**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to obtain informed consent regarding the potential risks and benefits associated with the use of a psychotropic medication (medications that affects behavior and alter mental thought processes) for 3 of 5 residents (Residents 2, 7, and 11) reviewed for psychotropic medications. This failure placed residents and/or the legal representative at risk of not being fully informed about the medication prior to administration or discontinuation. Findings included . <Resident 2> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and Post Traumatic Stress Disorder (PTSD-symptoms lasting for an extended time over a traumatic event). The 02/06/2025 comprehensive assessment showed Resident 2 was alert and oriented, made their needs known, had signs/symptoms of depression (sad affect) and anxiety (feelings of negative outcomes of events), was on an antidepressant (a type of psychotropic medication) and two antianxiety (a type of psychotropic medication) medications during the assessment period. Review of Resident 2 ' s physicians' order showed that an antidepressant and two antianxiety medications were ordered on 08/27/2024 and consents were signed at that time. During an interview on 03/11/2025 at 1:43 PM, Resident 2 stated they were concerned about their antianxiety medications being discontinued without them being informed and there was no discussion with their provider prior to the medications being discontinued. Resident 2 stated their pain had increased a bit and their anxiety was okay, but they were not happy with their current provider and asked them to be removed. Resident 2 stated they had chosen another provider to handle their medications and care. During an observation on 03/11/2025 at 2:00 PM, Resident 2 had a flat affect (lack of facial expressions) when talking to other staff. Resident 2 was able to express their feelings and communicate to staff and family who visited daily. Review of a 02/11/2025 pharmacist recommendation showed to discontinue all psychotropic medications, which included the combination of three or more Central Nervous System (CNS) active medications which could cause an increase in falls and fractures. The consultation report recommended the prescriber assess the risk/benefits if they continued the medications and the provider declined the recommendation. On 02/17/2025 the attending provider discontinued Resident 2's routine Buspar (a specific antianxiety medication) medication, and their routine clonazepam (a specific antianxiety medication) medication. The provider did not communicate with Resident 2 about the change or if Resident 2 consented to the proposed change in their antianxiety medications. Review of Resident 2 ' s psychotropic/behavior meeting, dated 02/06/2025, showed the residents psychotropic medications and/or behavior changes were not addressed. The psychotropic/behavior committee meeting consisted of the pharmacist, Social Services Director (SSD), Director of Nursing Services (DNS), and the physician. During an interview on 03/11/2025 at 2:30 PM, Staff K, SSD, stated the provider did not speak with them, the nursing staff, or Resident 2 about their medication changes. The order was received by the charge nurse on 02/17/2025. On 03/12/2025 at 10:00 AM, Staff B, Resident Manager, stated their process was to ensure Resident 2 was notified of changes in their medications but had not been notified of the medication changes on 02/17/2025. Also, as of 03/11/2025 Resident 2 had not had a discussion regarding the risks and benefits of continuing with these medications. <Resident 7> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of heart failure, depression, and anxiety. Review of the 12/23/2024 comprehensive assessment showed the resident was alert and able to make their needs known and required minimal assistance with activities of daily living (ADLs). The assessment showed Resident 7 used a wheelchair for mobility. Review of the 03/21/2024 Medication Administration Record (MAR) showed Resident 7 was started on Lexapro (a specific antidepressant) and Trazadone (a specific antidepressant) on 03/23/2024. During an interview on 03/10/2025 at 10:00 AM, Resident 7 stated they had not been educated or given information by the facility staff concerning their antidepressant or antianxiety medications and had not signed any consents for the medications. During an interview on 03/10/2025 at 10:40 AM, Staff K stated they did not review informed consents on Resident 7 for ordered antianxiety and antidepressant medications. Staff K stated it was the facility's process to review psychotropic medications with the resident/or Resident's Representative (RR) before administration of the medications to a resident. <Resident 11> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to included dementia (cognitive impairment) with behavioral disturbances, falls, and heart disease. Review of the 01/20/2025 comprehensive assessment showed the resident had impaired memory/cognition and required assistance in their ADLs. Resident 11 used a front wheeled walker for mobility. Review of the physicians ' orders for 01/15/2024 and 12/03/2024 showed that Duloxetine (a specific antidepressant medication) was started on 01/15/2024 for pain, and Risperidone (a specific type of psychotropic) was started on 12/03/2024 for increased verbal behaviors. During an interview on 03/11/2025 at 12:45 PM, Staff K stated they did not obtain consents or review risk and benefits of the psychotropic medications with Resident 11's RR. Staff K stated it was the policy of the facility to review these medications before administering them. During an interview on 03/13/2025 at 2:15 PM, Staff B stated the facility was to ensure the resident and/or the RR were informed of psychoactive medications benefits and side effects before administration of the medications. Staff B stated the facility failed to follow through on informed consent recommendation for new medications and when changes were made to resident psychotropic medications. Reference: WAC 388-97-0260(1)(a)(b)(2)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to comprehensively assess and identify side rails attached to resident beds as a physical restraint for 2 of 2 residents (Residents 8 and 7) reviewed for physical restraints. This failure placed the residents at risk for injury and poor quality of life. Findings included . Record review of a facility policy titled, Long-Term Care Residents Physical Restraints, revised 12/31/2024 showed, . Physical restraints are identified as .side rails that keep the resident from voluntarily getting out of bed. Procedure: A. A Safety Device Assessment will be completed by the licensed staff for the need of the restraint related to a medical symptom. B. The resident's consent will be obtained .and documented on the assessment form. C. A physician's order will be obtained prior to the use of the restraint. D. Family will be consulted by nursing or social services in the event the resident is unable to give consent. E. Multidisciplinary care planning [NAME] be done quarterly to reassess usage and identify least restrictive alternatives. <Resident 8> Review of the resident's medical record showed they were admitted with diagnoses that included dementia, atrial fibrillation (an irregular heartbeat), and dysphagia (difficulty swallowing foods or liquids). Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and required substantial assistance with their activities of daily living (basic skills required to care for oneself). An observation and interview on 03/10/2025 at 2:23 PM, showed Resident 8 lying in their bed with half side rails attached to both sides of their bed and in the up position. The resident had their arms crossed over their chest and was lying in the center of the bed. When asked if they used the side rails to move around in bed, Resident 8 stated, I don't know they just keep me in. Record review of Resident 8's care plan dated 12/11/2024 showed no information on the side rail use including directions for use. Review of the February 2025 and March 2025 physician orders showed no orders or medical symptom to justify the use of side rails. Additionally, there was no Safety Device Assessment or consent to use the side rails. During an observation on 03/11/2025 at 1:45 PM showed Resident 8 in bed with the side rails in the down position. During an interview on 03/11/2025 at 1:46 PM, Staff H, Registered Nurse, stated Resident 8 had side rails to assist them to move around in bed and they should be placed in the down position after cares and while in bed. Staff H stated there were no specific written care plan guidance on how to use Resident 8's side rails to include when the rails should be in the up or down position. During an observation on 03/12/2025 at 7:50 AM, showed Resident 8 lying in bed with both half rails in the up position. During an observation on 03/12/3025 at 11:15 AM, Resident 8 was in their room resting in bed with their side rails in the down position. During an interview on 03/12/2025 at 2:03 PM, Staff I, Nursing Assistant (NA), stated they were routinely assigned to work with Resident 8 and were very familiar with their care needs. Staff I stated they put up Resident 8's side rails because it made them feel safe and secure in bed as well as they prevented them from falling out of bed. Additionally, Staff I stated they also placed the side rails in the down position after cares as well. Staff I stated there were no specific directions on how to use Resident 8's side rails they just knew what to do. <Resident 7> Review of the resident's medical record showed the resident was admitted to the facility with diagnoses of depression, anxiety, heart failure, and respiratory issues. The comprehensive assessment dated [DATE] showed the resident was alert, oriented, and able to make their needs known. Additionally, Resident 7 required oversight assistance to transfer. On 03/10/2025 at 3:32 PM, observations of side rails for Resident 7 showed the residents bed on the left side was against the wall and half rails on both sides of the bed, in the up position. The half side rails when in the up position extended from the top of the bed to the middle of the bed. On 03/11/2025 at 8:40 AM, Resident 7's right half side rail was observed in the down position and the left side rail was in the up position. On 03/12/2025 at 1:30 PM, both half rails were in the up position while Resident 7 was napping in bed. On 03/13/2025 at 3:00 PM, an observation showed Resident 7's half rails were both in the up position. During an interview on 03/13/2025 at 3:39 PM, Resident 7 stated they had not been informed of the use of the side rails by staff, and they used the half rails in bed so they would not roll out of bed. During an interview on 03/13/2025 at 2:30 PM, Staff B, Resident Manager, stated there were no assessments, physician's orders, consents, or care plans for the use of any resident side rails. Staff B further stated they understood the need for an assessment for the side rails as some of the residents could be potentially restrained or injured using side rails. Reference: WAC 388-97-0620(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the Office of the State Long-Term Care Ombudsman of the discharge of 1 of 1 resident (Resident 5) reviewed for transfer/discharge notifications. This failure placed the residents at risk for decreased protection from being inappropriately discharged and lack of access to an advocacy group whom could inform them of their rights and options. Findings included . <Resident 5> Review of the resident's medical record showed they were admitted with diagnoses that included congestive heart failure (the heart is unable to keep up with the demands of the body), and history of a cerebral vascular accident (also known as a stroke when oxygen is cut-off from a part of the brain). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance with their activities of daily living (basic skills required to care for oneself). Review of Resident 5's progress notes showed the resident was discharged to the hospital on [DATE] for a urinary tract infection with sepsis (a life-threatening complication of an infection occurs when chemicals released to fight infection in the blood stream trigger inflammation throughout the body). Further review showed they remained in the hospital from [DATE] to 02/04/2025. During an interview on 03/11/2025 at 2:24 PM, Staff Social Services Director stated they did not notify the State Long-Term Care Ombudsman Office for Resident 5 related to their discharge to the hospital. Additionally, Staff K stated they did not have a process currently in place for notifying the Ombudsman office when residents transfer or discharged out of the facility. Reference: WAC [PHONE NUMBER](2)(a-d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a system was in place to provide a written notice of a bed-hold at the time of discharge to the hospital prior to a hospital transfer for 1 of 1 resident (Resident 5) reviewed for hospitalization. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed on the long-term care unit while in the hospital. Findings included . <Resident 5> Review of the resident's medical record showed they were admitted to the facility with diagnoses that included congestive heart failure (the heart is unable to keep up with the demands of the body), history of a cerebral vascular accident (when oxygen is cut-off from a part of the brain) and chronic urinary retention. Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance with their activities of daily living (basic skills required to care for oneself). Review of Resident 5's progress notes showed the resident was discharged to the hospital on [DATE] for a urinary tract infection with sepsis (a life-threatening complication of an infection which occurs when chemicals released to fight infection in the blood stream trigger inflammation throughout the body). Resident 5 remained in the hospital from [DATE] to 02/05/2025. Further review of the resident's record showed no written bed-hold notification had been given to the resident to inform them of their right to return to their bed on the long-term unit. During an interview on 03/11/2025 at 9:36 AM, Staff H, Registered Nurse, stated they did not send a written notice or information on bed-hold with residents when they discharge to the hospital. Staff H stated they had no bed-hold form available to them nor had they even heard of one. During an interview on 03/11/2025 at 2:35 PM, Staff B, Resident Supervisor, stated they were aware of the requirement to provide a written notice of bed-hold prior to a resident ' s discharge from the long-term care unit and they were working on a policy to start the process. Staff B stated the policy had not been initiated yet, therefore, the discharged residents had not been receiving bed-hold notices as required. Reference: WAC 388-97-0120(4)

Based on interview and record review the facility failed to implement an effective and individualized Infection Prevention and Control Program (IPC) for long-term care (LTC) residents that met the Center for Medicaid and Medicare Services federal regulatory requirements included monthly surveillance, monitoring/tracking of infectious diseases. This failure disallowed the designated Infection Preventionist (IP) the ability to identify trends and implement interventions. The failure placed residents at risk for infectious diseases and deterioration in their health status. Findings included . Record review of the October 2024 through March 2025 infection control process and reports which included all infections the hospital showed the LTC unit infectious diseases had not been tracked or reviewed for trends and infection rates. During an interview on 03/13/2025 at 10:11 AM, Staff Q, IP, stated they were the IP for the long-term care unit and the hospital. Staff Q stated they did not identify infection trends or rates specific to the LTC unit and had no surveillance reports or identifying data to include the infection rates. Staff Q further stated they looked at infections for the whole hospital including the Assisted Living unit, however had been unaware of the additional requirements for LTC and did not have a process in place. During an interview on 03/14/2025 at 9:50 M, Staff G, Nursing Operations Manager, stated Staff Q was new in the IP role and had not received the training they needed after the other IP left the position. Staff G stated the LTC Infection Control Program should have specific reports and data for the unit. Reference: WAC 388-97-1320(1)(a)

Based on interview and record review the facility failed to ensure the designated Infection Preventionist (IP) responsible for the facility's Infection Control Program met the education qualifications for certification prior to accepting the role as the IP in a long-term care facility. This failure placed residents at risk for not having an adequate oversight of infection control issues specific to long-term care. Findings included . During an interview on 03/13/2025 at 10:17 AM, Staff Q, IP, stated they had been hired as the IP for the hospital and the long-term care unit. Staff Q stated they had not completed the required infection control training for certification as an IP. No one told me I needed to be certified so I have not taken any of the trainings for long-term care. During an interview on 03/13/2025 at 2:36 PM, Staff B, Resident Manager, stated they were not aware that there were specific training requirements for the IP to be certified and stated they understood why it was important for the IP to have the training. Reference: WAC-388-97-1320(1)(a)

Based on interview and record review the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that met at least quarterly and included the Infection Preventionist who was a required member of the QAA committee. This failure minimized the effectiveness of the interdisciplinary QAA team ' s ability to identify processes and outcomes related to infection control practices and disease management. Findings included . Record review of the QAA quarterly committee team minutes dated 05/01/2024 to 03/06/2025 showed no input from the Infection Preventionist related to infection prevention and control data. Additional review of the minutes showed the third quarter QAA committee meeting was missed, and the data was included in the fourth quarter meeting (three months late). During an interview on 03/13/2025 at 10:17 AM, Staff Q, Infection Preventionist (IP), stated they had never participated or prepared a report for the QAA committee on infection control data and stated, I was not aware that I was required to be at the QAA committee or present any data. During an interview on 03/14/2025 at 9:24 AM, Staff G, Nursing Services Manager, stated the IP had not been included in the QAA committee meetings over the past year and infection control data had not been presented. Staff G stated they agreed that the IP needed to be at all the quarterly QAA meetings so infection control data could be reviewed and analyzed as a part of the meeting. Additionally, Staff G stated the third quarter QAA committee meeting had been missed therefore they had combined the two quarters and presented the data for both quarters together. Reference: WAC 97-388-1760(1)(2)

Based on observation and interview the facility failed to provide a sanitary environment by not providing scheduled maintenance services for cleaning for 1 of 1 kitchen. This failed practice placed the residents at risk for cross contamination, food borne illness, and negative health outcomes. Findings included . During an observation on 03/10/2025 at 11:24 AM, the air vent in the kitchen located on the overhead in the middle ceiling over the food preparation areas had fuzzy brown substances that were unclean around the air filter vent grills. The air vent ' s grill, located on the ceiling over the cook's area, had multiple areas of a dark brown fuzzy substances. The air vents grill, over the first entry door to the kitchen and towards the dry goods storage area had accumulated brown fuzzy dust. The ceiling air vent ' s grill, located inside of the second entryway had brown fuzzy substances. Additionally, the overhead light fixture and plastic covering located over the cook's area and food serve out area was dirty with yellow brown substances. During an interview on 03/10/2025 at 2:20 PM, Staff M, Environmental Services-Lead, visualized the vents in the kitchen and stated they were dirty and were not cleaned for a while. Staff M stated they had an assigned custodian for the kitchen and one of their responsibilities was to clean the kitchen vents but was not sure when the vents were scheduled to be cleaned. During an interview on 03/13/2025 at 12:46 PM, Staff L, Environmental Services Director, stated it had been two months of not cleaning the accumulation of dust and grime on the vents. Staff L stated they would replace the lighting fixtures over the stove which were discolored and unable to be cleaned. Staff L stated the cleaning of the kitchen vents and ceiling had not been on a scheduled cleaning and needed to be on a schedule. Reference: WAC 388-97-3220(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were given the opportunity to formulate an Advanced Directive (AD) and/or periodically reviewed/notified residents of their right to formulate an AD for 1 of 4 residents (Resident 2) reviewed for ADs. This failure denied residents the right to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their preferences and choices honored regarding emergent/end-of-life care. Findings included . Review of the facility's policy titled, Advance Directives, dated 02/06/2020, showed upon admission, and periodically thereafter, residents would be informed of their right to make health care decisions and advance directives. Additionally, if a resident wished to formulate an AD, then social services would assist in the process. <Resident 2> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including respiratory failure, and a lung infection. The 01/05/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Additionally, the medical records showed no documentation that Resident 2 had an AD nor that a discussion about formulating an AD had taken place with the resident. During an interview on 01/30/2024 at 10:49 AM, Staff E, Social Service Director (SSD), stated that during the resident admission a social service assessment would be completed and that was where residents were given the opportunity to formulate an AD if they did not already have one. Additionally, Staff E stated that ADs were also reviewed during the resident's first quarterly care conference (a meeting with the resident, nursing staff and/or their representative), and with a significant change in a resident. During a continued interview on 01/30/2024 at 10:59 AM, when reviewing Resident 2's medical records, Staff E stated they did not see where ADs were discussed with Resident 2. Staff E stated that Resident 2 was going to provide an AD from their last stay at the facility but that it was never obtained and should have been followed up on, .that will be something that I will be asking (Resident 2). Additionally, after reviewing resident records, Staff E stated that the facility had not been discussing or providing residents' the opportunity to formulate an AD after the first quarterly care conference. During an interview on 01/30/2024 at 1:51 PM, after explaining what ADs were, Resident 2 stated that no staff had discussed AD with them, maybe that is something I should fill out while I'm still able to. During an interview on 01/31/2024 at 11:50 AM, Staff B, Acting Director of Nursing Services, stated that the AD's were to be discussed with Resident 2 when they were admitted . Staff B stated the process should have been to provided Resident 2 the opportunity to formulate an AD when they were admitted . Additionally, Staff B stated that all residents should be periodically given the opportunity, during their quarterly care conferences, to formulating an AD if they want to. Reference: WAC 388-97-0280 (1)(3)(a)(d)

Based on interview and record review the facility failed to develop an abuse prohibition policy and procedures regarding the incorporation of Quality Assurance and Performance Improvement program (QAPI). This failure disallowed the QAPI committee determination regarding abuse investigations. Findings included . Review of the facility's policy titled Protection of Residents from Mistreatment, Neglect, and/or Misappropriation of Property, revised 03/03/2020, showed the facility did not develop written policies/procedures related to coordination with QAPI. During an interview on 02/02/2024 at 12:50 PM, Staff A, Administrator, stated QAPI should be included in the Abuse policies. Reference: WAC 388-97-0640

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report alleged violations related to abuse to include injuries of unknown source within the required time frame to the State Agency (SA) for 1 of 1 resident (Resident 10), reviewed for abuse and neglect. This failure placed residents at risk for unidentified abuse and neglect and the continued exposure to abuse and neglect. Findings included . Review of the facility's policy titled, Guidelines for Staff Reporting Resident Abuse or Neglect-Long Term care, revised on 4/28/2022, showed all employees are considered mandated reporters. According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), a nursing home employee (or other mandated reporter) is required to make a report immediately where there is a reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. Substantial injuries of unknown source must be reported within 24 hours, if through the process of a thorough investigation, the injury is not reasonably related to a disease process or known sequence of events. <Resident 10> Review of Resident 10's medical record showed they were admitted to the facility on [DATE] with diagnoses including heart failure (a condition where the heart cannot pump enough blood to meet the body's needs) and an intact cognition. Review of the facility's Incident Reporting Log, dated 09/14/2023, showed Resident 10 had a substantial injury of bruising deep in color of unknown origin. Further review of the log showed the incident happened on 08/28/2023 and was not reported to the SA. Review of nursing progress notes, dated 08/29/2023, showed Resident 10 had a three-centimeter bluish in color mark on their right upper breast. The progress notes also showed this was an unwitnessed event. During an interview on 02/02/2024 at 10:41 AM, Staff B Acting Director of Nursing Services, stated Resident 10's incident was not reported to the SA. Staff B further stated the incident should have been reported. During an interview on 02/02/2024 at 12:50 PM, Staff A, Administrator, stated alleged abuse and neglect were mandated to be reported to the SA by staff. Staff A stated due to the location of Resident 10's bruise, the facility should have ruled out sexual abuse. Reference: WAC 388-97-0640(5)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct a thorough investigation regarding allegations of abuse and/or neglect for 1 of 1 resident (Resident 10) reviewed for investigations. The failure to complete a thorough investigation placed residents at risk for abuse, neglect, and unmet care needs. Findings included . Review of the facility's policy titled, Guidelines for Staff Reporting Resident Abuse or Neglect-Long Term care, revised on 04/28/2022, showed the facility will follow the Purple Book for investigating reported incidents of resident abuse, neglect, injuries of unknown source. According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), all incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. A thorough investigation is a systematic collection of review of evidence/information that describes and explains an event or a series of events to determine what occurred and make necessary changes to resident's plan of care and services to prevent reoccurrence. The investigation should include the who, what, when, where, why and how, of the incident and establish a reasonable cause within 24 hours of the incident. <Resident 10> Review of Resident 10's electronic medical record showed they were admitted to the facility on [DATE] with diagnoses including heart failure and had an intact cognition. Review of the facility's Incident Reporting Log, dated 09/14/2023, showed Resident 10 had a substantial injury of bruising deep in color of unknown origin. Review of the facility's investigation report, dated 09/05/2023, showed Resident 10 was found to have an unwitnessed event and unknown cause that resulted in a three-centimeter bluish purple mark on their right breast. There was no documentation that showed the facility thoroughly investigated the cause of the unwitnessed event. During an interview on 02/01/2024 at 4:29 PM, Staff A, Administrator, stated this investigation was not a thorough investigation and did not even contain witness statements. During an interview on 02/02/2024 at 10:41 AM, Staff B, Acting Director of Nursing Services, stated they received the investigation report and read what the nurse wrote about the incident. Staff B stated they believed that Resident 10 bumped their area with the bruise. Staff B stated if they felt the incident needed to be reviewed more, they would talk to staff and residents, but that it was situational based on the incident reported. Reference: WAC 388-97-0640(6)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 3), reviewed for care and use of a urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) received appropriate care and services by positioning the catheter drainage bag below the level of the bladder to prevent infection. This failure placed the resident at risk for additional urinary tract infections (UTI) and serious medical complications. Findings included . Review of the Centers for Disease Control and Prevention Guidelines titled, Prevention of Catheter-Associated Urinary Tract Infections 2009, dated 06/06/2019, showed the Proper Techniques for Urinary Catheter Maintenance, included the catheter drainage bag must be kept below the level of the bladder. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), neurogenic bladder (a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem), benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland) and chronic UTI's. The 11/21/2023 comprehensive assessment showed the resident was dependent on assistance of two staff members for activities of daily living (ADLs - activities related to personal care such as bathing, dressing, using the toilet, and getting in and out of a chair or bed). The assessment also showed the resident was cognitively intact. An observation on 01/30/2024 at 3:23 PM, showed Staff J, Nursing Assistant (NA), and Staff N, NA, transferring Resident 3 from their wheelchair to their bed using a mechanical lift. Staff J removed the catheter drainage bag from below the seat of the wheelchair and hung it on the mechanical lift at the height of the resident's chest. The catheter drainage bag was higher than the level of the bladder. An observation on 01/31/2024 at 7:14 AM, showed Staff L, NA, and Staff O, NA, assisted Resident 3 with their morning personal cares and then transferred the resident to their wheelchair from the bed. While Resident 3 was lying flat in bed, Staff L and Staff O placed the sling (for the mechanical lift) under Resident 3 and attached the sling to the lift. Staff O removed the catheter drainage bag from the side of the bed and, with Resident 3 still lying flat, hung the catheter drainage bag above the resident's chest (higher than the level of the bladder) and proceeded to transfer the resident to their wheelchair. During a concurrent interview on 01/31/2024 at 9:47 AM, Staff L and Staff O stated they were trained to hang the catheter drainage bag below the level of the bladder to prevent the urine from flowing back into the bladder. During an interview on 02/01/2024 at 3:45 PM, Staff B, Acting Director of Nursing Services, stated the staff were not following the process with correct placement of Resident 3's catheter drainage bag during transfers. Reference: WAC 388-97-1060(3)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice for 2 of 2 residents (Resident 2 and 9) reviewed for trauma informed care. The facility failed to assess, monitor, and care plan residents' experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience). This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . <Resident 2> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including respiratory failure with a lung infection, Post Traumatic Stress Disorder (PTSD, a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), depression and anxiety. The 01/13/2024 comprehensive assessment showed the resident was cognitively intact, able to make their needs known. Review of Resident 2's care plan, dated 01/05/2024 and 01/12/2024, showed that a plan for the resident trauma history and PTSD was not developed, nor potential triggers identified. During an interview on 01/31/2024 at 4:00 PM, Resident 2 stated specific historical traumatic events that had taken place and lead to their diagnosis of PTSD. Additionally, Resident 2 stated that based on their experiences there were key triggers that could lead to them reliving the traumatic event that they had been working on with counselor from outside of the facility. During an interview on 01/31/2024 at 4:14 PM, Staff E, Social Service Director, stated they did not know about Resident 2's trauma history, why they had been diagnosed with PTSD, or if they had potential triggers. Staff E stated it was not their process to complete a trauma informed care assessment (an approach to care delivery that assesses signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, procedures, and practices to avoid re-traumatization) when residents were admitted to the facility. During an interview on 01/31/2024 at 4:35 PM, Staff I, Registered Nurse, stated they did not complete a trauma informed care assessment on any resident and was not aware that Resident 2 had traumatic experiences or was diagnosed with PTSD. During an interview on 02/01/2024 at 3:34 PM, Staff J, Nursing Assistant, stated they were not aware that Resident 2 had a history of traumatic events or of specific triggers to monitor for. During an interview on 02/02/2024 at 11:17 PM, Staff B, Acting Director of Nursing Services, stated they would have expected nursing staff to have assessed and monitor Resident 2's traumatic history and PTSD. Additionally, Staff B stated that Resident 2's PTSD and trauma triggers should have been care plan. During an interview on 02/01/2024 at 5:01 PM, Staff A, Administrator, stated the process should have been for Resident 2 to have a trauma informed care assessment completed when they were admitted to the facility. <Resident 9> Review of the medical record showed Resident 9 was admitted to the facility on [DATE] with diagnoses including dementia (a group of symptoms affecting memory, thinking and daily life) and depression. The 12/06/2023 comprehensive assessment showed Resident 9 had a severely impaired cognition. Review of Resident 9's 06/22/2023 progress note, showed the resident required two staff members for their shower due to Resident 9's behaviors of screaming and anger. The progress note further showed Resident 9 was combative during the shower and staff were unable to complete the shower for the resident. During an interview on 01/30/2024 at 1:28 PM, the Resident Representative stated the facility had attempted alternatives to showering, however Resident 9 would continue to be combative. The Resident Representative informed staff that Resident 9 had a traumatic event in their life that caused Resident 9 to be terrified of water. During an interview on 01/30/2024 at 1:54 PM, Staff K, Nursing Assistant (NA), stated they showered Resident 9 on 01/29/2024 and the resident screamed, yelled, and hit them throughout the shower. Staff K further stated Resident 9 did not like to be wet. During an interview on 01/30/2024 at 1:55 PM, Staff I, Registered Nurse (RN), stated they were aware the resident almost drowned when they were younger and getting wet was a trigger for Resident 9. During an interview on 01/31/2024 at 10:04 AM, Staff L, NA stated when Resident 9 was showered it took two staff members and must be done quickly. Staff L stated Resident 9 hated showers and screamed during the process of showering. Staff L stated they were aware of a near drowning when the resident was younger. During an interview on 01/31/2024 at 2:52 PM, Staff B, Acting Director of Nursing Services, stated the facility did not admit residents with behavioral issues. Staff B stated they were unaware of any residents who experienced trauma or had behavioral issues. Staff B stated there was no assessments for trauma or behaviors that was conducted when residents were admitted to the facility. Staff B continued to state that Resident 9 would become very distressed during showers and their behavior had become worse. Reference: WAC 388-97-1060(3)(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to consistently offer substantial nutritional snacks in the evening for 6 of 9 residents (Residents 112, 8, 9, 3, 6, and 7) reviewed for evening snacks. This failure placed the residents at risk for hunger and unmet nutritional needs. Findings included . Review of an undated, facility provided document titled, Service Cart Delivery Times, showed the dinner meal for Dining Room B was scheduled for 5:00 PM and the breakfast meal was scheduled for 8:00 AM (15 hours between the evening and breakfast meal). <Resident 112> Review of the medical record showed Resident 112 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances (a disease that effects a person's personality and habits that may lead to changes in their behavior including agitation and anxiety) and adult failure to thrive (a syndrome weight loss, decreased appetite and poor nutrition, accompanied by dehydration and depressive symptoms). The 01/26/2024 comprehensive assessment showed Resident 112 required partial assistance of one staff member for Activities of Daily Living (ADLs - activities related to personal care such as bathing, dressing, using the toilet, and getting in and out of a chair or bed). The assessment also showed the resident had a severely impaired cognition. During an interview on 02/01/2024 at 10:25 AM, Resident 112 stated that no one offered them a snack in the evening. They stated they would like a snack, but they did not get one. <Resident 8> Review of the medical record showed Resident 8 was admitted to the facility on [DATE] with diagnoses including age-related memory disorder and type 2 diabetes (a group of diseases that result in too much sugar in the blood). The 11/07/2023 comprehensive assessment showed Resident 8 required partial to maximum assistance of one staff member for ADLs. The assessment also showed the resident had a severely impaired cognition. <Resident 9> Review of the medical record showed Resident 9 was admitted to the facility on [DATE] with diagnoses including dementia (the impaired ability to remember, think, or make decisions that interfere with doing everyday activities) and depression (a feeling of sadness and loss of interest in activities causing a significant impairment in daily life). The 11/27/2023 comprehensive assessment showed Resident 9 required maximum assistance of one staff member for ADLs. The assessment also showed the resident had a severely impaired cognition. During a Resident Council (an organized group of residents that meet regularly to discuss and address concerns about their rights, quality of care, and quality of life) meeting conducted by the survey team on 01/30/2024 at 8:30 AM, Residents 8 and 9 stated they were not offered a snack in the evening or in between meals. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, atrial fibrillation (an irregular heart rate that causes poor blood flow), and depression. The 11/21/2023 comprehensive assessment showed the resident was dependent on assistance of two staff members for ADLs. The assessment also showed the resident was cognitively intact. During an interview on 01/29/2024 at 9:34 AM, Resident 3 stated they were not offered snacks in the evening. They stated they might like a snack if they were offered one. <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses including arthritis and muscle weakness. The 11/07/2023 comprehensive assessment showed Resident 6 required maximum assistance/dependent on one staff member for ADLs. The assessment also showed the resident had an intact cognition. During an interview on 02/02/2024 at 10:53 AM, Resident 6 stated they would like a snack in the evening. Resident 6 stated they had not seen anyone with snacks lately. <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and anxiety. The 12/18/2023 comprehensive assessment showed the resident required partial to maximum assistance of one staff member for ADLs. The assessment also showed Resident 7 had a moderately impaired cognition. During an interview on 02/02/2024 at 10:58 AM, Resident 7 stated no one had asked if they wanted a snack in the evening. They stated they might want one if they had been asked. During an interview on 01/31/2024 at 10:53 AM, Staff I, Registered Nurse, stated that not all residents received snacks in the evening. They stated the kitchen brought snacks for residents that have an order for evening snacks, but they did not offer snacks to all residents. During an interview with both Staff A, Administrator, and Staff B, Acting Director of Nursing Services on 02/01/2024 at 3:36 PM, Staff B stated that snacks were readily available to residents. They stated that the residents that had physician ordered snacks received them from the kitchen. Staff B stated they did not believe the staff were going around to residents and offering snacks in the evening. Staff A stated they agreed that evening snacks needed to be offered. Reference: WAC 388-97-1120(1)

Based on observation and interview, the facility failed to ensure the proper disposal of trash for 1 of 1 dumpster (Dumpster 1) reviewed for outdoor refuse storage. The failure to ensure Dumpster 1 was covered, placed the facility at risk of attracting bugs, rodents, and an unsanitary environment. Findings included . A concurrent observation and interview on 01/31/2024 at 10:19 AM with Staff F, Dietary Manager (DM), showed a tan dumpster with a wire mesh cover that was operated by a hand crank. The mesh cover was in the open position with bags of trash visible above the top of the dumpster. Staff F stated the cage top was always open so staff could put trash into the dumpster. An observation on 02/01/2024 at 7:37 AM, showed the same tan dumpster with the mesh cover in the open position. There were trash bags visible above the top of the dumpster and a cardboard box on the ground in the back corner of the dumpster enclosure. During an interview on 02/02/2024 at 9:50 AM, Staff F stated they reviewed the regulation and were not aware that the facility was responsible for the dumpster/refuse area. During an interview on 02/01/2024 at 3:41 PM, Staff A, Administrator, stated the facility needed to follow the regulations regarding the dumpster/refuse area to ensure compliance. Reference: WAC 388-97-1320(4)

