**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary assistance for eating, and drinking, for 2 of 2 residents (Residents 16 and 57) dependent on staff to ensure their needs were met. The failed practice placed residents at increased risk for medical complications, poor quality of life and psychosocial harm. Findings included . <RESIDENT 57> Resident 57 admitted [DATE] with diagnoses to include essential tremors, muscle weakness and lack of coordination. Review of the Minimum Data Set Assessment (MDS) dated [DATE] showed the resident required supervision or touching assistance for eating. Review of the care plan on 02/11/2025 at 1:09 PM, showed the resident had an ADL self-care performance deficit related to tremors in their upper extremities. The care plan directed staff to use a cup with lid for hot liquids. The care plan did not include the feeding assistance needed for Resident 57. In an observation on 02/10/2025 at 1:27 PM, Resident 57's lunch tray was delivered to their room. In an interview and observation on 02/10/2025 at 2:35 PM, Resident 57 was lying in bed then sat up with marked tremors all over. Their lunch tray was on their overbed table untouched. When asked if they were going to eat lunch, the resident stated they were waiting for an aide to come in because they needed to be fed. At 2:43 PM, Staff G, Registered Nurse went into Resident 57's room and began assisting them with eating. In an observation on 02/11/2025 at 9:06 AM, Resident 57's lunch tray was delivered to Resident 57. At 9:26 AM, Staff H, Nurse's Aide Certified (NAC) said they needed to help feed Resident 57. In an observation on 02/12/2025 at 8:38 AM, Resident 57's breakfast tray was placed on the nurse's station counter. At 9:09 AM, Resident 57 walked to their doorway independently and tremors were noted. The resident asked, Where is (Staff H)? I am hungry and I need someone to help feed me. Can you get (Staff H) for me At 9:12 AM, Staff C, NAC went into assist the resident. In an observation on 02/12/2025 at 1:20 PM, Resident 57's lunch tray was dropped off in their room. In an observation on 02/13/2025 at 8:35 AM, Resident 57's tray was delivered to their room. At 8:49 AM, the tray remained covered in their room. At 8:56 AM, Resident 57 received eating assistance from Staff H. At 11:02 AM, the resident stated they got help with breakfast earlier and they often have to wait to get help to eat long after their meal had been delivered. In an observation on 02/14/2025 at 9:03 AM, the breakfast tray was delivered to Resident 57. Resident 57 asked Staff K, NAC if they were going to help him eat now. Staff J said, Not yet, I have to get the other trays passed first. Resident 57 stated their tremors were really bad today. Staff M, NAC commented that sometimes other staff will help them pass trays. At 9:20 AM, Staff J, NAC knocked on the resident's door and said they were there to help them eat. The phone rang seconds later, and Staff J left to answer the phone. At 9:27 AM, Resident 57 came out of their room and stood up against the wall and stated their tremors were real bad today and they were waiting for their aide to help them eat. Staff J, returned to assist Resident 57 at 9:31 AM. <RESIDENT 16> Resident 16 admitted to the facility 06/07/2024 with diagnoses to include stroke, dementia and need for assistance with personal care. According to the most recent quarterly MDS assessment dated [DATE], the resident had severe cognitive impairment. The resident required extensive assistance of one to two staff members for all activities of daily living (ADL) including eating. The resident had vision impairment and limited range of motion both upper extremities. Review of Resident 16's [NAME] (tool to alert nursing assistants how to provide care) revealed Resident 16 was totally dependent on staff for eating requiring one to one feeding assistance. The care plan for Resident 16 showed the resident was totally dependent on staff for eating. In an observation on 02/11/2025 at 1:11 PM, Resident 16's lunch tray was delivered. Meal assistance was provided at 1:33 PM. In an observation on 02/12/2025 at 8:34 AM, Resident 16's breakfast tray was delivered. Staff H, Nurse's Aide Certified (NAC) went to assist the resident with their meal at 9:12 AM. In an observation on 02/12/2025 at 1:11 PM, Resident 16's lunch tray was delivered to them. Staff H, NAC went to assist Resident 57 with their meal at 1:30 PM. In an observation on 02/13/2025 at 8:37 AM, Resident 16's breakfast tray was delivered. Staff H, NAC went to assist Resident 57 with their meal at 8:53 AM. In an interview was done on 02/14/2025 at 9:34 AM with Staff B, Director of Nursing Services (DNS) were made aware the facility failed to provide timely ADL services to Resident's 16 and 57. The DNS stated Resident 57 needed weighted utensils, and they were getting an Occupational Therapy evaluation for that. Staff B stated they would address the eating assistance concerns for Resident 16 and 57. No additional information was provided. Reference: WAC 388-97-1060(2)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 5 residents (Resident 21) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to assess and alert the physician of elevated blood sugar levels and hold medications as directed for abnormal vital signs. This placed the residents at increased risk of unmet care needs. Findings included . Review of the facility's Medication Administration General Guidelines, dated January 2025, directed nurses to administer medications in accordance with written orders of the prescriber. The guidelines directed staff to obtain and record any vital signs as necessary prior to medication administration. The American Heart Association, dated April 21, 2017, considered a blood pressure to be within the normal range when both systolic and diastolic numbers were in these ranges: a normal reading would be any blood pressure below 120/80 mm Hg (millimeters of mercury) and above 90/60 mm Hg. Additionally, hypotension was the medical term for low blood pressure (less than 90/60). <RESIDENT 21> Resident 21 was admitted to the facility on [DATE] with cardiac diagnoses to include congestive heart failure, hypertension and diabetes. Review of Resident 21's current physician's orders showed directives for the nurses to give Hydralazine (medication to treat hypertension) twice daily and hold the medication if the heart rate (HR) was less than 60 beats a minute or hold for systolic blood pressure (SBP- the first number, called systolic blood pressure, measures the pressure in your blood vessels when your heart beats) less than 110 or diastolic (DBP)-the second number) was less than 60. The physician's order showed the provider was to be notified of blood sugars less than 60 or over 400. Review of Resident 21's December 2024 Medication Administration Record (MAR) showed Hydralazine was not held on 12/19/2024 at 9:00 AM when the DBP was 58 and on 12/20/2024 at 6:00 PM, when the DBP was 48. On 12/04/2024 at 6:00 PM, Resident 21's blood sugar level was 429 and at 9:00 PM, the blood sugar was 412. Review of Resident 21's December 2024 progress notes showed the provider was not notified of the elevated blood sugar levels. Review of Resident 21's January 2025 MARs showed their blood sugar on 01/07/2025 at 6:00 PM was 430, on 01/18/2025 at 9:00 PM it was 431 and on 01/26/2025 at 1:00 PM it was 412. Review of Resident 21's January 2025 progress notes showed the provider was not notified of the elevated blood sugars. Review of Resident 21's February 2025 MARs showed their blood sugar on 02/02/2025 at 1:00 PM was 580 and at 9:00 PM it was 420. Further review showed that the medication Hydralazine had not been held on 02/01/2025 for a DBP of 54. On 02/08/2025 Hydralazine was administered when the SBP was 108 and DBP was 50. Review of Resident 21's February 2025 progress notes showed the provider was not notified of the elevated blood sugars. In an interview on 02/14/2025 at 9:56 AM, Staff B, Director of Nursing Services stated the nurses may not have documented notifying the providers of the elevated blood sugars and should have followed physician orders and document these in the medical record. In an interview on 02/14/2025 at 10:04 AM, Staff I, Registered Nurse stated medications are to be held per physician's order. Staff I stated they were to notify the provider and document when blood sugars are below 60 or over 400. Reference WAC: 388-97-1060 (1)

**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 21) reviewed for dialysis services received consistent, ongoing communication and collaboration with the dialysis facility regarding care and services for dialysis residents. These failures failure had the potential to cause unmet care needs, medical complications, inadequate quality of care, and a diminished quality of life. Findings included . A review of the facility's policy, titled Hemodialysis dated August 2024, showed that the facility will assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice to including the ongoing assessment of the resident's condition and monitoring for complications before or after dialysis treatments. <RESIDENT 21> Resident 21 was admitted to the facility on [DATE] with a diagnosis of end stage renal (kidney) disease (stage of renal impairment that is irreversible and permanent), dependent on dialysis (a procedure that substitutes for the functions of the kidneys). Record review of Resident 21's care plan, revised on 04/26/2024, revealed the care plan lacked resident centered interventions and collaboration of dialysis care by the nursing home and dialysis staff. The care plan did not indicate what care or medications the facility would provide, nor what care the dialysis center would provide. Review of the form titled ECTS Dialysis Communication Form dated from 10/01/2024 through 02/11/2025 showed Resident 21 had twenty missing communication forms and five incomplete assessment