How many inspection deficiencies does CLARKSTON HEALTH AND REHAB OF CASCADIA have?

CLARKSTON HEALTH AND REHAB OF CASCADIA has 53 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at CLARKSTON HEALTH AND REHAB OF CASCADIA?

CLARKSTON HEALTH AND REHAB OF CASCADIA has a four-star staffing rating from CMS with 1.19 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CLARKSTON HEALTH AND REHAB OF CASCADIA located?

CLARKSTON HEALTH AND REHAB OF CASCADIA is located in CLARKSTON, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CLARKSTON HEALTH AND REHAB OF CASCADIA have?

CLARKSTON HEALTH AND REHAB OF CASCADIA has 90 certified beds.

Who owns CLARKSTON HEALTH AND REHAB OF CASCADIA?

CLARKSTON HEALTH AND REHAB OF CASCADIA is a for profit - partnership facility and is part of the CASCADIA HEALTHCARE chain.

CLARKSTON HEALTH AND REHAB OF CASCADIA

Name: CLARKSTON HEALTH AND REHAB OF CASCADIA
Address: 1242 ELEVENTH STREET, CLARKSTON, WA, 99403, US
Telephone: (509) 758-2523
Rating: 3.0

1242 ELEVENTH STREET, CLARKSTON, WA 99403 · (509) 758-2523

For profit - Partnership 90 Beds CASCADIA HEALTHCARE Data: November 2025

Trust Grade

45/100

#99 of 190 in WA

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Last Inspection: January 2024

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

Overview

Clarkston Health and Rehab of Cascadia has a Trust Grade of D, indicating below-average quality with some concerns. It ranks #99 out of 190 nursing homes in Washington, placing it in the bottom half, but is the only facility in Asotin County. The facility is showing improvement, with issues decreasing from 22 in 2024 to just 1 in 2025. Staffing is a strength, with a rating of 4 out of 5 stars and a turnover rate of 31%, significantly lower than the state average. However, the facility has faced serious issues, such as failing to monitor anticoagulant medication side effects, leading to a resident's re-hospitalization, and inadequate pain management for another resident, resulting in actual harm. Despite these weaknesses, the facility offers good RN coverage, exceeding 94% of state facilities, which can help catch potential problems.

Trust Score: D
In Washington: #99/190
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 31% turnover. Near Washington's 48% average. Typical for the industry.
Penalties: $32,711 in fines. Lower than most Washington facilities. Relatively clean record.
Skilled Nurses: Each resident gets 71 minutes of Registered Nurse (RN) attention daily — more than 97% of Washington nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 53 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 22 issues

2025: 1 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (31%)
17 points below Washington average of 48%

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

The Bad

3-Star Overall Rating

Near Washington average (3.2)

Meets federal standards, typical of most facilities

Staff Turnover: 31%

15pts below Washington avg (46%)

Typical for the industry

Federal Fines: $32,711

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: CASCADIA HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 53 deficiencies on record

2 actual harm

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) was properly monitored to ensure it was functioning for 2 of 2 sampled residents (Residents 1 & 3), reviewed for urinary catheters. This failure placed the residents at risk for complications, prolonged therapy, and unmet care needs. Findings included . Review of a facility's policy titled, Indwelling Catheters, revised 04/12/2022, showed if an indwelling catheter was in use, the facility provided appropriate care for the catheter in accordance with current professional standards of practice and staff were to monitor for changes in condition related to potential catheter-associated urinary tract infections. <Resident 1> Review of the admission assessment dated [DATE] showed Resident 1 was admitted to the facility with multiple diagnoses to include neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem) and urinary tract infection (UTI). In addition, the resident was able to make their needs known, was dependent on staff assistance with activities of daily living, and had an indwelling urinary catheter. Review of Resident 1's care plan initiated 01/07/2025 showed the resident had an indwelling urinary catheter related to neuromuscular dysfunction (lack of control of muscles). Interventions included for nursing staff to empty the catheter bag every shift. Additional interventions were for LNs to monitor and document for signs and symptoms of pain, blood-tinged urine, cloudiness, no output deepening of urine, foul smelling urine, and change in behavior. Review of Resident 1's treatment administration record (TAR) for March 2025 showed staff were to measure and record urinary output every shift (twice daily). Further review showed in March 2025 staff did not document urinary output on 21 of 62 opportunities. Additionally, on 03/05/2025, 03/06/2025, 03/12/2025, and 03/21/2025 the resident's urinary output was documented at less than 30ml (milliliter; unit of measurement) per hour. Review of the March 2025 progress notes showed no corresponding note on 03/21/2025 showing assessment of the low output and/or notification to the medial provider of a change in the resident's condition. A progress note the following day, 03/22/2025, showed the resident's bedsheets were soiled with urine, the urinary catheter was leaking, the resident's abdomen was firm and distended, and the resident reported they had pressure in their abdomen and perineal area (the area between the anus and genitals) since the previous day. The urinary catheter was replaced and the new catheter drained 1700ml within 25 min, after which the resident reported relief of the pressure sensation, and the abdomen was no longer hard and distended. Review of the April 2025 TAR for Resident 1 showed staff did not document urinary output on 2 of 14 opportunities. Additionally, on 04/01/2025 the resident's urinary output was documented at less than 30ml per hour. Review of the April 2025 progress notes showed no corresponding note on 04/01/2025 showing assessment of the low output and/or notification to the medial provider of a change in the resident's condition. A progress note the following day, 04/02/2025, showed the resident had a change in condition and was sent to the hospital. Observation on 04/15/2025 at 11:40 AM showed Resident 1 was sitting up in their wheelchair in their room with their urinary catheter attached to the lower portion of their wheelchair. The resident stated they had experienced multiple urinary tract infections while at the facility and that they did not feel staff responded timely when they reported concerns with their urinary catheter. Resident 1 stated before they were hospitalized on [DATE] they had reported concerns with their urinary catheter but staff did not respond until the day they were sent out. The resident stated they were diagnosed with a UTI when they arrived at the hospital. In an interview on 04/15/2025 at 1:53 PM Staff E, Licensed Practical Nurse, stated nursing assistants (NA) were responsible for routine urinary catheter care and nurses would assess the catheter if the NA or resident reported changes or concerns. Staff E stated on 04/01/2025 Resident 1 reported they were feeling unwell and the resident appeared flushed (red and hot skin as the result of illness or strong emotion) and they requested the next shift to monitor the resident. Per Staff E, the resident's condition worsened and the resident was sent to the hospital the following day where they were diagnosed with a urinary tract infection. Staff E stated the resident had frequent UTIs and were at risk for UTIs but their urine appeared clear on 04/01/2025 so no diagnostic testing of the urine was done prior to their hospitalization. In an interview at 4:36 PM the same day, Staff D, Resident Care Manager, stated urinary output was not measured on all residents, but if it was, the interdisciplinary team (IDT; group of medical professionals of various disciplines) monitored to ensure staff completed the required documentation. Staff D reviewed Resident 1's physician orders and TAR and confirmed there were many missing entries of the resident's urinary output. Staff D stated many of the staff in the facility were from an outside agency and did not always complete required documentation. During an interview on 04/15/2025 at 5:00 PM, Staff B, Director of Nursing, stated urinary output was only measured on residents with a physician's order for monitoring as most of the residents in the facility had stable urinary statuses. Staff D confirmed Resident 1 had orders for measuring urinary output as their urinary status was complicated and further stated the facility was working on a referral to a urologist (doctor who specializes in kidney/urinary care) prior to their hospitalization. Staff D stated they were aware of concerns with tracking urinary output due to both the use of agency staff and confusion amongst staff of which residents were or were not to have their urinary output measured. <Resident 3> Review of the admission assessment dated [DATE] showed Resident 3 was admitted to the facility with multiple diagnoses to include obstructive uropathy (bloackage that prevents urine from flowing normally through the urinary system. In addition, the resident was able to make their needs known, required substantial staff assistance with activities of daily living, and had an indwelling urinary catheter. Review of Resident 3's treatment administration record (TAR) for March 2025 showed staff were to measure and record urinary output every shift (twice daily). Further review showed in March 2025 staff did not document urinary output on 21 of 62 opportunities. Additionally, on 03/01/2025, 03/03/2025, 03/18/2025, and 03/27/2025 the resident's urinary output was documented at less than 30ml (milliliter; unit of measurement) per hour. Review of the March 2025 nursing progress notes for Resident 3 showed no corresponding note on 03/18/2025 showing assessment of the low output and/or notification to the medial provider of a change in the resident's condition. A progress note dated 03/27/2025 showed the resident's urinary catheter was in place and draining yellow urine with sediment, but no assessment of the low output and/or notification to the medical provider was found. Review of the April 2025 TAR for Resident 3 showed staff did not document urinary output on 6 of 28 opportunities. Additionally, on 04/05/2025 the resident's urinary output was documented at less than 30ml per hour. Review of the April 2025 nursing progress notes for Resident 3 showed no corresponding note on 04/05/2025 showing assessment of the low urinary output and/or notification to the medial provider of a change in the resident's condition. In an interview on 04/151/2025 at 4:36 PM, Staff D reviewed Resident 3's physician orders and TAR and confirmed there were missing entries of the resident's urinary output. At 5:00 PM the same day Staff B stated the facility was aware of concerns related to staff measuring and recording urinary outputs on residents with orders that specified to monitor output amounts. Reference WAC 388-97-1060(3)(c)

Nov 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting allegations of abuse to the State Agency (SA) within the required timeframe and completing thorough investigations for 1 of 3 sampled residents (Resident 1), reviewed for abuse/misappropriation. This failure placed the resident and other residents at risk for abuse/misappropriation. Findings included . Review of the facility's policy titled Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin, revised 08/01/2023, showed staff were to report any form of alleged abuse to the SA immediately, but not later than two hours after the allegation is made if abuse was alleged and there was serious bodily injury. All other allegations were to be reported within 24 hours. Additionally, the facility would investigate the allegation and document evidence of the investigation. Review of the September and October 2024 facility incident logs showed no reported incidents for Resident 1. Review of the October 2024 Medication Administration Record showed Resident 1 had an order for a narcotic pain medication, hydrocodone-acetaminophen, to be given every 6 hours as needed. The resident could take 1 tablet for mild to moderate pain and 2 tablets for moderate to severe pain. In an interview on 11/01/2024 at 12:28 PM Resident 1 stated they took narcotic pain medications to treat their pain and on several occasions when Staff E, Licensed Practical Nurse, administered their medications they tasted differently and did not treat their pain effectively. Resident 1 stated on 10/08/2024 when Staff E administered their narcotic pain medications, they did not swallow the medications and instead spit them out after the staff member left the room. The resident stated they showed the nurse on the next shift, Staff D, Registered Nurse, the two pills they spit out and reported that one of the pills was not their prescribed medication. In an interview at 3:34 PM the same day Staff D confirmed Resident 1 reported to them that Staff E was giving them a medication they were not prescribed when they were documenting that they were administering the resident's narcotic pain medication. Staff D stated they asked the resident to keep monitoring the situation and then on 10/08/2024 the resident showed them two pills that were not the same at the beginning of their shift following Staff E. Staff D stated they reported the incident to Staff B, Assistant Director of Nursing, on 10/08/2024 and believed the facility administration had investigated and reported to the SA as required. At 4:40 PM the same day Staff B, Assistant Director of Nursing, confirmed Staff D reported the incident on 10/08/2024 to them and they immediately went to interview the resident. Staff B stated Resident 1 alleged Staff E was giving them an over-the-counter medication they were not prescribed instead of their prescribed narcotic pain medication. Staff B confirmed the resident reported misappropriation of their narcotic pain medication and stated they reported the concern to Staff A, Director of Nursing, who was responsible for investigating and reporting allegations of abuse/misappropriation. In an interview on 11/01/2024 at 4:51 PM Staff A stated they were aware of the report from 10/08/2024, though they were not aware the resident had reported it was a repeatedly ongoing issue. Staff A stated they did investigate the incident and did not substantiate abuse, but the investigation was undocumented, and they were unable to provide evidence of a completed investigation. Staff A stated because the investigation showed the allegation was not substantiated, the resident's allegation was not reported. Reference WAC 388-97-0640(2)

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), reviewed for medication administration, received medications appropriately, in accordance with the physician's order. This failure resulted in a pattern of significant medication errors which placed the resident at risk for medical decline, discomfort, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Errors, revised 08/01/2024, showed a medication error occurred when a medication was not administered in accordance with the prescriber's orders. Review of the September 2024 Medication Administration Record (MAR) showed Resident 1 had an order for a narcotic pain medication, hydrocodone-acetaminophen, to be given every 6 hours as needed. The resident could take 1 tablet for mild to moderate pain and 2 tablets for moderate to severe pain. The order included instructions not to administer more than four tablets every 24 hours. Further review showed the resident was administered more than 4 tablets on 15 occasions: 09/07/2024, 09/09/2024, 09/11/2024, 09/14/2024, 09/15/2024, 09/16/2024, 09/17/2024, 09/18/2024, 09/19/2024, 09/20/2024, 09/22/2024, 09/23/2024, 09/24/2024, 09/25/2024, and 09/27/2024. Review of the October 2024 MAR showed the resident received more than four tablets of their hydrocodone-acetaminophen in a 24-hour period on an additional four occasions: 10/07/2024, 10/17/2024, 10/18/2024, and 10/21/2024. In an interview on 11/01/2024 at 1:11 PM Staff F, Licensed Practical Nurse, stated Resident 1 would intermittently request medication for pain in their legs, hydrocodone-acetaminophen one or two tablets as needed. Staff F did not include the listed medication parameters of only four tablets in a 24-hour period. Staff F stated the resident's pain medication needed to be changed to something that did not affect the liver due to elevated liver enzymes identified on a recent laboratory report. In an interview at 4:51 PM the same day, Staff A, Director of Nursing, stated the entire nursing team was responsible for double checking that medications with parameters/restrictions on administration were administered correctly. Staff A stated Staff C, Resident Care Manager, reviewed a medication administration report daily. In an interview at 5:12 PM the same day, Staff C stated they were the nurse manager responsible for overseeing Resident 1's care. Staff C stated they were not aware of the special instructions not to exceed four tablets in 24 hours on Resident 1's pain medication because they did not administer the medications. Staff C stated the pharmacy also reviewed resident's medication regimens and made reports to Staff A. At 5:27 PM pharmacy audits for Resident 1 were requested; none were provided. Reference: (WAC) 388-97-1060 (3)(k)(iii)

Oct 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1) reviewed for dental services received adequate pain management and timely dental services for an impacted wisdom tooth and abscess. This failure placed residents at increased risk of pain, unmet dental needs, and a diminished quality of life. Findings included . Review of an 11/28/2017 facility policy titled Dental Services showed the facility provided the assistance needed or requested to obtain dental services and if a referral did not occur within 3 business days, the facility would ensure the resident would drink and eat adequately while awaiting dental services. The policy defined emergency dental services as services needed to treat an episode of acute pain in teeth, gums, or palate, broken or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. <Resident 1> Review of a 09/17/2024 assessment showed Resident 1 re-admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 1 had moderate cognitive impairment and had no oral or dental issues. Review of a 06/24/2024 progress note showed Resident 1 told the staff that they felt like they had an abscess to their upper gum area where one of [the Resident's] teeth were removed. Upon inspection, the area is slightly red and swollen. The resident reported to the staff that it was painful and would like to have an order for a dental appointment, as well as something for the pain besides Tylenol as needed. The staff gave the resident Orajel, an over-the-counter topical gel analgesic, the resident applied it to their gumline. Progress notes showed the facility medical provider (Provider) referred the resident to a dentist on 06/25/2024 . On 06/26/2024 the provider assessed Resident 1's mouth related to redness, swelling along with c/o [complaints of] pain. The provider prescribed an antibiotic twice a day for 10 days for the diagnosis of periodontal abscess (pocket of infection that forms in the gums and the associated pain can be severe, constant, throbbing, can spread to the jawbone, neck or ear, and cause pain or discomfort with the pressure of chewing or biting). Review of the June 2024 Medication Administration Record (MAR) showed no documention of non-pharmacological interventions. Review of a 07/05/2024 progress note, 10 days after the facility received an order to refer Resident 1 to a dentist, showed the resident told the staff that they felt the tooth abscess is not getting better. There was no documentation to show the staff updated the provider of the resident's oral status, to include an assessment of the mouth. Review of a 07/08/2024 progress note showed Resident 1 requested of the staff to get an order to apply Oragel to possible dental abscess site until resident is seen by dentist. The 07/09/2024 progress note showed the provider agreed to the Oragel [sic] application up to four times a day. Record review showed no [Oragel] orders were scheduled routinely or as needed in the July 2024 MAR. Review of the July 2024 Medication Administration Record (MAR) showed no documention of non-pharmacological interventions. Review of a 07/09/2024 progress note, 14 days after the facility received an order to refer Resident 1 to a dentist, showed the resident complained of bleeding to the right upper gum and wants to see provider about this, also requesting to see the Dentist. The note showed the nurse already informed the resident they had an appointment in August. The nurse assessed Resident 1's mouth, saw no bleeding but confirmed dry blood around the lips, and provided [the resident] a washcloth. Review of the medical record showed the provider responded the following day on 07/10/2024 with a second request for a dentist referral. Review of the medical record showed Resident 1 was seen at the dentist office on 07/12/2024. The 07/12/2024 dental clinic notes showed the resident required oral surgery due to a partially erupting and impacted wisdom tooth. The dental clinic prescribed another antibiotic and a prescription mouthwash. Review of a 07/19/2024 progress note showed Resident 1 requested stronger pain medication than the as needed Tylenol. The staff described the pain was related to the resident's tooth, caused moderate pain, and that Resident 1 stated that the pain is worse than what Tylenol can manage. The staff informed the provider and requested a stronger analgesic. Review of the July 2024 MAR showed staff did not deliver non-pharmacological interventions to help manage Resident 1's oral/dental pain. Record review showed no Orajel orders were scheduled routinely or as needed in the July 2024 MAR. Review of the medical record showed that on 07/23/2024, four days after the nurse notified the provider of Resident 1's need for stronger pain medication due to dental pain, the facility received an order from the provider for a stronger analgesic and the instruction to, Patient needs to follow up with dentist if having this much pain. In an interview on 10/04/2024 at 11:21 AM, Staff A, Director of Nursing, was asked when they expect a complaint of unrelieved pain to be addressed. Staff A stated, It was addressed originally with the Oragel. This is just a continuation of the same situation. The nurses assessed the resident, and they notified the provider right away. I'm not a provider so I can't say what that process looks like. Staff A acknowledged that a response time of 4 days to address increased pain, seems a little longer than it normally takes but I don't know the reason for that. Review of a 07/26/2024 progress note showed staff assessed Resident 1 who was experiencing increased swelling to their gums, and Resident 1 was seen by the provider in the morning who prescribed an antibiotic for 10 days. Review of the 07/26/2024 associated provider notes showed the resident was seen for Tooth concerns, that the resident is scheduled with oral surgery in September, and had a left upper gum abscess present today. Review of a 07/27/2024 progress note showed that staff assessed Resident 1 had a 1cm [centimeter, a unit of measurement] x 1cm palpable mass to upper right jaw. Record review showed no documentation the staff notified the provider of this finding. No documentation was provided by the facility when requested on 10/04/2024 at 11:28 AM. Review of 07/29/2024 progress notes showed, Resident 1 stated the pain comes and goes. Another later note dated 07/29/2024 showed Resident 1 complained their jaw is painful at this time, instead of just the gumline area. Left side of face is possibly slightly swollen, though difficult to discern due to [their] beard. PRN [as needed] Tramadol ( Pain medication) is partially effective. Record review showed no documentation of how the staff addressed the partially effective analgesic. Review of a 07/30/2024 progress note, 38 days after Resident 1's initial dental complaints, showed a detailed account where a nurse notified the provider and informed them that Resident 1, has ongoing left upper palate, gumline and now jaw pain from an impacted wisdom tooth. [The resident] is receiving [analgesic], which is only partially effective. Background/Data: Impacted left upper wisdom tooth; he has an appointment for excision, but it is not until sometime in September. The nurse told the provider that the resident's level of pain is approximately 5-6, or moderate, that the frequency of the analgesic is every 6 hours as needed, and that the resident seemed, to be having end-dose failure (medication wears off before the next analgesic dose is due) after about 3 or 4 hours. Additionally, the nurse informed the provider that Resident 1's left side of the face is becoming swollen, and the resident began to ask for soft foods only, to minimize irritation. The nurse asked the provider to consider increasing the frequency or the dose of the analgesic being considered, or both. The nurse suggested that possibly a different narcotic analgesic may be more helpful. The nurse ended the communication with the provider by stating that they and the resident are concerned that [the resident] is going to have to wait at least another month before being able to have the tooth taken out. The following day the provider answered, Please notify dentist of situation. Record review showed no documentation the facility followed through with the provider's order to notify the dentist or address Resident's 1 oral/dental pain. On 10/04/2024 at 11:35 AM, Staff A was asked if the facility coordinated the dentist referral or considered other treatment option. Staff A stated, We got his dental appointment bumped up to August 16 [2024]. Review of an 08/04/2024 progress note showed Resident 1 asked about the follow-up appointment with the dentist and that the Resident complained of pain, tenderness, reports oral pain medication not effective. An 08/05/2024 progress note showed that even though the resident completed their course of antibiotics, The swelling and pain from tooth abscess [sic] does not appear have gotten any better. This note showed the staff asked the provider if a stronger antibiotic should be considered to prepare for their upcoming appointment with the dentist. Review of a 08/05/2024 progress note showed Resident 1 continued to complain of upper left gumline and jaw pain. An 08/06/2024 progress note showed the resident still complaints [sic] pain to area. Review of an 08/07/2024 progress note showed the staff received a signed note by the provider, two days after the staff notified the provider of Resident 1's ineffective dental pain management, that showed, Need to call dentist office to see what they recommend. The nurse called the dental clinic, and an appointment was scheduled for Resident 1 on 08/08/2024. Review of an 08/09/2024 progress note, 46 days after Resident 1's initial dental complaints, showed the dental clinic requested of Resident 1 to complete a Release of Information form. Review of an 08/09/2024 provider note showed Resident 1 was seen for pain - 2 week follow up. The note showed the provider assessed Resident 1 continues with increased pain and that the facility was trying to get an appointment with the dental clinic moved up. The provider assessed Resident 1 experienced pain 8 out of 10 today [or severe] and that, we will continue to monitor this area for further concerns. Review of an 08/14/2024 progress note showed the staff notified the dental clinic that the oral surgeon's appointment was canceled due to the resident's insurance not being accepted. The nurse requested an oral surgeon referral to a city two-plus hours away by car. Additionally, the nurse notified the provider that Resident 1 continued to, have increased pain and swelling to left side of face. Area is also noted to be very firm. The provider gave an order four days later, on 08/18/2024, for an antibiotic for 30 days and a narcotic analgesic. Review of an 08/21/2024 provider note showed Resident 1was seen for chronic conditions review, and assessed the resident as stable on treatment interventions, no changes needed at this time, no concerns at this time per patient or nursing staff, and Referral in place to oral surgeon - scheduled in September. Review of an 08/25/2024 progress note showed the staff assessed Resident 1 had a small abscess area to right upper jaw still palpable externally and hardened nodule felt left upper jaw. A week later, on 09/01/2024, the staff documented that Resident 1's, Tooth abscess has grown. That the prior week the nurse could feel the mass to the upper left jaw, measuring about 1 cm x 1 cm, but now was 2cm x 2cm and visible. The nurse went to describe, Left cheek is notably swollen and warm to touch. The affected area on gums is creamy/yellow. Surrounding gum tissue is swollen and red. The nurse wrote that the Orajel was administered twice on their shift with somewhat effective results. Resident states it takes the pain away enough to be tolerable. Resident states narcotic pain medication does not alleviate [their] tooth pain at all. Record review showed no documentation the staff notified the provider of the new or worsening oral/dental symptoms. Review of a 09/08/2024 progress note showed Resident 1 continued to complain to the staff about abscess to upper left jaw. The staff described the abscess grew to a palpable size of 4cm x 8cm, extending clear back to [the resident's] left ear'. The nurse informed the provider of these findings. No instructions were received by the staff to address the growing abscess. A subsequent note showed Resident 1 reported to the staff a pain level of 10, the most severe pain level on a scale of 1 to 10, and discomfort to tooth abscess. The resident informed the staff that the as needed narcotic analgesic does not alleviate pain at all. Expresses frustrations in not being able to eat because of [their] pain, and that the Oragel [sic] to affected area with ineffective results. The notes showed the provider was to see the resident in person this week per the Medical Director. Staff A acknowledged that a change in the treatment plan to address the resident's severe oral/dental pain and a growing abscess was not evident in the medical record. Review of a 09/10/2024 provider notes showed the provider saw Resident 1 for Chronic wound. A 09/20/2024 progress note showed the staff notified the provider that Resident 1 experienced shooting pains in their mouth and developed four new sores inside his mouth. The staff requested of the provider to, please evaluate for recommendations. A 09/24/2024 follow-up provider note showed the provider responded four days later and asked the facility if the resident had a follow-up with the oral surgeon and instructed the staff to follow-up with current dentist. Review of 09/22/2024 progress note showed Resident 1 experienced a significant change in condition and was transferred to the hospital. Review of a 09/30/2024 hospital discharge summary showed diagnostics identified a large erosive mass involving the left aspect of the head and neck with metastatic adenopathy [condition that occurs when cancer cells spread from a tumor to the lymph nodes, causing the lymph nodes to swell]. Reference WAC 388-97-1060 (3)(j)(vii).