Based on interview and record review, the facility failed to conduct a Performance Improvement Project (PIP) that focused on a high risk or problem prone areas of the resident population annually for 3 of 3 quarterly (Q, every three months) meetings (Q1, Q2 and Q3) reviewed for the Quality Assurance and Performance Improvement (QAPI) process. This failure placed residents at risk regarding quality care improvement, unidentified complications, and prompt corrective action towards high-risk/problem prone areas. Findings included . Review of the facility's policy titled, Performance Improvement Plan, dated 08/09/2022, showed that a PIP's focused on .areas of high risk, high volume or prone components of care ., and that the Administrator was to manage the QAPI program. Review of the facility's 2023 QAPI meeting minutes (Q1, Q2, Q3), showed that a PIP was not implemented in any of the quarters reviewed. During an interview on 02/02/2024 at 12:32 PM, Staff A, Administrator, stated they monitored, analyzed, and evaluated high-risk problem prone resident care areas, but don't remember the last PIP done. Reference: WAC 388-97-1760(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer and/or provide an influenza (a common viral infection that attacks the lungs, nose, and throat) immunization (a vaccine that protects against infection by influenza viruses) for 2 of 5 residents (Resident 1 and 3) reviewed for immunizations. This failure placed the residents at risk for illness and transmission of a communicable disease. Findings included . Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Influenza (flu); Flu Season, dated 09/20/2022, showed flu season usually occurs in the fall and winter. While influenza viruses spread year-round, most of the time flu activity peaks between December and February. Review of the undated Washington State Department of Health guidance titled, What's new for flu for 2023 - 2024 advised obtaining an influenza vaccination before October, although the vaccine was available through the winter months. Review of the facility provided policy titled, Flu and Pneumonia Vaccination (immunization) for Patients or Residents, dated 02/04/2020, showed the licensed healthcare professional would assess the resident for appropriateness for receiving the influenza vaccine. They would provide the resident and/or their representative with information regarding the risks and benefits of receiving the vaccine. If the resident declined, they would be educated by a licensed nurse regarding risks and benefits. The influenza vaccine would be given during the current influenza season. Administration of the influenza vaccine would be documented in the resident's medical record. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and anxiety. The 01/23/2024 comprehensive assessment showed the resident had an upper extremity (arm) impairment on one side and was dependent one to two staff members for activities of daily living (ADLs). The assessment also showed Resident 1 had a severely impaired cognition. Record review of Resident 1's immunization record showed they did not receive an influenza immunization for the 2023 influenza season. There was no documentation that the resident had been offered the influenza immunization, had received education regarding the risks and benefits of the immunization, or that the resident had declined the immunization. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, atrial fibrillation (an irregular heart rate that causes poor blood flow), and depression (a feeling of sadness or loss of interest that can interfere with daily living). The 11/21/2023 comprehensive assessment showed the resident was dependent on assistance of two staff members for ADLs. The assessment also showed the resident was cognitively intact. During an interview on 02/01/2024 at 1:32 PM, Resident 3 stated they thought they had received their influenza immunization at their previous facility. They stated they were not offered one when they were admitted to this facility, and no one had asked them if they already had one. Resident 3 stated they would have liked to have one (2023 influenza immunization) if they had not had it yet. Review of Resident 3's immunization record showed the resident last received an influenza immunization on 10/28/2019. There was no documentation in their medical record that showed they were offered, received education regarding risks and benefits, or that the resident had declined the immunization. During an interview on 02/01/2024 at 9:19 AM, Staff C, Infection Preventionist, stated they were responsible for tracking influenza immunizations. They stated Residents 1 and 3 had declined the immunization and there was a declination for both residents in their medical record . Staff C stated they expected all residents to be offered or given the flu shot. They stated education with risks and benefits were a pop up screen on the computer that had to be acknowledged before the nurses would be able to continue charting in the medical record During an interview on 02/01/2024 at 11:23 AM, Staff B, Acting Director of Nursing Services, stated the nurses that worked on the floor were responsible for administering the influenza immunization. Staff B stated they would locate the declinations for Residents 1 and 3. During an interview on 02/01/2024 at 1:14 PM, Staff D, Administrative Assistant, stated Staff B was unable to locate the declinations for Residents 1 and 3. Reference: WAC 388-97-1340(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan that addressed the resident's medical, physical, mental, and psychosocial needs for 5 of 7 residents (Resident 3, 2, 112, 6, and 7) reviewed for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) use, medication use, and transfers. These failures placed the residents at risk for not receiving care and services to meet their individualized needs. Findings included . <Urinary Catheter Use> <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, atrial fibrillation (an irregular heart rate that causes poor blood flow), obstructive uropathy (a disorder of the urinary tract that occurs due to obstruction in urinary flow), neurogenic bladder (a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem) and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). The 11/21/2023 comprehensive assessment showed the resident was dependent on assistance of two staff members for activities of daily living (ADLs - activities related to personal care such as bathing, dressing, using the toilet, and getting in and out of a chair or bed). The assessment also showed the resident was cognitively intact. An observation on 01/29/2024 at 9:46 AM, showed Resident 3 lying in bed, a urinary catheter tube exiting their left pant leg, connected to a drainage bag that was hanging on the side of the bed. Resident 3 stated the urinary catheter had been in place for about five to six years. Review of the Resident 3's comprehensive care plan, last updated 11/07/2023, showed there was no problem area, goal, or interventions related to the use of Resident 3's urinary catheter. <Medication Use> An observation on 01/30/2024 at 10:08 AM, showed Resident 3 lying in bed. They had dark purple bruising to their right elbow area and left forearm. Record review of Resident 3's physician orders, dated 11/07/2023, showed the resident received a blood thinning medication used to treat and prevent blood clots and lower the risk of stroke, that can cause excessive, unwanted bruising or bleeding. Review of the Resident 3's comprehensive care plan, last updated 11/10/2023, showed it did not reflect the resident's current use of, or interventions related to the use of the blood thinner. <Resident 2> Review of the medical record showed Resident 2 was admitted on [DATE] with diagnoses including respiratory failure with a lung infection, seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements), a heart condition that required a blood thinning medication, depression, and anxiety. The 01/13/2024 comprehensive assessment showed the resident was cognitively intact, able to make their needs known. Review of Resident 2's physician medication orders, dated 01/05/2024, showed the resident was being administered apixaban (a blood thinning medication used to treat and prevent blood clots and strokes), paroxetine (a medication used to treat depression and anxiety disorders), lamotrigine [a medication used to treat seizures and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and remeron (a medication used to treat depression). Review of Resident 2's care plan, last updated 01/12/2024, showed there was no problem area related to the resident's use of the apixaban, paroxetine, lamotrigine, and remeron medications or diagnoses connected to them. During an interview on 02/02/2024 at 11:17 AM, Staff B, Acting Director of Nursing Services, stated that Resident 2 should have been care planned with goals and interventions for their seizures, heart condition, depression, anxiety, and the high-risk medications being administered with the diagnoses. <Resident 112> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbances (an impairment of brain function, which causes memory loss, forgetfulness, impaired thinking abilities and can be accompanied with mood/behavior change) and chronic (long term) right hip pain. The 01/26/2024 comprehensive assessment showed the resident was cognitively impaired but was able to communicate and make their needs known to staff. Additionally, the comprehensive assessment showed the resident was taking Cymbalta (high-risk psychotropic medication used to treat certain mental/mood disorders) medication for their dementia. Review of Resident 112's physician medication orders, dated 01/15/2024, showed the resident was being administered Cymbalta for their dementia with behavioral disturbances and an analgesic (a medication used for pain management) medication for their chronic right hip pain. Review of Resident 112's care plan, last updated 01/22/2024, showed there was no problem area, goals, or interventions related to the resident's high risk psychotropic medication or chronic right hip pain. During an interview on 02/02/2024 at 11:26 AM, Staff B, stated that Resident 112 should have been care planned with goals/interventions for their dementia with behavioral disturbances, with high-risk medication, and chronic right hip pain. <Transfers> <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses including arthritis and muscle weakness. The 11/07/2023 comprehensive assessment showed Resident 6 required maximum assistance/dependent on one staff member for ADLs. The assessment also showed the resident had an intact cognition. An observation on 01/29/2024 at 1:17 PM, showed Staff K, Nursing Assistant, transferring Resident 6 from their wheelchair to their recliner using a sit-to-stand (a mechanical lift that assists individuals with limited mobility to a standing position from a seated position) mechanical lift. Review of Resident 6's comprehensive care plan, last updated 1/22/2024, showed no interventions related to transfers or the use of the sit-to-stand lift. <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and trigeminal neuralgia (a type of chronic pain disorder that involves sudden, severe facial pain). The 12/18/2023 comprehensive assessment showed the resident required partial to maximum assistance of one staff member for ADLs. The assessment also showed Resident 7 had a moderately impaired cognition. During an interview on 01/31/2024 at 2:52 PM, Staff I, Registered Nurse stated the resident used a front wheeled walker and assistance of one staff member for transfers, unless their condition (trigeminal neuralgia) flared up (a worsening of the disease process) then they would need to transfer with staff assistance and the use of the sit-to-stand. Review of Resident 6's comprehensive care plan, last updated 12/11/2023, showed no interventions related to the use of the sit-to-stand lift, including when staff were to use it for safe transfer of the resident. During a follow up interview on 02/02/2024 at 12:23 PM, Staff I stated the care plans were created based on the comprehensive assessments and were individualized from there. Staff I stated they adjusted the care plans quarterly to ensure accuracy. They stated the comprehensive care plan should contain information such as their ADLs, mobility, toileting requirements, and medication use. Staff I stated they were able to individualize the care plan for each resident's needs. Staff I stated all current resident care plans were comprehensive and up to date, with exception of the resident who was recently admitted (01/15/2024). During an interview on 02/01/2024 at 3:40 PM, with Staff B and Staff A, Administrator, Staff B, stated the resident's care plans needed to be comprehensive, up to date, and reflect the current needs of the resident. Staff A, stated they agreed with Staff B. Reference: WAC 388-97-1020(1)(2)(a)(b)