information, excluding their refusals: - 10/01/2024 absent from medical record - 10/03/2024 absent from medical record - 10/05/2024 absent from medical record - 10/07/2024 absent from medical record - 10/12/2024 incomplete with no kidney center information - 11/12/2024 absent from medical record - 12/03/2024 absent from medical record - 12/04/2024 vital signs only post treatment - 12/06/2024 missing condition post dialysis - 12/10/2024 absent from medical record - 12/12/2024 absent from medical record - 12/19/2024 no post treatment assessment - 12/21/2024 absent from medical record - 12/24/2024 absent from medical record - 12/28/2024 absent from medical record - 12/31/2024 absent from medical record - 01/02/2025 absent from medical record - 01/04/2024 absent from medical record - 01/09/2025 no post treatment assessment - 01/11/2025 absent from medical record - 01/14/2025 absent from medical record - 01/16/2025 absent from medical record - 01/18/2025 absent from medical record - 01/28/2025 absent from medical record - 01/30/2025 vital signs only post treatment - 02/01/2025 absent from medical record In an interview on 02/14/2025 at 9:49 AM, Staff B, Director of Nursing stated the facility had a communication form that the nurses fill out their portion of the sheet, and then the kidney center fills out their portion. Residents on dialysis were to be assessed pre and post dialysis. Staff B was informed there was missing or inconsistent documentation from either kidney center or facility for Resident 21. Staff B stated the kidney center did not always send the form back and they should fax the report to us due to Resident 21's impaired vision. Reference: WAC 388-97-1900 (1),(6)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Resident 43) reviewed for unnecessary medication use. This failure placed the resident at risk for experiencing medication related complications and a decreased quality of life. Findings included . Resident 43 admitted to the facility on [DATE] with diagnoses to include diabetes (a chronic condition that affects how the body uses sugar for energy), and long-term kidney disease. Review of the monthly MMR note to attending physician/prescriber for Resident 43, dated 08/28/2024, showed recommendation to consider starting dapagliflozin (antidiabetic medication) 5miligram(mg) daily and to increase to 10mg daily next month if tolerated well. The provider agreed with recommendation on 08/29/2024. Resident 43's MMR showed recommendation of ensuring orthostatic hypotension monitoring was evaluated due to antipsychotic use and frequency determined by the facility policy and protocol. The provider ordered to monitor orthostatic hypotension weekly. Review of Resident 43's monthly MMR dated 11/29/2024 and 12/20/2024, showed repeated recommendation of ensuring that regular orthostatic hypotension monitoring was being evaluated due to antipsychotic use and frequency determined by facility protocol and policy. Review of Resident 43's February 2025's Medication Administration Record (MAR) showed an order of dapagliflozin 5 mg by mouth one time a day for diabetes if tolerated well increase to 10mg daily in October. Review of Resident 43's electronic medical record showed no documentation of orthostatic hypotension monitoring. Review of documentation from advanced registered nurse practitioner, dated 02/12/2025, under history of present illness showed Resident 43 was on dapagliflozin 10 mg daily. In an interview on 02/13/2025 at 9:10 AM, Staff I, Registered Nurse, confirmed Resident 43 was taking dapagliflozin 5mg currently. Staff I stated they were not sure why the dosage was not increased in the following month. In an interview on 02/13/2025 at 9:10 AM, Staff I, confirmed Resident 43 had no orthostatic hypotension monitoring on the MAR. In an interview on 02/13/2025 at 10:14 AM, Staff F, Licensed Practice Nurse/Resident Care Manager, stated they were not sure why the dosage of dapagliflozin did not increase in the following month after the medication started and there was no provider's documentation of the rationale to keep the 5mg dosage. Staff I stated as a part of the order, they did not know how to decide if Resident 43 tolerated the medication well or not. Staff F stated there was no documentation of orthostatic hypotension monitoring after August and they were not aware of this recommendation. In an interview on 02/13/2025 at 11:40 AM, Staff B, Director of Nursing, stated they did not work for the facility in August and did not know why the medication dosage was not increased for the dapagliflozin, or why orthostatic hypotension monitoring was not implemented. Reference: WAC 388-97-1060 (3)(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 1 of 5 sampled residents (Resident 460) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors and update the care plan. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care. Findings included . Review of the facility policy titled; Use of Psychotropic Medication(s) undated showed the intent of the policy was to ensure residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. The policy explained the effects of psychotropic use would be evaluated on an ongoing basis to include physician evaluation, pharmacist medication reviews, Minimum Data Set (an assessment tool) reviews, and nursing assessments and the resident's care plan. Resident 460 admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease (a disorder of the central nervous system affecting movements), stroke, dementia without behaviors (memory loss), and depression. Review of Resident 460's February 2025 Medication Administration Record on 02/13/2025, showed they were prescribed Abilify (an antipsychotic) 5 mg at bedtime for dementia starting 01/22/2025. Review of Resident 460's February 2025 Treatment Administration Record on 02/13/2025, showed no behavior monitor or interventions associated with the use of an anti-psychotic medication. Review of Resident 460's electronic medical record on 02/13/2024, showed no Abnormal Involuntary Movement Scale (AIMS) assessment was completed for the use of an antipsychotic. Review of Resident 460's care plan dated 01/28/2025, showed no indication they were taking an antipsychotic and had no behavior monitors or interventions found to document symptoms or behaviors associated with the use of an anti-psychotic medication. Review of the January monthly medication review (MMR), conducted by the pharmacist on 01/30/2025, showed Resident 460 was reviewed with a recommendation to check the indication for the use of Abilify. The pharmacist notated the diagnosis in the electronic health record showed a diagnosis of dementia for the use of Abilify, and a supporting diagnosis would be needed for the use of the antipsychotic medication. Review of Resident 460's Care Area Assessment (CAA- an assessment of a specific resident care or medical issue) dated 01/28/2025, showed they would remain free of complications related to their psychotropic medication use. The CAA lacked details regarding Resident 460's use of an antipsychotic medication, behavioral interventions, symptoms, or indications for use. In a review of Resident 460's provider note dated 02/03/2025, showed they met with the resident and reviewed the use of Abilify to which they endorsed a history of hallucinations related to their Parkinson's medication. Additionally, the note showed Resident 460 was not sure what the Abilify was being used for and a discussion of discontinuing it. In an interview on 02/13/2025 at 1:35 PM Staff N, Social Services Director, stated they meet with new residents as soon as possible, gather information about them, complete assessments and set up care conferences. Staff N stated they refer residents who take psychotropic medication if needed, ensure medications and diagnoses are reviewed, and review their medical record to gather as much information as possible. Staff N stated Resident 460 had diagnoses that included dementia, anxiety and depression. Staff N stated Resident 460 had a diagnosis of dementia as the indicator for use of Abilify. Staff N stated they did not know if dementia was an indication for use of an antipsychotic. Staff N stated they had not had any concerns about Resident 460 regarding psychosis and had not discussed with them their medication use, mental health diagnoses, or the reasons they were taking psychotropic medications. Staff N stated Resident 460 had no monitor in place for psychotic symptoms. In an interview on 02/13/2025 at 3:04 PM Staff O, Minimum Data Set (MDS) Coordinator, stated they completed the CAA for Resident 460's psychotropic medication use. Staff O stated they interviewed Resident 460 regarding their psychotropic medication use and signs/symptoms of not taking the medication. Staff O stated Resident 460 stated if they did not take their psychotropic medication, they get quiet and not participate in activities. Staff O stated they documented Resident 460's information on a form in which they kept internally. Staff O stated part of the admission process included reviewing a resident's medications and completing consents as needed with residents. Staff O stated the facility just recently started weekly meetings to review the care plans of residents and work with the nurse managers to ensure all the data complied matches a resident's care plan. Refer to WAC 388-97-1060(3)(k)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise care plans for four of 14 residents (Residents 3, 11, 43 and 57) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for weight loss, dehydration, unmet care needs and a diminished quality of life. Findings included . <RESIDENT 57> Resident 57 admitted to the facility on [DATE] with diagnosis to include essential tremor and gait and mobility abnormalities. Review of the Minimum Data Set Assessment (MDS, an assessment tool) assessment dated [DATE] showed Resident 57 required supervision or touching assistance for eating. Review