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the Resident Representative (RR) of changes to the resident's weight, treatments, wound status, medication changes, refusals of treatments, and changes in condition for one (1) of 4 residents reviewed for the right to be informed of care for a span of five months. This failure precluded the RR from the opportunity to contribute to help Resident 1 make an informed decision related to medication and treatment changes and move forward with the treatment options being proposed. Findings included . Review of an 11/28/2017 facility policy titled Resident Change in Condition, described a change in condition as a change from the resident's normal status or whenever there was a change in the resident's medical condition. Some of the examples of a change in condition included, new or increasing confusion, newly identified incontinence, weight loss of more than 5 % (percent) of body weight, behavior changes, and potentially life-threatening conditions due to a change in the resident's chronic disease and medical condition. The policy instructed the staff to notify the resident representative (consistent with their authority), family member, or responsible party, when there was a significant change or a deterioration in the resident's physical, mental or psychosocial status in health, life-threatening conditions or clinical complications, a need to change treatment significantly, the decision to transfer the resident from the facility, and/or when there is a change in room or roommate assignment. Additionally, the policy instructed the staff to document in the resident's medical record all attempts to notify the resident's family member or responsible party of the change in condition. <Resident 1> Review of a 09/17/2024 assessment showed Resident 1 re-admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 1 had moderate cognitive impairment and the family participated in the assessment and goal setting. Record review showed the resident admitted to the facility with a chronic wound and a history of falls. Review of the medical record showed Resident 1 had two designated Power-of-Attorneys (POA) for health care decision-making. A POA has the privilege, in the event of an unfortunate medical condition, to make health-related decisions for the resident. The medical record also showed designated Emergency Contacts and in what order staff should contact them, like Emergency Contact # [number] 1. Review of the medical record also showed physician orders that read, Patient is aware of patient's medical condition(s), Resident is capable of making his/her own health decisions, and Resident is incapable of making his/her own health decisions. Record review showed supporting POA documents were available to the staff in the electronic medical record since on 04/02/2024. A 04/02/2024 progress note showed the resident, has family for support and that their son is POA and a source of support to [the resident]. Review of the progress notes showed Resident 1 experienced events that met the definition of a change in condition, but no documentation to show the staff notified the RR as instructed: 04/12/2024 - Resident lethargic and very confused. awaiting lab results. will place note in Provider's box for review and Received signed lab results from [provider]. Received orders for referral to nephrology [kidney specialist]. 04/25/2024 - Rec'd [Received] call from infectious disease stating resident's WBC's [white blood cell count] are low and gave the following new orders to discontinue one antibiotic and start another. 04/26/2024 - Resident came out of room with visible 2cm [centimeter - a unit of measurement] x 2cm bump to his right eye brown [sic]. Purple bruising already present and Lung have rhonchi [wheezing breaths] throughout . Due to change in respiratory assessment and new injury to eyebrow, Dr. [NAME] was notified. RN [Registered Nurse] advised to start neuro [neurological] checks to monitor patient and put an order in for the AM [morning] for a 2-view chest xray. 5/17/2024 - RT [Resident] tested positive for COVID at this time 06/06/2024 - Provider reviewed pharmacy recommendation to discontinue sliding scale (insulin dose based on your blood sugar level just before your meal), order signed and discontinued by provider. 06/06/2024 - Review of a 06/07/2024 Notice of Room-to- Room Transfer showed no documentation the facility adequately informed Resident 1 or their representative. There were no resident or RR signatures, and page 2 of the notice was entirely blank. Page 2 required the date the notice was issued, the room Resident 1 was being transferred to, that they were informed of their rights to transfer, to include the rationale for the transfer. 06/17/2024 - The resident complained to the staff of left ring finger pain and that it had been hurting for two weeks. the resident requested an xray. On 06/19/2924, the staff, Received new orders from provider for X-ray to L hand r/t [related to] pain. X-ray tech [technician] here now to do exam. X-ray results back, conclusion possible avulsion [a bone fragment is pulled away from its main body by soft tissue that is attached to it] fx [fracture] of base of the L 4th proximal [finger]. Placed in provider box for review. Resident stated to this LN [Licensed Nurse] finger has been this way for over a month and a half. 06/24/2024 - Resident 1 told the staff they felt like, an abscess on [their] upper gum area where one of [their] teeth were removed. Upon inspection, the area is slightly red and swollen. [Resident] said it is painful and would like to have an order for a dental appt [appointment] as well as something for the pain besides prn [as needed] Tylenol. 06/26/2024 - Provider in and assessed Resident 1's mouth due to redness, swelling along with c/o [complaints of] pain. New order received for [antibiotic twice a day for 10 days] r/t peridontal [sic] abscess [a pocket of infection that starts in your gums]. 07/12/2024 - The progress note showed the Resident 1 returned from the dental clinic who referred the resident to an oral surgeon for impacted wisdom teeth and extraction was recommended. The resident was prescribed antibiotics and a prescription mouthwash. 07/22/2024 - Orders received by the staff for stronger analgesics and another dentist referral secondary to Resident 1's complaints of pain. 07/26/2024 - Resident gum swelling increased, seen by Dr. [NAME] this [morning] who gives the following new order: [antibiotic twice a day for 10 days]. 07/27/2024 - The staff identified Resident 1 had a 1cm x 1cm palpable mass to upper right jaw. 08/14/2024 - Resident continues to have increased pain and swelling to left side of face. Area is also noted to be very firm and orders for antibiotics for 30 days and a narcotic analgesic were received. 09/01/2024 - Tooth abscess has grown. Last week this RN could palpate mass to upper left jaw, measuring about 1 cm x 1 cm. It now is felt on his face measuring 2cm x 2cm and is visible and, Left cheek is notably swollen and warm to touch. The affected area on gums is creamy/yellow. Surrounding gum tissue is swollen and red. 09/04/2024 - Resident with new orders to continue antibiotic and an additional antibiotic was added by the Infectious Disease clinic. Review of the progress notes showed that on 09/06/2024, the facility received a call from Resident 1's RR who expressed concern that he was not being kept up and informed on resident's condition, new orders, especially related to resident's left foot lesion and the plan to resolve the infection in it. This author apologized to [them] for the lack of communication and stated would inform nursing staff to remember to contact [the POA] for any changes, new orders, etc.[etcetera]. Short discussion regarding resident's new antibiotic orders, upcoming repeat [lab work], and the consideration for IV [intravenous - by vein] antibiotics. Record review showed no documentation the facility informed or updated the RR of the oral/dental status/concerns. 09/08/2024 - The progress notes showed the resident continued to complain about the abscess to the upper left jaw and staff described a palpable area measured the previous week to be at 4cm diameter, now increased in size to 4cm x 8cm, extending clear back to [the resident's] left ear and red, scabbed rash to both arms and legs. The notes also showed they assessed Resident 1's left foot wound with increased drainage that required additional dressing changes and with redness that spread to the top of the foot. The drainage was described as copious. While the staff notified the provider, who in turn gave treatment orders, it showed no documentation the staff informed the RR. 09/9/2024 - The progress note showed a chronology of events about the abscess to the resident's upper left jaw, completed/pending/incomplete dental appointments and referral to an oral surgeon. It showed no documentation the facility shared this information with the RR. Review of 09/10/2024 and 09/18/2024 provider notes showed the staff acknowledged Resident 1 was chronically refusing their dressing changes to the left foot wound to include becoming combative with staff at times and not allowing the staff to change the dressings. It showed no documentation the facility shared this information with the RR. 09/20/2024 - The nurses reported to the provider that Resident 1 stated that they experienced shooting pains in their mouth and also has four new sores. 09/21/2024 - The progress note showed the staff assessed Resident 1 had, Foul smelling, copious amount of drainage to the foot wound. The staff described the entire foot is macerated and raw with thick layers of dead skin. Open area is measuring 5 x 5 cm, center is dark purple. Patient has redness and warmth extending 6 inches up calf. 09/22/2024 - Staff reported, episodes of confusion over the last 2-3 days. Patient frequently taking [their] pants off and urinating on the floor and that Resident 1 acted like they didn't know how to put [their] pants back on. Review of the medical record showed Resident 1 weighed 283 # (pounds) on 03/29/2024. The record showed that on 04/28/2024, the resident experienced a loss of 14 pounds (268.2), a significant weight loss of 5.23% in a 30-day period. On 07/01/2024, the resident weighed 259.2, or a significant weight loss in 90 days of 8.41%. On 9/30/2024, Resident 1 weighed 235 pounds, or a 16.96% significant weight loss at 180 days. Resident 1 lost 48 pounds in six months. Record review showed no documentation the staff informed Resident 1's representative of the continued and significant weight loss or plans to address it. In an interview on 10/03/2024 at 12:35 PM, the POA stated that when Resident 1 was in room [ROOM NUMBER], one of the staff told them, They did not know the resident had a POA or a medical proxy. The POA stated that the staff did not inform them of Resident 1's changes in mentation, referral to specialists, refusal of cares, medication changes, bruise and bump to the right eyebrow, a possible fracture to the left fourth finger, or status of the wound throughout the resident's stay, until they called to complain to the facility about the lack of communication early September. I had no knowledge of the dental issues until the Spokane appointment in September. I never heard of an oral surgeon. The POA stated that they never heard someone talking specifically about a significant weight loss. I've never had a conversation like that. The POA stated that when they brought up the lack of care concerns to the facility, the staff told them Resident 1 was refusing care and being disgruntled. They never contacted me about [the refusals]. They haven't been telling me [Resident 1] was argumentative or refusing. I am the POA, maybe they should have called me at least to let me know of any issues [Resident 1] has been giving them. The above information was shared with Staff A, Director of Nursing, on 10/4/2024 at 10:40 AM. Staff A stated, I agree to the communication [with the POA] was lacking and managed poorly and that the staff, Yes, should have called POA. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b). .

Jan 2024 16 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure investigations related to allegations of abuse/neglect were initiated, thorough, and completed timely for 2 of 2 sampled residents (1, 50), reviewed for abuse. These failures placed the residents at risk for repeated incidents and potential abuse. Findings included Review of the 08/01/2023 Freedom from Abuse, Neglect, and Exploitation facility policy showed allegations of abuse were to be reported to the CEO (Chief Executive Officer) or designee immediately and the state agency within 2 hours if there was alleged abuse or serious bodily injury as a result of an event, and within 24 hours if the event that caused the injury did not involve abuse or did not result in serious bodily injury. The policy also showed a thorough investigation of an alleged violation would be completed and would include conducting interviews and an assessment of the alleged victim as appropriate. The policy also showed the results of all investigations would be reported to the State agency in accordance with State and Federal law within 5 working days of the incident, and if substantiated, corrective action would be taken. <Resident 1> Per the 06/06/2023 admission assessment, Resident 1 was cognitively intact and able to make decisions regarding their care, and had diagnoses of severe vision loss in both eyes, and anxiety. In addition, the assessment showed the resident needed extensive assistance for mobility, such as standing, and moving from recliner to wheelchair. During an interview on 01/19/2024 at 11:36 AM when asked if they had experienced any negative interaction with other residents, Resident 1 stated there were multiple incidents with their previous roommate who was violent. Resident 1 stated on one occasion while they were sitting in their recliner, the roommate lifted the recliner by the footrest and wedged another piece of furniture under it which resulted in Resident 1 not being able to lower the footrest and get out of the recliner. They said on a separate occasion the roommate lifted the recliner chair by the footrest and tried to dump Resident 1 of out of it onto the floor. Resident 1 stated at times, their leg would be grabbed and squeezed hard by the roommate. Resident 1 also stated a cane had been held against their throat by their previous roommate They could not remember the date of the incidents and stated they occurred a couple of months ago. Review of the facility records showed these allegation of abuse were neither recorded in the Accident/Incident log nor the Grievance log. Review of Resident 1's record from 07/01/2023 through 01/26/2024 found no documentation or progress notes regarding these allegations of abuse with the exception of the following: - A progress note dated 08/16/2023 and marked late entry, by Staff F, Social Services, showed Social Services met with Resident 1 and they stated there had been a few incidents with their roommate coming to Resident's 1's side of the room, Resident 1 stated they felt safe and did not want to change rooms. - On 08/16/2023 a progress note from Staff B, Director of Nusring, stated per conversation with BOM (Business Office Manager) Resident 1's family member expressed that they spoke with Resident 1, and they did not wish to move rooms at that time. Voiced that Resident 1 felt safe within their room with their roommate. Neither progress note went into detail or provided any information regarding the incident. In an interview on 01/22/2024 at 10:18 AM with Staff B, DON, they stated they had not heard about Resident 1's allegation of their former roommate holding a cane against their throat. Review of the State incident tracking system, STARS (Secure Tracking and Reporting System), showed no report(s) made regarding these allegations until 01/22/2024 at 4:02 PM. In a follow up interview on 01/24/2024 at 3:23 PM Resident 1 repeated the allegation and stated, a cane was pressed against their throat by their previous roommate who held it with both hands and stood over them, until Resident 1 pushed them away, and when staff came into the room the roommate started waving the cane around. Resident 1 stated they told staff about the incident at the time but couldn'r remember who was told. Resident 1 stated Staff S, CRN (Clinical Resource Nurse) came and spoke to them the other day about the incident and had them sign a paper. Resident 1 stated they couldn't read the paper because they are totally blind and in the dark. They stated Staff S read it to them, and it sounded accurate to what they had said. Resident 1 stated they thought it mentioned a couple other incidents such as when the roommate had picked up their chair up by the footrest and lifted it while they were in it. They said it seemed like the roommate was trying to turn it over. When asked to clarify, Resident 1 stated the incident with the chair was a separate incident than what had occurred with the cane. Resident 1 knew the correct date for the day of this interview was Wednesday, and stated Staff S had talked to them on Sunday or Monday. In an interview on 01/24/2024 at 3:55PM, the surveyors read Resident 1 the statement Staff S had them sign. After hearing it, Resident 1 stated the part which read Resident 1 thought their former roommate was going to put the cane on their throat was inaccurate. Resident 1 stated they couldn't see the roommate to know or think what they were going to do until the cane was actually held against their throat by the roommate. Resident 1 was upset that the information recorded by Staff S inaccurate and that they were asked to and had signed it. In an interview on 01/23/2024 at 7:15 PM, Staff R, Registered Nurse, who was visibly upset, approached the surveyor, and stated in August 2023, Resident 1 had told them about having a cane pushed against their throat by their roommate and that they were afraid until the roommate fell asleep that night. Resident 1 also told Staff R, at the same time, their leg hurt because a week prior to that incident, the roommate picked it up and tweaked it, and Resident 1 stated they didn't tell anyone at the time because they thought no one would believe them. Staff R stated they immediately called and notified Staff B, who instructed them to write a statement, and to check Resident 1's leg. Staff R stated they thought Staff B would call it into the State hotline, and were told by either Staff B or Staff A, Administrator there would be an investigation. Staff R stated they were approached by Staff C, Resident Care Manager this evening and asked to sign a paper regarding the incident and was just now discovering the allegation hadn't been reported to the State. Staff R stated nothing was done about the allegation and they felt sick over it. Staff R stated they had just called the State hotline, prior to this interview, to report the incident. When Staff R was asked if they received training on being a mandatory reporter, they said training was done yearly via Relias (a provider of healthcare workforce education). <Resident 50> Per the 07/27/2023 admission assessment, showed Resident 50 was cognitively intact and able to make decisions regarding their care. In addition, the assessment showed the resident needed extensive assistance for activities of daily living, such as dressing and toileting. In an interview on 01/20/2024 at 7:31 AM, Resident 50 stated their former roommate, they couldn't remember their name, punched them in the face, they couldn't remember date it occurred, but thought it had been a month or two ago. Review of the facility records showed these allegations of abuse were not recorded in the Accident/Incident log. A reveiw of Resident 50's record from 07/21/2023 through 01/26/2024 found no documentation or progress notes regarding this allegation of abuse, nor was any documentation found to show the incident had been thoughly investigated. Review of the Grievance log showed an entry dated 11/30/2023 for Resident 50 requesting a room change. In an interview on 01/22/24 at 10:18 AM, Staff B stated Staff A investigated the allegation and ruled it out because Resident 50 stated their roommate didn't touch him, there was no physical contact, but the roommate was being verbally abusive to the staff and Resident 50 didn't like it. When Staff B was asked for the investigation, they stated it was only Staff A's statement, but they would provide it. In an interview on 01/22/2402 at 10:27 AM, Staff A stated they initially received report in a clinical meeting that Resident 50 had reported their roommate punched them in the face. Staff A stated they interviewed Resident 50 right away and ruled out abuse because Resident 50 denied being hit and stated they got mad and got into a verbal confrontation with their roommate and asked for a new roommate. Staff A stated Resident 50 was monitored for any signs or symptoms of trauma, and none was noted. Staff A provide the Grievance/Recognition Comment form which was dated 11/30/2023 and stated since abuse was ruled out immediately the incident was not called to that State Agency and the form was the only documenatation. Review of the Grievance/Recognition Comments form, dated 11/30/2023, provided by Staff A, showed Resident 50 felt their roommate was mean to staff and requested to either move to a different room or be assigned a new roommate. This is a repeat citation, please see the SOD dated 10/28/2022. Reference: WAC 388-97-0640 (6)(a)(b)(c)

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 50> According to admission assessment, dated 07/27/2023, Resident 50 was admitted on [DATE] with diagnoses which...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 50> According to admission assessment, dated 07/27/2023, Resident 50 was admitted on [DATE] with diagnoses which included anxiety, depression, psychotic disorder, and post-traumatic stress disorder (anxiety and flashbacks triggered by a traumatic event). Resident 50's Level I PASARR showed it was completed and signed by Staff F on 09/07/2023, 49 days after the resident's admission to the facility, and not prior to admission as required. Reference: WAC 388-97-1915 (1)(2)(a-c) Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions], was completed for 2 of 5 sampled residents (50, 55), reviewed for PASARR services. This failure placed the residents at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs. Findings included . <Resident 55> According to the 11/07/2023 quarterly assessment, Resident 55 was admitted on [DATE] with diagnoses which included dementia and received psychotropic medication, (medications that affect the mind, emotions, and behavior). Review of Resident 55s's Level I PASARR showed it was completed and signed by Staff F, Social Services, on 09/02/2023, 35 days after the resident's admission to the facility, and not prior to admission as required. In an interview on 01/24/2024 at 5:13 PM Staff F, stated PASARR's needed to be completed prior to admission. In an interview on 01/24/2024 at 5:42 PM, Staff B, Director of Nursing, stated the PASARR should have come with the resident from the hospital and if not, it needed to have been completed upon arrival.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 12> The 10/17/2023 quarterly assessement showed Resident 12 was dependent on staff for personal hygiene, such as...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 12> The 10/17/2023 quarterly assessement showed Resident 12 was dependent on staff for personal hygiene, such as oral care/brushing teeth. Resident 12's care plan dated 10/17/2019, directed nursing staff to assist the resident with personal hygiene and ensure their glasses were kept clean. During an observation on 01/18/2024 at 3:14 PM, Resident 12 was lying in bed, teeth were coated with food debris, and their glasses were unclean. Subsequent observations made on 01/21/2024 at 9:20 AM, 01/22/2024 at 9:35 AM, 01/22/2023 at 11:17 AM, 01/22/2024 at 4:09 PM, 01/23/2024 at 8:57 AM, and 01/23/2024 at 6:19 PM showed Resident 12's teeth was covered in food debris and glasses were unclean. In an interview on 01/23/2024 at 7:01 PM, Staff G, Nursing Assistant, stated teeth were brushed before bed and glasses were cleaned in the morning. When Staff G was asked if Resident 12's teeth had been brushed because they were in bed, they stated they needed to be brushed and were unclean. This is a repeat citation please see SOD dated 10/28/2022 Reference: (WAC) 388-97-1060(2)(c) Based on observation, interview and record review, the facility failed to ensure 2 of 3 sampled residents (53, 12) reviewed for activities of daily living, received assistance with grooming and maintaining clean glasses. These failures placed residents at risk for poor hygiene and impaired vision. Findings included . <Resident 53> According to Resident 53's quarterly assessment dated [DATE], they required assistance with activities of daily living, including transferring, dressing, personal hygiene, and bathing. Resident 53's care plan dated 05/02/2023, directed nursing staff to assist them with personal hygiene, such as trimming facial hair and shaving. During an observation on 01/18/2024 at 10:21 AM, Resident 53 was sitting in their wheelchair and had nasal hair that protruded out of their nose. Subsequent observations made on 01/20/2024 at 8:10 AM, 01/21/2024 at 9:02 AM, 1/21/2024 at 1:02 PM, 01/22/2024 at 9:19 AM, 01/22/2024 at 11:18 AM, and 01/23/2024 at 8:57 AM, all showed Resident 53's nasal hair protruded out of their nose. In an interview on 01/22/2024 at 11:18 AM, Resident 53's spouse, stated if Resident 53 was aware that their nasal hair was long that would have upset them. In an interview on 01/25/2024 at 8:42 PM, Staff C, Resident Care Manager, stated nasal hair was to be trimmed on shower days or when needed and was completed by nursing assistants.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled residents (2) reviewed for activities, received an ongoing program of activities that met their interests. Failure to assess the resident's activity preferences placed the resident at risk for boredom and diminished quality of life. Findings included Review of the 12/26/2023 quarterly assessment showed Resident 2 had severe cognitive impairment, was able to direct their care, and had diagnoses which included dementia and depression. The assessment showed the resident was independent with activities of daily living, including moving around the facility in their wheelchair, and it was very important to the resident to be involved in activities that included: reading materials, pets, news, and doing favorite activities. Review of Resident 2's 08/22/2023 care plan showed a quarterly and annual assessment would be done to ensure resident's activity preferences were accurate. Review of resident's record from 12/14/2021 through 01/20/2024 showed no activity assessments had been completed as care planned. In an interview and observation on 01/18/2024 at 11:23 AM, Resident 2 was sitting up in their wheelchair in their room alone. They stated they would like to do cooking and sewing activities, but none were offered. Additional observations of Resident 2 were made on the following: on 01/22/2024 at 09:39AM, the resident was in bed, on 01/22/2024 at 11:23AM, the resident was again lying in bed, on 01/23/2024 at 09:13AM, the resident was wearing a night gown while sittiing in thier wheelchair in their room, and on 01/23/2024 at 06:13PM, the resident was wheeling themself down the hall in their wheelchair. During these times, no observations of the resident being offered or attending activities were made. Review of facility December 2023 activity calendar showed a cooking activity 12/8, 12/13, 12/21, and 12/29/2023, as well as a craft activity on 12/07/2023. Review of facility January 2024 activity calendar showed a cooking activity every Thursday at 10:00am and Project time every Friday at 1:00pm. Review of Resident 2's record from 12/01/2023 through 01/23/2024 found no documentation that showed the resident was invited, attended, or refused the cooking and project activities in the months of December 2023 or January 2024. In addition, further review found not activity documentation was found in the resident record. In an interview on 01/24/2024 at 10:20 AM Staff L, Activity Director stated the activity charting was done on paper, and, when asked for Resident 2's documentation, Staff L stated they would provide the documentation for December 2023 and January 2024. On 01/24/2024 at 10:50 AM, 30 minutes after requesting documentation, a follow-up interview was done with Staff L. Upon entering the activity room, Staff L was observed sitting on floor with papers spread on floor and stated they were trying to get the activity documentation organized and copied. Staff L was asked where the documentation for the activity assessments were done, and they it was done in Point Click Care (PCC - the electronic medical record system used by the facility). On 01/24/2024 at 12:40 PM, two hours after requesting the documentation, it still had not been provided. Reference: WAC 388-97-0940(1)

