Resident 24 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 24 was moderately cognitively impaired. On 07/20/2023 at 9:49 AM, Resident 24 was observed sitting up in the wheelchair with the foley catheter drainage bag hooked very low under the wheelchair with the drainage bag lying on the floor. A foley catheter drainage bag holder was observed under the wheelchair, not in use. Resident 24 was observed rocking forward and backward in the wheelchair with the left rear wheel rolling on bag as resident rocks wheelchair back and forth. At 9:52 AM, Staff L, Certified Nursing Assistant, said foley catheter drainage bags should be hanging off the side of the bed or on the bottom of the wheelchair lower than the level of the bladder and off the floor. Staff L said the wheelchairs had a bag holder under them to place the foley catheter drainage bag into for privacy and to keep it up off the floor. When asked about Resident 24's placement of the foley catheter drainage bag on the floor, Staff L stated, No. It shouldn't be on the floor. Staff L was observed putting the foley catheter drainage bag in the empty bag holder hanging on the bottom of the wheelchair. Staff L stated, It should be in there. It shouldn't be on the floor. 4) Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The Medicare/5 day MDS, dated [DATE], documented Resident 1 was moderately cognitively impaired. On 07/20/2023 at 10:03 AM, Resident 1's foley catheter drainage bag was observed lying on the floor to the left side of bed. At 10:05 AM, when asked where a foley catheter drainage bag was placed when a resident was in bed or up in a chair, Staff E, Infection Preventionist and RN, said it should be hooked under the bed and if in a wheelchair hung under the chair. Staff E said the catheter bag should never be lying on the floor. When asked about Resident 1's foley catheter drainage bag lying on the floor, Staff E shook her head, was observed picking up the foley catheter bag and hung it off the side of Resident 1's bed, and stated, Yes. That should be hanging off the bed. At 3:25 PM, Staff B said it was his expectation foley catheter drainage bags should be hanging on the bed or the wheelchair. Not on the floor. Reference WAC 388-97-1060 (3)(c) Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (foley catheter, a flexible tube inserted into the bladder to drain urine into a drainage bag), received appropriate care and services to minimize the risk of associated urinary infections for 4 of 5 sampled residents (10, 36, 24 & 1), and failed to ensure hand hygiene and glove changes were performed when indicated in the kitchen during tray line service by 1 of 3 sampled kitchen staff (Staff 0) reviewed for infection prevention and control. These failures placed the residents at risk for infections, medical complications and a diminished quality of life. Findings included <Hand Hygiene> On 07/19/2023 at 11:34 AM, Staff O, Dietary Cook, was observed preparing the lunch meal. No hand hygiene was observed when Staff O started prepping the meal. Staff O was observed gathering items needed for the meal with her bare hands. At 11:40 AM, Staff O was observed ready to serve the lunch meal. Staff O placed gloves on her hands without washing her hands. Staff O continued to serve the meal. At 12:24 PM, Staff O removed her gloves and placed new gloves without washing her hands. At 2:30 PM, Staff O said she washed her hands prior to the lunch meal. Staff O said she touched things before putting on gloves. Staff O said there were times she did not wash her hands before and after removing gloves during the meal service. Staff O said she tried to wash her hands as much as possible. At 2:39 PM, Staff N, Dietary Manager, said she would expect staff to wash hands before and after removing gloves. On 07/21/2023 at 10:49 AM, Staff E, Infection Preventionist and Registered Nurse (RN), said she would expect dietary staff to wash their hands before and after glove use. <Urinary Catheter> 1) Resident 10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 07/18/2023, documented the resident had moderate cognitive impairment, and required the use of an indwelling urinary catheter. Resident 10's urinary care plan, dated 05/23/2023, documented Resident 10 required a foley catheter for retention issues. An intervention documented catheter care would be performed according to facility protocol. On 07/20/2023 at 12:50 PM, Resident 10 was observed sitting in bed eating lunch. The resident's indwelling urinary catheter bag was observed on the floor. At 3:04 PM, after observing Resident 10's catheter bag on the floor, Staff J, Registered Nurse (RN), said Resident 10's catheter bag should not be on the floor. On 07/21/2023 at 9:30 AM, Resident 10 was observed laying in bed. The resident's indwelling urinary catheter bag was observed on the floor. At 10:49 AM, Staff E, Infection Preventionist and RN, said catheter bags should not be on the floor. At 11:58 AM, Staff B, Director of Nursing Services and RN, said he expected staff to follow the proper catheter care techniques.