of Resident 57's care plan on 02/11/2025 at 1:09 PM, showed the resident had an activities of daily living (ADL) self-care performance deficit related to tremors in their upper extremities. The care plan directed staff to use a cup with lid for hot liquids. The care plan did not include the feeding assistance needed for Resident 57. In an observation on 02/10/2025 at 1:27 PM, Resident 57's lunch tray was delivered to their room. In an interview and observation on 02/10/2025 at 2:35 PM, Resident 57 was observed lying in bed then sat up with marked tremors all over their body. Their lunch tray was on their overbed table untouched. When asked if they were going to eat lunch, the resident stated they were waiting for an aide to come in because they needed assistance with eating. At 2:43 PM, Staff G, Registered Nurse (RN) went into Resident 57's room and began assisting them with eating. In an observation on 02/11/2025 at 9:06 AM, Resident 57's lunch tray was delivered to the resident. At 9:26 AM, Staff H, Nurse's Aide Certified (NAC) stated they needed to help feed Resident 57. In an interview on 02/14/2025 at 9:34 AM, Staff B, Director of Nursing Services was informed of the lack of directive on the care plan for Resident 57's meal assistance. <RESIDENT 11> Resident 11 admitted to the facility on [DATE], with diagnoses to include morbid obesity, muscle weakness, heart failure, and depression. The modified admission MDS dated [DATE], showed the resident had intact cognition. The MDS showed the resident had an active pressure ulcer, was a high risk for pressure ulcers, and at the time had one unstageable pressure wound (a full thickness wound where the base of the injury is obscured by dead tissue). Review of Resident 11's physician orders showed an active order dated 02/01/2025 for wound care to the resident's sacrum that read; to cleanse the area with normal saline, pat dry, apply a skin prep to inside of the wound, apply collagen (a protein that provides structural support and promotes the formation of new tissue grow) to wound bed and cover with a hydrocolloid (a self-adhesive, waterproof bandage that was used to protect and heal wounds) dressing. The orders instructed the licensed nurse to change the dressing every three days and as needed in the event of accidental removal and soiling. Review of Resident 11's wound care notes dated 02/07/2025 showed the wound to the sacrum was classified as a Stage 4 (full-thickness tissue loss exposing underlying muscle, tendon, or bone) that measured 2.5 centimeters (cm) in width, 5 cm in length, and 0.2 cm in depth. In an observation and interview on 02/10/2025 at 2:00 PM, Resident 11 stated they had admitted to the facility with a wound to their sacrum. The resident stated they felt the facility was doing a great job managing the wound, and that it had improved. The resident was observed to be lying on an air mattress, and had a trapeze grab bar above their bed to assist in self-repositioning. Review of Resident 11's care plan on 02/11/2025 had no reference that the resident admitted with an unstageable pressure wound, the wound had been classified at a Stage 4. The care plan did not address any individualized goals of care for the active stage 4 wound or list any resident-centered interventions to prevent worsening or aid in improvement of the wound. The air mattress and trapeze bar were not on the plan of care for the resident. <RESIDENT 3> Resident 3 admitted to the facility on [DATE] with diagnosis to include urinary retention, obstructive uropathy (a condition where urine flow was blocked or hindered, leading to backup of urine in the urinary tract), and benign prostatic hyperplasia (BPH) (enlargement of the prostate gland which can cause urinary retention). The quarterly MDS dated [DATE] showed the resident had a urinary catheter (tube inserted into the bladder to drain urine) and had occasional incontinence (loss of control of bladder elimination). Resident 3 was hospitalized on [DATE] and readmitted to the facility on [DATE] after diagnosis of septic shock (life-threatening condition that occurs when an infection spreads throughout the body) related to urinary infection caused by urinary retention. The significant change in condition MDS dated [DATE] showed the resident readmitted with a urinary catheter. Review of Resident 3's physician orders dated 12/03/2024 showed an order for Finasteride a medication which treats BPH and reduce risk for urinary retention. Review of Resident 3's hospital Discharge summary dated [DATE], showed there was difficulty placing a urinary catheter, and unable to place at bedside, and that surgical guidance was required to place the catheter. Recommendations included keeping the catheter in place after discharge, with urology follow-up. Review of Resident 3's care plan on 02/11/2025 showed no reference to the resident's urinary retention, or their enlarged prostate that could cause urinary retention. There was no individualized goals of care or interventions to prevent or treat the resident's urinary retention. In an interview on 02/13/2025 at 9:13 AM, Staff C, NAC stated that they rely on the electronic medical record to access the care plan to determine what level of care to provide to residents. In an interview on 02/13/2025 at 10:38 AM, Staff D, NAC stated they determine what level of care to provide to the residents by reviewing the residents care plan. Staff D stated that Resident 11 required assistance for repositioning, and that they had a bandage on their sacrum but was not aware of any interventions for care of the wound, as it was managed by the nurse. Staff D stated that Resident 3 used a urinal and was not aware the resident had any issues with urinary retention. In an interview on 02/13/2025 at 12:12 PM, Staff E, RN stated they had worked at the facility since October of 2024 through an agency service. Staff E stated that the care plan was how they obtained the residents care directives. Staff E stated they review the care plan every shift to familiarize themselves with what level of care each resident required. Staff E stated that the nurse managers were usually responsible for updating and revising the plan of care. Staff E stated that Resident 11 was repositioned, and used a trapeze for reposition in bed. Staff E confirmed that there were no interventions for the Stage 4 pressure wound to their sacrum on the care plan. Staff E stated they were not aware that Resident 3 had urinary retention concerns or that the resident had difficulty with catheter placement due to their BPH. Staff E confirmed that information should be in the care plan. In an interview on 02/13/2025 at 2:10 PM, Staff F stated all the staff used the care plan to direct their care for residents. Staff F stated the licensed staff and themselves were responsible for updating and revising the care plan. Staff F confirmed that Resident 11 had a Stage 4 pressure ulcer to their sacrum. Staff F confirmed that the care plan should reflect resident centered goals and interventions for staff to implement to reduce and assist in healing of Resident 11's stage 4 pressure ulcer. Staff F was asked to look at Resident 11's care plan and was unable to locate any information for their pressure ulcer on their sacrum or any goals or interventions. Staff F confirmed that Resident 3 had urinary retention, and that placing a catheter was difficult for the resident. Staff F confirmed that the urinary retention for the resident and monitoring for retention should be on the care plan and confirmed that it was not. In an interview on 02/13/2025 at 10:53 AM, Staff K, LPN stated the nurse managers and Director of Nursing Services (DNS) update the care plans. In an interview on 02/13/2025 at 3:04 PM, Staff O, MDS nurse stated they worked with the care managers to make sure the care plan matched the data collected. In an interview on 02/14/2025 at 10:09 AM, Staff B, DNS, stated they had been at the facility now for about 90 days, and had become aware recently that updates and revisions to the resident's care plans had not been getting completed timely. They were working with the nurse managers on educating the staff more on care plan revisions. Reference WAC 388-97-1020(2)(a)(5)(b) <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses to include dementia, depression and psychosis (a condition when people lost contact with reality). According to quarterly MDS, dated [DATE], Resident 43 showed severe cognitive impairment and took antidepressant and antipsychotic (A medication that affects mood, perception and thinking) medications. Review of Resident 43's February 2025's Medication Administration Record (MAR) showed Resident 43 was taking medications antidepressant since 12/19/2024 and antipsychotic since 06/14/2024. Review of Resident 43's care plan, copy date 02/11/2025 showed no focus, no goals or any intervention of antidepressant or antipsychotic medications. The care plan did not include monitoring of medication side effects or target behaviors for these medications. In a record review and interview on 02/12/2025 at 1:34 PM, Staff I, RN stated they get information of how to take care of resident from care plan. Staff I stated resident care manager was responsible to update and revise the plan of care. Staff I stated the care plan should include psychotropic medications with target behaviors and side effects monitoring. Staff I confirmed Resident 43's care plan did not include interventions for the antidepressant or antipsychotic medications, side effects or target behavior monitoring. In a record review and interview on 02/12/2025 at 3:15 PM, Staff F, Licensed Practice Nurse/Resident Care Manager, stated nurse obtain directive of resident care from the care plan. Staff F stated psychotropic medication side effects and target behavior monitoring should be included in the care plan but it had been missed for Resident 43. Staff F stated they should update and revise the care plan.