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure nutritional supplements were offered as ordered for 1 of 5 sampled residents (9), reviewed for nutrition. This failure placed the resident, who had experienced significant weight loss, at risk for further loss. Findings included . The 11/28/2017 Nutritional Assessment facility policy, last revised on 08/01/2023, defined nutritional supplements as products that are used to complement a resident's dietary needs. A review of the record showed Resident 9 had diagnoses including diabetes (a disease in which your body does not make enough insulin), kidney failure and depression. According to a 01/16/2024 annual assessment, Resident 9 was cognitively intact, did not reject care, was able to eat independently, weighed 143 pounds (lbs.) and had lost 5% of their weight in one month or 10% in six months, and was not on a prescribed diet. A 01/12/2024 Nutrition at Risk assessment by Staff J, Registered Dietitian (RD,) documented Resident 9 weighed 170.4 lbs on 07/06/2023 and had lost 15.8% of their weight. Staff J documented resident had poor intake and had consumed 0-75% of meals, with an average of 30%. Staff J recommended a nutritional supplement three times a day. The provider order dated 01/12/2024, documented Resident 9 was to be given nutritional drinks three times a day with their meals. Resident 9's weights were reviewed and documented the following: -07/06/2023 170.4 lbs. -10/11/2023 158.4 lbs. -12/11/2023 162.4 lbs. -01/02/2024 143.4 lbs. This showed Resident 9 lost 15.85% of their weight over six months, 11.7% in three months and 9.47% in one month. During an observation on 01/21/2024 at 9:05 AM, Resident 9's meal card documented nutritional supplement on trays, however, no house supplement was observed on the resident's breakfast tray. A subsequent observation at 10:07 AM, showed no nutritional supplement was in resident's room. During an observation on 01/21/2024 at 12:20 PM, Resident 9's lunch tray was on their tray table without a nutritional supplement. Subsequent observations at 1:04 PM and 1:28 PM showed no nutritional supplement was in resident's room. During an observation on 01/22/2024 at 9:01 AM, Resident 9's breakfast was on their tray table and contained no nutritional supplement. Subsequent observations at 11:17 AM and 1:59 PM showed no nutritional supplement was in resident's room. During an observation on 01/23/2024 at 8:53 AM, Resident 9 was eating their breakfast, again, no nutritional supplement was on the tray. A subsequent observation at 11:14 AM showed resident's breakfast tray was still in their room and still contained no nutritional supplement. In an interview on 01/25/2024 at 8:47 AM, Staff X, Nursing Assistant, stated if a resident had poor intake, they would have offered a nutritional supplement and snacks throughout the day. Staff X added the nutritional supplements come on the meal trays. In an interview on 01/25/2024 at 5:41 PM, Staff C, Resident Care Manager, stated Resident 9 had lost weight and thought their nutritional supplements came on their meal trays. Staff C added if Resident 9 had not received their nutritional supplement that could contribute to weight loss. Staff C stated the resident was given nutritional supplements. In an interview on 01/24/2024 at 4:23 PM, Staff P, Dietary Manager, stated tray cards were printed every morning and included what each resident's diet and nutritional needs were. Staff P stated if the tray card said nutritional supplement, it would have been sent on the meal tray. Staff P stated you could tell the difference between the milk and the vanilla nutritional supplement as the vanilla was creamy and not white like milk. In an interview on 01/25/2023 at 3:39 PM, Staff J, Registered Dietician, stated Resident 9 received nutritional supplements and they should be sent on meal trays. Staff J stated Resident 9's poor intake and not receiving their nutritional supplements could contribute to weight loss. Staff J added they would talk to the dietary staff about the nutritional supplements. Reference: WAC 388-97-1060(3)(h)

CONCERN (D)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to complete performance reviews at least once every 12 months, and provide in-service education based on the outcome of the reviews as required, for 1 of 5 sampled staff (L), whose records were reviewed. This failure placed residents at risk for receiving care from inadequately trained staff. Findings included . Per review of Staff L, Nursing Assistant's file, they had a performance evaluation that was last completed on 06/16/2021, not yearly as required. During an interview on 01/26/2024 at 3:08 PM, Staff M, Staff Development Coordinator, stated they were unsure how often performance evaluations were completed. Staff M stated they had a workshop last year in which certain skills had been performed by nursing staff. During an interview on 01/26/2024 at 3:42 PM, Staff B, Director of Nursing, stated they completed performance evaluations yearly and were aware that some employees did not have theirs completed or updated. Reference: WAC 388-97-1680 (1)(2)(a-c)

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

<Resident 16> Per the 12/26/2023 quarterly assessment, Resident 16 had diagnoses including kidney failure and diabetes (a disease in which your body does not make enough insulin). Review of the ...

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<Resident 16> Per the 12/26/2023 quarterly assessment, Resident 16 had diagnoses including kidney failure and diabetes (a disease in which your body does not make enough insulin). Review of the physciain orders showed on 07/03/2023, Resident 16 was presecribed Lispro (sliding scale insulin, a hormone used to treat diabetes and given based on blood glucose levels). The July, August, and September 2023 Monthly Medication Review (MMR) documented a recommendation to discontinue the sliding scale insulin as mentioned above and no response was obtained. The October 2023 MMR documented a recommendation to discontinue the Lispro insulin sliding scale and the physician responded on 11/10/23, nearly four months since the recommendation was first made. Reference: WAC 388-07-1300 (4)(c) Based on interview and record review, the facility failed to follow-up on pharmacist recommendations for medication changes, and to implement recommended changes in a timely fashion for 2 of 5 sampled residents (16, 55), reviewed for unnecessary medications. This failure placed the residents at risk for unidentified medication complications, or adverse effects from medications. Findings included . <Resident 55> Per the 11/07/2023 quarterly assessment, Resident 55 had diagnoses including dementia, arthritis, allergies, and repeated falls. A review of the physician orders showed on 08/08/2023 Resident 55 was prescribed Lorazepam (a medication used to treat anxiety) and it was to administered as needed. Review of the August, September, and October 2023 Monthly Medication Review (MMR) documented a recommendation from the pharmacist to discontinue the as needed Lorazepam and make it routine. Per the October review, the physcian responded to the recommendation on 10/17/2023, nearly months after the recommendation was first requested. In an interview on 01/26/2024 at 4:54 PM, Staff B, Director of Nursing, stated the expectation for obtaining responses from pharmacy recommendations was 30 days. Staff B added they have had difficulty in obtaining the physician's response timely.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview, and record review, the facility failed to ensure that orders for as needed (PRN) psychotropic medication (a type of medication used to affect mood, behavior, and perceptions) was limited to14 days, and was given for an appropriate diagnosis for 1 of 5 sampled residents (55). These failures placed the residents at risk for unintended medication side effects and a decreased quality of life. Findings included . <Resident 55> A review of records showed Resident 55 had diagnoses including dementia without behavioral disturbance, depression, and anxiety. A quarterly assessment completed on 11/07/2023 showed Resident 55 had moderate cognitive impairment and was not able to make needs known. Review of physician orders showed on 08/08/2023, Resident 55 was prescribed and received Lorazepam as needed for anxiety. Review of the Order Summary Report documented the last 14 day stop date as required for the as needed Lorazepam was obtained on 08/11/2023. A review of the resident's Medication Administration Records (MAR) for August 2023 through October 17, 2023, documented the resident received the as needed Lorazepam. Resident 55's records did not include progress notes or assessments from the resident's providers for the continued use of the Lorazepam for more than 14 days. Review of the Order Summary Report documented on 08/03/2023 Resident 55 was prescribed Trazodone for insomnia and the diagnosis was changed on 08/10/2023 to be given for dementia without behavioral disturbance. In an interview on 01/24/2024 at 5:26 PM, Staff C, Resident Care Manager, was asked what appropriate indications for the use of an anti-depressant medication would be for Resident 55. Staff C stated depression or insomnia were appropriate, but not dementia without behavioral disturbance. In an interview on 01/26/2024 at 4:54 PM, Staff B, Director of Nursing, stated as needed psychotropic medications needed a 14 day stop date and would have required an assessment by the provider to evaluate the continued need of the medication. Reference: WAC 388-97-1060(3)(k)(i)

CONCERN (D)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to employ sufficient staff with the appropriate licensing necessary to carry out the functions of the nutritional services for 68 residents. Failure to ensure Staff J, Registered Dietician (RD) had a license to practice in Washington State placed residents at risk for unmet nutritional needs and possible unintended weight loss or gain. Findings included . On [DATE], a review of the Washington State Department of Health Provider Credential database showed Staff J's license to practice as a dietitian had been expired since [DATE], and they were no longer licensed to practice as a dietician in Washington State as of that date. In an interview on [DATE], Staff J confirmed their license had expired on [DATE], and stated they were not aware it had expired until Staff B, Director of Nursing, had called and asked for it. Upon learning it was expired, Staff J immediately called the licensing board and paid the fees to renew the license. Review of an email correspondence provided by Staff J from the Washington State Department of Health, showed as of [DATE], their dietician license was renewed through [DATE]. Reference: WAC 388-97-1160(1)

CONCERN (D)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dietary staff had the required qualifications (current Food Worker Cards) for one dietary staff (W). This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . A review of the dietary cards showed no Washington State Food Workers card for Staff W (hire date 2/18/2023). Staff W did have a certificate dated 1/25/2024 from Food Handler Solutions for completing the food handler's course. Review of Food Handler Solutions website, foodhandlersolutions.com/[NAME]-food-handler-card/ showed, the Food Handler Solutions Program is currently not approved in the state of [NAME]. This program is only intended to be used for personal development and preparation for the state provided training. A review of the staffing schedules showed Staff W had worked in the kitchen the following dates/times: 1/18/2024 1:04pm - 6:32pm 1/20/2024 8:05am - 2:29pm 1/21/2024 4:51am - 12:57pm 1/22/2024 1:30pm - 6:55pm 1/24/2024 1:52pm - 6:45pm During an interview on 01/25/24 at 10:54 AM, Staff P, Dietary manager, was asked if a staff member can be working in the kitchen without a food handler's card and they stated probably not. Reference: WAC 388-97-1160

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

<Resident 2> Per the 09/26/2023 admission assessment, Resident 2 had diagnoses which included dementia, and depression, and received psychotropic medications daily. A review of the Order Summa...

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<Resident 2> Per the 09/26/2023 admission assessment, Resident 2 had diagnoses which included dementia, and depression, and received psychotropic medications daily. A review of the Order Summary Report showed on 08/01/2023, Resident 2 was prescribed psychotropic medication (Trazodone) to treat depression, and on 12/14/2023 was prescribed psychotropic medication (Seroquel( to treat adverse behaviors which may be associated with dementia. Review of the Psychoactive Medication Informed Consent showed the form included the above psychotropic medication and the doses prescribed, but did not inform the resident or responsible party when the medication would be started, what the medication was prescribed to treat, nor did it include the potential benefits that could occur from taking the medication. In addition, the form was dated and signed by the nurse, and documented the resident's responsible party was aware of the medication, but the form did not include the responsible party's signature. Review of the Psychoactive Medication Informed Consent for Trazadone did not include a start date for the medication. Further review of Resident 2's record did not show any additional documentation, either verbally or written, that education related to the psychotropic medication with regards to the reason for being prescribed or the benefits expected from taking the medication had occurred. During an interview on 01/26/2024 at 10:05 AM, Staff C, Resident Care Manager stated informed consents should be obtained prior to the resident receiving the first dose of the medication. This ia repeat citation, please see SOD dated 09/25/2023 Reference: WAC 388-97-0300(3)(a) <Resident 53> Per the 11/07/2023 quarterly assessment, Resident 53 had severely impaired cognitive skills, and had diagnoses which included depression and insomnia. In addition, the assessment showed the resident received psychotropic medication daily. A review of the Order Summary Report showed on 09/22/2023, the physician had prescribed a psychotropic medication (Trazodone) to treat depression. Review of September 2023 Medication Administration Records (MARS) showed the medication was started on 09/23/2023. Review of Resident 53's record did not show documentation that the risks and benefits of the medication were discussed, either verbally or written, with the resident or their representative, until two days after the resident had received the medication. <Resident 55> Per the 11/07/2023 quarterly assessment, Resident 55 had severly impaired cognitive skills, and had diagnoses which included dementia and received psychotropic medication, (medications that affect the mind, emotions, and behavior). A review of the Order Summary Report showed on 08/03/2023, the physician had prescribed a psychotropic medication (Trazodone) to treat insomnia. Review of August 2023 MARS showed the medication was started on 08/03/2023. Review of Resident 55''s record did not show any documentation verbally or written that education for use of a psychotropic medication was obtained. On 01/26/2024 at 10:05 AM, Staff C, was asked about the consent for the Trazodone and stated it was missed. Based on interview and record review, the facility failed to ensure 4 of 5 sampled residents (117, 53, 2, and 55), reviewed for unnecessary medications, were informed of the potential risks and benefits associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). Failure to obtain the informed consents and/or include necessary information about the medication such as reasons for taking and benefits resulted in the resident and/or representative not being fully informed. Findings included . <Resident 117> Per the 01/22/2024 admission assessment, Resident 117 had diagnoses which included anxiety, depression, and schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, and perceives reality) and received psychotropic medications daily. A review of the Order Summary Report showed on 01/17/2024, Resident 117 was prescribed psychotropic medication (Trazodone and Venlafaxine) to treat depression, and Risperidone to treat the symptoms associated with Schizophrenia. In addition, the report showed the psychotropic medication Alprazolam was ordered 01/19/2024 to treat anxiety. Review of the January 2024 MAR showed the resident received the medications as ordered. Review of the Psychoactive Medication Informed Consent, a form used to provide education related to the potential risks and benefits of psychotropic medications, the dose, and the reason the medication was being prescribed, showed the form included the above psychotropic medication and the doses prescribed, but did not inform the resident what the medication was prescribed to treat, nor did it include the potential benefits that could occur from taking the medication. In addition, the form was dated and signed by the nurse, and documented the resident was aware of the medication, but the form did not include the resident's signature. Further review of Resident 117's record did not show any additional documentation, either verbally or written, that education related to the psychotropic medication with regards to the reason for being prescribed or the benefits expected from taking the medication had occurred. In an interview on 01/25/2024 at 12:36 PM, Staff D, Licensed Practice Nurse, stated informed consents should be obtained prior to the first dose being given, and the form should include the medication, reason for taking, the dose and the risks and benefits of the medication. In an interview 01/25/2024 at 12:50 PM Staff E, Resident Care Manager stated that psychotropic medication informed consents should include the medication, dose, reason for being prescribed, and the risks and benefits to taking the medication. After review of the resident's record, Staff E confirmed the form did not include all the components.

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 9> Per the 01/16/2024 annual assessment, Resident 9 was cognitively intact and was independent with toileting. ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 9> Per the 01/16/2024 annual assessment, Resident 9 was cognitively intact and was independent with toileting. Review of the care plan dated 11/03/2021 documented the resident was at risk for constipation and had interventions which instructed nursing staff to monitor bowel movements (BM's) and initiate interventions per orders. Review of the December 2023 Medication Administration Record (MAR) documented on 11/23/2023, the physician had ordered a laxative (Milk of Magnesia) to be given if the resident had not had a BM in 72 hours, and if there still was no bowel movement by the next shift, an additional laxative (Dulcolax suppository) was to be given, and if no BM by the next shift, an additional laxative (Fleets enema) was to be given. Review of the bowel records from 12/26/2023 through 01/24/2024, showed Resident 9 had no BM's from 12/29/2023 through 01/02/2024 (five days), and from 01/11/2024 through 01/13/2024 (three days). Additional review of the MARS for December 2023 and January 2024, documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 9's record that stated the reason for the omissions. <Resident 10> Per the 10/12/2023 quarterly assessment, Resident 10 was unable to make decisions regarding cares, and needed assistance from staff for activities of daily living, such as toileting. Review of the care plan dated 11/18/2013 documented the resident was at risk for constipation and had interventions which instructed nursing staff to monitor BM's and initiate interventions per orders. Review of the resident's bowel record from 12/26/2023 through 01/23/2024 documented Resident 10 had no BM's from 12/29/2023 through 01/02/2024 (five days), 01/05/2024 through 01/07/2024 (3 days), and 01/11/2024 through 01/13/2024 (3 days). Additional review of the MARS for December 2023 and January 2024 documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 10's record that stated the reason for the omissions. <Resident 55> Per the 11/07/2023 quarterly assessment, Resident 55 was unable to make decisions regarding cares and needed assistance from staff to complete activities of daily living, such as toileting. Review of the care plan dated 08/23/2023 documented the resident was at risk for constipation and had interventions which instructed nursing staff to monitor bowel movements and initiate interventions per orders. Review of the resident's bowel record from 12/25/2023 through 01/22/2024 documented Resident 55 had no BM from 12/25/2023 through 12/27/2023 (three days), 12/31/2023 through 1/02/2024 (three days), 01/06/2024 through 01/08/2024 (three days), and 01/16/2024 through 01/18/2024 (three days). Additional review of the MARS for December 2023 and January 2024, documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 55's record that stated the reason for the omissions. In an interview on 01/24/2024 at 5:46 PM, Staff C, Resident Care Manager, stated there was a facility bowel protocol and the expectation was that the nurses followed the protocol to prevent constipation and possible impaction. This is a repeat citation, please see the SOD dated 10/28/2022. Reference: WAC 388-97-1060(1) Based on observation, interview, and record review, the facility failed to ensure 1 of 5 sample residents (56), reviewed for medication management, received adequate monitoring to ensure appropriate administration of a high-risk medication. Failure to monitor edema (excess fluid in the tissues) placed the residents at risk for compromised heart health. In addition, the facility failed to ensure timely bowel care was provided for 3 of 3 sample residents (9,10, and 55) reviewed for constipation which placed the residents at risk for constipation and unmet care needs. Findings included . According to the article Loop Diuretics published by the National Library of Medicine on 05/22/2023, Loop diuretics (such as Furosemide) included a black box warning (the highest safety-related warning that has been assigned by the Food and Drug Administration to inform consumers of the medications potential and serious side effects) and careful medical supervision was necessary to monitor the patient's response (blood pressure, weight, and edema) to the medication and dosage adjustments should be done according to the patient's needs. <Resident 56> The 11/21/2023 quarterly assessment showed Resident 56 had a diagnosis of congestive heart failure (a condition in which the heart has lost the ability to pump enough blood to the body's tissues), and took a diuretic (medication to help the body eliminate excess fluids). Review of the August 2023 through January 2024 Order Summary Reports showed on 08/18/2023, the physician prescribed the loop diuretic Furosemide to help manage the symptoms of heart failure. Review of the 08/18/2023 care plan showed nursing staff were instructed to monitor Resident 56 for any changes in cardiac status, which included monitoring for dependent edema (swelling in the extremities from excess fluid) and to notify the physician as indicated. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from August 2023 through October 2023 showed no edema monitoring had been implemented. Review of the progress notes from 08/18/2023 through 10/02/2023 showed no documentation that the resident's edema was being monitored with the exception of a nutritional note on 08/31/2023 at 12:42 pm by Staff J, Registered Dietician, which documented Resident 56 had no edema. A progress note on 10/03/2023 at 7:10 PM documented Resident 56's face appeared fuller, they were falling asleep during meals, and their lung sounds had wheezes (all potential symptoms of excess fluid). On 10/05/2023 at 8:54 AM a progress note documented Resident 56's face and lower extremities were swollen, assessment of their lungs revealed wheezes, and the physician was notified. At 11:57 AM that same day, it was documented the resident had a change in condition and was being sent to the hospital for evaluation. On 10/06/2023 at 9:14 AM a progress note documented Resident 56 had been admitted to the hospital with an exacerbation of their congestive heart failure. A progress note on 10/11/2023 at 2:44 PM documented Resident 56 had returned to the facility from the hospital after being treated for increased edema. On 01/19/2024 at 9:22 AM, Resident 56 was observed in their room sitting in their wheelchair beside the bed. When asked about their care and if the nursing staff monitored them for edema, the resident politely declined to discuss their care, except to state they had been at the facility for awhile. Additional review of Resident 56's record from the date of readmission on [DATE] through 01/25/2024, showed Staff J documented the status of the resident's edema during nutritional reviews on 11/03/2023, 11/16/2023, 12/14/2023 and 12/28/2023, but no documentation was found that nursing was monitoring the resident for edema. In an interview on 01/25/2024 at 3:25 PM, Staff J stated they reviewed the resident for nutrition and monitored weights, but the monitoring of edema was done by the nurses, and the nutritional documentation was based on the resident's record and if staff had reported any concerns. In an interview on 01/25/2024 at 3:39 PM, after discussion and review of Resident 56's record, Staff E, Resident Care Manager, confirmed no edema monitoring had been implemented and the expectation would be that monitoring was done for a resident taking diuretics.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medication boxes/kits which contained controlled medications (medications that have a high risk for abuse such as narcotics, anti-anxiety, hypnotic and hallucinogenic) and stored in the medication refrigerators were affixed as required for 2 of 2 medication rooms reviewed for medication storage. In addition, the facility failed to consistently monitor the medication refrigerator temperatures to ensure they were at safe storage levels. These failures placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . Per the 01/20/2023 article titled Storage and Handling of Immunobiologics published by the Center for Disease Control, failure to follow recommended storage and refrigerator temperatures for immunobiologics (a medicinal preparation made from living organisms and their products, such as a serum or vaccine) can reduce or destroy the potency resulting in inadequate or no immune response in the recipient. Refrigerator storage should be kept between 36 through 46 degrees Fahrenheit and prompt immediate action should occur when the temperature was out of range. On 01/25/2024 at 7:57 AM with Staff N, Licensed Practical Nurse (LPN) present, the Dogwood unit medication storage room refrigerator was observed to contain a white plastic see-through emergency medication kit sealed with a red tag. Inside the container were several vials of insulin, a hormone used to treat diabetes, and a medication used to treat anxiety (Lorazepam). The container was not permanently affixed to the refrigerator as required. Review of the Dogwood medication refrigerator temperature logs for December 2023 and January 2024 showed no monitoring of the temperature was done on 12/11/2023, 12/22/2023, 01/01/2024, 01/20/2024, 01/21/2024, and 01/22/2024. During the review of the [NAME] unit medication room with Staff C, Resident Care Manager, on 01/25/2024 at 7:33 AM, the emergency medication kit in the medication refrigerator was observed to be sealed with a green tag and contained several vials of the anti-anxiety medication, Lorazepam. The kit was not permanently affixed to the refrigerator as required. In addition, the refrigerator contained several vials of Influenza vaccine. Review of the [NAME] medication refrigerator temperature log for January 2024 showed on 01/14/2024, the temperature was 32 degrees Fahrenheit, which is below the acceptable storage range. In an interview on 01/25/2024 at 7:33 AM, Staff C stated they were not aware that boxes/kits that were stored in the medication refrigerator needed to be affixed to the refrigerator if they contained controlled medications. In a follow-up interview on 01/25/2024 at 8:25 AM, Staff C confirmed the temperature of the [NAME] medication refrigerator on 01/14/2024 was below the acceptable range and the vaccine should be discarded. During an interview on 01/25/2024 at 11:53 AM, Staff B, Director of Nursing, confirmed medication refrigerator temperatures should be checked daily and any medication discarded if the temperature was below or above the acceptable range. With regards to the medication boxes/kits not being affixed, Staff B stated they were not aware they needed to be. Reference: WAC 388-97-1300 (2) & -2340