Based on interview and record review, the facility failed to ensure nursing staff had the appropriate competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares), and skill sets, which included an assessment of the staff's demonstration of competency in the skills needed to provide care and services for the facility's resident population, for 5 of 5 nursing staff (Staff I, K, O, P and Q) reviewed for staff competencies. This failure placed residents at an increased risk of adverse effects regarding the quality of care provided to the residents and unmet care needs. Findings included . Review of the facility's document titled, Facility Assessment Tool, dated 01/17/2021, showed the Facility Assessment [(FA) a tool used to determine the resources necessary to care for residents during both day-to-day operations and emergencies] had not been completed for the 2023 to 2024 year. Additionally, the document showed the type of care the resident population would require included, .indwelling or other urinary catheter .pressure injury prevention and care, skin care, wound care .identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder (a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event) .identification and containment for infections, prevention of infections .resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process .prevent abuse and neglect .identify hazards and risks for residents .person-centered care planning and advance care planning ., but did not include what staffing competencies would be needed to provide the level of care/services regarding the resident population. Review of the facility's skills fair documentation, dated 12/12/2023, showed that Staff I, Registered Nurse, Staff K, Nursing Assistant (NA), Staff O, NA, Staff P, NA and Staff Q, Licensed Practical Nurse, obtained skills fair training, which included review of restraints, sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection), and resident transfer devices. Additionally, the training did not include an evaluation of the Staff I, K, O, P and Q's competences regarding the training and/or through a form of return demonstration for the training activities that were reviewed. Review of Staff I, K, O, P and Q's personnel education and training records, dated 01/01/2023 to 12/31/2023, showed that no staff had completed any competencies. During an interview on 02/01/2024 at 12:21 PM, Staff B, Acting Director of Nursing Services, stated the facility did not complete competencies or skills check offs every year with nursing staff. Staff B stated they had facility staff complete trainings through an online platform, then attended a skills fair which was held by the facility on 12/12/2023, and that no other trainings were conducted. Staff B stated that the skills fair did not include skills check offs or an assessment of staff demonstration of competencies. Refer to F656, F699, F880 for additional information. Reference: WAC 388-97-1680(2)(a)(b)(i-ii)(c)

Based on interview and record review, the facility failed to perform an annual review of the Facility Assessment (FA, an evaluation that determine what resources are required to meet each resident's care/service needs with the facility's resident population) and did not include a representative of the governing body or medical director in the development of the FA. Additionally, the FA failed to address the staffing competencies necessary to provide the level and types of care needed for the resident population. These failures placed all residents at risk of unidentified and/or unmet care and service needs. Findings included . Review of the 02/03/2023 Centers for Medicare and Medicaid Services (CMS) State Operations Manual - Appendix PP, showed, CFR 483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update the assessment, as necessary, and at least annually . Additionally, The facility assessment must address or include .the staff competencies that are necessary to provide the level and types of care needed for the resident population . Review of the facility's document titled, Facility Assessment Tool, dated 01/17/2021, showed the FA had not been completed for the 2023 to 2024 year and did not involve the medical director nor a representative of the governing body in the FA. Additionally, the document did not include the staffing competencies that would be needed to provide the level of care need for the current resident population. During an interview on 02/01/2024 at 5:01 PM, Staff A, Administrator, stated they were aware that the FA was required to be completed annually and that a current FA had not been completed. Additionally, Staff A stated that the FA should have addressed the staffing competencies needed to care for the resident population. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review the facility failed to; 1) maintain a Quality Assessment and Assurance (QAA) committee that included the medical director, or their designee, to participate in the committee's effort for 3 of 3 quarterly (Q, every three months) meetings (Q1, Q2, Q3 2023) reviewed for the QAA process, and 2) ensure that a thorough analysis of the high risk/adverse events were acted upon, and, a good faith attempt was made (once the facility had become aware of the adverse event) to correct quality deficiency and care concerns identified by the facility's infection control committee (which information was submitted to the facility's QAPI committee) for 2 of 3 quarterly meetings (Q2 and Q3 2023), reviewed for QAPI and infection control concerns identified on survey. This failure placed all residents at risk for unidentified complications and prompt corrective action in resident care/services areas. Findings included . Review of the facility's policy titled, Performance Improvement Plan, dated 08/09/2022, showed that the administrator, a representative of the governing body, medical staff and departmental managers would be involved in the performance improvement committee for managing of the Quality Assurance Performance Improvement (QAPI) program. The Policy showed the committee's responsibilities were to have a planned, continuous, systematic and organization wide approach to designing, measuring, assessing, and improving performance. Oversight of staff education and training for performance improvement .Identify organizational trends or opportunities for improvement projects from reports received throughout the organization. Sources of data and information include report from infection control studies .integrating PI (Performance Improvement) efforts with daily work activities. Additionally, each department was to submits quality assessments studies that were being conducted on an ongoing basis and could lead to a performance improvement studies or a quick fix process which was to be used for identified problems, which do not require a comprehensive approach to problem solving and solutions implementation. Review of the facility's 2023 QAPI meeting minutes (Q1, Q2 and Q3) showed the medical director, or their designee were not in attendance during the meetings. The Q2 infection control section showed that the facility had an outbreak of COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death). Additionally, the Q3 infection control section showed that a COVID-19 outbreak had occurred in the assisted living section of the facility (the nursing home and assisted living were connected by a double door) isolation precautions were initiated but 7 other residents were affected. Review of the facility's 2023 infection control /QAPI meeting minutes showed that in Q2 2 long-term patients contracted COVID, the source of the infection was not determined . and that all staff were to wear an N95 (a mask used to filter out and protect against harmful viruses like COVID-19) mask while preforming care with resident on the assisted living side and on the hospital side for the duration of the outbreak. The Q3 meeting noted that a COVID-19 outbreak had taken place in the assisted living side of the facility and that staff were wearing a surgical mask (a mask that does not filter out viruses like COVID-19) unless staff had become positive and then would wear and N95 mask. The Q3 meeting also noted that 14 staff were COVID-19 positive in September. During an interview on 02/02/2024 at 12:32 PM, Staff A, Administrator, stated the medical director, or their designee, did not always attend the QAPI meeting. Staff A explained if the medical director or designee had attended QAPI meeting, it would have been documented on the QAPI meeting minutes. Staff A stated that a COVID-19 outbreak would have been a high-risk/adverse event and they implemented the same outbreak measures and monitored the same quality indicators as they had been doing in previous quarters regarding infection control. Staff A stated that they were aware of the COVID-19 outbreaks and were monitoring the COVID rates in the facility but that no additional monitoring or revisions of corrective action had taken place. Refer to F880 for additional information. Reference: WAC 388-97-1760(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk of exposure and transmission of COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) were consistently implemented during a COVID-19 outbreak [two or more facility-acquired cases with epi-linkage (an overlap on the same unit or other patient location, or having the potential to have been cared for by common healthcare professionals (HCP) within a seven day time period of each other)]. The facility failed to implement infection control interventions for: • personal protective equipment (PPE - protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) use for 8 of 9 staff (Staff K, B, Q, L, O, I, R, and P) reviewed for PPE use; • COVID-19 testing for 2 of 2 residents (Residents 8 and 112) reviewed for COVID-19 testing; • implementation of transmission-based precautions (TBPs) for 1 of 1 resident (Resident 7) reviewed for implementation of precautions; • hand hygiene for 3 of 3 staff (Staff L, O, and I) reviewed for hand hygiene while providing personal cares for 1 of 1 resident (Resident 3) and passing medications for 3 of 3 residents (Resident 4, 6, and 3); • annual review of the infection control policies and procedures. These failures in infection control practices placed all residents at risk for exposure to COVID-19 and serious medical complications. Findings included . Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 05/08/2023, showed HCP that enter the room of a resident with suspected or confirmed COVID-19 infection should adhere to Standard Precautions (minimum infection prevention practices that apply to all patient care) and use of a National Institute of Occupational Safety and Health (NIOSH) approved N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). Additionally, a resident identified as suspected or confirmed COVID-19 infection, should be placed in a single-person room. The door should be kept closed. Information regarding residents with suspected or confirmed COVID-19 infections should be communicated to appropriate personnel before transferring them to other departments in the facility (e.g., radiology). HCP that entered the room of a patient with suspected or confirmed COVID-19 infection should use Standard Precautions and use an N95 respirator, gown, gloves, and eye protection. Review of the CDC's guidance titled How to Use Your N95 Respirator, dated 05/16/2023, showed an N95 respirator must form a seal to the face to work properly. Gaps could occur if the N95 respirator was too big, too small, or not put on correctly. The N95 respirator should be placed under the chin with the nose piece bar at the top. The top strap should be pulled over the head and placed near the crown of the head. The bottom strap should be pulled over the head and placed at the back of the neck, below the ears. The straps should not be crisscrossed or twisted. Review of the facility policy titled, Hand Hygiene - CDC Guidelines), dated 03/21/2021, showed effective hand hygiene was required to prevent the transmission of bacteria, germs, and infections. The policy showed staff were required to perform hand hygiene (HH): • Before starting their shift; • When hands were soiled; • Before each patient encounter; • After coming in contact with the resident's skin; • After working on a contaminated body site and then moving to a clean body site on the same resident; • After coming in contact with bodily fluids, dressings, mucous membranes; • Always after removing gloves or facemasks; • Leaving an isolation area. <Resident 8> Review of the medical record showed Resident 8 was admitted to the facility on [DATE] with diagnoses including age-related memory disorder and type 2 diabetes (a group of diseases that result in too much sugar in the blood). The 11/07/2023 comprehensive assessment showed Resident 8 required partial to maximum assistance of one staff member for ADLs. The assessment also showed the resident had a severely impaired cognition. <Resident 112> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbances (an impairment of brain function, which causes memory loss, forgetfulness, impaired thinking abilities and can be accompanied with mood/behavior change) and chronic (long term) right hip pain. The 01/26/2024 comprehensive assessment showed the resident was cognitively impaired but was able to communicate and make their needs known to staff. Additionally, the comprehensive assessment showed the resident was taking a high-risk medication for their dementia. <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and trigeminal neuralgia (a type of chronic pain disorder that involves sudden, severe facial pain). The 12/18/2023 comprehensive assessment showed the resident required partial to maximum assistance of one staff member for ADLs. The assessment also showed Resident 7 had a moderately impaired cognition. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, atrial fibrillation (an irregular heart rate that causes poor blood flow), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), neurogenic bladder (a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem) and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). The 11/21/2023 comprehensive assessment showed the resident was dependent on assistance of two staff members for activities of daily living (ADLs - activities related to personal care such as bathing, dressing, using the toilet, and getting in and out of a chair or bed). The assessment also showed the resident was cognitively intact. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE]. The 11/27/2023 comprehensive assessment showed the resident required substantial/maximal assistance of one staff member for ADLs. The assessment also showed the resident had a severely impaired cognition. <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses including arthritis and muscle weakness. The 11/07/2023 comprehensive assessment showed Resident 6 required maximum assistance/dependent on one staff member for ADLs. The assessment also showed the resident had an intact cognition. <PPE> An observation on 01/29/2024 at 8:47 AM, showed signage on the door to a resident's room that showed airborne contact precautions were required when entering the room. There was a PPE cart outside of the room that contained N95 masks, surgical masks, gowns, hair covers, briefs, and wipes. There were four paper bags on the floor outside of the door. The paper bags were labeled with staff names and contained eye protection and used N95s. There was a trash can with a lid next to the left of the door, along with a food cart that contained a breakfast meal tray. Staff K, Nursing Assistant (NA), put on a gown, gloves, and hair cover. Their N95 mask had both straps around their neck. Staff K removed eye protection from a bag labeled JG (belonged to another staff member) and put them on. Staff K entered the COVID-19 isolation room. At 9:07 AM, Staff K exited the room holding their gown and gloves. They placed them in the trash can in the hallway. Staff K then placed the eye protection back into the paper bag and performed HH. They did not remove their N95 and proceeded to the nurse's station. A second observation that same day at 10:16 AM, showed Staff K putting on PPE to enter the COVID-19 isolation room. Staff K donned a clean N95 and placed both straps around their neck. Staff K stated they were trained on how to properly don PPE and were fit tested for their N95. Staff K then entered the COVID-19 room while wearing the improperly donned N95 mask. During an observation on 01/29/2024 at 11:56 AM, Staff B, Acting Director of Nursing Services, and Staff Q, Licensed Practical Nurse (LPN) were at the nurse's station. Staff B was wearing an N95 mask with the straps crossed at their ears, and Staff Q had an N95 mask dangling around their neck, leaving their nose and mouth exposed. During an interview on 01/29/2024 at 12:25 PM, Staff Q stated they were told that on the unit, they were required to wear an N95 and when at the nurse's station, they were able to wear a surgical mask. They stated that the paper bags outside of the COVID-19 isolation room contained eye protection and N95s that were reused when going into that room. They stated they were not aware of any shortage of PPE and staff were just being conservative. An observation on 01/31/2024 at 7:14 AM showed Staff L, NA, and Staff O, NA, entering a resident room wearing N95's with both straps around their neck. During an observation on 01/31/2024 at 8:11 AM, showed Staff L, NA, wearing an N95 mask with straps around their neck, don gown, gloves, and eye protection and entered the COVID-19 isolation room. At 8:23 AM, Staff L exited the room, removed their PPE in the hallway with exception of the N95 mask, cleaned their eye protection and placed them into a paper bag, performed HH, and proceeded to the nurse's station, still wearing the same N95 mask. During an interview on 01/31/2024 at 9:47 AM, both Staff L and Staff O stated they were trained to wear their N95s with one strap over the top of their head and one around the neck. Staff L stated they did not remove their N95 when exiting the COVID-19 isolation room because there were no N95 masks on the PPE cart and no trash can outside the room (that day). They stated they should report concerns such as no PPE or needing a trash can on both the inside and outside the COVID-19 isolation room to management but had not done that. An observation on 01/31/2024 at 7:14 AM, showed Staff I, Registered Nurse (RN), at the medication cart with their N95 respirator straps around the back of their neck. An observation on 02/01/2024 at 8:10 AM, showed Staff R, Licensed Practical Nurse (LPN), standing at the medication cart wearing an N95 respirator. Both straps of the respirator wear at the crown of their head. An observation on 02/02/2024 at 9:12 AM, showed Staff P, NA, sitting at the nurse's station with their N95 respirator pulled down to their chin, leaving their nose and mouth exposed. During an interview on 01/30/2024 at 1:18 PM, Staff C, Infection Preventionist (IP), stated staff were to wear their N95 respirator with all patient care, not just the COVID-19 isolation resident. They stated they were permitted to wear a surgical mask at the nurse's station if there were no residents in the area. They stated staff were required to wear full PPE (N95 respirator, gown, gloves, and eye protection) when going into the COVID-19 isolation room. Staff were not to store soiled PPE in paper bags. N95 respirators needed to be replaced after leaving the COVID-19 isolation room and eye protection needed to be cleaned at that time. Staff C stated there was no shortage of PPE for staff use, the practice of reusing N95 respirators was a left over practice from when there were PPE shortages. <COVID-19 Testing> An observation on 01/31/2024 at 9:33 AM, showed Staff I at a COVID-19 testing cart outside of Resident 8's room. The cart had three shelves, the top contained a box of gloves, plastic bags that contained a test tube and swab for the specimen, resident labels, lab slips, a black pen, and hand sanitizer. The middle shelf contained a bin for the completed tests. Staff I was wearing an N95 mask with both straps around the back of their neck and eye protection. Staff I picked up a bag containing a test tube, placed a resident label on the tube and opened a swab for testing. Staff I donned clean gloves, and without wearing a gown, entered Resident 8's room. Staff I performed the nasal swab and placed the swab into the test tube, then placed the specimen into the bag. Staff I removed their gloves and exited the room with the bag and placed it into the bin on the cart. Staff I performed HH and moved the cart to Resident 112's room. Staff I, still wearing the same N95 respirator and eye protection, proceeded to complete the lab slip, remove the test tube and swab from a bag, and placed a label on the test tube. Staff I entered Resident 112's room wearing gloves, the same soiled N95 and soiled eye protection, and without putting on a gown, entered Resident 112's room and performed the nasal swab test. Staff I removed their gloves, placed the specimen into the test tube, placed the test tube into the bag, exited the resident's room and placed the bag into the bin on the cart. Staff I, wearing the same N95 and eye protection, moved to the next resident room. During a concurrent observation and interview on 01/31/2024 at 10:44 AM, Staff I stated they were trained to test for COVID-19. They stated they wore their N95 with both straps around the back of their neck because it was more comfortable that way. Staff I then placed the top strap in the correct position, at the crown of their head. Staff I stated they did not change their N95 in between resident testing because the residents were not symptomatic. They stated if a resident had coughed on them, they would have changed it. They stated they were not trained to wear a gown during testing, only if going into a COVID-19 isolation room. They stated they cleaned their eye protection after all the testing was completed because the cleaner left streaks on their glasses. During an interview on 02/01/2024 at 9:19 AM, Staff C, Infection Preventionist, stated during COVID-19 testing, they expected staff to wear full PPE, that included N95 respirator, gown, gloves, and face shield or eye protection. Staff C stated the process for testing was a failed process . <Transmission Based Precautions> During a concurrent observation and interview on 02/01/2024 at 8:10 AM, Staff R, LPN, wearing an N95 with both straps at the crown of their head, stated Resident 7 was congested that morning. They stated Resident 7 was seen by the provider that morning and had ordered a COVID-19 test to rule out infection because they were symptomatic. Observation of Resident 7's room showed the door was open and there was no signage or PPE cart that indicated isolation precautions were needed. Resident 7 was seated in their room in their wheelchair, coughing that was audible and visible from the hallway. Staff R stated a chest x-ray was also ordered. Staff R stated Resident 7 was currently not on precautions because they were keeping them isolated to their room. Staff R stated they had not done the COVID-19 rapid test yet because they did not know how to order it in the computer system. During a concurrent observation and interview on 02/01/2024 at 8:24 AM, Resident 7 stated they did not feel very well that day. They stated their nose was runny and they had a cough. Resident 7 was sitting in their wheelchair coughing and had a runny nose with watering eyes. During an interview on 02/01/2024 at 9:42 AM, Staff C, IP, stated if there were residents that were suspect for COVID-19 infection, they should be isolated to their room with the door closed until lab results proved negative. They stated the suspect resident should be placed under isolation precautions with appropriate signage on the door. Staff C stated the process for testing was a failed process . <Hand Hygiene> During an observation on 01/31/2024 at 7:14 AM, Staff L and Staff O entered the room of Resident 3, both wearing N95 respirators with the straps around the back of their necks. Both Staff L and Staff O put on clean gloves and proceeded to assist Resident 3 with their morning cares. Staff O performed personal care around the residents' genitals, then rolled Resident 3 towards Staff L. Staff O removed the residents brief that was soiled with fecal matter, while Staff L held the resident in place. Staff O placed a clean brief under the resident and Staff L rolled Resident 3 to their back. Both Staff L and Staff O positioned the resident on the brief and secured the tabs on the brief. Staff L proceeded to apply lotion Resident 3's legs and arms, still wearing the same gloves. Staff O placed the Resident 3's shirt over their head, and while still wearing the same gloves, both Staff L and Staff O assisted the resident in pulling their shirt down. Staff L and Staff O then assisted the resident by placing their legs into their pants. Staff O threaded the urinary catheter (a hollow tube placed into the bladder to drain urine) bag through the pant leg. Wearing the same gloves, Staff L and Staff O positioned the resident onto the mechanical lift sling and transferred Resident 3 to their wheelchair. Staff O, still wearing the same gloves, proceeded to make the resident's bed, while Staff L, still wearing the same gloves, obtained an electric razor from the resident's sink area, and proceeded to shave the resident. Wearing the same gloves, Staff L obtained the residents dentures from their denture cup, applied denture adhesive, and handed them to Resident 3 to place in their mouth. Staff O, wearing the same gloves, used a sanitizing wipe to clean the mechanical lift. Staff L then removed their gloves and washed their hands with soap for 11 seconds. Staff O removed their gloves and left the room without performing HH. During an interview on 01/31/2024 at 9:40 AM, Staff O stated they sanitized their hands before putting gloves on. They stated they like to change their gloves between personal cares and clean things. During an interview on 01/31/2024 at 9:45 AM, Staff L stated when doing personal cares, they should change gloves between the dirty and clean cares. They stated their process was to change their gloves before handling dentures but had not done it that day. During an observation on 01/31/2024 at 7:14 AM, Staff I prepared Resident 4's medications at the medication cart by placing them in a cup of applesauce. Staff I carried the medications into the resident's room, did not perform HH, and administered the medications to the resident using a spoon. Without performing HH, Staff I then removed gloves from their pocket, donned gloves, swabbed Resident 4's abdomen with an alcohol pad and administered their insulin (a medication delivered by a needle and syringe that helps the body turn food into energy and manages blood sugar levels). Staff I disposed of the needle into the sharp's container, removed their gloves, and performed HH upon exiting the room. A second observation the same day at 7:28 AM showed Staff I prepared Resident 6's medications at the medication cart by putting them into a cup of applesauce. Staff I carried the medications to the Resident 6's TBP room. Without performing HH, Staff I, wearing an N95 respirator, put on a gown and gloves. They removed eye protection from a paper bag located on the cart outside the room. Staff I then entered the resident's room and administered their medications. Staff I disposed of their gown and glove in the trash bin in the resident's room, left the room, shut the door, and performed HH. A third observation at 9:54 AM showed Staff I entered Resident 3's room, did not perform HH, administered an inhaled medication to the resident along with a cup of medications (pills), and orange juice. <Annual Policy and Procedure Review> Review of the facility's infection control standards, policies, and procedures showed they were last reviewed in their entirety on 09/30/2019. During an interview on 02/01/2024 at 9:19 AM, Staff C stated the facility infection control policies and procedures were not up to date and were not updated annually. Staff C stated they try to do them every two years and was not aware of the requirement to review them at least annually. During an interview on 02/01/2024 at 11:23 AM, Staff B, Acting Director of Nursing Services, stated they expected all staff to gel in, gel out, between the dirty and clean tasks during personal cares, and remove gloves and perform HH before moving on. Staff B stated PPE and TBP use had been communicated to staff. They were instructed to wear an N95 respirator for any patient care and should not wear their N95 from room to room. Staff B stated they should be using a paper bag for storing their N95 and could wear a surgical mask at the nurse's station. Staff B stated PPE use for the COVID-19 isolation room consisted of putting on gloves, a gown, an N95 respirator, and eye protection. They stated the N95 respirator could be reused for the isolated resident and staff should be putting in a paper bag. They needed to clean their eye protection after leaving the isolation room. Staff B then stated the use of paper bags was not a current need as there was plenty of PPE available. Staff B stated staff should be throwing away their N95 after each use. Staff B stated they did not have a lot of experience in infection control and was not aware of the requirement for policy review. During an interview on 02/02/2024 at 1:10 PM, Staff A, Administrator, stated what we are dealing with right now (continued COVID-19 outbreak), there is absolutely something wrong with our process that we need to look at with the PPE failures and continued cases of COVID-19. Reference: WAC 388-97-1320(1)(a)(c)(2)(a)(b)(5)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a home-like environment for two of five residents (3 and 6) reviewed for a safe, clean, home-like environment. Observations showed cardboard boxes of medical supplies and equipment stored in resident rooms. This failed practice placed the residents at risk for a lack of home-like environment, and a diminished quality of life. Findings included . Resident 3. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including quadriplegia (inability to move or deliberately control muscles in all four limbs) and traumatic brain injury (brain dysfunction caused by an outside force such as a violent blow to the head). The 10/17/2022 comprehensive assessment showed the resident required total assistance of one to two staff for all Activities of Daily Living (ADL's). The assessment also showed the resident had a severely impaired cognition and was non-verbal. An observation on 01/09/2023 at 9:43 AM, showed the residents room contained a large vanity with sink across from the resident's bed. The surface of the vanity contained personal toiletries, jewelry, a box of disposable gloves, and a package of sanitary wipes. Next to the vanity higher on the wall was a mounted television. Directly below the television was an over the bed table that contained a cardboard box of 50 milliliter (mL) syringes, a cardboard box of 60 mL syringes, a cardboard box of enteral feeding (a tube that allows liquid food to enter the stomach or intestine) adaptors, and a cardboard box containing five 1500 mL bottles of Jevity 1.2 calorie tube feeding formula which, from the residents position, blocked 25 percent of the television screen. Further, there were two customized wheelchairs next to the over the bed table (under the television) with one of the wheelchairs containing several blankets, heel protectors, and miscellaneous clothing and personal items. Additionally, a second bedside table was located along the wall to the right of the resident's bed, which held a cardboard box of 12 mL syringes, a nebulizer machine (a machine that aerosolizes medications for inhalation) with tubing and mask, a paper cup with water, and an opened 60 mL syringe. There was no chair for visitors. During an interview on 01/09/2023 at 9:48 AM, Staff N, Registered Nurse (RN), stated that the resident had two wheelchairs in their room because one belonged to the family and they had no place to store it. Observation on 01/10/2023 at 8:14 AM and 12:14 PM, showed that the resident room was in the same condition as on 01/09/2023 at 9:43 AM. During an interview on 01/11/2023 at 8:24 AM, Staff K, RN, stated that the bulk of the resident's enteral feeding supplies were kept in central supply. Night shift staff stocked supplies in the residents room to have them readily available. Staff K further stated that one wheelchair belonged to the family and it has become a storage area. During a concurrent observation and interview on 01/12/2023 at 12:40 PM, Staff B, Director of Nursing Services (DNS), observed the storage within Resident 3's room. When asked if the room was home-like, Staff B stated no, this storage should not be here; the extra wheelchair should have a different place to be stored. Staff B stated that they would make sure there was a chair in the room for visitors. Resident 6. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (nerve damage that disrupts communication between the brain and the body causing fatigue and impaired coordination) and dementia (impaired ability to remember, think, or make decisions). The 11/21/2022 comprehensive assessment showed the resident required extensive assistance of one staff for all ADL's. The assessment also showed the resident had a severely impaired cognition. An observation on 01/09/2023 at 9:19 AM, showed the resident resided in a shared room; their wheelchair and a sit to stand lift (a mechanical lift device that staff used to assist residents from a sitting to standing position) was parked at the foot of the resident's bed. Observations on 01/10/2023 at 8:11 AM and 12:12 PM showed the mechanical lift device continued to be stored at the foot of the residents bed. During an interview on 01/12/2023 at 9:39 AM, the resident stated that the nurses left the mechanical lift device in their room so they didn't have to go find it. During an interview on 01/12/2023 at 9:48 AM, Staff P, Nursing Assistant (NA), stated that they left the mechanical lift device in the resident's room because there was an outlet at the foot of the residents bed where they recharged the devices battery. During an interview on 01/12/2023 at 12:42 PM, Staff B, DNS, stated that staff should not be leaving the mechanical lift device in the resident's room, we would purchase a new battery if that was needed. Reference: WAC 388-97-0880(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan that addressed the resident's medical, physical, mental, and psychosocial needs for one of one resident (3) reviewed for rehabilitation and restorative services, and one of two residents (5) reviewed for oxygen use. This failure placed the residents at risk for a delay in the quality of care and services received and a diminished quality of life. Findings included . A. Rehabilitation and Restorative Services Resident 3. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including quadriplegia (inability to move or deliberately control muscles in all four limbs) and contractures (a shortening of muscles or tendons leading to deformity and rigidity of joints) of ankle and foot joints. The 10/17/2022 comprehensive assessment showed the resident required total assistance of one to two staff for all Activities of Daily Living (ADL's) and had received one episode of range of motion exercises in the previous seven days. The assessment also showed the resident had a severely impaired cognition. An observation on 01/09/2023 at 9:43 AM, showed the resident lying in bed, leaning towards their left side. The head of the bed was at 45 degrees, their left arm supported with a pillow. Their right arm was contracted to 90 degrees and had a stuffed animal in their arm for positioning. Their legs were outstretched on the bed and had bilateral ankle and foot contractures. During an interview on 01/09/2023 at 9:48 AM, when asked how the staff knew when and how to perform range of motion exercises for the resident, Staff N, Registered Nurse (RN), stated that they looked in the binder from physical therapy. During an interview on 01/12/2023 at 9:48 AM, Staff P, Nursing Assistant, stated that they did range of motion exercises with the resident every day and documented it in the electronic medical record. Review of the physical therapy notes dated 07/25/2022 showed an evaluation was completed. An extensive individualized restorative program was created, and nursing staff were in-serviced on how to perform the exercises. Review of the resident's most recent individualized care plan, dated 12/08/2022, showed a lack of care planning for the resident's individualized restorative program. B. Oxygen Resident 5. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (low oxygen level in the blood) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The 12/05/2022 comprehensive assessment showed the resident required extensive assistance of one staff member for ADL's and used supplemental oxygen. The assessment also showed the resident had a moderately impaired cognition. Review of the resident's individualized care plan, dated 08/03/2022, showed that a care plan had not been developed based on the resident's supplemental oxygen needs, including interventions and goals for the resident's identified needs. During an interview on 01/12/2023 at 11:15 AM, Staff B, Director of Nursing Services (DNS), stated that Staff N, RN, and Staff K, RN, were responsible for creating and updating care plans. During an interview on 01/12/2023 at 12:36 PM, Staff K stated that they had worked in the facility for 14 years. When asked if they created or updated care plans, Staff K stated that they did not because they had not yet been trained on the process. Staff K stated that if a care plan was not complete, Staff B would need to make the changes. Reference: WAC 388-97-1020 (1)(2)(a)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify hazards and risks regarding six unsecured, half sized, free standing (not secured down or in a rack) oxygen cylinder tanks for one of one resident (2) reviewed for accidents/hazards who was sitting in their wheelchair within proximity of the unsecured oxygen tanks. The unsecured tanks were located within a clean linen storage closet across from the nursing station, until the facility self-identified and secured the oxygen tanks in another location. This failure placed Resident 2 at risk for potential injury from the unsecured oxygen tanks. Findings included . Review of the facility's guidelines titled, Medical Gas Storage Guidelines and Requirements, dated October 2016, showed that oxygen tank cylinders, must be secured by chains, racks or in stands. Resident 2. Review of the medical records showed the resident admitted on [DATE] with a diagnosis of lower back pain and decreased mobility. Observation of the clean linen storage closet on 01/09/2023 at 10:24 AM showed six unsecured half sized oxygen tank cylinders that were free standing and not in a rack. Additionally, the door to the linen storage was left open and Resident 2 was sitting in their wheelchair directly across from the storage closet door. During an interview on 01/09/2023 at 11:59 AM, Collateral Contact, Medical Oxygen Supplier, stated that they would expect the facility to store the oxygen tank cylinders in a rack/cart designed to hold them and never free standing. The Collateral Contact further stated that there was a risk for injury if the tank fell over and the valve broke, but it was a very minimal chance that it could happen with the half size oxygen tanks. During an interview on 01/09/2023 at 12:28 PM, Staff B, Director of Nursing Services, stated that the oxygen tanks should not be free standing and should be stored in a secured rack. Staff B further stated, that is not the correct process, and that they were going to fix that. Reference: WAC 388-97-1060(3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the cleanliness of oxygen concentrator filters (protects the resident from particulate matter and the risk of infection), change nasal cannula oxygen tubing (a small flexible tube that contains two open prongs intended to sit just inside the nose and carry oxygen from an oxygen source to a person) every week, and change the humidifier bottles every week according to the facility protocol for two of two residents (5 and 10), reviewed for respiratory care. This failure placed the residents at increased risk for infection and unmet care needs. Findings included . Review of the 01/2022 World Health Organization's Care, Cleaning and Disinfection of Oxygen Concentrators, showed that the humidifier must be washed, rinsed, and disinfected daily. Additionally, the air intake filter should be removed from the concentrator, placed in cool soapy water, and swirled gently to remove debris. The filter should then be placed in a [NAME] area until completely dry. Review of the facility's 01/22/2021 policy, Oxygen Concentrator, showed that oxygen concentrator filters were cleaned with warm soap and water, then towel dried, every week. In addition, oxygen tubing needed to be changed weekly. Resident 5. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (low oxygen level in the blood) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The 12/05/2022 comprehensive assessment showed the resident required extensive assistance of one staff member for Activities of Daily Living (ADL's) and used oxygen. The assessment also showed the resident had a moderately impaired cognition. An observation on 01/09/2023 at 11:38 AM, showed the resident sleeping in bed, their oxygen nasal cannula correctly placed. The oxygen concentrator was located next to the resident's bed. Observation of the oxygen tubing showed no date indicative of the last date it was changed. The air intake filter was covered with thick, gray dust. There were no dates for the last cleaning or service to the concentrator. An observation on 01/10/2023 at 1:31 PM, showed a second concentrator in the dining room, specifically for that resident's use. There was a service card (record of maintenance) secured to the back of the concentrator. Documentation on the card showed the last date of service as 08/27/2018 at 16,031 hours of use, with new filters installed at that time. The current hour meter showed 20,526 hours and no further documentation that service had been completed or that filters had been changed since 08/27/2018. During a concurrent observation and interview on 01/12/2023 at 12:42 PM, Staff B, Director of Nursing Services (DNS), inspected the dirty air intake filter on the concentrator in the resident's room. Staff B stated that yes, that's a concern. During a second interview at 4:45 PM, Staff B stated that they had just cleaned the filter in the resident's concentrator. Resident 10. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including interstitial pulmonary fibrosis (chronic inflammation and scarring of the lung that make it hard for the lungs to get enough oxygen) and anxiety. The 12/19/2022 comprehensive assessment showed that the resident required extensive assistance of one staff member for ADL's and used oxygen. The assessment also showed the resident had a moderately impaired cognition. An observation on 01/10/2023 at 8:16 AM, showed an oxygen concentrator with humidifier in the resident's room. There was no documentation or dates indicating when the filters, humidifier, and oxygen tubing were last cleaned and/or changed. The nasal cannula was draped across the back of the resident's recliner with the nasal prongs touching the fabric of the recliner. An observation of the dining room on 01/10/2023 at 1:31 PM showed an oxygen concentrator with humidifier and nasal cannula that was specifically used for that resident. The service card on the back of the concentrator showed the last date of service was 01/25/2021. New filters were installed at that time. The oxygen tubing and humidifier were not dated with last date of change. The nasal cannula was draped over the top of the concentrator with the nasal prongs touching the concentrator. During an interview on 01/10/2023 at 2:04 PM, Staff N, Registered Nurse (RN), stated that they did not clean the filters on the oxygen concentrators and did not know when they were last cleaned or changed. They stated that if a concentrator needed service, they would call for service (from a contractor), depending on who owned the concentrator. Staff N stated that they refill the humidifiers as needed and change out the bottles when they get crusty stuff on them. During an interview on 01/12/2023 at 12:36 PM, Staff K, RN, stated that the licensed nurses cleaned the concentrators and wash the filters when they looked dirty and changed the humidifiers if needed. Review of the facility's weekly cleaning list for the North Wing night shift, dated January 2023, showed that licensed nurse cleaning duties included dating and replacing the oxygen tubing and humidifier every Wednesday. The list also showed that the licensed nurses were responsible for cleaning the filters on the oxygen concentrators every Wednesday. There was no documentation that indicated the tasks were performed at any time. During an interview on 01/13/2023 at 12:44 PM, Staff B stated that there were no other maintenance records for the oxygen concentrators other than what was on the back of the machines. Reference: WAC 388-97-1060(3)(j)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five sampled residents, (5) reviewed for unnecessary medication, was free of a significant medication error resulting from the mixing of insulins (a hormone/medication injection that is given to help regulate a resident's blood sugar level), Lantus (a long-acting insulin) and Humalog (a short acting insulin) in the same syringe. This failure placed the resident at risk for ineffective insulin management that could jeopardize their health and safety. Findings included . Review of the manufacture information sheet (comes in package with Lantus insulin) titled, Instructions for Use, Lantus (a long-acting insulin), revised December 2020, showed that this type of insulin should not be diluted or mixed with any other insulins or solution. Resident 5. Review of the medical record showed they were admitted to the facility on [DATE] and included a diagnosis of diabetes (a disease that effect how the body can regulate blood sugar levels). Review of Resident 5's physician order, dated 09/24/2022, showed they were receiving Lantus insulin daily and Humalog insulin four times a day. During a concurrent observation and interview on 01/11/2023 at 7:14 AM, showed Staff K, Registered Nurse (RN), preparing Resident 5's insulin medications. Staff K was observed drawing up Lantus and Humalog insulin within the same syringe. Staff K explained that drawing up both insulin medications within the same syringe was their standard of practice. During an interview on 01/12/2023 at 11:58 AM, when asked what would happen if Lantus was mixed with Humalog in the same syringe, Staff M, Pharmacist, stated that the mixture of the two insulins should not be done, due to the fact that the Lantus characteristics would be altered, and the medication effects would wear off quicker than expected. During an interview on 01/12/2023 at 1:01 PM, When informed of the two insulins having been mixed within the same syringe and administered to resident 5, Staff Q, Advanced Registered Nurse Practitioner, (ARNP), stated In the same syringe! .I would never draw up those two at the same time. Staff Q further stated that this practice was not helping with Resident 5's insulin management and that the process would need to be changed. During an interview on 01/12/2023 at 1:20 PM when informed of the medication error involving the insulin combination, Staff B, Director of Nursing Services, stated that this was not the right practice and that staff should have given the Lantus/Humalog insulin medication as two separate injections. Reference: WAC 388-97-1060(3)(k)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication error rate was less than five percent during the medication administration observation task. Further the facility failed to ensure one of one nurse (Staff K) followed the Manufacture's (a company that made a certain medication) specifications regarding the preparation/administration of Insulin (a hormone/medication that is given to help regulate a resident's blood sugar level). Of the 25 medication opportunities, two were in error resulting in an error rate of eight percent which affected one of two residents (5) observed for medication administration. This placed residents at risk for side effects and/or reduced medication effectiveness due to improper administration. Findings included . Review of the manufacturer information titled, Instructions for Use, Lantus (a long-acting insulin), revised December 2020, showed that this type of insulin should not be diluted or mix with any other insulins or solution. Resident 5. Review of the medical records showed that they were admitted to the facility on [DATE] with diagnosis of diabetes (a disease that effect how the body can regulate blood sugar levels) and was able to make their needs known. During a concurrent observation and interview on 01/11/2023 at 7:14 AM, showed Staff K, Registered Nurse (RN), preparing insulin medications for Resident 5. During preparation Staff K had drawn up Humalog insulin (a short-acting insulin) and Lantus insulin (a long-acting insulin) within the same syringe which was then administered to Resident 5. When inquired about mixing of the two insulin's, Staff K stated that they had always drawn up the two types of insulin's together in the same syringe when administering them to Resident 5. An observation of Lantus insulin vial on 01/11/2023 at 9:05 AM showed that the label instructed that the Lantus insulin was not to be mixed (in the same syringe) with any other insulins. During an interview on 01/12/2023 at 10:49 AM, Staff I, Long Term Care Pharmacist, explained that nursing staff should refer to the Lantus manufactures instructions for use handout that comes with the medication. During an interview on 01/12/2023 at 11:20 AM, Staff B, Director of Nursing Services (DNS), stated they would not have mixed the two insulin's and would have given them separately. Reference: WAC 388-97-1060(3)(k)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have a system in place to resolve grievances (a resident concern or complaint) promptly for seven of seven residents (1, 2, 4, 5, 7, 8, and 9) reviewed for grievances. The failure to ensure that concerns were addressed, followed-up on, and resolved, delayed interventions for one of one resident (1) and placed all facility residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's Resident/ Resident Representative admission packet section titled, Grievance Procedure, dated 06/17/2021, showed that a grievance was .a problem that a resident feels should be corrected ., and when a grievance was reported a form would be filled out to ensure that the grievance was addressed appropriately. Additionally, the section showed that the reporter would be notified/followed-up on the results of the grievance process. During an interview on 01/09/2023 at 11:15 AM, when requested facility grievance logs, Staff B, Director of Nursing Services (DNS), stated that the facility had not received any grievances in the past six months, so no log was available. Additionally, Staff B stated that Staff L, Social Services Director (SSD), oversaw all grievances. Resident 1. Review of the medical record showed the resident admitted on [DATE]. The resident was alert and able to make their needs known. During an interview on 01/09/2023 at 11:18 AM, Resident 1, stated that they had lost their dentures and when asked how long they had been without their dentures the resident stated, it's been a while. Review of Resident 1's progress notes on 09/19/2022 showed staff documentation regarding the resident having misplaced both their upper and lower dentures. Review of the September 2022 incident log showed nothing regarding Resident 1's missing dentures. Record review of the resident council meeting documentation for September 2022 showed that residents reported concerns that staff were on their phones excessively which effected how long residents had to wait for help along with the time staff usually spent conversing with the residents. Record review of the resident council meeting documentation for October 2022 showed, nursing staff using their phones too much, has not changed. And there is still no bonding time. Record review of the resident council meeting documentation for November 2022 showed residents expressed concerns regarding staff response times to the residents call lights and not receiving drinks during mealtimes. Record review of the resident council meeting documentation for December 2022 showed that residents had concerns around staff taking their meal tray before they were done eating it. Observation of information boards within resident hallways on 01/10/2023 at 1:50 PM, showed no information for residents on how to file a grievance, which staff was overseeing the grievance process or how to contact them. During the Resident Council meeting/interview on 01/10/2023 at 2:30 PM, Residents 1, 2, 4, 5, 7, 8, and 9 ( review of all resident medical records show all resident were able to make there needs known) stated in agreeance that they were not aware of what a grievance was. Further, after explanation of what a grievance was the residents were still unaware of how to file/report a grievance, the process of communicating a grievance to the grievance officer/staff or which staff oversaw the grievance process. Additionally, none of the residents were able to confirm that grievance concerns documented during the, September through December 2022, resident council meetings had been followed-up on or resolved. During an interview on 01/11/2023 at 8:48 AM, Staff L, SSD, stated that they did not oversee the grievance process and that the facility did not have a grievance log for residents. During an interview on 01/11/2023 at 12:30 PM, Staff B, DNS, stated that they were mistaken and that Staff H, Executive Assistant, oversaw the grievance process. During an interview on 01/11/2023 at 1:02 PM, Staff H, Executive Assistant, stated that they did not oversee the grievance process for the nursing home side of the hospital and had not received grievances from any of the residents. During an interview on 01/11/2023 at 1:33 PM, Staff B, DNS, stated that they did not see concerns documented in the resident council meetings as grievances and more specifically Resident 1's missing dentures, I did not handle it that way. Staff B stated that they had not documented a grievance investigation regarding Resident 1's missing dentures. Staff B further stated that they did not have a staff member in charge of overseeing the grievance process regarding the residents and that they have not been documenting any grievance on a log. During a continued interview on 01/11/2023 at 1:33 PM, Staff B, stated, need to put a better process in place, regarding collection, addressing/tracking and follow-up with the residents on the grievance process, we all need better education on that. Reference: WAC 388-97-0460 (2)

Based on observation and interview the facility failed to ensure infection control practices were observed for one of one kitchen. Resident meals were delivered to the dining room on an uncovered, open shelved food cart, exposing the resident's food and beverage containers to potential contaminates when traveling from the kitchen to the dining room. Additionally, inspection of the kitchen showed opened beverages on the meal tray line. These failures placed all residents that eat food prepared and/or served at the facility, at risk for contamination, food borne illnesses, and a diminished quality of life. Findings included . An observation on 01/09/2023 at 11:58 AM showed the uncovered, open shelved meal cart arrived at the dining room from the kitchen via a main corridor that connected the facility to the hospital. The cart contained 10 resident meal trays that included a Styrofoam take out container of food, fruit in plastic containers with plastic lids, and beverages (both ready to drink and served in plastic cups with plastic lids). One resident tray contained a banana, uncovered and sitting directly on the tray. Staff performed meal set up for the residents, who then touched the outside of the exposed containers while eating and drinking. An observation on 01/10/2023 at 12:03 PM, showed the same delivery of the lunch meals on the uncovered, open shelved meal cart. During a concurrent observation and interview on 01/10/2023 at 1:43 PM, showed a black water bottle with screw top lid and a large, clear plastic cup with lid and straw containing iced coffee that was half empty, on the serve out/meal tray line. When asked about the water bottle and coffee cup on the serve out/meal tray line, Staff R, Food Service Associate, did not respond to the question. Observation showed Staff R avoided eye contact and walked away. During an interview on 01/11/2023 at 11:56 AM, Staff C, Infection Preventionist, stated that staff could not have personal beverages in the kitchen area. During an interview on 01/11/2023 at 12:43 PM, Staff O, Dietary Manager, stated that staff were not permitted to have personal beverages in the food service area. When asked about covering the food delivery carts to the dining area for meals, Staff O stated that I agree, they should be covered. Reference: WAC 388-97-1100(3)