Based on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for five of five employees (J, P, Q, R, and S) reviewed, who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NACs, and the quality of care provided to residents. Findings included . Review of the staff roster provided on 02/13/2025, showed Staff J was hired on 02/25/2022, Staff P was hired on 06/13/2022, Staff Q was hired on 02/02/2022, Staff R was hired on 06/28/2021 and Staff S was hired on 07/11/2023. In an interview on 02/13/2024 at 3:28 PM, Staff T, Registered Nurse/Staff Development, stated they were new to the position, and they were in the process of putting in structures to ensure evaluations were completed for NAC's. There were no evaluations provided by Staff T for the NAC's identified. In an interview on 02/14/2025 at 10:09 AM, Staff A, stated they were aware of annual evaluations had not been completed as required. Staff A stated they had recently begun to develop a new system to ensure education would be completed as required. Refer to WAC 388-97-1680 (2) (a-c)

Based on observation, interview and record review, the facility failed to ensure foods were served in a timely manner and at a palatable temperature on 1 of 2 floors (5th Floor). Failure to ensure timely meal delivery could negatively impact the residents' nutritional status, appetite, and meal acceptance. Findings included . Record review of the posted hall mealtimes for the 5th floor showed: - Breakfast 8:35 -8:45 AM, - Lunch 1:10-1:20 PM, - Dinner 6:35-6:45 PM. In an observation on 02/10/2025, a meal cart with breakfast trays was delivered to the 5th floor at 9:05 AM. In an observation and interview on 02/10/25 at 1:26 PM, Resident 9's meal was delivered. Resident 9 stated their soup was cold and the staff does not heat up their cold food, at 2:49 PM Resident 9's meal tray was still sitting in front of them. In an observation on 02/10/2025 at 1:27 PM, Resident 57's lunch tray was delivered to their room. In an observation on 02/10/2025 at 1:31 PM, the second tray cart was delivered to the 5th floor. Staff began passing the trays from the second cart at 1:37 PM. In an observation on 02/10/2025 at 1:43 PM, one hallway had not had trays delivered. The trays were observed to be delivered and completed at 2:10 PM. In an observation and interview on 02/10/25 at 2:09 PM, Resident 30 stated their meal tray was just delivered and stated, every one of these meals are cold, breakfast lunch and dinner .cold, maybe they can explain why these lunches are so (expletive) late. In an interview and observation on 02/10/2025 at 2:35 PM, Resident 57 was lying in their bed then sat up with marked tremors all over. Their lunch tray was on their overbed table untouched. When asked if they were going to eat lunch, the resident stated they were waiting for an aide to come in because they needed to be fed. At 2:43 PM, Staff G, Registered Nurse, went into Resident 57's room and began assisting them with eating. In an observation and interview on 02/11/2025 at 1:31 PM, Resident 30 was observed to have received their meal tray. Resident 30 stated it was a food item they liked, but then complained that the portion was small, it was not hot, and the kitchen must be slow again. In an interview on 02/11/2025 at 1:37 PM, Resident 31 stated sometimes lunch arrived at 12:30 PM and sometimes not until 2:00 PM. In an interview on 02/14/2025 at 9:25 AM, Staff M, Certified Nursing Assistant, NAC stated they felt the issue with trays being delayed was due to the meal carts arrive late from the kitchen and stated the floor staff pass them out as fast as they can. In an interview on 02/14/2025 at 10:09 AM, Staff A, Administrator and Staff B, Director of Nursing stated they were not aware of an issue with timely meal delivery. Refer to WAC 388-97-1100(1)(2)

Based on interview and record review the facility failed to ensure 2 of 5 nurse aides (Staff P and S) had their required 12 hours of in-service training, and 5 of 5 nurse aides (Staff J, P, Q, R and S) failed to receive the required dementia training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training and required dementia training placed residents at risk of less than competent care and services from staff. Findings included . In a review of the nursing aides' training hours showed Staff P and S, Certified Nursing Assistants, (NAC), had did not have receive a minimum of 12 hours of training within the year. In a review of the nurse aides' dementia training, showed Staff J, P, Q, R and S, NACs, did not receive dementia training. In an interview on 02/13/2024 at 3:28 PM Staff T, Registered Nurse/Staff Development, stated they were new to the position, and they were in the process of putting in structures to ensure required trainings and skills checks were completed for NAC's. In an interview on 02/14/2025 at 10:09 AM, Staff A, Administrator stated they were aware of annual trainings had not been completed as required. Staff A stated they had recently begun to develop a new system to ensure education would be completed as required. WAC 388-97-1680(2)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 2 of 3 residents (Residents 5 and 22) sampled for hospitalization. This failed practice placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital. Findings included . <RESIDENT 5> Resident 5 admitted to the facility on [DATE]. Review of Resident 5's medical record showed a progress note that resident was sent to the hospital on [DATE]. Review of Resident 5's medical record showed no record that resident or responsible party was offered a bed hold. In an interview on 03/29/2024 at 3:11 PM, Staff A, Administrator stated they were unable to find documentation that Resident 5 was offered a bed hold or that a copy of the bed hold policy was sent to the hospital with the resident. <RESIDENT 22> Resident 22 admitted to the facility on [DATE]. Review of an interact transfer form (communication form sent with the resident that contains information about their condition) showed the Resident 22 was sent to the hospital on [DATE]. Review of the medical record showed no record that Resident 22 or their responsible party was offered a bed hold. During an interview on 03/28/2024 at 9:38 AM, Staff C, Licensed Practical Nurse, stated the nurse sending the resident to the hospital was to send the bed hold form with them and then social services was to follow up to see if the resident wanted to do a bed hold. During an interview on 03/28/2024 at 11:24 AM, Staff H, Medical Records, reported there was no record of a bed hold in Resident 22's medical record. Staff H reported there was no documentation in the progress notes that social services followed up with the resident or their responsible party. Refer to WAC 388-97-0120(4) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed use of a respirator (N-95 mask that provides more protection) and Personal Protective Equipment (PPE, equipment to protect staff from contact with potentially harmful germs such as gown and gloves) for 1 of 2 rooms (room [ROOM NUMBER]) reviewed for Transmission Based Precautions (TBP, list of precautions staff were to use based on the type of disease or condition). Failure to follow TBP put staff and residents at risk for the transmission of communicable diseases. Findings included . Review of a facility's undated policy titled, Aerosol Generating Policy (AGP) and Procedure, showed the use of a bipap machine (uses air pressure to push air into the lungs) was considered an aerosol generating procedure (procedure that can cause germs to enter the air from the respiratory tract). Staff entering the room during an AGP and for three hours after discontinuation of the procedure required the use of a respirator. During an observation on 03/27/2024 at 10:20 AM, a sign was noted hanging outside of the door to room [ROOM NUMBER]. The sign showed an Aerosol Generating Procedure was in progress, and to restrict visitation. The sign showed the AGP started at 10:00 PM, was completed at 8:00 AM, and the precautions ended at 11:00 AM. The sign showed prior to entering the room, persons needed to use a respirator and wear eye protection. During an observation and interview on 03/27/2024 at 10:20 AM, Staff D, Nursing Assistant Certified, was observed to open the door to room [ROOM NUMBER] and start to enter, wearing only a procedure mask, and no other PPE. Staff D stated they worked for an agency and was not familiar with what the sign posted at the doorway meant. During an observation and interview on 03/27/2024 at 10:29 AM, Staff E, Registered Nurse (RN), was observed to knock on door to room [ROOM NUMBER], open the door and proceed to enter. Staff E stated they did not know what PPE was required to enter room [ROOM NUMBER] before 11:00 AM because they worked for a contracted agency and was not actually a facility employee. During an interview on 03/27/2024 at 10:39 AM, Staff B, RN/Director of Nursing Services, stated they expected staff, including agency staff, to put on a respirator, eye protection, gown, and gloves prior to entering a room if AGP precautions were still in place. Refer to WAC 388-97-1320 1(a), 2(a)(b) .