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure resident medical records were complete and accurate, in accordance with accepted professional standards and practices, for 2 of 2 sampled residents (1, 50) reviewed for abuse, 1 of 1 sampled resident reviewed for activities (2), and 1 of 1 sampled resident (12) reviewed for care planning. Failure to document pertinent resident information placed the residents at risk for unmet care needs, decreased continuity of care, and diminished quality of life. In addition, the facility failed to provide access timely to resident records for 15 of 17 sampled residents (169, 62, 1, 16, 2, 53, 167, 33, 55, 58, 3, 117, 25, 18, and 56) reviewed for Advance Directives, and failed to timely provide the facility staffing documentation that had been requested for review of the sufficient staffing task. Findings included . <Resident 1> The 12/05/2023 quarterly assessment showed Resident 1 had no cognitive impairment and was able to make decisions regarding their care. In addition, the assessment showed the resident was blind. During an interview on 01/19/2024 at 10:36 AM Resident 1 was observed sitting in their room in their recliner. When asked if they had experienced any negative interaction with other residents, Resident 1 stated there were multiple incidents that occurred a couple months ago with their previous roommate who was violent. Resident 1 stated they let staff know, but was unable to recall who they informed. When asked about the incidents, Resident 1 stated the following: - the roommate held a cane against their throat. - the roommate lifted the recliner by the footrest and wedged another piece of furniture under it while Resident 1 was sitting in the recliner which prevented them from being able to lower the footrest and get out of the recliner. - the roommate lifted the recliner chair by the footrest and tried to dump Resident 1 of out of it onto the floor. - at times, the roommate grabbed their leg and squeezed it hard. Review of Resident 1's record from 07/01/2023 through 01/26/2024 found no documentation of the incidents. <Resident 50> The 10/24/2023 quarterly assessment showed Resident 50 had no cognitive impairment and made decisions regarding their care. In an interview on 01/20/2024 at 07:31 AM, Resident 50 stated their former roommate, they couldn't remember their name, punched them in the face. Resident 50 stated they couldn't remember the date it occurred, but thought it was a month or two ago. Review of Resident 50's record from 07/21/2023 through 01/26/2024 found no documentation of the incident. Please see F610 for additional information <Resident 12> The 10/17/2023 quarterly assessment showed Resident 12 had moderate cognitive impairment and was usually able to make their needs known to staff. On 01/18/2024 at 3:14 PM, Resident 12 was observed lying in bed. When asked about their care at the facility, the resident smiled, said thank you and then began counting out loud. During an interview on 01/20/2024 at 11:28 AM, when asked if the facility held care conferences or care planning meetings to discuss the resident's care, the resident's representative stated they had never been invited to and/or attended a care planning meeting. Review of Resident 12's record from 07/01/2023 through 01/25/2024 found no documentation that care conferences and/or care planning meetings had been offered or held. During an interview on 01/22/2024 at 10:31 AM, Staff B, Director of Nursing, was asked how often care conference/care plan meetings were held and where was the notes from the meetings were documented. Staff B stated care conferences were held when the resident admitted , then quarterly and the documentation was done in the resident's record. When informed no documentation was found, Staff B stated she would follow up with Staff F, Social Services. In a follow up interview on 01/22/2024 at 11:06 AM, Staff B stated they discussed the care conference documentation with Staff F and learned Staff F documented the care conference notes in a notebook, but had not documented in the resident's records. Staff B stated they reviewed the notebook, and realized it was not best practice, but the documentation showed care conferences were being held. It was explained to Staff B that care conference documentation should be a part of the resident's record and the survey team would need to review the notebook. As of 01/26/2024 at 6:31 PM, the notebook had not been provided. In an interview with Staff F at that time, Staff F confirmed they had documented care conference meetings in a notebook and not the resident's record. When asked to view the notebook, Staff F looked through the notebook on their desk and replied that there was no documentation for the resident found. Staff F then stated they had recently gotten a new notebook and had taken the other notebook home. <Resident 2> The 12/26/2023 quarterly assessment showed Resident 2 had diagnosis of dementia and depression, was severely cognitively impaired, but was able to make their needs known to staff. In addition, the assessment showed it was very important to the resident to be involved in activities that included: reading materials, pets, news and doing favorite activities. In an interview and observation on 01/18/2024 at 11:23 AM, Resident 2 was sitting up in their wheelchair in their room alone. They stated they would like to do cooking and sewing activities, but none were offered. Review of the 08/22/2023 activity care plan for Resident 2 showed a quarterly and annual assessment would be done to ensure resident's activity preferences were accurate. Review of Resident 2's records from 12/14/2021 through 01/20/2024 showed no activity assessments had been completed, nor was any documentation found that the resident had attended any activities. In an interview on 01/24/2024 at 10:20 AM Staff L, Activity Director stated the activity charting was done on paper. The December 2023 and January 2024 activity charting was then requested for Resident 2, and Staff L stated they would provide it. On 01/24/2024 at 10:50 AM, 30 minutes after requesting documentation, a follow-up interview occurred with Staff L. Upon entering the activity room, Staff L was observed sitting on floor of with papers spread on floor and stated they were trying to get the activity documentation organized and copied. When asked where the activity assessments were documented, Staff L stated they were done in Point Click Care (PCC - the electronic medical record system used by the facility). On 01/24/2024 at 12:40PM, two hours after requesting documentation, the surveyors found the activity room door locked and through a window by the door observed Staff U, Laundry Aide, and Staff V, Housekeeper sitting at a table drawing circles on papers in front of them. Staff A, Administrator was also present in the room. After knocking, Staff L, Activity Director opened the door, and as the surveyors walked towards the table, Staff A left the room. When the surveyors reached the table and asked Staff U and Staff V what they were working on, Staff U stood up and held the papers against their chest, and Staff V, housekeeper continued to write on the papers. The papers in front of Staff V were observed to be December 2023 activity calendars with resident names on them and they were circling different activities for the residents. Staff L, Activity Director, then came to the table and handed the surveyors the activity participation documentation for December 2023, and January 2024. Staff L stated Staff U and Staff V were helping to document the activities that had been done today, however the activity calendars that Staff U and V were completing were observed to be for December 2023. When Staff L was asked if Staff U and Staff V normally helped document activities for the residents, Staff L stated no. When asked how Staff U and Staff V would know what activities to document, Staff L stated they told them what activities the residents had participated in. (When Staff U and Staff V were observed marking the activities prior to entry into the room, Staff L was in their office and not near the desk where Staff U and Staff V were sitting). Review of the documentation that was just provided showed activity participation was completed for December 2023 and January 2024 for Resident 2. Prior to this, the documentation had not been provided. In an interview on 01/24/2024 at 01:00 PM, the surveyors requested additional activity participation documentation for October and November 2023 for Resident 2. Staff L stated they had dropped their binder that contained the activity documentation, and the papers were unorganized. When the surveyors stated it was all right, they could sort through to find the documentation, Staff L gestured to a stack of papers on their desk, stated Here you go, and walked out of the room. Review of the binder found no activity documentation for October and November 2023 was present. Please see F679 for additional information <Advance Directives> On 01/19/2024 at 09:39 AM, Staff B was asked where advance directive documentation was located. Staff B stated the documentation should be in the Document tab of the resident's record or with the Social Service Director. On 01/20/2024 during the initial record reviews for the following residents, 169, 62, 1, 16, 2, 53, 167, 33, 55, 58, 3, 117, 25, 18, and 56, no documentation was found in the resident records to show if the resident had an advance directive in place, nor was there documentation found to show the facility had informed the residents of their right to form an advance directive. On 01/21/2024 at 8:51 AM, Staff B was informed the survey team did not have access to the Document tab. Staff B stated they would work to get the team access. On 01/21/2024 at 11:21 AM, Staff B, Director of Nursing was informed again that the survey team needed access to the above resident's advance directives and signed admission records as they contained needed information. A list with the above resident's names was provided to Staff B. On 01/21/2024 at 11:26 AM, Staff B notified the survey team that the Document Manager tab under the Admin tab in the resident's electronic records contained the advance directives and signed admission paperwork and access had been granted. On 01/21/2024 at 1:34 PM, Staff B provided Durable Power of Attorney documentation for Resident 169, but this was for financial matters and did not include advance directives for healthcare. At 1:35 PM, Staff B provided advance directive information for Resident 2. Review of the residents records after access was granted, showed that the documentation accessible to the survey team only included residents who had been admitted within the last 30 days, and no other documentation was accessible. Per review of the available records, documentation related to the right to form an advance directive and/or advance directive paperwork was found to be in place for residents 62, 167, and 117. On 01/21/2024 at 2:11 PM, Staff B provided a copy of Resident 3's advance directive. On 01/22/2024 at 7:49 AM Staff A provided advance directive information for Resident 16. At 2:04 PM that same day, advance directive information for Resident 53 was received. As of 5:00 PM on 01/24/2024, no additional advance directive documentation, or signed admission paperwork had been provided, and information was still needed for multiple residents. On 01/25/2024 at 9:27 AM, Staff B was informed again that the survey team still had not received advance directive documentation for residents (169, 1, 55, 58, 25, 18, 33, and 56) and the information was not accessible in the Document Manager. the surveyor showed Staff B that when attempts to access the information was made, a message appeared which stated, You do not have the proper security privileges for this screen. Your System Administrator can grant access. Staff B replied that they would speak with Staff A, Administrator to ask if access could be given. Staff B further stated they would obtain the information for the residents on the list we have provided earlier since it may take the IT department a long time to grant access. On 01/25/2024 at 10:43 AM, Staff B provided the advance directive documentation for the above residents, five days after the intitial request for the documentation. On 01/25/2024 at 11:43 AM during a conversation with Staff B, it was explained that the survey team not having access to needed resident records, not being provided requested records, and resident records not containing all documentation pertaining to the resident's care, created difficulty in being able to complete the survey process, and while the advance directive documentation had now been provided, it had only occurred after several requests had been made. In addition, having incomplete resident records created the potential for not having continuity of care for the residents. Staff B stated there had been discussions with Medical Records before about the importance of making sure documents were in the resident records, but it had been a challenge. <Staffing Documentation> On 01/18/2024 at 9:21 AM, during the Entrance Conference with Staff A, Administrator and Staff B, Director of Nursing, a copy of the Entrance Conference Worksheet and the Dear Administrator letter was provided which detailed the documents and items the facility needed to provide to the survey team. The surveyor conducting the meeting read and reviewed each item on both the worksheet and the letter with Staff A and B. On 01/24/2024 at 3:15 PM, the 30-day staffing pattern form was requested from Staff A. Staff A was reminded that a blank copy of the form had been provided during the Entrance conference (and is listed on the Dear Administrator letter). At 3:46 PM, Staff A stated that they misunderstood the request to be for the staffing schedules. and the form was in the process of being filled out. At 5:52 PM, the completed form was received, six days after the intital request. On 01/25/24 at 9:43 AM, a request was made to Staff A to provide the staffing schedules that showed the actual hours staff worked. On 01/26/2024 at 12:59 PM, another request was made for the staffing schedules that included the actual hours worked from Staff A. Staff A stated they believed Staff B was working on getting the documentation. Staff A stated they had not been asked for the documentation earlier. The surveyors reminded Staff A that the request was done during the entrance conference, a copy of both the entrance conference worksheet, dear administrator letter, and a blank copy of the staffing pattern form had been discussed and provided at that time. The surveryors clarified that there were separate State and Federal tasks that have to be reviewed with regards to staffing and the documentation was needed to complete both. On 01/26/2024 at 1:48 PM the survey team received the staffing schedules that included actual hours that staff worked from 01/18/2024 through 01/26/2024 from Staff B, eight days after the initial request. During the exit conference interveiw on 01/26/2024 at 8:43 PM with Staff A and B the survey team disccused concerns that the resident records were incomplete and did not include all documentation pertaining to the residents. In addition, the lack of timliness with being provided access to records and requested documentation prolonged the survey process and made it difficult to complete investigations. This is a repeat citation, please see the SOD dated 10/28/2022. Reference (WAC): 388-97-1720(1)(a)(i-iv)(b),(c), (2)(a-m), 0360(1-3)

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Wound Care> According to the 12/04/2023 admission assessment, Resident 58 had diagnoses of chronic venous insufficiency (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Wound Care> According to the 12/04/2023 admission assessment, Resident 58 had diagnoses of chronic venous insufficiency (a form of venous disease that occurs when veins in the legs are damaged and cannot manage blood flow effectively) and lymphedema (a condition of tissue swelling in the limbs caused by accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), was cognitively intact and able to direct their care, and required set-up assistance for activities of daily living such as dressing, toileting, and mobility. Although no wounds were recorded on the admission assessment, a 11/28/2023 clinical evaluation progress note showed wounds to both lower legs related to a history of cellulitis (a bacterial infection of the skin and the tissues beneath the skin). On 1/21/2024 at 10:06 AM, an observation was made of the wound care and dressing change to right and left lower leg with Staff AA, Registered Nurse, and Staff C, Resident Care Manager. The right lower leg wound was covered with a foam dressing, the left lower leg wound was wrapped in gauze. Staff AA, RN donned gloves wiped resident's tray table with a sanitizing wipe, picked up a piece paper off the floor, then without changing gloves or performing hand hygiene took another sanitizing wipe and used it to wipe down scissors. Staff C, RCM donned gloves and removed the soiled dressing from the right lower leg wound. The wound was red and swollen and partially filled with yellow slough (a non-viable fibrous yellow tissue formed because of infection or damaged tissue in the wound). Staff AA cleaned the wound with moistened gauze then without performing hand hygiene or changing gloves, applied a new dressing, covered it with an adhesive foam, and secured the dressings with a self-adhering bandage wrap. Observation showed two wounds were present on the left lower leg. Both wounds were red, with the surrounding skin red and swollen with small blisters. Staff C used scissors to cut off the gauze wrap covering both wounds. The scissors were not sanitized after being used and Staff C did not perform hand hygiene or change gloves after removing the old dressings. Staff AA cleaned the wound on the inner leg with moistened gauze then without changing gloves or performing hand hygiene used a different piece of moistened gauze to clean the wound on the outer leg. Staff AA, wearing the same gloves, used the dirty scissors to cut pieces of the new dressing and then applied it to the wounds. Staff C then proceeded to use the same dirty scissors to cut pieces of an additional dressing and applied it to the wounds. Staff AA then placed an adhesive foam over both wounds and secured it with a self-adhering bandage wrap which was cut by Staff C using the same dirty scissors. In an interview on 01/21/24 at 10:40 AM Staff C and Staff AA were asked when hand hygiene and glove changes should be performed during wound care. Staff AA stated before starting wound care, after removing the old dressing, and when done with wound care. Staff AA and Staff C both stated hand hygiene and glove changes should have been performed between cleansing wounds and applying clean dressings. Reference (WAC) 388-97-1320 (1)(c) Based on observation and interview, the facility failed to ensure appropriate hand hygiene was performed during the meal service for 1 of 3 dining rooms, and during wound care for 1 of 1 sampled residents (58) reviewed for non-pressure wounds. These failures placed the residents at risk for infections and unmet care needs. Findings included . <Dining Room> During a lunch observation in the [NAME] unit dining room on 01/18/2024 at 11:53 AM, Staff O, Nursing Assistant, cut up a resident's turkey, without gloves and touched the prongs of fork with their hands and gave it to the resident to eat with. Staff O, then pushed a resident up to the table, did not perform hand hygiene and continued to pass meal trays. During an observation at 12:13 PM, Staff O passed out meal trays to residents who did not eat in the dining room. Staff O entered room [ROOM NUMBER] with a meal tray and placed it on resident's tray table and left the room without performing hand hygiene. Staff O then went to the dining room, grabbed another tray for another resident in room [ROOM NUMBER] without performing hand hygiene. In an interview on 01/18/2024 at 12:34 PM, Staff O stated hand hygiene needed to be performed after obtaining a tray, when touching things like wheelchairs and steam tables and they may have forgotten to do so at times. Staff O added when hand hygiene was not performed this could spread bacteria and cause illness. During a lunch observation on 01/21/24 at 11:58 AM, Staff Q, Nursing Assistant, without performing hand hygiene or wearing gloves, opened a straw for a resident, then touched the straw with their bare hands and stirred the resident's drink. The resident then used the straw to drink the liquid. At 12:05 PM, Staff Q opened the refrigerator and obtained some milk and juice, then grabbed the ice scoop, poured drinks, without performing hand hygiene in between. In an interview on 01/21/2024 at 12:16 PM, Staff Q stated they should not have opened the straw without performing hand hygiene and wearing gloves, and should have done hand hygiene prior to the ice scoop being picked up. Staff Q added this was how germs are spread. <Medication Pass> During observation of a medication pass on 01/25/2024 at 6:49 AM, Staff T, Licensed Practical Nurse, placed a resident's medications into a cup, placed their hand into the cup and using their bare fingers, removed a pill, and placed it in another medication cup. Staff T did not perform hand hygiene. Staff T then entered the resident's room, put gloves on, took the resident's blood pressure, and wearing the same gloves, gave insulin injections to the resident, and handed them their medication. Staff T then removed the gloves and washed their hands. In an interview on 01/25/2024 at 7:06 AM, Staff T stated they should have worn a pair of gloves or used a spoon and removed the pill from the cup. Staff T added they should have performed hand hygiene and changed their gloves prior to administering insulin to prevent bacteria. During an observation on 01/25/2024 at 7:32 AM, Staff T entered a resident's room, washed hands, put on gloves, and gave an insulin injection into the abdomen of the resident without the cleaning the abdominal area first. In an interview on 01/25/2024 at 7:37 AM, Staff T stated they realized they had not used an alcohol swab to clean the abdominal area prior to giving the injection and that could allow bacteria to enter the skin.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Food temperatures and Transporting of Food> Food Safety regulations states temperatures are critical in preventing foodbo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Food temperatures and Transporting of Food> Food Safety regulations states temperatures are critical in preventing foodborne illness and monitoring the food's internal temperature is important and will help ensure a microorganism can no longer survive and food is safe for consumption. During an observation of the [NAME] tray line on 01/25/2024 at 11:29 AM, the temperature of the lettuce sitting on the counter was 40 degrees. Staff Y, Cook, had used the surveyor's thermometer to check the temperature and stated they usually used the temperature in the refrigerator as a guide rather than temping the cold food. On 01/25/2024 at 11:52 AM, Staff Z, Dietary Aide, transported fruit cocktail from the kitchen to the [NAME] unit without it being covered. When asked what the process was for transporting food, Staff Z stated they did not know. Staff Y stated they usually covered the fruit cocktail during transport. Staff J stated the fruit cocktail should have been covered. In an interview on 01/25/2024 at 11:55 AM, Staff Y, when asked about how often they took the temperature of the food, stated they don't have a thermometer and had asked many times for one. Staff J, Registered Dietician, left the area to get a thermometer. Staff Y stated they had not been taking the temperature of the food since COVID ended. <Sanitary Practices> During an observation on 01/25/2024 at 10:42 AM in the kitchen, Staff Z, Dietary Aide, wore gloves and pulled down their mask, drank from a mug, handled plates, and placed cake on them, scratched their neck and never changed their gloves or performed hand hygiene. In addition, Staff Z was not wearing a hair net as required. During an observation on 01/25/2024 at 10:53 AM, Staff Y coughed into their hands, performed no hand hygiene and handled serving utensils. During an observation on 01/25/2024 at 10:54 AM, Staff P made coffee and while a hair net was being worn, it did not cover all their hair. At 11:15 AM, Staff P got ice out of the ice machine and was not wearing any gloves. At 12:04 PM, Staff P handled tray tickets with gloves, served food, but had not performed hand hygiene or changed gloves in between tasks. During an observation on 01/25/2024 at 12:14 PM, Staff Z picked up papers from the floor, removed their gloves, and placed new gloves on, but did not performed hand hygiene prior to putting on new gloves. In an interview on 01/25/2024 at 11:01 AM, Staff P stated hair nets should be worn so that all hair is covered so the food does not become contaminated. In an interview on 01/25/2024 at 11:41 AM, Staff Z stated normally they removed their gloves to drink their coffee and then put the same gloves back on. Staff Z stated they should have changed their gloves to avoid cross contamination. Staff Z added they should have changed their gloves and performed hand hygiene after scratching their neck. In an interview on 01/25/2024 at 12:15 PM, Staff Y stated it's important to cover food when transporting to avoid contamination. Reference: WAC 388-97-1100 (3), 2980 Based on observation and interview, the facility failed to monitor the temperature of food being served, failed to ensure a resident's meal tray (9) was discarded timely, and failed to prepare food in a sanitary manner. These failures placed the residents at risk for food borne illnesses and decreased quality of life. Findings included . <Resident 9> A progress note dated 01/06/2024 at 10:40 PM, documented Resident 9's dinner tray was being left at bedside and resident would eat items from the tray and that was concerning since it had been sitting on the bedside table for quite awhile. On 01/21/2024, breakfast had been served at 7:45 AM. During an observation at 9:05 AM, Resident 9's breakfast tray was observed sitting untouched on their bedside tray table. At 10:07 AM, it was observed that the breakfast tray had been removed except for the hot cereal and orange juice. At 12:20 PM, the hot cereal and orange juice still remained on the bedside table untouched and the lunch tray had been delivered. At 1:04 PM, Resident 9 had consumed three quarters of their orange juice from breakfast, and all fluid and food from lunch meal was untouched with the cereal remaining on bedside table. In an interview on 01/21/2024 at 1:28 PM, Staff O, Nursing Assistant, stated all trays had been picked up and taken to the kitchen. During an observation immediately after this conversation, Resident 9's lunch tray was observed still sitting on the bedside table untouched along with their cereal from breakfast. During an observation on 01/22/2024 at 9:01 AM, Resident 9 was sitting in their recliner eating some breakfast. Subsequent observations on 01/22/2024 at 11:17 AM and 1:59 PM showed Resident 9's breakfast tray remained in the room which consisted of eggs, hashbrowns and hot cereal. During an observation on 01/23/2024 at 8:53 AM, Resident 9 was sitting in their recliner eating a few bites of eggs. Subsequent observation that same day at 11:14 AM showed the resident's breakfast tray was still sitting on the tray table and consisted of eggs, potatoes, sausage, gravy, and toast. On 01/23/2024 at 8:16 PM, the resident's dinner tray was on their tray table. In an interview on 01/25/2023 at 8:00 AM, Staff P, Dietary Manager stated they thought the trays could be left out and the food would be safe to eat for a half hour. In an interview on 01/25/2024 at 3:39 PM, Staff J, Registered Dietician, stated the meal would typically be placed in the refrigerator and served later. Staff J added food could be left out for an hour and would be safe to eat if it held it's temperature.

Jan 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure an injury of unknown origin was reported to the State Survey Agency as required, for 1 of 3 sampled residents (Resident 1), reviewed for abuse. Failure to report potential abuse placed Resident 1 and additional residents in the facility at risk for uninvestigated abuse, mistreatment, and poor quality of life. Findings included . Review of 09/28/2023 admission assessment showed Resident was unable to make themself understood and required substantial staff assistance for activities of daily living. Review of the facility incident log for October and November 2023 showed Resident 1 had a fall on 10/08/2023 that resulted in superficial skin injuries and a fall on 10/16/2023 with no injuries. No additional entries for Resident 1 were found on the logs. In an interview on 01/12/2024 at 4:44 PM, a representative for Resident 1 stated the resident was admitted to the facility September 2023 after a surgery to repair a fractured hip. Per the representative, they received a phone call from unidentified facility staff on 10/29/2023 that the resident was unable to get out of bed and had pain to their leg. The representative stated the resident was transferred to the hospital that day, where the leg was found to be dislocated and was manually relocated by hospital staff. Review of hospital records dated 10/29/2023 confirmed the resident arrived at the hospital from the facility with a dislocated hip and no recently reported falls. In an interview on 01/16/2024 at 3:38 PM, Staff A, Chief Nursing Officer, stated the facility investigated the incident and found Resident 1 did not have any falls after 10/16/2023, and there were no injuries related to that fall per a post-fall X-ray. Staff A stated the resident's dislocated hip was not reported because the facility provider did not feel it was uncommon or significant for a resident to have a hip dislocation after a hip surgery and because the resident was no longer in the facility when it was determined that the hip was dislocated. Reference: WAC 388-97-0640 (5) (a)

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure intravenous (IV) services were provided in accordance with professional standards of practice for 1 of 1 sample residents (Resident 2) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed the resident at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Review of the 10/14/2023 admission assessment for Resident 2 showed they received IV antibiotics. Per the assessment, the resident was cognitively intact and did not refuse care. Review of the home care instructions dated 10/13/2023 showed Resident 2 had a dual lumen (two separate working channels) PICC placed that day, that was 41 centimeters (cm), and the resident had an upper arm circumference above the PICC of 22cm. Per the instructions, the PICC should be flushed (injecting each cap of the PICC with 10 milliliters of normal saline using a push/pause method) daily and after medications, and the dressing over the insertion site and the cap should be changed weekly, or sooner if loose or dirty. Review of the comprehensive care plan, initiated 10/10/2023, showed no care plan had been developed or implemented that addressed the presence, management, or monitoring of Resident 2's PICC. Review of Resident 2's October and November 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no directions to staff to change the PICC dressing and cap, no directions to flush after medications, and no directions to monitor the resident for signs of infection or changes to the PICC. Further review showed an order to flush the PICC with 5 units of Heparin (a medication that prevents blood clots) each shift was started on 10/23/2023 (10 days after the insertion of the PICC). In an interview on 01/11/2024 at 4:20 PM, a representative for Resident 2 stated they saw the resident in the facility on 11/03/2023 with a dressing dated 10/13/2023 over the PICC line insertion site. The representative provided a photograph of the resident's PICC line dressing taken on 01/04/2023 at 1:32 PM with a label showing a date of 10/13/2023. In an interview on 01/16/2024 at 3:06 PM, Staff B, Resident Care Manager, stated facility nurses monitored the resident's PICC line with each IV medication administration, and documentation showing care and maintenance including dressing changes would be documented in the MAR and/or TAR. Staff B reviewed the resident's record and confirmed no documentation of weekly dressing/cap changes was available, and stated they would continue to review the resident record for documentation. No additional information was provided. In an interview on 01/16/2024 at 3:38 PM the same day, Staff A, Chief Nursing Officer, stated the facility did not have a policy specific to PICC line care and maintenance but the pharmacy utilized by the facility had a policy to perform dressing changes 24 hours after insertion, then every seven days or when dirty/loose. Staff A stated the policy required clarification. Reference WAC 388-97-1060 (3)(j)(ii)

Sept 2023 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0757 (Tag F0757)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure anticoagulant (AC) medication (medication that stops blood from clotting) side effects were consistently monitored for 3 of 4 sampled residents (Residents 1, 5 and 6), reviewed for unnecessary medications. This failure caused Resident 1 re-hospitalization and treatment to reverse blood thinning and placed additional residents at risk of experiencing medication side-effects and a diminished quality of life. Findings included . <Resident 1> Review of the 07/31/2023 admission assessment showed Resident 1 was severely cognitively impaired and had a diagnosis of irregular heart rhythm for which they took an AC medication. Review of the July 2023 and August 2023 Medication Administration Records (MARs) showed Resident 1 took Apixaban (an AC medication) twice daily from 07/26/2023 to 08/16/2023. The MARs and associated monitors did not show any documentation of monitoring for complications of AC use. In an interview on 08/31/2023 at 2:09 PM, Collacteral Contact 1 (CC1) stated the resident had signs of bleeding while in the facility including bruises, lacerations that would not stop bleeding, and bleeding in the urine. CC1 stated the resident was discharged from the facility on 08/16/2023 to the family's care, and was re-hospitalized within five hours after due to excessive bleeding. CC1 stated they had reported bloody discharge in the resident's brief twice while they were still in the facility, including in the days immediately prior to discharge. Review of a provider note dated 08/08/2023 showed laboratory (lab) work for Resident 1, per the resident's family reporting urinary symptoms, and no signs of infection were found. The note did not specify which urinary symptoms the family was referring to and the lab work did not include tests specific to blood clotting. Review of the nursing progress notes for August 2023 showed Resident 1 fell out of bed on 08/10/2023 around 4:30 AM and had frank blood (visible bright red blood) present under a scab to their right forearm and under a scab to their left knee, as well as blood present on the bed sheets. At 7:00 PM the same day the resident's knee was still bleeding, and the resident was sent to the hospital where a pressure bandage was applied. The resident returned to the facility at 11:00PM the same day. The bandage was removed on 08/12/2023 with no further bleeding from the left knee. Review of the nursing progress notes and provider notes for August 2023 showed no further monitoring and/or lab tests related to blood clotting/AC medication side effects. Review of the 08/16/2023 hospital records showed Resident 1 was admitted to the hospital the same day as they discharged from the facility with bright red blood in their urine, vaginal bleeding, and a significantly elevated PT/INR (Prothrombin Time Test and International Normalized Ratio, lab tests related to blood clotting) for which they received intravenous (IV) vitamin K. In an interview on 08/31/2023 at 3:00 PM, Staff H, Nursing Assistant, confirmed that Resident 1 had blood in their brief in the days prior to their discharge from the facility and they had not reported it to the nurse because it had already been reported by other staff members. Staff H stated if they were the first person to note bleeding of any source, they would report it to the nurse. At the same time, Staff G, Licensed Practical Nurse, was standing at the nurse's station and listening to Staff H's interview. They stated they were not aware of any concerns related to Resident 1 bleeding (after 08/10/2023). Staff G stated it should have been reported so the nurse could visually assess the resident to find the source of the bleeding, which could be urinary, rectal or from a cut to the skin. On 09/06/2023 at 9:40 AM, Staff E, Advance Registered Nurse Practitioner (ARNP), stated all residents who were on AC medications should be monitored (for adverse side effects), and since Resident 1 was on an AC medication they would have related documentation in the MAR. Staff E confirmed Resident 1 went to the hospital on [DATE] for uncontrolled bleeding after a fall and stated no lab work was performed at the hospital, or at the facility after their return, because the bleeding came under control with bandaging. Additionally, Staff E stated they did not speak directly with CC1 about their urinary concerns and were not aware of concerns for frank blood in the resident's brief. <Resident 5> Review of the July 2023 and August 2023 MARs showed Resident 5 took daily AC medication (Eliquis, Pradaxa, Lovenox) starting 07/14/2023. The MARs and associated monitors did not show any documentation of monitoring for complications of AC use. Review of the July 2023 and August 2023 nursing progress notes showed Resident 5 was monitored for AC use and had no adverse side effects from 07/14/2023 to 07/18/2023, with an additional monitor on 07/21/2023 and 07/23/2023. No further notes related to AC monitors were found after 07/23/2023. In an interview on 09/06/2023 at 9:40 AM, Staff E stated Resident 5 was started on a short-term AC medication during a hospital visit for a blood clot in their lower extremity, and was transferred to a long-term AC medication after the short-term medications were completed. Per Staff E, residents who took AC medications should have monitors in place for bruising and bleeding as AC medications increased the risk of bleeding. On 09/25/2023 at 12:55, Staff I, Registered Nurse, stated Resident 5 continued on a daily AC medication and had an order for daily monitoring initiated on 09/08/2023. An observation at 4:04 PM the same day showed Resident 5 had no signs of bleeding or bruising. <Resident 6> Review of the August 2023 MAR showed Resident 6 took a daily AC medication (Xarelto) for an irregular heart rhythm. The MAR and associated monitors did not show any documentation of monitoring for complications of AC use. Review of the August 2023 nursing progress notes showed no monitoring for AC use. In an interview on 09/25/2023 at 2:56 PM, Staff C, Resident Care Manager, stated when a resident admitted to the facility with an order for AC medications medical records staff would enter orders for nursing staff to monitor for adverse side effects. Per Staff C, if medical records did not identify the AC medication and enter orders for monitoring, it would be caught by the interdisciplinary team during a care plan review. Staff C reviewed Resident 6's record and confirmed no AC monitors were present. In an interview at 4:38 the same day, Staff A, Chief Nursing Officer, stated the facility identified concerns related to AC medication monitors on 09/08/2023 (after the surveyor interview with Staff E). Reference WAC 388-97-1060 (3)(k)(i)

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure the resident and/or the resident's representative was informed of and consented to a new medication for 1 of 3 residents (Resident 1), reviewed for care planning. This failure disallowed the resident and/or the resident representative to make an informed decision regarding treatment, and placed the resident at risk of diminished quality of life. Findings included Review of the 07/31/2023 admission assessment showed Resident 1 was severely cognitively impaired and needed assistance with decision making. Per the assessment the resident had diagnoses of fractures to their spine and anxiety. Review of a Durable Power of Attorney (DPOA; document that establishes who is in charge of a person's health or financial decisions), dated 12/16/2019, showed Resident 1 had a personal representative appointed to assist in their health care planning. Review of the 07/2023 and 08/2023 Medication Administration Records (MARs) showed an order for Depakote sprinkles (an anticonvulsant medication used to treat seizures, bipolar disorder, and/or migraines) was entered on 07/31/2023, and started on 08/01/2023. Per the MARs, the medication was for agitation. Review of the 07/2023 and 08/2023 progress notes showed no notes the resident's representative was notified of the initiation of the Depakote. A note dated 08/11/2023 (11 days after the medication was started) showed the Depakote dosage was increased that day, per the note resident and family aware. In an interview on 08/31/2023 at 2:33 PM, Resident 1's representative stated the resident took medication for their anxiety but had never previously taken Depakote, and neither they or the resident were aware of the risks/benefits of the medication. The representative stated they were not notified of the initiation of the Depakote and found out the name of the medication from paperwork provided by the facility after the resident was discharged . In an interview on 08/31/2023 at 2:03 PM, Staff B, Assistant Chief Nursing Officer, stated they were responsible for obtaining consent for psychotropic medications (medications that affect the mind, emotions and behaviors) that were present on admission to the facility and Resident Care Managers (RCMs) and/or the staff member who received the order were responsible for obtaining consent for medications started after admission. Staff B stated they were not involved in the consent process for Resident 1's Depakote. At 2:16 PM the same day, Staff A, Chief Nursing Officer, stated Staff F, Licensed Practical Nurse, was the staff member who processed the Depakote order on 07/31/2023, and either they or Staff C, RCM, were responsible for obtaining consent for the new medication from the resident representative. On 09/06/2023 at 9:40 AM, Staff E, Advance Registered Nurse Practitioner, stated they ordered the Depakote for Resident 1 due to fear and agitation that persisted despite non-medication interventions attempted, and they typically relied on facility staff to discuss psychotropic medications with resident representatives. Per Staff E the family was aware of dosage changes made to the Depakote, but did not clarify when or how the resident's representative was notified. In an interview on 10:13 AM the same day, Staff F stated they had not interacted with Resident 1's representative (to discuss the resident's medications). In an interview on 09/25/2023 at 2:56 PM, Staff C stated they notified resident representatives of changes when the processed medication orders. Staff C stated they did not enter the initial order for Resident 1's Depakote on 07/31/2023, and did not talk to the resident's representative until 08/11/2023, when they entered the order to increase the dosage. Reference WAC: 388-97-0300(3)(a), -0260(2)(a-d), -1020(4)(a-b)

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to provide the necessary care and services for 1 of 2 residents (Resident 6), reviewed for non-pressure skin wounds. Failure to perform wound treatments as ordered placed the resident at risk for delayed wound healing, worsening of wounds, and/or potential infection and a diminished quality of life. Findings included . Review of the skilled nursing transfer report, dated 08/07/2023, showed Resident 6 admitted to the facility from the hospital with a surgical wound to their lower leg, and had a specialty dressing that was not to be removed for 14 days. Review of the August 2023 progress notes showed on 08/13/2023 the skin below Resident 6's incision was red and had large fluid filled blisters. New wound care orders were given by an orthopedic specialist. Review of the August 2023 Treatment Administration Record (TAR) showed beginning on 08/13/2023 Resident 6 was to have daily wound care and and dressings. Further review showed no documentation that the ordered wound care was provided on 08/14/2023, 08/15/2023, 08/17/2023, 08/19/20023, or 08/21/2023. Further review of the August 2023 progress notes showed no documentation of wound care/dressing changes provided on the dates (listed above) that wound care was not documented in the TAR. In an telephone interview on 09/22/2023 at 2:17 PM a representative for Resident 6 stated the resident was admitted to the facility for wound care after a hospitalization, but did not receive adequate wound care, so the resident discharged home against medical advice for outpatient wound care managed by the family. The representative added that the resident's wound was healing with outpatient care. In an interview on 09/25/2023 at 1:33 PM, Staff F, Licensed Practical Nurse, stated Resident 6's dressing change was not scheduled on their shift, and if they had provided wound care to the resident it would be documented in the TAR. Staff F added that the resident was typically compliant and allowed necessary care unless they were sleeping, in which case staff would return at a later time to provide care. At 2:56 PM the same day, Staff C, Resident Care Manager, reviewed Resident 6's TAR and confirmed no wound care was documented on five different dates in August, after orders for daily dressing changes were entered, and they had no additional information related to the missing wound care documentation. Per Staff C wound care follow-up was done by Staff A, Chief Nursing Officer, and Staff B, Assistant Chief Nursing Officer. In an interview at 3:28 PM Staff A stated Staff C was responsible for Resident 6's wound care on one of the days no wound care was provided and did not know why the staff member was not able to provide additional information. Staff A further stated that Staff F was responsible for completing the wound care on three additional days no wound care was documented, but that the staff member did provide the care. Staff A was notified of the above interview with Staff F where they stated they did not perform Resident 6's wound care; Staff A did not provide a response. Reference: (WAC) 388-97-1060 (1)

May 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely implement recommendations of the dental provider and to provide required follow-up dental services for one of three sampled residents (Resident 2), reviewed for dental services. This failure placed the resident at risk for continued dental problems and a diminished quality of life. Findings included . Review of the quarterly assessment dated [DATE] showed Resident 2 had an obvious likely cavity and/or broken tooth and mouth/facial pain. Per the 01/25/2023 care plan, facility staff were to coordinate arrangements for Resident 2's dental care, including transportation. On 04/20/2023 at 9:14 AM, Resident 2's dental provider stated the resident was unable to receive a necessary dental extraction at their most recent appointment. Per the provider, the resident had been prescribed antibiotics for a tooth infection, which the resident was dependent upon the facility to provide, but the resident had not been given the antibiotics. The provider also stated they had concerns about communication with the facility. Review of the April 2023 dental provider notes showed on 04/14/2023, the resident was assessed at the dental clinic for a tooth abscess. Per the notes, an antibiotic had previously been prescribed by the facility (Keflex), but the resident still had swelling so a different antibiotic was ordered (Amoxicillin); the resident was to return for a tooth extraction. On 04/19/2023 the resident returned to the dental clinic, but was unable to have the required tooth extraction due to not starting the Amoxicillin, which resulted in an inability to numb the tooth. Per the notes, the Amoxicillin was once again ordered, and the resident was to return after a few days. Review of the April and May 2023 nursing progress notes showed the following: - On 04/19/2023, the resident started the ordered Amoxicillin. There were no previous notes showing why it was not started after the initial order on 04/14/2023. - On 04/25/2023, the resident continued to have tooth pain which required pain medication to manage. There was no information regarding follow-up dental appointments. - On 04/29/2023, the resident reported their jaw was hard to open, it was difficult and painful to chew food, and there was a slight lump to the left of the cheek near the infected tooth. There was no additional information showing either the medical or dental provider was notified of the resident's condition, or plans to continue following up with dental care. - On 05/02/2023, the staff were unable to give the resident their Amoxicillin, as it was not available. There was no information regarding the resident's dental status. - On 05/09/2023, the resident had not received their antibiotic for the last four days, and the medication was discontinued. There was no information regarding the resident's dental status and/or orders related to a follow-up dental appointment for the tooth extraction. Observation on 05/09/2023 at 2:57 PM showed Resident 2 was lying in bed. They stated at their last appointment the dental provider was unable to deaden the tooth enough to perform the extraction, and they still needed a follow-up appointment to perform the procedure. The resident stated facility staff were to make their dental appointments and arrange transportation. When asked about pain, they stated they were still having intermittent pain, which was reported to staff. In an interview the same day at 3:20 PM, Staff C, Transport/Scheduling, stated when Resident 2 returned from their previous appointments all paperwork regarding follow-up appointments and ordered medications were given to the nurses, who would then let them know what additional services the resident needed scheduled. Per Staff C, the resident was supposed to go back to the dentist (for their procedure) but they did not have any additional information about whether an appointment had already been completed or was scheduled for the future. At 3:29 Staff B, Director of Nursing, was asked for additional information regarding the resident's antibiotics, current dental status, and upcoming dental appointments. At 4:43 PM, Staff B stated Resident 2 still had dental needs but had completed their antibiotics and an appointment had been made for follow-up with the dental clinic. There was no additional information provided about the delay in starting the ordered antibiotics (on 04/14/2023). In an interview at 4:50 PM on 05/09/2023, a representative of the dental clinic stated a follow-up appointment for Resident 2 had been made within the last 10 minutes (after the surveyor questioned the facility). Reference WAC 388-97-1060 (1), (3)(j)(vii)

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report a COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness]) outbreak within the facility, which affected 12 residents and seven staff, to the State Survey Agency, as required. This failure placed facility residents at risk for spread of a communicable disease, related to the State Survey Agency not being able to review the facility's infection prevention measures during a COVID-19 outbreak in a timely manner. Findings included . Per the Code of Federal Regulations (CFR 483.80) facilities must establish an infection prevention and control program that includes a system for reporting communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arragnement. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, a communicable disease outbreak was to be reported to the State Survey Agency and the Washington State Department of Health. Observation during the entrance to the facility on [DATE] at 11:50 AM showed carts with personal protective equipment (PPE) were placed throughout the hallways and signs were hung on multiple room doors documenting that visitors must check in with facility staff before entering. When asked about the signs, Staff B, Director of Nursing, stated the facility currently had residents who were positive for COVID-19 residing within the facility, and the signs indicated which resident rooms required additional precautions. Staff B stated one resident (Resident 4) was positive for COVID-19 after a hospital admission, one resident (Resident 5) tested positive after a community outing, and several additional residents had tested positive on Sunday 05/07/2023. Review of the Respiratory Surveillance Line List dated 04/25/2023 and 05/07/2023 showed 12 residents had recently tested positive for COVID-19, beginning with Resident 4 on 04/23/2023. Additionally, the spreadsheets showed seven staff also tested positive since the beginning of the outbreak. In a follow-up interview at 4:27 PM the same day, Staff A, Administrator, stated the current outbreak was reported to the local health jurisdiction and resident representatives, but was not reported to the State Survey Agency, as required. Reference: (WAC) 388-97-1320