Based on interview and record review, the facility failed to provide documentation that staff were provided education regarding the benefits and potential risks associated with the COVID 19 (an infectious disease of a virus 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) Vaccine for 2 of 2 staff (Staff F and G) reviewed for immunizations. This failure put staff at risk of not having adequate information to decide if the COVID 19 vaccination was appropriate for them. Findings included . During an interaction on 03/28/2024 at 11:47 AM, Staff C, Infection Control Specialist, was requested to provide documentation that Staff F, hospitality aide and Staff G, Registered Nurse, had been provided education regarding the risks and benefits of the COVID 19 vaccine. Staff C reported they would have to check their records. During an interview on 03/29/2024 at 10:52 AM, Staff B, Director of Nursing Services, stated the facility had not been providing education to staff on the COVID 19 vaccine. Staff B stated they did not have any documentation that Staff F and Staff G had been provided COVID 19 vaccine education. No Associated WAC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan, for 3 of 4 sampled resident (Residents 38, 152 and 248) whose care plans were reviewed for dialysis (medical procedure to purify the blood) care. Failure to establish care plans that were timely, individualized, accurately reflected assessed care needs, and provided direction to staff placed residents at risk for unmet care needs. Findings included . <RESIDENT 38> Resident 38 was admitted to the facility on [DATE], with diagnoses including but not limited to end stage kidney disease dependent on dialysis. Review of the comprehensive care plan on 03/29/2024, showed a focus area that Resident 38 has end stage renal disease. The interventions in place on the care plan did not include when (times) and where the resident received dialysis, contact information for the dialysis center or transportation information, specific care information for nursing assistants such as which arm, they should not obtain blood pressures on. In an interview on 04/01/2024 at 9:34 AM, Staff J, Licensed Practical Nurse (LPN)/Nurse Manager, stated dialysis specific care plans should include specific information on where the residents go for treatments, contact information for dialysis center and doctors, monitoring of the site before and after treatments, where it was safe to take blood pressure on a resident, fluid or diet restrictions, days/times and appropriate labs that needed to be monitored. Staff J was unable to provide documentation Resident 38 had a detailed care plan in place at the time of this interview. <RESIDENT 152> Resident 152 admitted to the facility on [DATE], with diagnoses including but not limited to end stage kidney disease dependent on dialysis. Review of the comprehensive care plan on 03/29/2024, showed a focus area Resident 152 required hemodialysis related to renal failure. The interventions in place on the care plan did not include fluid and/or diet restrictions (if applicable), when (times) and where the resident received dialysis, contact information for the dialysis center or transportation information, specific care information for nursing assistants such as which arm, they should not obtain blood pressures on. <RESIDENT 248> Resident 248 admitted to the facility on [DATE], with diagnoses including but not limited to end stage kidney disease dependent on dialysis. Review of the comprehensive care plan on 03/29/2024, showed a focus area Resident 248 required hemodialysis related to renal failure. The interventions in place on the care plan did not include fluid and/or diet restrictions (if applicable), when (times) and where the resident received dialysis, contact information for the dialysis center or transportation information, specific care information for nursing assistants such as which arm, they should not obtain blood pressures on. In an interview on 04/01/2024 at 09:20 AM, Staff G, Registered Nurse (RN), stated all the dialysis information/monitoring they need for Resident 248 was located on the treatment administration record and they were unsure what a care plan was. In an interview on 04/01/2024 at 9:45 AM, Staff A, Administrator, stated care plans should be resident specific and include dialysis specific information for all resident's dependent on dialysis. Staff A was unable to provide any additional information. Refer to WAC 388-97-1020 (1),(2)(a)(b),(3) .

Based on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and to ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 2 (Fourth floor and Fifth floor) medication refrigerators observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Findings included . <FIFTH FLOOR> During an observation and interview on 03/28/2024 at 10:10 AM, the Fifth -floor medication refrigerator contained 20 packets of Veltassa (a medication that treats high levels of potassium in the blood), 10 Insulin (manages sugar in the body) pens, 16 insulin vials, one Procrit (a medication to treat low red blood cells), six individual flu vaccines, two multi dose flu vaccine vials, two RSV (a respiratory virus) vaccination vials, and two multi-dose Tubersol (a prescription solution to test for Tuberculosis which was a potentially serious infectious disease that mainly affect the lungs) vial, and one Emergency Kit containing nine insulin pens, and three Ativan (a medication used to treat anxiety) vials. Staff I, Licensed Practical Nurse (LPN), stated resident medications, Tubersol, and vaccines were stored in the refrigerator. Review of Fifth floor's medication room temperature log, dated March 2024, showed only documentation for the AM shift and no PM documentation. <FOURTH FLOOR> During an observation and interview on 03/28/2024 at 11:00 AM, the Fourth-floor medication refrigerator contained 36 insulin pens, eight insulin vials, one RSV vaccination, 20 individual use flu vaccinations, two multi-use flu vaccine vials, three multidose COVID vaccine vials, and one Emergency Kit containing 10 insulin pens. There was a refrigerator temperature log, dated March 2024, taped to the front of the medication refrigerator, showed five missing readings for the AM shift and ten missing readings for the PM shift. Staff J, LPN, stated vaccinations and resident medications were stored in the refrigerator. Staff J was unsure of who was responsible for documenting and checking documentation of refrigerator temperatures. In an interview on 03/28/2024 at 11:25 AM, Staff C, Infection Preventionist/Assistant Director of Nursing Services, stated vaccinations were stored in the medication room refrigerators, and temperatures should be documented two times daily by a nurse. Staff C reviewed the refrigerator temperature log for the Fifth floor and stated the log should have a place to document for AM and PM shifts, and stated the log was incorrect and refrigerator temperatures were only being documented on the AM shift. When reviewing the Fourth-floor log, Staff C stated there were a lot of holes. In an interview on 03/28/2024 at 2:06 PM, Staff B, Registered Nurse/Director of Nursing Services, stated medication refrigerator logs should be documented two times daily. Staff B stated vaccinations and medications may be compromised. Refer to WAC 388-97-1300 (2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of transfer, including the reason for the transfer, to the resident and/or representative for one of one resident (Resident 182) reviewed for hospitalization. This failure placed the resident at risk of not having the opportunity to make informed decisions about transfers and access to an advocate who informed residents about options and resident rights. Findings included . Resident 182 admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE]. Review of the resident's electronic medical record showed no documentation the resident or Ombudsmen (resident advocate) received written notification of the resident's transfer to the hospital. In an interview on 02/03/2023 at 2:16 PM, Staff C, Licensed Practical Nurse/Resident Care Manager (RCM), stated no written notice of transfer was provided for the transfer to the hospital. In an interview on 02/06/2023 at 1:04 PM, Staff B, Director of Nursing Services, stated they were unaware of any documentation that needed to be provided, and that nursing was not responsible for the any written documentation of transfer for a resident. In an interview on 02/06/2023 at 1:37 PM, Staff D, Social Services Assistant, stated the nurse that sends the resident out or the RCM will usually complete the written notification of transfer. Staff D stated no documentation was found and had no further information as to why it was not done. Reference: (WAC) 388-97-0120 (2) (a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written bed-hold notice at the time of transfer or within 24 hours of transfer to the hospital for one of one resident (Resident 182) reviewed for bed holds. This failure placed the resident at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Resident 182 admitted to the facility on [DATE]. The resident was transferred to the hospital on [DATE]. Review of the resident's electronic medical record showed no documentation the resident was offered or received written notification of the bed hold policy. In an interview on 02/03/2023 at 2:16 PM, Staff C, Licensed Practical Nurse/Resident Care Manager (RCM), stated they did not offer a bed hold. In an interview on 02/06/2023 at 1:04 PM, Staff B, Director of Nursing Services, stated nursing was not responsible for offering bed holds for transfer of residents to hospital. In an interview on 02/06/2023 at 1:37 PM, Staff D, Social Services Assistant, stated the nurse that sends the resident out or the RCM would usually complete the bed hold. Reference: (WAC) 388-97-0120 (4) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 5 Resident 5 was readmitted from the hospital on [DATE] with diagnoses to include diabetes (high blood sugar level), morbid obesity, and obstructive uropathy (blockage of urine flow from the bladder). Resident 5 was readmitted with a urinary catheter (tubing inserted into bladder to drain urine). Review of the urinary catheter CAA worksheet, dated 01/06/2023, showed that it did not contain the risks or benefits of the use of a catheter, any complications the resident was having from the catheter, or if any education was provided to Resident 5 on care of the catheter. The urinary catheter CAA did not address if the catheter was expected to be temporary or permanent, or if a referral to a urologist was recommended. Review of the nutritional state CAA worksheet, dated 01/05/2023, showed that it did not contain the resident's goals, preferences, strengths or needs for the specific care area to assess whether a care plan was needed or what interventions were required. The CAA worksheet did not address if Resident 5 wanted to lose weight or what education had been provided to them. The CAA worksheet did not assess if Resident 5 followed recommended dietary restrictions or how that affected other medical conditions such as diabetic management and weight fluctuations. RESIDENT 18 Resident 18 admitted to the facility on [DATE]. In an observation and interview on 02/01/2023 at 3:25 PM, Resident 18 stated they had just one upper tooth and seven teeth on the bottom. Review of the admission MDS dated [DATE], incorrectly coded the resident's dental status as no obvious or likely cavity or broken natural teeth. Review of the 02/20/2022 MDS showed the dental CAA was not triggered. No dental assessment was completed. RESIDENT 21 Resident 21 admitted on [DATE] with diagnoses to include dementia (memory loss) with behavioral disturbance, anxiety, depression, panic disorder, psychosis (a mental disorder that results in difficulties determining what is real and what is not real) and delusions (false fixed belief). Review of the Psychotropic Drug Use CAA worksheet, dated 03/07/2022, revealed the resident was on Seroquel (medication affecting thought processes) routinely and as needed (prn), an antianxiety medication prn and an antidepressant medication. There was no information about the length of time medications had been used, if the resident felt the medications were effective, or if the resident had experienced any side effects. Review of the Behavioral Symptoms CAA worksheet, dated 03/04/2022, was blank with information entered on it except for computer generated checkmarks. There was no assessment of what the behaviors were, what triggered the behaviors or what interventions were effective when behaviors were observed. Review of the Mood State CAA worksheet, dated 03/04/2022, was incomplete with one sentence written to refer to other disciplines Pharmacy, Medical Doctor, Counselor if the resident accepts Mental Health professionals. Review of the CAA worksheets for Residents 5, 18 and 21 showed no evidence a comprehensive analysis was completed for the triggered CAA's. In an interview on 02/06/2023 at 11:52 AM, Staff X, MDS Nurse, was unable to state what information should be documented on a CAA worksheet. In an interview on 02/06/2023 at 12:02 PM, Staff B, Director of Nursing Services, stated that a CAA worksheet should contain what the issue was, why it was or was not a problem for the resident, what interventions were needed or what information was needed for the care plan. In an interview on 02/07/2023 at 1:38 PM, Staff B stated there had been lots of turnover in the MDS position and they had shared one MDS nurse with two other facilities. Reference: (WAC) 388-97-1000 (1)(a)(b)(d)(2)(5)(a) Based on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments (CAA), an assessment of a specific care or medical issue, to holistically analyze the plan of care for three of five residents (Residents 5,18 & 21) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs. Findings included . The RAI consists of three basic components: The Minimum Data Set (MDS) assessment, the Care Area Assessment process, and the RAI Utilization Guidelines. The CAA Process is designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers use current, evidence-based clinical resources to conduct an assessment of the potential problem and determine whether or not to care plan for it. The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services necessary to maintain good grooming and personal hygiene for residents who were unable to carry out their own activities of daily living (ADL) for three of four residents (Residents 87, 21 and 18) reviewed for ADLs. The failure to assist with oral hygiene, washing their hands and face, and bathing placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's undated Standards of Care and Best Practice policy showed, assist the resident with a shower/tub bath at least weekly and as requested. RESIDENT 87 The resident admitted to the facility on [DATE] and had diagnoses to include generalized muscle weakness and adult failure to thrive. According to the resident's Baseline Care Plan, dated 01/27/2023, the resident needed one-person physical assist with personal hygiene. In an interview on 02/01/2023 at 11:20 AM, the resident stated they had not had their teeth brushed and needed assistance to do that. In an interview and observation on 02/06/2023 at 9:06 AM, the resident stated they had not yet brushed their teeth since they were in the hospital, and they did not think they even had a toothbrush. The resident stated they did not get to wash up that morning and they did not know the last time when they got to wash their hands and face. The resident's hair was observed to be disheveled. An observation of the resident's room showed there was no toothbrush or toothpaste in the resident's room. Review of Resident 87's Personal Hygiene documentation for 02/06/2023 showed Staff Q, Certified Nursing Assistant (NAC), had documented personal hygiene had been done at 8:03 AM that morning. In an interview on 02/06/2023 at 9:23 AM, Staff Q was asked about their documentation that personal hygiene had been done that morning at 8:03 AM, Staff Q stated they documented they had washed the resident's back that morning, but no other personal hygiene was done. Staff Q stated they did not know if the resident had their own teeth or if they had dentures. Staff Q searched the resident's room and found no toothbrush or toothpaste. The resident was observed to tell Staff Q they wanted to brush their teeth and wash their hands and face at the sink. In an interview on 02/06/2023 at 9:58 AM, the resident stated that was the first time their teeth got brushed since they got to the facility. RESIDENT 21 Resident 21 admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had severe cognitive impairment, did not receive bathing in the last seven days, and they did not reject care. Review of the February 2023 [NAME] (guide to direct nurse's aides how to care for a resident) showed the resident was to receive bathing or showers on Tuesday day shift and Friday evenings. Review of the bathing documentation dated September 2022 through 02/07/2023, showed the resident received bathing as follows: February 2023: No shower or bathing January 2023: One shower December 2022: No shower or bathing November 2022: No shower or bathing October 2022: One shower September 2022: Three showers In an observation and interview on 02/02/2023 at 1:17 PM, Resident 21's hair was greasy, and they stated they were supposed to get showers twice a week. In an observation on 02/06/2023 at 9:26 AM, Resident 21 had greasy hair and their nails were long with caked brown matter. In an interview on 02/07/2023 at 9:56 AM, Staff O, NAC, stated they had not given Resident 21 a shower in the past few weeks. Staff O said Resident 21 always refused. RESIDENT 18 Resident 18 admitted to the facility on [DATE]. Review of the February 2023 [NAME] showed the resident was to receive bathing or showers on Thursdays and Sundays. Review of the bathing documentation dated September 2022 through 02/07/2023, showed the resident received bathing as follows: February 2023: One shower January 2023: Four showers December 2022: Two showers November 2022: Two showers October 2022: Four showers September 2022: Five showers In an interview on 02/07/2023 at 9:43 AM, Staff I, Licensed Practical Nurse (LPN), stated the residents were to receive showers twice a week or tailored to their preference, depending on their care plan. Staff I stated Residents 18 and 21 refused showers. Staff I stated the NACs were to report if residents refuse so they can be reapproached or rescheduled. Staff I stated there were no procedures in place to reschedule or reapproach the following day. In an interview on 02/07/2023 at 10:28 AM, Staff L, Registered Nurse/Resident Care Manager, said the NACs were responsible to complete showers and nail care. Staff L stated the NACs should tell their nurse if they refuse and they will pass this information on to the next shift. Staff L said all attempts for bathing should be documented. In an interview on 02/07/2023 at 11:56 AM, Staff K stated the staff were expected to try at least three attempts to get the resident to shower if they refused. In an interview on 02/07/2023 at 1:33 PM, Staff B, Director of Nursing Services (DNS), stated the NACs were responsible to complete showers on their assigned residents. The DNS stated they had not been informed of any concerns with bathing not occurring and they did not audit showers. Reference: (WAC) 388-97-1060 (2)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two residents (Resident 18) received treatment and care in accordance with professional standards of practice and ensure medications were given in accordance with the facility policy, physician order and blood pressure. In addition, the facility failed to thoroughly monitor and treat skin conditions for one of one resident (Resident18) reviewed for non-pressure skin conditions. These failures placed the resident at risk for medical complications, discomfort, unmet needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Medication Administration, directed the nurses to obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Take another set of vital signs as a follow up and document on Medication Administration Record (MAR), notify provider as needed. MEDICATION PARAMETERS Resident 18 admitted on [DATE] with high blood pressure, atrial fibrillation (irregular heart rhythm), liver failure, eczema (red itchy rashes) and pruritis (uncomfortable, itching sensation that creates an urge to scratch). Review of the physician orders showed an order dated 04/18/2022 for Metoprolol Tartrate (blood pressure medication) tablet two times a day for atrial fibrillation. The physician wrote parameters to hold the medication if the systolic blood pressure (top blood pressure value) was less than 100 and diastolic (bottom blood pressure value) was less than 60 and to call the physician for a pulse greater than 110. Review of the November 2022 MARs showed Metoprolol Tartrate was administered when it should have been held on the following dates: 11/03/2022 9:00 AM= 116/58 11/08/2022 9:00 AM =117/56 11/18/2022 9:00 AM =108/46 11/23/2022 9:00 AM =118/45 11/25/2022 9:00 AM =102/58 11/26/2022 9:00 AM =102/58 11/27/2022 9:00 AM =102/58 Review of the facility's Reporting Log showed no incidents/and or investigations of medication errors for Resident 18's medications administered outside of the physician ordered parameters. In an interview on 02/08/2023 at 10:42 AM, Staff P, Licensed Practical Nurse said the expectation was that vital signs be taken prior to administration of Metoprolol. Staff P said they were to hold the Metoprolol dose if the blood pressure was below the ordered parameter. SKIN CONDITIONS In an interview and observation on 02/01/2023 at 3:10 PM, Resident 18 was in bed scratching her left anterior foot with her right foot. The right foot had a red raised blotchy area approximately 3 centimeters (cm) by 3 cm. The resident stated they kept getting blisters. The resident stated they discussed it with their doctor who kept asking if the cream was working. The resident responded, What cream? They said the nurses were not applying any cream. Review of the physician's order dated 12/09/2022, showed Resident 18 was to receive Triamcinolone Acetonide Cream (steroid cream) applied to their skin, twice daily as needed for rash/itching. Review of a provider visit note on 12/05/2022 at 00:00 by Staff AA, Physician's