Oct 2022 11 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess and document pain levels and administer pain medication timely as ordered/needed for 1 of 3 sampled residents (267), reviewed for pain. These failures caused actual harm to the resident, who experienced inadequate pain control and a diminished quality of life. Findings included . An admission assessment dated [DATE] showed Resident 267 was cognitively intact and had diagnoses including fracture of right tibia and fibula (bones in the lower leg) requiring surgical repair, and diabetes. A pain assessment completed by a registered nurse on 10/18/2022 showed the resident had verbally reported frequent significant pain at a level of 7 on a scale of 0 to 10 (0 meaning no pain, and 10 the worst pain a person could experience), which was rated on a pain severity scale. The assessment also showed the resident's acceptable level of pain was 5. The same assessment showed the pain the resident was experiencing interfered with their ability to rest, sleep, dress themselves, and perform personal hygiene. The direction listed on the pain assessment was to notify the physician if the resident scored 3 to 4 out of 10 on the pain severity scale. No documentation of any medical provider being notified of the pain level of 7 was found. Resident 267's initial care plan had a goal for the resident to express their pain as controlled, and included interventions to manage pain such as anticipating the need for pain relief and responding immediately to any report of pain. During an observation on 10/24/2022 at 4:48 PM, the resident reported a pain level of 8 out of 10 to Staff U, Nursing Assistant, and asked Staff U to tell the nurse that they needed pain medication. Staff U was observed to report the pain indicator of 8 to Staff V, Registered Nurse. Staff V entered Resident 267's room at 4:55 PM with medication. During an interview on 10/25/2022 at 9:10 AM, Resident 267 stated that the nursing staff usually asked about their pain level, but then waited too long to bring the medication, and their pain was out of control. The resident went on to say they had asked for pain medication from a nursing assistant during the previous night shift (evening of 10/24/2022 into early morning of 10/25/2022), and then waited outside their room in their wheelchair. When the nurse did not come, the resident used their wheelchair to go up to the nurses' station and ask for pain medication again. The resident reported they received the pain medication about 6:00 AM, but the nurse did not ask about their pain level, and the resident stated they were upset because the nurse just gave them the medication and walked away. The resident stated it had been about seven hours since they had pain medication, and that the pain was really bad, and had woken them from sleep. On 10/26/2022 at 11:26 AM, Resident 267 was observed in their wheelchair with Staff W, Physical Therapy Aide, at the nurses' station telling Staff S, Registered Nurse, that their pain was a 7 out of 10 and they needed a pain pill. Staff S stated that they were aware that the resident needed pain medication, but the resident's supply of pain medication was gone. The resident stated the night nurse had given them one tablet that morning instead of two and told them it was because their pain medication was gone, and they thought the staff would have gotten the medication by that time. Resident 267 then stated that they had called the hospital where they had surgery to get more pain medication, but they were told they would have to go to the hospital to pick it up, and that they were in pain and needed the medication. Staff S then stated, that is not how it works, and stated that they would try and go find another nurse to figure out how to get a narcotic pain medication from the building supply. Resident 267 was visibly upset during the conversation and spoke with an elevated tone and facial grimace. During an interview with Staff S, Registered Nurse, just after the conversation above, they stated that they were an agency nurse and were not sure how to get narcotic pain medication from the building supply. They said they were aware the resident was out of pain medication but had not had time to figure out how to get the medication. Review of Resident 267's active physician orders from 10/18/2022 until 10/26/2022 showed one order for Norco tablets 10-325 milligrams (a pain medication with a narcotic and acetaminophen combined), with the direction to give one tablet by mouth every four hours as needed for pain, related to the resident's diagnosed right lower leg injury and subsequent surgery. Another physician order showed the same narcotic pain medication, with the order to give two tablets every four hours for the same injury. No further direction for how to determine when to give one or two tablets was written in the order. Resident 267's October 2022 Medication Administration Record (MAR) was reviewed on 10/26/2022 and 10/27/2022 and included an entry for staff to assess the resident's pain, using the 0 to 10 pain severity scale, prior to administration of pain medication. The MAR showed recorded pain levels of 4 to 8 out of 10. Another section of the MAR directed nursing staff to assess the resident's pain level each shift, and report pain that was not controlled to the resident's acceptable level to the medical provider. This section had recorded pain levels of 0 to 8 without a time associated with the pain assessment, and no indication the medical provider had been notified of pain levels greater than 5 (the resident's acceptable level of pain), which had occurred 7 times. The section listing non-medication interventions to attempt prior to administering pain medication was blank. Further review of Resident 267's MAR showed a pain level of 5 recorded prior to administration of pain medication on 10/24/2022 at 4:54 PM, when the resident was observed to have reported a pain level of 8. The next pain medication was not administered until 6:15 AM the morning of 10/25/2022 (greater than 13 hours later), where a pain level of 4 was recorded (when the resident stated when interviewed [see above] that the nurse had not asked about their pain level). On 10/26/2022, when the resident was overheard to have run out of pain medication, one pain medication tablet was recorded administered at 5:27 AM, with a pain level of 7 recorded. The next administration of pain medication was recorded at 12:21 PM (almost 7 hours later), and 45 minutes after the resident was observed to report a pain level of seven, with a pain level of 8 recorded. No indication of a medical provider being notified of the resident's pain level above 5 was found, as per order. During an interview on 10/27/2022 at 9:32 AM, Staff G, Resident Care Manager, stated that a pain assessment which indicated frequent significant pain, and a level of 4 to 8 during pain assessments, prior to pain medication administration, did not seem like an acceptable level of pain control, especially if it was waking the resident up at night. They went on to say that usually the floor nurses would notify the physician or nurse practitioner if a resident did not have good pain control, but they were not aware of either medical provider having been notified of Resident 267 having inadequate pain control. During an interview on 10/27/2022 at 10:40 AM, with Staff W, Physical Therapy Assistant, they stated that they had been working with Resident 267 for a couple of days and the resident had been having some issues with pain. They continued to state that the day before, the resident had run out of pain medication, was in significant pain, and declined therapy sessions a couple times because of pain. Staff W stated it seemed like Resident 267's pain level was on the high side. During an interview on 10/27/2022 at 10:10 AM, Staff E, Nurse Practitioner, stated that they had been made aware by Staff G that Resident 267 was reporting unresolved pain, and they would start another medication. Staff E further stated that Resident 267 had told them that they had been shot five times in their past, and the pain they were experiencing was different and worse. Reference: WAC 388-97-1060 (1)

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop thorough policies, and implement abuse and neglect prevention policies and procedures including, identifying, reporting, and investigating abuse, and protection of residents after verbal reports of rough handling during care were made, for 2 of 4 sampled residents (39, 31), reviewed for abuse. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs. Findings included . A revised 07/13/2018 facility policy and procedure titled Preventing Abuse showed: Procedure - Prevention - (2) (c) Observe residents, visitors and staff to identify inappropriate behaviors, such as using derogatory language, rough handling, taking or using photographs or recording in any manner that would demeanor humiliate a resident(s), etc. The policy and procedure showed instructions to the staff regarding the observation of rough handling. Further review of the policy showed no instruction to staff on how to address verbal reports of abuse. A revised 07/23/2019 facility policy and procedure titled Detecting Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin showed: Procedure - Protection of resident during and after an investigation - (2) A staff member(s) implicated in an abuse/neglect situation, regardless of discipline, is: a. Immediately remove from any resident contact. b. Interview and version of event documented. c. Suspend pending investigation result. Procedure - Investigate - (4) (d) Interview and obtain alleged perpetrator's version of the situation. Procedure - Report/Response - (1) (c) Other officials in accordance with state regulations through established procedures (including to the State survey and certification agency and law enforcement as indicated). RESIDENT 39 Review of the 09/24/2022 admission assessment showed Resident 39 required extensive assistance from staff with toilet use, personal hygiene, and bed mobility. In addition, the assessment showed that the resident had severe cognitive impairment but was able to make their needs known. On 10/25/2022 at 9:42 AM, Resident 39 stated that one staff member was rough during peri area care, but the resident couldn't recall the name of the staff or the exact date of the incident. Resident 39 stated they did not inform facility staff. Review of the resident records showed no documentation that the facility was aware of the incident. RESIDENT 31 Review of the 09/15/2022 admission assessment showed Resident 31 had no cognitive deficits, and made decisions regarding their care. On 10/25/2022 at 11:04 AM, Resident 31 stated that two staff were rough during a skin check assessment. The resident couldn't recall the exact date of the incident but stated it was about two weeks ago. The resident declined to name the staff involved in the incident. Resident 31 stated they did not inform facility staff. Review of resident records showed no documentation that the facility was aware of the incident. Review of the facility grievance and incident logs from April 2022 through October 27, 2022 showed no documentation regarding the reported incidents, for either Resident 31 or 39. Failure to identify and report: On 10/25/2022 at 11:44 AM, Staff A, Administrator, was informed of the allegations of rough handling during care from Residents 39 and 31 by the survey staff. In a follow-up interview on 10/26/2022 at 11:25 AM, Resident 31 stated Staff D, Social Services Director, asked about the incident. Resident 31 informed Staff D that they felt they had been abused. On 10/27/2022 at 8:30 AM, a review of the State Agency internal reporting system, showed that the facility had not reported the allegation of abuse made by Residents 39 and 31, as required. Failure to investigate and protect In a follow-up interview with Staff A on 10/27/2022 at 8:50 AM, Staff A stated during the interviews with residents, two staff were identified (Staff M and Staff L, Nursing Assistants) as the alleged perpetrators, but the facility didn't feel the allegations rose to the level of abuse that required the facility to conduct a full investigation or necessitated the suspending of Staff M and L. Staff A further stated that there was no written investigation and that they would type one out. On 10/27/2022 at 12:00 PM, Staff A provided the facility investigation regarding the allegations of abuse. When asked if Staff M and L had been taken off the work schedule, Staff A stated they had. Staff A further explained that Resident 31 and 39 stated it was rough, not abuse. On 10/27/2022 at 12:50 PM, Staff M was observed assisting residents in room [ROOM NUMBER] and 403. Review of the facility investigation showed it was undated and did not include the specific details that had been reported to the facility by the surveyors, nor did the interviews of Residents 39 and 31 reflect the details that had been reported to Staff A. In addition, there was no documentation to show Staff M and L had been interviewed. Aside from the interviews of Resident 39 and 31, the only other documentation was undated interviews from 12 residents, which very not thorough. The facility concluded that abuse and neglect could not be substantiated. Review of the staffing schedules from 10/24/2022 through 10/28/2022 showed Staff M worked 12-hour shifts, on both 10/26/2022 and 10/27/2022. Reference: (WAC) 388-97-0640 (2)

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to report resident verbal reports of rough handling during care as an allegations of abuse for 2 of 4 sampled residents (39, 31), reviewed for abuse. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs. Findings included . RESIDENT 39 Review of the 09/24/2022 admission assessment showed that Resident 39 had severe cognitive impairment but was able to make their needs known. Resident 39 reported to surveyor, during the initial interview on 10/25/2022 at 9:42 AM, that one staff member was rough during care. RESIDENT 31 Review of the 09/15/2022 admission assessment showed that Resident 31 had no cognitive deficits and made decisions regarding their care. Resident 31 reported to the surveyor, during the initial interview on 10/25/2022 at 11:04 AM, that two staff members were rough during an assessment. On 10/25/2022 at 11:44 AM, Staff A, Administrator, was informed of the allegations of rough handling during care, from Residents 39 and 31. On 10/27/2022 at 8:30 AM, a review of the State Agency internal reporting system showed that the facility had not reported the allegation of abuse made by Residents 39 and 31, as required. On 10/27/2022 at 08:59 AM, Staff D, Social Services Director, explained that after being aware of any allegation, they would conduct interviews with the residents and ask clarifying questions; then they would meet with the Administrator and Director of Nursing to make a team decision regarding whether or not to report the allegations. On 10/27/2022 at 09:40 AM, Staff B, Director of Nursing, explained that they referred to the Purple Book (Guideline Nursing Homes can use for the prevention, identification, investigation, and reporting of abuse and neglect of residents), when making a decision to report allegations to the State Survey Agency. Staff B further explained that Staff D would conduct the initial phase of the investigation by asking clarifying questions. Staff B further explained that that process would allow the facility to decide whether the allegation should be reported or not. Staff B explained that if the resident was not feeling safe, the facility would offer alternative options to the resident, like offering a different room/floor, and that the facility would also discuss a discharge plan. In a follow-up interview with Staff A on 10/27/2022 at 8:50 AM, Staff A stated that the facility didn't feel the allegations rose to the level of abuse. On 10/27/2022 at 12:00 PM, Staff A explained that Resident 31 and 39 stated it was rough, not abuse. The facility did not call in the allegations of rough handling, which fit the criteria for allegations of abuse, as required. Please refer F 607 for more information. Reference: WAC 388-97 -0640(5)(a)

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to thoroughly investigate resident verbal reports of rough handling during care as allegations of abuse for 2 residents of 4 sampled residents (39, 31), reviewed for abuse. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs. Findings included . RESIDENT 39 Review of the 09/24/2022 admission assessment showed that Resident 39 had severe cognitive impairment but was able to make their needs known. Resident 39 reported to surveyor during initial interview on 10/25/2022 at 9:42 AM that that one staff was rough during care. RESIDENT 31 Review of the 09/15/2022 admission assessment showed that Resident 31 had no cognitive deficits and made decisions regarding their care. Resident 31 reported to surveyor during initial interview on 10/25/2022 at 11:04 AM, that two staff members were rough during an assessment. On 10/25/2022 the facility was made aware of Resident 31 and 39's allegations. The allegations were reported to Staff A, Administrator, by the surveyors. In a follow-up interview with Staff A on 10/27/2022 at 8:50 AM, Staff A stated that the facility didn't feel the allegations rose to the level of abuse that required the facility to conduct a full investigation. The facility had no written investigation, but Staff A stated upon questioning by the survey team that they would type one out. On 10/27/2022 at 12:00 PM, a facility investigation was provided to surveyors by Staff A. A review of the facility investigation consisting of five pages and 12 resident interviews, showed no documentation of interviews with the alleged perpetrators. Upon further review of the investigation documents, no allegations were identified. The investigation documents contained minimal information regarding the allegations, alleged victims, and alleged perpetrators. The interviews with alleged victims did not reflect the allegations. The interviews with the other 12 residents were composed of four questions (Have you ever been abused? Have you ever witnessed someone being abused? Do you feel safe? Would you like to share anything else with me?). The questions of rough handiling when receiving care was not asked. The documented residents responses to the questions were yes or no. No interviews were dated or signed by any staff members or residents. The investigation documents showed that the two investigations had been combined into one. The facility concluded that abuse and neglect could not be substantiated. Please refer F 607 and F 609 for more information. Reference (WAC) 388-97-0640(6)(a)(b)

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide grooming for 1 of 3 sampled residents (40), reviewed for activities of daily living. This failure placed the resident at risk for poor personal hygiene and a diminished quality of life. Findings included . According to the 09/20/2022 quarterly assessment, Resident 40 had severe cognitive impairment and needed assistance from one staff to complete activities of daily living, such as grooming. Observations of Resident 40 while sitting in their wheelchair with unshaved facial stubble were made on 10/24/2022 at 3:30 PM, 10/24/2022 at 4:41 PM, 10/25/2022 at 8:49 AM, and 10/26/2022 at 9:16 AM. In an interview on 10/27/2022 at 10:13 AM, Staff N, Nursing Assistant, stated residents were shaved on their bath days. Staff N further stated if the resident refused, then they would re-approach, and any refusals were documented in the resident's record. Review of Resident 40's bathing and grooming records from 10/24/2022 through 10/26/2022 showed the resident was bathed on 10/24/2022, and no refusals for assistance with shaving were documented. In an interview on 10/27/2022 at 10:59 AM, Staff F, Resident Care Manager, confirmed residents should be shaved on their bath days and any refusals documented in their record. Reference: (WAC) 388-97-1060 (2)(c)

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 267 According to an admission assessment dated [DATE], Resident 267 was cognitively intact, and had diagnoses including fracture of right tibia and fibula (bones in lower leg) with surgical repair, and diabetes. In an interview on 10/25/2022 at 9:44 AM, Resident 267, stated that they had broken their right lower leg and had surgery to repair the broken bones. During the interview, the resident was observed laying in bed with an orthopedic boot (a boot used to protect broken bones and other injuries of the lower leg, ankle, or foot) on their right lower leg. A compression wrap (used to put pressure on an affected body part to help improve circulation and reduce swelling) was visible at the resident's toes extending up the leg to just above the resident's knee. When asked how many incisions there were, the resident stated they did not know, and that no one had looked at the incisions or changed any dressings since their arrival on 10/18/2022 (7 days prior). On 10/25/2022 during record review of the resident's hospital discharge paperwork an order was found for knee wound and dressings, with direction to change if dressing is soiled. Upon review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) no order was found for dressings, treatment, or monitoring of surgical sites or wounds. On 10/26/2022 at 11:26 AM, Staff S, Registered Nurse, stated that they were unaware of any wounds or surgical incisions for Resident 267, and that there were no orders on the resident's MAR or TAR for any monitoring or wound care. On 10/27/2022 at 9:10 AM, Staff T, Registered Nurse, stated that they assumed there was a surgical incision somewhere on the resident's right leg because of their injury, but that there was no direction on the resident's MAR or TAR on day or night shift to monitor, assess, or treat any wounds or surgical incisions. Staff T stated that this was not typical and there should be direction to look at or have some kind of treatment for a surgical incision. On 10/27/2022 at 9:32 AM, Staff G, Resident Care Manager, stated that they did not know if Resident 267 had surgical incisions or treatments in place, or what kind of dressing they had. Staff G stated that residents had skin checks weekly and that would be recorded on the skin check. Record review of Resident 267's skin inspection evaluations completed on 10/18/2022 and 10/25/2022 showed a notation of surgical incision to RLE (right lower extremity) and right outer ankle surgical incision. No measurement or assessment of the wounds or incisions was found. Record review of Resident 267's progress notes and admission records showed no documentation of location, size, or condition of any surgical incisions or wounds. On 10/27/22 at 10:10 AM, Staff E, Nurse Practitioner, stated that the hospital surgeon usually gives really specific direction for dressing changes but the direction they could see from the hospital for Resident 267 was not typical. Staff E stated that the facility nursing staff should have some direction to monitor and provide treatment to any wounds or incisions on the right leg, especially because the resident was diabetic. An order for a dressing change for the resdient's right lower leg was placed with date to start of 10/27/2022 by Staff E. On 10/27/2022 at 5:33 PM a nursing progress note was completed showing the resident refused assessment and dressing change to the incisions and wounds on their right lower extremity. Per email communication with Staff B, Director of Nursing, the resident continued to refuse assessment or dressing changes to their right lower extremity until 10/31/2022 when they saw their medical provider in the community. On 10/31/2022, the orthopedic provider in the community wrote a note indicating the resident's incisions were healing with no signs or symptoms of infection present. Reference (WAC): 388-97-1060 (1). RESIDENT 25 Review of an 08/30/2022 quarterly assessment showed Resident 25 admitted to the facility on [DATE] with medically complex conditions. The assessment showed Resident 25 had severe cognitive impairment and required two people assist for most activities of daily living. Review of a 06/01/2022 comprehensive care plan showed the staff identified Resident 25, has the potential for constipation r/t [related to] decreased mobility, diminished appetite . [and] medications side effects. The care plan showed a goal that Resident 25 would, have a normal bowel movement at least every (2-3) days. The care plan instructed the staff to, Follow facility bowel protocol for bowel management. Review of Resident 25's October 2022 Mecidation Administration Record (MAR) showed orders to administer Milk of Magnesia (MOM, a laxative), if the resident did not have a bowel movement (BM) for two days. The MAR instructed the staff to administer a Dulcolax (laxative) suppository if there was no BM 24 hours after administering the MOM, and an enema if there was no BM 24 hours after the Dulcolax suppository administration. Review of Resident 25's BM records showed there were no BMs on 10/10/2022, 10/11/2022, and 10/12/2022. Review of the October 2022 MAR showed no documentation the staff implemented the bowel protocol as ordered on 10/12/2022. Review of Resident 25's BM records showed there were no BMs on 10/16/2022, 10/17/2022, 10/18/2022, and 10/19/2022. Review of the October 2022 MAR showed no documentation the staff implemented the bowel protocol as ordered on 10/18/2022 or 10/19/2022. The above findings were shared with Staff G, Resident Care Manager, on 10/27/2022 at 11:05 AM. Staff G acknowledged the staff did not but should have implemented the bowel protocol orders as instructed on 10/12/2022 and 10/18/2022. Review of the October 2022 MAR showed an order for Miralax (a laxative) to be administered by mouth as needed. Staff G was asked when did staff decide to give the Miralax as needed. Staff G stated that the order did not show when the laxative should be administered by the staff and that it should be clarified. Based on observation, interview, and record review, the facility failed to implement bowel protocol orders as instructed for 1 of 5 sampled residents (25), reviewed for unnecessary medications. In addition, the facility failed to ensure care and services were provided for 2 of 4 sampled residents (43, 267) reviewed for non-pressure skin conditions. Failure to treat Resident 25's constipation, consistently monitor blood pressure for Resident 43, and obtain wound care orders for Resident 267 placed the residents at risk for clinical complications and unmet care needs. Findings included . RESIDENT 43 Per the 09/20/2022 annual assessment, Resident 43 had diagnoses of high blood pressure and took a diuretic (a medication used to help the body get rid of excess fluid by producing more urine), daily. Observations on 10/24/2022 at 3:44 PM, 10/25/2022 at 8:51 AM, 10/26/2022 at 9:18 AM and 10:59 AM showed the resident sitting in their wheelchair beside their bed; both feet were without shoes, socks and were edematous (swelling that is caused from excess fluid). Review of the Order Summary Report, showed on 10/05/2022, the physician prescribed a diuretic daily to treat the edema, and nursing staff were instructed to take the resident's blood pressure prior to administering the medication, and to hold the medication if the systolic value (a measurement of the pressure of the heart's arteries during heart beats) was less than 90. Review of the resident's record on 10/27/2022 at 7:51 AM, showed the resident had received the diuretic daily as ordered. In addition, the documentation showed the resident's blood pressure had only been taken on 10/08/2022, 10/09/2022, 10/18/2022, and 10/19/2022, (four times out of the 22 times the medication had been given). In an interview on 10/27/2022 at 9:41 AM, Staff O, Registered Nurse, stated the blood pressure should be taken prior to administering the diuretic. Staff O stated a daily vital sign sheet was used as well, but the values should be documented in the resident's record. On 10/28/2022 at 10:54 AM, after review of Resident 43's record and Medication Administration Record (MAR), Staff F, Resident Care Manager, confirmed the blood pressure had not been taken as instructed.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to show adequate indication for the use of a seizure medication for 1 of 5 sampled residents (25), reviewed for unnecessary medications. This failure placed the resident at risk for receiving an unnecessary medication, and its adverse outcomes. Findings included . Review of an 08/30/2022 quarterly assessment showed Resident 25 admitted to the facility on [DATE] with medically complex conditions, to include cardiac diagnoses, dementia, and psychiatric disorders. The assessment showed Resident 25 had severe cognitive impairment. Review of the October 2022 Medication Administration Record (MAR) showed an order for Gabapentin (a seizure medication) Tablet, by mouth at bedtime for -. The Gabapentin order showed a start date of 05/28/2022, the day of Resident 25's admission to the facility, and no indication for its use. The MAR showed the staff administered the Gabapentin every night at bedtime. Review of a 09/06/2022 physician progress note showed no mention of the presence of Gabapentin in Resident 25's medication regimen, or why it was being administered by the staff. On 10/27/2022 at 11:16 AM, Staff G, Resident Care Manager, stated, Oh, I see a dash there. We need a diagnosis for it. No further information was provided to show why the staff administered the seizure medication to Resident 25. Reference (WAC): 388-97-1060 (3)(k)(i).

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. Three medication errors were identified for 2 of 3 sampled residents (78,16), observed during 29 medication opportunities, resulting in a medication error rate of 10.34 percent. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication. Findings included: RESIDENT 78 On 10/25/2022 at 9:17 AM Staff P, Licensed Practical Nurse, was observed to administer one 450 milligram (mg) Cranberry tablet and one 81 mg. enteric coated aspirin (a medication which had a special coating that prevents release and absorption of contents until it reaches the small intestine) to the resident. On 10/26/2022 at 10:45 AM Staff Q, Registered Nurse, was observed to administer one 81 mg. enteric coated aspirin to the resident. When the order for the Cranberry tablet was reviewed by the nurse, they recognized they did not have the correct dose per the physician order and spoke with Staff R, Central Supply, to see if the ordered dose could be obtained. Staff R stated that they would research the order for the resident and get back to Staff Q. Review of physician's orders and resident's Medication Administration Record (MAR) showed the ordered dose for the Cranberry tablet was 600 mg. In addition, the aspirin was ordered to be chewable (absorbed primarily through the mouth and stomach), not enteric coated. RESIDENT 16 On 10/26/2022 at 11:02 AM Staff Q, Registered Nurse, was observed to administer one 81 mg. enteric coated aspirin to the resident. Review of the physician's orders and the resident's MAR showed the order was for one 81 mg. chewable aspirin. Staff Q was observed during the medication pass between 10:45 to 11:10 AM on 10/26/2022 to continually open and close drawers of the four-drawer medication cart searching for medications, and frequently making comments they were unable to locate the correct dose of over-the-counter medications. They stated that they were the Minimum Data Set (MDS) Registered nurse (the nurse who completes assessments for residents using facility data), and had not worked on that cart for a long time. On 10/26/2022 at 1:35 PM Staff R, Central Supply, stated that the facility had 450 mg. doses of the Cranberry tablets, and that the 600 mg. ones had not been in stock, and could not be ordered. Staff B, Director of Nursing, then showed the surveyor a printed set of orders dated 07/25/2022 with a handwritten note in margin - change to house stock 450 mg next to order for Cranberry tablet 600 mg. When asked if the resident had been getting 450 mg since admission or the 600 mg, they said the 450 mg. Reference (WAC): 388-97-1060(3)(k)(ii)

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean, comfortable, homelike, and safe environment for 3 of 17 rooms (211, 213, 106), sampled for a safe and sanitary environment. Failure to ensure that the facility was free from damaged walls and a broken door, placed the residents (25, 33, 38) at risk for injury and a decreased quality of life. Findings included . room [ROOM NUMBER]-A Observations on 10/24/2022 at 3:12 PM showed Resident 33 sitting between the bed and the wall. The wall showed areas of chipped paint. Resident 33 stated, The door can't close. It's broken. It gets worse each time they mess with it. It's been over a week now. That's a safety issue, it's a fire door. Observation of the door showed it closed half of the way. room [ROOM NUMBER]-B Observations on 10/24/2022 at 4:26 PM showed two unfinished and rough-to-touch white patches to the wall, next to an empty bed in Resident 25's room. The size of each of the identified areas was approximately 1 to 1 ½ feet by 4 inches. room [ROOM NUMBER]-2 Observations on 10/27/2022 at 8:10 AM showed Resident 38 in bed by the window. An empty bed occupied the other side of the room by the door. The wall that the empty bed was against showed thick scratch marks and gouged areas of approximately four feet wide. On 10/27/22 at 9:15 AM, environmental rounds were conducted with Staff K, Maintenance Director. Staff K acknowledged the walls were in disrepair and needed to be re-spackled and re-painted. Staff K stated that the facility was aware of the broken door to Resident 33's room since, last week. Reference (WAC): 388-97-3220 (1). .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to ensure multiple food items in the kitchen were properly labeled, and that out-of-date foods were identified and discarded. In addition, the facility failed to ensure unpasteurized eggs were not used for foods not fully cooked. The failure to properly label foods, ensure the visibility of Best By dates, and use pasteurized eggs, placed residents at risk for consuming expired/spoiled foods and exposure to food borne illness. Findings included . Observations of the kitchen showed: Unlabeled and expired food items Refrigerator observations on 10/24/2022 at 2:07 PM showed: 1. Three large unlabeled and undated items wrapped in aluminum foil on the lower shelf of the refrigerator. On 10/24/2022 at 2:09 PM, Staff I, Dietary Manager, stated that they were just cooked turkey meat and acknowledged the food items needed a Use By date. 2. An unopened large bag of unlabeled and undated greens. 3. Three bags of six English muffins per bag, with a Best By date of 08/2022, for a total of 18 expired muffins. Staff I stated, I'll throw it away here. 4. Six bags of bagels, a box full of Hawaiian buns and five bags of hot dog buns with no Best By date were observed. Staff I stated, I'll get rid of these. I didn't know. Are all the breads like that? On 10/24/2022 at 2:19 PM, Staff I was asked how staff knew when to discard food items, or how long to keep them in the refrigerator. Staff I stated, Two weeks after opened. I would want to see it gets used up within a week or two. Staff I stated that food items should show an expiration or Best By date and, Probably mark when we open it. Staff I acknowledged that the food items should be labeled with a Best By or Use By date, but were not. A follow-up visit to the kitchen pantry on 10/27/2022 at 8:22 AM showed observations of 10 unopened boxes of rice pilaf, 19 unopened boxes of corn muffin mix, four unopened boxes of corn bread mix, and four unopened boxes of pancake waffle mix, with no Best By or Use By dates. Staff I acknowledged the food items did not but should show a Best By or Use By date. Unpasteurized eggs On 10/24/2022 at 2:19 PM, Staff I was asked if there were any residents who preferred to have meals with their eggs not fully cooked. Staff I stated that Resident 38 consumed an egg-over-easy every morning. Observation of the refrigerated eggs showed three crates of eggs inside an opened and used box of eggs. Observation of the eggs and the box showed no indication that they were pasteurized eggs. Staff I stated, I didn't know about that. I didn't know that's what we should be looking for. On 10/27/2022 at 8:10 AM, Resident 38 was observed sitting up in bed. Staff served Resident 38 pancakes, cold cereal, bacon, and a fruit juice. Resident 38 stated that he ate an egg-over-easy, Maybe once a week. I had to fight for that. At first they told me, 'We can't fix 'em like that.' Resident 38 stated that staff served them egg-over-easy, Since November of 2021. I got here in September of 2021. On a follow-up visit to the kitchen on 10/27/2022 at 8:22 AM, the box of eggs observed on 10/24/2022 at 2:19 PM showed the words, DO NOT USE, written in a black marker and capital letters. When asked why the staff was instructed not to use the eggs anymore, Staff I stated, Because I was gonna' pull them out because I was unsure if they were pasteurized or not. Staff I stated that one of the kitchen staff served Resident 38 eggs-over-easy at least four days a week. No further information was provided to show the facility used pasteurized eggs when preparing eggs-over-easy for Resident 38. On 10/27/2022 at 11:35 AM, Staff J, Registered Dietitian, stated, No unpasteurized eggs should be in the facility refrigerator. Staff I stated that, The pasteurized eggs are now on order. Reference (WAC): 388-97-1100(3). .

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 26 According to a comprehensive admission assessment, dated 09/02/2022, Resident 26 had diagnoses which included diabetes and skin ulcers. The assessment further showed that the resident had moderately impaired cognition. A progress note, dated 09/01/2022 showed an admission care conference was attended by Staff D, Social Services, and the resident's family member. This note showed that the facility, Reviewed Durable Power of Attorney and concluded that it was, Accurate. A review of the resident's record showed the Physician Order for Life-Sustaining Treatment (POLST, which is an order for emergency medical care) was signed on 08/29/2022 by the family member who attended the care conference. A Psychosocial History form provided by Staff D, under the heading of POA/Living Will, showed working on POA-coming down tomorrow. This form did not have a date. There were no Power of Attorney (POA) documents found in the resident's medical record, nor was there any mention that the facility had requested POA documents. Resident 47 According to a comprehensive admission assessment, dated 10/04/2022, Resident 47 had diagnoses of infection in the tissue of their legs and their urinary tract. The assessment further showed that the resident had severely impaired cognition. A progress note, dated 10/04/2022 showed that an admission care conference was attended by Staff D, the resident, and the resident's family member. This note showed that the facility, Reviewed Durable Power of Attorney and concluded that it was, Accurate. A review of the resident's record showed that the POLST was signed on 10/04/2022, by the family member who attended the care conference. A Psychosocial History form provided by Staff D, under the heading of POA/Living Will, showed Brother - POA. This form did not have a date, and only showed the resident's first name, not their last. There were no POA documents found in the resident's medical record, nor was there any mention that the facility had requested POA documents. During an interview on 10/28/2022 at 9:08 AM, Staff A acknowledged that the facility did not have POA documents for Residents 12, 25, 26, 33 and 47. No further documentation was provided. Vaccine Consents Review of a 04/25/2022 Vaccine Information Acknowledgment form (a consent record) showed Resident 33 declined to receive pneumonia vaccinations. Review of a 10/12/2022 Vaccine Information Acknowledgment form showed Resident 33 declined to receive the COVID-19 (a virus that can cause severe respiratory disease) booster vaccine. Both records showed Resident 33 did not sign the consents and that Staff C, Infection Preventionist, obtained a verbal consent instead. Staff C's signature was observed next to the words, verbal consent and Resident 33's written name. On 10/28/2022 at 11:55 AM, Staff C stated that Resident 33 did not sign the vaccine consent forms because the resident, wasn't real good as far as his signature. Staff C stated that Resident 33 had difficulty signing their name on both dates that they declined the vaccines. When asked how the facility showed on a consent that a resident's answers were accurate or reflected the resident's choice when the resident was unable to sign, Staff C stated, Two nurses would be in the room and the other nurse and I would sign. Staff C acknowledged the missing second staff signature to the vaccine consent form and stated, I guess I was thinking there wasn't any need for it. Reference (WAC): 388-97-1720 (1)(a)(i-iv)(b). Based on interview and record review, the facility failed to ensure residents' records had complete and readily accessible Advance Directives and Vaccination Consents for 6 residents (6, 12, 25, 26, 33, and 47) of 15 residents whose records were reviewed for Advance Directives and immunizations. This failure placed the residents at risk for unmet care needs. Findings included . Advance Directives Resident 12 Review of an 08/13/2022 comprehensive admission assessment showed Resident 12 admitted to the facility on [DATE] with medically complex conditions. The assessment showed the staff assessed Resident 12's cognition as moderately impaired. Review of an 08/10/2022 admission Care Conference note showed Resident 12 and their representative attended the care conference. This note showed the facility conducted a Review of Advance Directive and concluded the review was Accurate. Review of an 08/12/2022 Psychosocial History form showed the staff identified Resident 12 had a POA [Power of Attorney]/Living Will, and who the POA was. Review of the medical record showed no documentation of the presence of Advance Directives records for Resident 12, to include a Living Will or POA. Resident 25 Review of an 08/30/2022 quarterly assessment showed Resident 25 admitted to the facility on [DATE] with medically complex conditions. This MDS showed staff assessed Resident 25 had severe cognitive impairment. Review of a 06/01/2022 Care Conference record showed the facility, Reviewed Durable Power of Attorney (DPOA) - [family member] states [they have] POA, asked [them] to bring in copy. Review of a 06/17/2022 Care Conference record showed Resident 25 had an Advanced Directive and that the facility had a copy of it on file. This record showed the facility, Reviewed Durable Power of Attorney and concluded it was, Accurate. Review of the medical record showed no documentation of the presence of Advance Directives records for Resident 25, to include a Living Will or POA. Resident 33 Review of a 09/18/2022 comprehensive admission assessment showed Resident 33 admitted to the facility on [DATE] with medically complex conditions, to include dementia. This assessment showed Resident 33 was able to make their needs known. Review of a 07/07/2022 Care Conference Record showed the facility reviewed the status of Resident 33's Advance Directives and showed that Resident 33, believes [their family member] has a copy and will have [them] bring it in. This record identified who the DPOA was. Review of an undated Psychosocial History form showed only Resident 33's first name and no date of when the document was created. This document showed who Resident 33's POA was and that they would be, bringing in copies. Review of the medical record showed no documentation of the presence of Advance Directives records for Resident 33, to include a Living Will or POA.

Jun 2019 14 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure equal care was provided to two of two sample residents (#9, 56), reviewed on the Cabin Cove unit, who were dependent on staff for eating assistance. Failure to offer residents with developmental disabilities snacks in a manner consistent with their peers, placed them at risk for exclusion from standard care. Findings included . Observation of snack service on 06/19/19 from 10:14 AM to 10:22 AM showed Staff K, Nursing Assistant, did not stop and offer snacks to Resident #9 or #56. In an interview on 06/20/19 4:53 PM, when asked about who gets snacks, Staff L, Nursing Assistant on the evening shift, stated anyone who wants one. When asked about whether they offered Resident #9 and Resident #56 a snack, she stated they did not have snack, but said, That's a good question as to why we don't. In another observation of snack service on 06/21/19, concluding at 10:26 AM, Resident #9 and #56 were not offered a snack. Resident #56's eyes were closed at that time, but Resident #9 was lying alert in bed. When asked about whether Residents' #9 and 56 were offered snacks that day, Staff K stated they were not. When asked whether they usually were offered the same opportunities for snacks as other residents, Staff K stated, Not always. In an interview on 06/21/19 at 11:16 AM, Staff D, Resident Care Manager, stated staff should offer every resident a midmorning and bedtime snack. She stated if the resident required assistance with eating, staff should provide the snack, with assistance. WAC 388-97-0180 (1)(2)(3)

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure grievances were resolved promptly for three of four sample residents (#27, 28, 32), reviewed for grievances. Failure to follow up with residents to notify them of any actions taken, and to determine if the grievance had been resolved, placed the residents at risk for a diminished quality of life. Findings included . 1. According to a grievance form filled out by Staff I, Social Services, on 05/03/19, Resident #27 was unhappy with the way an unidentified staff member removed her bandages. The form showed the staff member was educated regarding removing the resident's bandages more slowly. The Administrative Review and Follow Up sections of the form were unsigned and blank. In an interview on 06/20/19 at 8:59 AM, Resident #27 stated that the facility had not followed up with her regarding the grievance. 2. A 03/11/19 grievance form, filled out by Staff I, showed a staff member had threatened Resident #28, related to his call light use. Per the report, the action taken was to have the staff member involved stay out of the resident's room. The report was reviewed by the administrator on 03/22/19. The Follow Up section of the document was blank, and no other information regarding the grievance was documented. The resident discharged from the facility on 06/20/19, and was unavailable for interview. 3. According to a grievance form filled out by Staff I on 05/13/19, Resident #32 was upset that another resident kept wandering into her room. Per the report, a stop sign was to be placed across Resident #32's door, and the unnamed wandering resident was to be kept by the nursing station in staff's line of site. The Administrative Review and Follow Up sections were unsigned and blank. In an observation on 06/13/19 at 11:29 AM, a yellow plastic stop strip was posted across the resident's doorway. In an interview that same day at 12:06 PM, Resident #32 stated the stop strip was kept across her doorway to prevent another resident from wandering into her room, a habit Resident #32 found unnerving. The resident added that often staff did not remember to put the strip up, after entering/exiting the room. In a follow-up interview on 06/21/19 at 11:15 AM, Resident #32 stated that the facility had not followed up with her, to determine if the stop strip had been helpful, and if the grievance had been satisfactorily resolved. In an interview on 06/19/19 at 11:29 AM, the facility's grievance process was reviewed with Staff I. She stated that grievance forms were available on each unit for residents or staff members to fill out. Per Staff I, the forms were then reviewed and followed up on, by the appropriate departments. Staff I added she would ask the resident what they thought a good resolution to the issue would be, at the time the forms were filled out, but did not necessarily follow up with the resident to ensure the actions taken were effective, and whether or not they considered the grievance resolved. In an interview with Staff I and Staff A, Administrator, on 06/21/19 at 11:41 AM, Staff A stated that both he and Staff I followed up with residents regarding their grievances, but was unable to provide any documentation of the follow up for Residents' #27, #28 or #32. Refer to F610 for additional information. Reference: WAC 388-97-0460

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure an allegation of potential verbal abuse was reported to the State Survey Agency as required, for one of two sample residents (#28), reviewed for abuse. This failure placed the resident at risk for additional abuse. Findings included . Per a 03/11/19 grievance report filled out by Staff I, Social Services, Resident #28 alleged that a staff member entered his room, and told him if he kept using his call light that the staff member would mess him up, and the resident did not want that staff member in his room anymore. The report showed the steps taken to address the grievance were to have the staff member stay out of the resident's room. The report was reviewed by Staff A, Administrator, on 03/22/19. An entry regarding the incident was not found in the facility's incident log, nor was the incident called in to the State Survey Agency as required, for all allegations of abuse. In an interview on 06/19/19 at 2:07 PM, Staff I was asked for any documentation regarding the allegation. Staff I stated that she would check with Staff A. In an interview with Staff I and Staff A on 06/19/19 at 3:33 PM, Staff A stated that he had signed off on the incident, but did not remember all the details. Staff A confirmed the allegation was not reported to the State Survey Agency, as required. (This is a repeat citation from a complaint investigation dated 01/09/19). Reference: WAC 388-97-0640(5)(a)

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one of two sample residents (#28), reviewed for abuse. This failure placed the resident at risk for continued abuse. Findings included . Per review of a grievance form, dated 03/11/19, filled out by Staff I, Social Services, Resident #28 reported that a staff member came into his room and told the resident if he kept using the call light that the staff member would mess him up. The report showed the actions taken were to have Staff J, Nursing Assistant, stay out of the resident's room. No other actions or information was documented on the report. Per record review, the report was reviewed and signed by Staff A, Administrator, on 03/22/19. No mention of the allegation, or any follow up was found in the resident's record, as of 06/18/19. On 06/19/19 at 2:07 PM, any further documentation regarding the allegation of verbal abuse, and any follow up investigation, was requested from Staff I. In an interview with Staff I and Staff A on 06/19/19 at 3:33 PM, Staff A stated that he vaguely remembered the incident. Staff A stated that he thought the resident did not want Staff J taking care of him, because Staff J was from a different racial background, adding that was why the facility did not investigate the allegation any further. Staff A stated that the facility's former director of nursing had spoken with Staff J, and asked him to stay out of the resident's room, but no documentation had been found of that conversation. Staff A confirmed that Resident #28 was interviewed by staff on 06/19/19 (three months after the allegation was reported, and after the surveyor asked for documentation), and stated that Staff J had always been nice to him, he felt safe in the facility, and did not remember the incident (or making the allegation). Per Staff A, Staff J no longer worked at the facility, and other staff members involved in the handling of the initial grievance did not remember it. No documentation that the facility interviewed Staff J, Resident #28, or other staff or residents at the time the allegation was made (to rule out possible abuse),was found. Reference: WAC 388-97-0640 (6)(a-c)

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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2. Per the 06/07/19 quarterly assessment, Resident #38 admitted to the facility in March 2018, and was cognitively intact to make decisions regarding her care. On 06/18/19 at 8:46 AM, Resident #38 was observed in the dining room after breakfast, sitting in a wheelchair with oxygen on. She stated she had breathing problems, and had gone to the hospital a few times. When asked if the facility informed her about the bed-hold policy when she transferred to the hospital, she stated she was informed about the policy, cost, etc., when she admitted to the facility (but not each time she was hospitalized ). A review of Resident #38's record showed she was transferred to the hospital due to breathing problems on 01/27/18, 02/18/19, 02/27/19, 03/21/19, and 05/08/19. No documentation was found to show the resident had been informed about the bed-hold policy, and costs for holding the bed, at the time she was transferred. In an interview on 06/20/19 at 10:20 AM, Staff I, Social Services, confirmed the bed-hold policy and costs had not been discussed with the residents at the date/time of the transfer to the hospital. Reference (WAC) 388-97-0120(4) Based on observation, interview, and record review, the facility failed to ensure a system was in place to notify residents or their representative, at the time of transfer/discharge to the hospital, of the facility's written bed-hold policy, for two of two sample residents (#81, 38), reviewed for hospitalization. This failure placed the residents at risk for a lack of knowledge regarding the right to hold their bed, while out of the facility. Findings included . 1. Resident #81. Review of the medical record showed the resident was initially admitted in August 2018, and on 04/02/19, was discharged to the hospital, and did not return to the facility. Record review showed there was no evidence the bed-hold policy was discussed and provided to the resident or his representative, upon discharge to the hospital.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure proper positioning of urinary catheter tubing and collection bags (a catheter is a tube which drains urine from the bladder, into a collection bag outside the body), for one of two sample residents (#67), reviewed for catheter use. Failure to position catheter tubing to allow unobstructed flow of urine, and to consistently keep the urine collection bag positioned below the level of the resident's bladder, placed the resident at risk for urinary tract infections. Findings included . Per the Centers for Disease Control Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, catheter bags must be positioned below the level of the bladder at all times, and tubing positioned in a manner to promote an unobstructed flow of urine, from the bladder into the collection bag. According to a 05/29/19 admission assessment, Resident #67 required assistance with most activities of daily living, had short-term memory problems, and admitted to the facility with a urinary catheter, as well as a urinary tract infection. A 06/10/19 care plan directed staff to ensure the resident's catheter bag was positioned below the level of her bladder, and to avoid obstructions in the drainage of urine into the bag. On 06/14/19 at 10:28 AM, Resident #67 was observed sitting in her wheelchair, with the catheter tubing positioned in a dependent loop, from the bottom of her pant leg back up to the collection bag, which was tucked next to the resident's side (not below bladder level). Similar observations were made at 11:16 AM and 12:20 PM that same day, as well as on 06/18/19 at 9:32 AM, and 06/19/19 at 12:23 PM. In an interview on 06/19/19 at 10:25 AM, Staff F, Nursing Assistant, stated that the resident usually kept her catheter bag in the seat next to her, while up in the wheelchair. In an interview on 06/19/19 at 2:34 PM, Staff G, Nursing Assistant, stated that catheter bags were normally hung from the bottom of a resident's wheelchair, but that Resident #67 often kept it next to her in the wheelchair. When asked if staff approached the resident regarding proper catheter bag positioning when they observed it next to her, Staff G stated that he did not. On 06/20/19 at 10:24 AM, Staff C, Resident Care Manager, confirmed that catheter bags were to be kept positioned below a resident's bladder, generally under the seat, when sitting in a wheelchair. Reference: WAC 388-97-1060 (3)(c)