Assistant, showed the resident does report itchiness throughout her body, this occasionally keeps her from sleeping. Review of the November 2022 through 02/07/2023 MARs showed Triamcinolone was documented as: November 2022: 11/04/2022 Refused 11/10/2022 Hold, see progress notes 11/22/2022 Vital signs outside of parameter 11/26/2022 Hold, see progress notes 11/28/2022 Absent from home with medications Review of the progress notes on 11/10/2022 and 11/26/2022 did not include any mention of the Triamcinolone being held. December 2022: 12/29/2022 Refused January 2023: 01/02/2023 Administered February 2023: Not administered in February. In an interview on 02/07/2023 at 9:58 AM, Staff I, LPN, stated that Resident 18 has itchiness from liver disease and has Triamcinolone steroid cream that could be applied. Staff I stated the resident would need to ask for the cream when they needed it. In an interview on 02/07/2023 at 10:54 AM, Staff L, Registered Nurse/Resident Care Manager, stated the resident had liver disease and itching related to that. Staff L said they had tried many topicals and oral medications for itching. Staff L was informed of the infrequent use of Triamcinolone cream and was not aware that it was rarely used. In an interview on 02/08/2023 at 10:42 AM, Resident 18 stated they had asked for the cream we had talked about, and the nurses could not find it. Reference: (WAC) 388-97-1060 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate supervision and implement effective interventions to prevent the elopement for one of one resident (182) reviewed for avoidable accidents and supervision. The facility failed to implement their policy and procedure for a cognitively impaired resident who was found wandering alone on a busy street, without footwear or proper attire for the weather environment and had to be returned to the facility by law enforcement. The facility failed to provide adequate supervision for the resident who had a known history of elopement and continued to be found outside of the facility. This failure to evaluate and analyze the risks of multiple unwitnessed elopements placed the resident and all other like residents at risk for potential serious injuries, harm, and/or death. Findings included . Review of the facility's undated policy titled, Elopements and Wandering Residents, showed the facility would utilize a systemic approach to monitoring and managing residents who are at risk for elopement . including identification and assessment of the risk, evaluation and analysis of hazards and risk, implementation of interventions, monitoring the effectiveness and modifying interventions as necessary. Resident 182 admitted to the facility on [DATE] with diagnoses including Huntington's disease (progressive breakdown of nerve cells in the brain), mood disorder, wandering, and dementia. The Quarterly Minimum Date Set (MDS) assessment dated [DATE] showed the resident had severe cognitive impairment. Review of the facility document titled, Providence Regional Medical Center [NAME] Medical Hospitalist Team Discharge Summary, dated 05/04/2020, showed the resident had a history of wandering the streets, they had frequently wandered away from their adult family home . the resident had been deemed a safety risk and elopement risk .the resident had been found to not be able to make their own decisions. Review of the facility document titled, Wander Risk Assessments, dated between 01/31/2022 and 12/30/2022, showed that the resident had been assessed to be a high risk for elopement. Review of the resident's care plan on 02/02/2023 showed the resident had a focus that stated the resident was an elopement risk related to poor safety awareness and wandering. The goal of care was to ensure the resident stayed on the floor and would not leave unattended. Review of the facility investigation dated 10/21/2022 showed a staff member had left the facility at the end of their shift and had observed the resident to be sitting on a bench outside of the facility. The staff member had phoned the facility, as the facility had been unaware the resident had eloped. The resident had stated they were waiting for their car to come and pick them up to leave. The investigation showed no new interventions were added to the care plan. Review of the facility investigation dated 11/23/2022 showed that another resident had phoned the facility to inform them that the resident had been observed walking down the busy street near the facility, the staff had been unaware the resident had eloped. The investigation stated staff were to encourage the resident to attend activities and monitor them frequently. Review of the resident progress notes dated 11/26/2022 at 8:55 PM and 9:17 PM, 11/27/2022 at 2:46 AM, and 4:38 AM, showed the nurse documented the resident had made several attempts to elope the facility. Review of the resident progress note dated 12/06/2022 at 3:26 PM showed the resident had been found in a locked stairwell on another floor of the building, that was not associated with the facility. Review of the resident progress note dated 12/11/2022 at 7:00 PM showed that the resident had exited the facility using the elevator, the staff had been unable to redirect the resident back into the building. The resident had been located on a busy street outside of the facility. The resident had to be returned to their room with the assistance of the local law enforcement. Review of the facility investigation dated 12/20/2022 showed that the resident had been found on another floor of the building not associated with the facility, the staff had been unaware the resident had eloped. The investigation showed the resident had been educated on the risk and benefits of elopement. Review of the resident progress note dated 12/29/2022 at 2:10 PM the social worker noted the resident had been found on another floor of the building and was escorted back to their room. Review of the facility investigation dated 12/30/2022, showed that the resident had been found without footwear or proper attire for the weather conditions. The resident had been found walking down a busy street when a staff member, who had left the facility at the end of their shift and observed the resident. The resident had to be returned to the facility by the local police department, and staff had been unaware the resident had eloped. The investigation stated the resident would be placed on 30-minute checks. Review of the facility undated document titled, [NAME] Transitional Care Services Safety Monitor Flow Sheet Check every 30 minutes, showed the 30-minute checks were not initiated untll 12/31/2022 at 2:00 PM. Review of the investigation dated 12/31/2022, showed that the resident had been seen by a staff member leaving the facility at the end of their shift. The resident had been found by the police several blocks away from the facility. The facility had been unaware that the resident had eloped. The investigation showed there were no new interventions added to the care plan. Review of the resident progress note dated 01/02/2023 at 1:42 PM, showed that the resident had exited the facility. The progress note stated a staff member had followed the resident; however, the resident had been observed walking without a sense of direction and had not adhered to the traffic lights when they were observed to have walked into traffic. The resident had to be brought back to the facility with law enforcement. Review of the resident progress note dated 01/03/2023 at 8:56 AM, showed the resident had left the facility while a staff member had followed the resident. The resident walked several blocks away from the facility, the staff member attempted to get the assistance of law enforcement, however they were unavailable. Staff was able to redirect the resident back to the facility. Review of the resident progress note dated 01/05/2023 at 3:45 PM and 5:43 PM, showed the resident had left the facility with a staff member who followed. The progress note stated that at 4:10 PM the resident was observed to walk to the park located a half-a-mile away from the facility. The resident was observed to step off the sidewalk into traffic and had been unaware of their own personal safety. Review of the resident's care plan on 02/02/2023 showed the facility had not monitored or modified the effectiveness of the care plan and failed to implement effective interventions to prevent the resident from future elopements after the resident had eloped on 10/20/2022, 11/23/2022, 12/06/2022, 12/11/2022, 12/20/2022, 12/29/2022, 12/30/2022, 12/31/2022, 01/02/2023, and 01/03/2023. Review of the resident progress note dated 01/05/2023 showed the resident had been placed in an involuntary hold at the local hospital, because they were gravely disabled. In an interview on 02/03/2023 at 2:13 PM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that the resident would be found all over the place, and was hard to redirect. The resident had refused a wander guard, and the resident had no guardian so our hands were tied as to what they could do to keep the resident safe. Staff C stated the resident was disruptive and they could no longer have them attend activities, and they were unable to place a one-to-one care giver with them as they did not have enough staff. Staff C confirmed they had started the 30-minutes checks. Staff C did not offer a reason as to why they were started until the next day after the resident had eloped again. Staff C stated that the RCM's, Director of Nursing Services (DNS) and social services were responsible for updating the care plans. In an interview on 02/06/2023 at 9:33 AM, Staff F, Nursing Assistant Certified (NAC) stated that the resident was quick to elope, and that they knew how to get out of the facility. In an interview on 02/06/2023 at 9:51 AM, Staff G, NAC stated the resident would elope often, they could not stop them. Staff G would just call or use the walkie-talkie to let someone in the facility know the resident had eloped. Staff G stated the care plan was how they are informed of what type of care they are to provide to the residents. In an interview on 02/06/2023 at 1:04 PM Staff B, DNS stated they were unable to provide a one-to-one care giver for the resident related to staffing issues. Staff B confirmed that the staff were unaware the resident had left the faciity on [DATE], 11/23/2022, 12/20/2022, 12/30/2022 and 12/31/2022. Staff B stated due to the resident's severe cognition impairment and that the resident had no guardian, they were unable to implement any new interventions to the plan of care. In an interview on 02/07/2023 at 10:28 AM, Staff L, Registered Nurse (RN)/RCM stated the resident had been a big elopement risk, as they would leave the facility and be missing often. Staff L stated the resident would be found on other floors of the building that were not associated with the facility or even outside. In a follow-up interview on 02/07/2023 at 1:09 PM, Staff B, DNS confirmed they had not implemented effective interventions to prevent further elopements and keep the resident safe. The DNS confirmed the resident was currently at the hospital on an involuntary psychological hold under physical restraints. No further information was provided. Reference: (WAC) 388-97-1060 (3)(g) .