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to monitor a peritoneal dialysis site (a site used for a process that uses a person's own body tissue inside the abdominal cavity to filter blood for removal of waste), for one of one sample residents (#71), reviewed for dialysis. This failure placed the resident at risk for complications including infection. Findings included . According to a 06/04/19 admission assessment, Resident #71 had diagnoses including end-stage kidney disease and diabetes, and received dialysis treatments. A progress note dated 05/28/19 showed the resident had admitted to the facility that day and had two dialysis access sites; one on her lower abdomen, and one on her right upper chest. A 06/03/19 care plan directed staff to monitor the resident's dialysis access sites for signs of infection. Review of the resident's progress notes from 05/28/19 through 06/20/19 (a three week period) revealed only two notes referring to the resident's peritoneal dialysis catheter (a thin tube inserted into the abdomen, to transfer fluid into and out of the abdominal cavity) - on 06/01/19 and 06/02/19. Review of the resident's Treatment Administration Record (TAR) for 06/01/19 through 06/20/19 did not show any documentation that the resident's abdominal dialysis catheter was assessed. In an interview on 06/20/19 at 3:18 PM, Staff C, Resident Care Manager, stated that an outside dialysis center performed all care for the abdominal site, but facility staff were to monitor the site for signs of infection and bleeding, each shift. After reviewing the resident's electronic record including the TAR, Staff C confirmed there was no documentation the site was consistently being assessed. Reference: WAC 388-97-1900(1)

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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2. Review of Resident #25's record showed a pharmacy recommendation dated 04/19/19, to get an assessment for abnormal involuntary movements, related to the use of an antipsychotic medication (AIMS test). Review of the record showed an AIMS test dated 05/14/19, almost a month from date of the recommendation. In an interview on 06/21/19 at 11:54 AM, when asked if the recommendation was addressed within the expected timeline, Staff B, Director of Nursing, confirmed it was not. Reference (WAC) 388-97-1300(1)(c)(i), (4)(c) Based on interview and record review, the facility failed to consistently monitor medication (Depakote) blood levels for one resident (#24), and to follow up on pharmacy recommendations for one resident (#25), in a sample of five residents reviewed for unnecessary medications. These failures placed the residents at risk for receiving medications at higher doses than necessary, and receiving unnecessary medication for longer than the recommended duration. Findings included . 1. Per the record, Resident #24 was admitted in July 2016, with multiple medical diagnoses including a mood disorder. The April 2019 facility assessment showed the resident was alert, able to make some needs known, and dependent on facility staff for all activities of daily living. Review of the June 2019 physician orders showed Resident #24 received medication to treat her mood disorder (Depakote), twice daily. Review of the June 2019 physician's orders showed an order to obtain a Depakote blood level every three months for Resident #24, beginning on 05/09/18. According to the recommendations by the United States National Library of Medicine(https://medlineplus.gov/druginfo/meds), Depakote levels are routinely checked by a blood test to make sure there is neither too little nor too much of the drug in the blood. Too little will render the medication (Depakote) ineffective, while too much may be toxic. Review of the resident's record showed a Depakote level drawn in August 2018, and no further laboratory results for the ordered Depakote. Record review of the monthly pharmacy medication regimen reviews showed no blood tests were reviewed as required in the months of September 2018 through June 2019. Review of the undated facility policy, Medication Regimen Review showed The consultant pharmacist identifies irregularities through a variety of sources including .laboratory and diagnostic test results . In an interview on 06/18/19 at 3:00 PM., Staff B, Director of Nursing, stated she reviewed Residents #24's record and confirmed the ordered Depakote levels had not been completed every three months, as ordered by the resident's physician. Staff B stated she planned to contact the pharmacist and physician regarding the missed blood work for Resident #24.

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure laboratory tests were completed as ordered for one resident (#24), in a sample of five residents, reviewed for medication management. This failure placed the resident at risk for medical complications, related to a lack of monitoring chronic medical conditions. Findings included . Review of the June 2019 physician's orders showed an order to obtain a Depakote level (a medication used to treat certain mood disorders and seizures), every three months for Resident #24, beginning on 05/09/18. According to the recommendations by the United States National Library of Medicine(https://medlineplus.gov/druginfo/meds), Depakote levels are routinely checked by a blood test to make sure there is neither too little nor too much of the drug in the blood. Too little will render the medication (Depakote) ineffective, while too much may be toxic. Review of the resident's record showed a Depakote level drawn in August 2018, which was reviewed by the physician, and no changes were made in the scheduled dose. Further review showed the resident had no additional blood tests as ordered for the Depakote levels, from September 2018 through June 2019. In an interview on 06/18/19 at 3:00 PM., Staff B, Director of Nursing, stated she reviewed Residents #24's record, and confirmed the ordered Depakote levels had not been completed every three months, as ordered by the resident's physician. Staff B stated she did not know why the tests were missed, as she was currently in the process of learning the ordering procedure for residents labs. In an interview on 06/18/19 at 3:40 PM, Staff E, Registered Nurse, stated orders were entered into the computer, and then generated on the Medication Administration Record (MAR). Per Staff E, the ordered date is then placed on the calendar, and followed up on by the nurses. She stated if the order only included direction to draw the lab every three months, and was not specific to the month, date, or time, it would not generate on the MAR, and would be missed. She stated Resident 24's order was not specific. Reference: (WAC) 388-97-1620(2)(b)(i)

CONCERN (D)

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

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of three sample residents (#25), reviewed for dental care, received timely assistance to coordinate appropriate denture services. This failure placed the resident at risk for discomfort and difficulty eating. Findings included . In an observation and interview on 06/14/19 at 8:56 AM, Resident #25 gestured to her lower dentures, and stated they did not fit well. She stated that had been the case for a while. Review of a progress note dated 05/20/19 showed Resident #25 reported to staff that her dentures were a little loose, and per the note, facility staff would be requesting a referral to a denturist for fitting. A physician order dated 05/22/19 showed the provider ordered the referral. In an interview on 06/19/19 at 3:31 PM, Staff D, Resident Care Manager, looked in her e-mail history, and stated she sent the referral of 05/22/19 to the scheduler, but it appeared the resident was mixed up with another resident with the same last name, and no appointment was scheduled for Resident #25. In a follow-up interview on 06/19/19 at 4:05 PM, Staff D stated the scheduler had now made an appointment for Resident #25 to see the denturist on 07/02/19. There was nearly a month delay in initiating the appointment. Reference:(WAC) 388-97-1060(3)(j)(vii)

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plan interventions were consistently implemented for four of four sample residents (#40, 9, 30, 56), reviewed for mobility. This failure placed the residents at risk for increased joint stiffness and overall decline. Findings included . 1. Review of a care plan dated 10/17/18 showed staff were to provide Resident #40 with passive range of motion (moving the joints through their natural movements) six to seven times per week to each joint of her left arm, as part of a restorative program (consisting of nursing interventions aimed at assisting residents to maximize their functioning). According to restorative program documentation from 03/01/19 to 06/18/19, Resident #40 received range of motion nine times, and refused it once. The documentation showed the program was not offered, per the care plan. 2. Review of Resident #9's functional activities of daily living and rehabilitation potential care plan, initiated 06/04/18, showed a goal of tolerating passive range of motion to his hips, knees and feet on both sides of his body, six times per week. The restorative program documentation from 03/01/19 to 06/18/19 showed he consistently received passive range of motion from 03/01/19 through 03/13/19, then had periods when the program was not offered from 03/13/19 to 03/27/19, 03/28/19 to 04/01/19, 04/01/19 to 04/11/19, 04/11/19 to 04/14/19, 05/01/19 to 05/05/19, 05/06/19 to 05/15/19, 05/16/19 to 05/19/19, 05/20/19 to 05/30/19, 05/30/19 to 06/02/19, 06/04/19 to 06/11/19, and 06/13/19 to 06/16/19. 3. Review of Resident 30's care plan dated 10/17/18 showed Resident #30 was to receive passive range of motion to his upper and lower extremities six to seven times per week. Review of Resident #30's progress notes showed he was out at the hospital from [DATE] to 05/06/19. Review of the resident's restorative program documentation from 03/01/19 to 04/21/19 showed staff provided the passive range of motion program nine times in a little over seven weeks. Review of the restorative documentation from 05/07/19 to 06/18/19 showed he received the program six times in over a month. 4. Review of Resident #56's care plan intervention for a restorative program, dated 09/07/16, showed she was to receive passive range of motion six times per week for 15 minutes. Review of her restorative program documentation for 03/01/19 to 06/18/19 showed the following gaps in the provision of her passive range of motion: 03/03/19 to 03/06/19, 03/07/19 to 03/10/19, 03/13/19 to 03/17/19, 03/21/19 to 03/25/19, 03/28/19 to 04/01/19, 04/01/19 to 04/09/19, 04/11/19 to 04/14/19, 04/17/19 to 04/21/19, 04/21/19 to 04/25/19, 04/25/19 to 04/29/19, 05/01/19 to 05/05/19, 05/16/19 to 05/19/19, 05/20/19 to 05/28/19, 05/30/19 to 06/02/19, 06/04/19 to 06/10/19 and 06/13/19 to 06/17/19. The documentation showed she routinely did not receive the program the care plan showed she required. In an interview on 06/20/19 at 10:59 AM, when asked about gaps in providing restorative programs, Staff M, Restorative Aide, stated she prioritized residents with two programs, and got to other residents as often as possible. Reference (WAC) 388-97-1060(3)(d)

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of four sample residents (#40, 9, 30, 56) reviewed for mobility, consistently received care and services to maximize their mobility. This failure placed them at risk for complications related to immobility, including contractures (permanent shortening of a muscle, reducing joint range of motion), and pain. Findings included . 1. In an observation and interview on 06/14/19 at 9:37 AM, Resident #40's left ankle was extended at rest, with her toes pointing forward. When asked whether she could move that foot and ankle independently, Resident #40 showed the surveyor that she could move her right foot and ankle, but not the left. When asked if she got exercises or stretches on her left foot and ankle, Resident #40 stated she did not. Review of a care plan dated 10/17/18 showed staff were to provide Resident #40 with passive range of motion (moving the joints through their natural movements) six to seven times per week to each joint of her left arm, as part of a restorative program (nursing interventions aimed at assisting residents to maximize their functioning). The care plan did not address any range of motion needs related to the left leg, ankle or foot. According to her 12/24/18 assessment, Resident #40 required supervision of one person for transfers, limited assistance of one person for bed mobility and personal hygiene, and extensive assistance of one person for toileting and dressing. The assessment showed the resident walked once or twice during the assessment period in her room and in the corridor, and required one person assist to do so. Review of the progress notes showed on 01/11/19, Resident #40 was transferred to the hospital due to medical concerns, and returned to the facility on [DATE]. Review of a significant change assessment dated [DATE] showed the resident was cognitively intact, needed limited assistance of one person for transfers, and extensive assistance of two people for bed mobility, toileting, and personal hygiene. It further showed she did not walk during the assessment period. According to restorative program documentation from 03/01/19 to 06/18/19, Resident #40 only completed her left upper extremity range of motion program a total of nine times, and refused it once. In an interview on 06/20/19 at 10:59 AM, Staff M, Restorative Aide, confirmed Resident #40's program only focused on her left arm, and did not include the left leg, ankle, and foot. When asked about gaps in providing Resident #40's restorative program, Staff M stated she prioritized residents with two programs, and Resident #40 only had one. She said she did get to Resident #40's program once in the previous week. Review of the progress notes showed an entry dated 06/20/19 which indicated there was an order from the resident's physician for physical therapy to evaluate and treat her, related to her left lower extremity. Review of the progress notes did not show any periodic evaluations of the resident's restorative program, or discussion of the adequacy of her range of motion program, after her hospitalization and decline. In an interview on 06/21/19 at 11:27 AM, Staff D, Resident Care Manager, stated she requested and received an order for Resident #40 to have a physical therapy referral. When asked what prompted her to request the referral, Staff D stated she noticed Resident #40's left foot was overextending a little bit, and she had a concern with that. She stated there was resistance when she tried to move the resident's ankle and foot through the normal range of motion. In an interview on 06/24/19 at 11:02 AM, Staff Q, Physical Therapist, stated his evaluation on 06/21/19 showed the resident did not have any permanent muscle damage at that point, and the treatment would include working with the resident to decrease muscle tightness through physical therapy for a time, and then possibly a stretching and range of motion program. 2. According to his 06/13/19 assessment, Resident #9 required extensive assistance with activities of daily living, including bed mobility, transfers, dressing, eating, and hygiene. The assessment showed he was not able to understand others, or make himself understood, through verbal or non-verbal expression. Review of his functional activities of daily living and rehabilitation potential care plan, initiated 06/04/18, showed a goal of tolerating passive range of motion to the hips, knees and feet on both sides of his body, six times per week. The restorative program documentation from 03/01/19 to 06/18/19 showed he consistently received passive range of motion from 03/01/19 through 03/13/19, then had gaps when the program was not offered from 03/13/19 to 03/27/19, 03/28/19 to 04/01/19, 04/01/19 to 04/11/19, 04/11/19 to 04/14/19, 05/01/19 to 05/05/19, 05/06/19 to 05/15/19, 05/16/19 to 05/19/19, 05/20/19 to 05/30/19, 05/30/19 to 06/02/19, 06/04/19 to 06/11/19, and 06/13/19 to 06/16/19. Review of Resident #9's progress notes showed Staff M, Restorative Aide, wrote notes, including one dated 06/13/19, which documented that the resident maintained his program, and denied pain or discomfort. The notes did not show what the resident's functional range of motion was, or show in an objective manner whether the resident declined or improved. Further review of the resident's progress notes and observations did not show any periodic evaluation by a nurse of his joint range of motion, with discussion or assessment of the effectiveness of the restorative program. In an interview on 06/21/19 at 11:25 AM, Staff D, Resident Care Manager, was asked about objective evaluations of range of motion for residents who received restorative programs, in order to determine whether there had been an improvement, decline, or if the resident stayed the same. She confirmed there were not objective evaluations documented for the restorative programs, and stated she had not noted any changes to Resident #9's range of motion. 3. According to his 04/11/19 assessment, Resident #30 was not able to understand others, or make himself understood, through verbal or non-verbal expression. The assessment showed he was dependent upon staff for activities of daily living, including bed mobility, dressing, and hygiene. Review of a care plan intervention dated 10/17/18 showed Resident #30 was to receive passive range of motion to his upper and lower extremities six to seven times per week. Review of Resident #30's progress notes showed he was out at the hospital from [DATE] to 05/06/19. Review of his restorative program documentation from 03/01/19 to 04/21/19 showed staff provided the passive range of motion program a total of nine times. Review of the restorative documentation from 05/07/19 to 06/18/19 showed he received the program a total of six times. Review of Resident #30's progress notes and observations did not show any periodic evaluation by a nurse of his joint range of motion, with discussion and/or assessment of the effectiveness of the restorative program. In an interview on 06/21/19 at 11:26 AM, Staff D, Resident Care Manager, stated the resident had not had any recent change in his range of motion. 4. Review of Resident #56's 05/16/19 assessment showed she was dependent upon staff for all activities of daily living such as bed mobility, transfers, dressing, eating, and hygiene, was not able to understand others, or communicate verbally or non-verbally to others, in a way to make herself understood. Review of a care plan intervention dated 09/07/16 showed Resident #56 was to receive passive range of motion six times per week for a total of 15 minutes. Review of her restorative program documentation for 03/01/19 to 06/18/19 showed the following gaps in the provision of her passive range of motion: 03/03/19 to 03/06/19, 03/07/19 to 03/10/19, 03/13/19 to 03/17/19, 03/21/19 to 03/25/19, 03/28/19 to 04/01/19, 04/01/19 to 04/09/19, 04/11/19 to 04/14/19, 04/17/19 to 04/21/19, 04/21/19 to 04/25/19, 04/25/19 to 04/29/19, 05/01/19 to 05/05/19, 05/16/19 to 05/19/19, 05/20/19 to 05/28/19, 05/30/19 to 06/02/19, 06/04/19 to 06/10/19 and 06/13/19 to 06/17/19. The documentation showed she routinely did not receive the program the care plan showed she required. Review of progress notes and observations in the record for Resident #56 showed no periodic evaluation of her joint mobility, or objective assessment of the effectiveness of her restorative program. In an interview on 06/20/19 at 10:59 AM, Staff M stated she was the only restorative aide employed by the facility since March 2019, and confirmed she was not able to get to everyone's restorative program as scheduled. In an interview on 06/21/19 at 11:25 AM, Staff D, Resident Care Manager, was asked about objective evaluations of range of motion for residents who received restorative programs, in order to determine whether there had been an improvement, decline, or the resident stayed the same. She confirmed there were not objective evaluations documented for the restorative programs, and stated it was something they were working on. Reference: (WAC) 388-97-1060 (3)(d)

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure sufficient staffing levels to maintain restorative nursing care programs, for four of four sample residents reviewed (#40, 9, 30, 56). This failure placed residents at risk for declines in their mobility. Findings included . Review of restorative documentation between 03/01/19 and 06/18/19 for Residents #40, 9, 30 and 56 showed they did not receive restorative nursing programs (consisting of nursing interventions aimed at assisting residents to maximize their functioning) as often as their plans of care indicated they were required. (See F-688 for additional information). In an interview on 06/20/19 at 10:59 AM, Staff M, Restorative Aide, stated she was the only restorative aide employed by the facility since March 2019. When asked about gaps in providing restorative programs for the above residents, Staff M stated she had to prioritize whose programs she could complete, and did the others when she could. Staff M stated she typically worked five days per week. When asked about how residents received their restorative programs six days per week when she was the only staff, Staff M stated she came in on her days off to provide the care for residents, when it was their assessment period. She stated otherwise she provided the programs as often as she could. Review at the time of the interview with Staff M of her notes for 06/01/19 to 06/20/19, related to provision of the restorative programs, showed she was pulled to work as a nursing assistant on the unit several days, including 06/05/19, 06/06/19, and 06/08/19. Staff M also stated taking residents to appointments was sometimes part of her duties as well, including on 06/20/19, just prior to the time of the interview. Reference: (WAC) 388-97-1080(1)

CONCERN (E)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to appropriately provide specialized diets for seven randomly observed residents (#8, 24, 38, 51, 57, 68, 76) during meal service. This failure placed the residents at risk for complications of their medical conditions, which required specialized diets. Findings included . Review of physician's orders revealed the following: - Resident #8's diet order dated 12/27/18 was for a two gram (2 gm.) low sodium, and Consistent Carbohydrate diet (CCHO). - Resident #51's diet order dated 03/18/19 was for CCHO. - Resident #38's diet order dated 05/10/19 was for CCHO. - Resident #24's diet order dated 03/30/18 was for CCHO. - Resident #76's diet order dated 12/20/17 was for 2gm. Sodium. - Resident #68's diet order dated 06/19/19 was for CCHO. - Resident #57's diet order dated 06/12/19 was for CCHO, and included other instructions. According to the diet spreadsheet provided by Staff N, Dietary Services Manager, the 06/19/19 dinner meal for CCHO residents included half a serving of cake, and no dinner roll. Observation of Staff O, Cook, serving the dinner meal throughout the facility on 06/19/19, from 5:36 PM to 6:26 PM, showed Residents #38, 24, 8, 51 and 68 received the same size dessert as other residents. Residents' #51 and 68 also received a dinner roll. Additionally, the alternate menu showed for residents on a 2 gm.sodium diet, no chips were to be served, however during the dinner service on 06/19/19 at 6:07 PM, Resident #76 was served potato chips with her soup and sandwich. According to the diet spreadsheet provided by Staff N on 06/20/19, the lunch menu for CCHO diets did not include cornbread. Observations of Staff P, Cook, serving lunch in Dogwood dining room on 06/20/19 from 12:07 PM to 12:22 PM showed she served Resident #51 and Resident #57 cornbread, although it was not indicated per the CCHO menu. In an interview on 06/20/19 at 12:19 PM, Staff N and Staff P confirmed residents with CCHO diets should not have received cornbread. On 06/20/19 at 12:20 PM, the surveyor notified Staff N of concerns with the dinner meal service on 06/19/19, when staff did not serve CCHO and 2 gm. sodium diets, according to the menu. Reference: (WAC) 388-97-1200(1)

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 31% turnover. Below Washington's 48% average. Good staff retention means consistent care.

Concerns

• 53 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
• $32,711 in fines. Higher than 94% of Washington facilities, suggesting repeated compliance issues.
• Grade D (45/100). Below average facility with significant concerns.

Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Clarkston Health And Rehab Of Cascadia's CMS Rating?

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

How is Clarkston Health And Rehab Of Cascadia Staffed?

CMS rates CLARKSTON HEALTH AND REHAB OF CASCADIA's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 31%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Clarkston Health And Rehab Of Cascadia?

State health inspectors documented 53 deficiencies at CLARKSTON HEALTH AND REHAB OF CASCADIA during 2019 to 2025. These included: 2 that caused actual resident harm and 51 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Clarkston Health And Rehab Of Cascadia?

CLARKSTON HEALTH AND REHAB OF CASCADIA is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CASCADIA HEALTHCARE, a chain that manages multiple nursing homes. With 90 certified beds and approximately 77 residents (about 86% occupancy), it is a smaller facility located in CLARKSTON, Washington.

How Does Clarkston Health And Rehab Of Cascadia Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, CLARKSTON HEALTH AND REHAB OF CASCADIA's overall rating (3 stars) is below the state average of 3.2, staff turnover (31%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Clarkston Health And Rehab Of Cascadia?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Clarkston Health And Rehab Of Cascadia Safe?

Based on CMS inspection data, CLARKSTON HEALTH AND REHAB OF CASCADIA has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Clarkston Health And Rehab Of Cascadia Stick Around?

CLARKSTON HEALTH AND REHAB OF CASCADIA has a staff turnover rate of 31%, which is about average for Washington nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Clarkston Health And Rehab Of Cascadia Ever Fined?

CLARKSTON HEALTH AND REHAB OF CASCADIA has been fined $32,711 across 1 penalty action. This is below the Washington average of $33,406. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Clarkston Health And Rehab Of Cascadia on Any Federal Watch List?

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

Facility Details

Beds: 90
Avg. Residents: 77
Occupancy: 85.8%
Ownership: For profit - Partnership
Chain: CASCADIA HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
2 Actual Harm citations: -10
53 Deficiencies: -10
Fines ($32,711): -5
Final Score: 45/100

Nearby Alternatives

No other facilities found in this area.

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505283