Based on observation, interview, and record review, the facility failed to initiate non-pharmacological interventions prior to the administration of pain medication for 3 of 3 residents (13, 18, and 28) reviewed for pain. This failure placed residents at risk for unmet pain needs, unnecessary medications and/or diminished quality of life. Findings Included . RESIDENT 13 Review of the physician orders showed an order for oxycodone-acetaminophen (narcotic pain medication) every four hours as needed for pain initiated on 09/20/2022. Review of the December 2022 Medication Administration Record (MAR) showed Resident 13 received 60 doses of oxycodone-acetaminophen for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 12/01/2022 through 12/31/2022 showed no documentation of non-pharmacological interventions prior to pain medication being given. Review of the 01/20/2023 through 01/31/2023 MAR showed Resident 13 received 35 doses of oxycodone-acetaminophen for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 01/20/2022 through 01/31/2022 showed no documentation of non-pharmacological interventions prior to pain medication being given. Review of the 02/01/2023 through 02/07/2023 MAR showed Resident 13 received 13 doses of oxycodone-acetaminophen for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 02/01/2023 through 02/07/2023 showed no documentation of non-pharmacological interventions prior to pain medication being given. RESIDENT 28 Review of the physician orders showed an order for oxycodone every 24 hours as needed for pain initiated on 11/16/2022. Review of the December 2022 MAR showed Resident 28 received 18 doses of oxycodone for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 12/01/2022 through 12/31/2022 showed no documentation of non-pharmacological interventions prior to pain medication being given. Review of the Janurary 2023 MAR showed Resident 28 received 25 doses of oxycodone for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 01/01/2022 through 01/31/2022 showed no documentation of non-pharmacological interventions prior to pain medication being given. Review of the 02/01/2023 through 02/07/2023 MAR showed Resident 28 received 4 doses of oxycodone for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 02/01/2023 through 02/07/2023 showed no documentation of non-pharmacological interventions prior to pain medication being given. In an interview on 02/07/2023 at 10:15 AM, Staff T, Licensed Practical Nurse, was asked if interventions were tried to alleviate pain prior to as needed pain medication being given. Staff T stated, if the resident received a non-pharmacological intervention, it would be documented in the progress notes. In an interview on 02/07/2023 at 10:54 AM, Staff L, Registered Nurse/Resident Care Manager, stated the nurses should be documenting non-pharmacological interventions prior to giving narcotics. In an interview on 02/07/2023 at 11:35 AM, Staff B, the Director of Nursing Services, stated non-pharmacological interventions should be attempted prior to giving as needed pain medication and they should be documented in the resident's medical record. Reference: (WAC) 388-97-1060(1) RESIDENT 18 Review of the physician's order beginning 04/17/2022, the resident was to receive oxycodone 2.5 MG every 24 hours as needed for pain. Review of the December 2022 MAR showed Resident 18 received 28 doses of oxycodone for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 12/01/2022 through 12/31/2022 showed no documentation of non-pharmacological interventions prior to pain medication being given. Review of the January 2023 MAR showed Resident 18 received 30 doses of oxycodone for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 01/01/2022 through 01/31/2022 showed no documentation of non-pharmacological interventions prior to pain medication being given. Review of the February 2023 MAR showed Resident 18 received 5 doses of oxycodone for complaints of pain and showed no non-pharmacological interventions documented prior to pain medication being given. Review of the progress notes dated 02/01/2023 through 02/07/2023 showed no documentation of non-pharmacological interventions prior to pain medication being given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medically related social services were provided for one of one residents (182) reviewed for medically related social services. The facility failed to ensure a guardian was in place for a resident with a progressive brain disease and who had severely impaired cognition. This failure placed the resident at risk for lack of assistance in making complex medical decisions which could affect their quality of life. Findings include . Resident 182 admitted to the facility on [DATE] with diagnoses including Huntington's disease (progressive neurological disease), mood disorder, wandering, and dementia. The Quarterly Minimum Data Set (MDS) assessement tool, dated 10/16/2022, showed the resident had severe cognitive impairment. Review of the resident's hospital Discharge summary dated [DATE] showed the resident was incapable of making their own decisions and in need of a guardian. Review of the resident's medical record on 02/02/2023 showed no guardian listed for medical decisions for care and treatment. Review of the resident's functional cognition assessments dated 10/16/2020 through 01/05/2022 showed the resident had moderate impairment to their cognition. In January 2022 the resident's cognition declined again to severe. In July of 2022 the resident's cognition was so severe the assessment could not be completed. In an interview on 02/03/2023 at 2:13 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, stated the resident was not able to comprehend or make any decisions related to their care due to severe cognitive impairment. Staff C stated the resident did not have a guardian to assist with medical decisions on their behalf, or to consent to treatment. In an interview on 02/06/2023 at 10:37 AM, Staff D, Social Services Assistant, stated the previous guardian was unable to provide guardianship services because they were from another county. Staff D confirmed they had not obtained guardianship for the resident. In an interview on 02/06/2023 at 1:04 PM, Staff B, Director of Nursing Services, confirmed the resident had severely impaired cognition and was incapable of making any decisions related to their care. Staff B confirmed the resident did not have a guardian. Staff B stated they were unsure as to why the resident had not had a guardian and stated that the facility had been unclear on the process on how to obtain a guardianship for a resident with impaired cognition. Reference WAC 388-97-0960 (1) .

Based on interview and record review, the facility failed to ensure nurses documented joint nurse inventories of controlled substance medications every shift as required for one of two medication carts (4th floor medication cart #2) reviewed. This failed practice placed residents at risk for lost accountability of their medications. Findings included . In a controlled substances count/record review on 02/07/2023 at 1:28 PM, the 4th Floor Medication Cart #2 controlled substances book, joint inventories lacked nurse signatures on 13 shifts from dates reviewed 12/20/2022 - 02/07/2023. In an interview on 02/07/2023 at 1:56 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, stated the night shift nurses weren't signing the controlled substances count records properly. Reference: (WAC) 388-97-1300 (1)(b)(ii)(3)(a)

Based on interview and record review, the facility failed to provide adequate rationale for not following pharmacist recommendations for one of five residents (18) reviewed for unnecessary medications. This failure placed the residents at risk for experiencing the use of unnecessary medications and a potential diminished quality of life. Findings included . RESIDENT 18 Review of the pharmacy consultant Medication Regimen Review (MRR), dated 01/27/2023, showed a request to evaluate Diphenhydramine (a medication used to treat allergies) due to risk of serious side effects for older adults including increased risk of falls due to drowsiness. The physician signed no changes and wrote that benefits exceed risks. The physician did not include a written rationale for declining the pharmacist's recommendations. In an interview on 02/07/2023 at 10:54 AM, Staff L, Registered Nurse, was unaware the physician failed to document the action taken or not taken to address the irregularity, including prior failed attempts at reduction or discontinuation and assessment of medications with less side effects. Reference: WAC 388-97-1300 (4)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dental services were provided for one of two residents (18) reviewed for routine dental services. This failure placed Resident 18 at risk for complications such as difficulty chewing, weight loss, pain, infection, and embarrassment related to unmet dental needs. Findings included . A review of the facility's undated Dental Services policies showed it was the policy of the facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. The policy showed Routine dental services means annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. The compliance guidelines showed the dental needs would be identified through the physical assessment and Minimum Data Set (MDS) assessment processes and were addressed in each resident's plan of care. The oral/dental status shall be documented according to the assessment findings. Resident 18 admitted to the facility on [DATE]. Review of the nutritional risk assessment on 02/10/2022 and 05/03/2022 showed Resident 18 had missing/broken teeth. The resident confirmed they were missing mostly their back and side teeth. They declined an altered texture diet and said, it just takes me longer. Review of the quarterly nutritional risk assessments on 08/06/2022 and 11/18/2022 noted the resident was experiencing chewing problems and their diet was downgraded to minced and moist texture. A review of the admission MDS assessment (an assessment tool), dated 02/10/2022, showed the resident was examined and had no dental abnormalities. A review of Quarterly MDS assessments, dated 05/13/2022, 08/13/2022 and 11/13/2022, showed the resident was examined and had obvious or likely cavity or broken natural teeth. In an observation and interview on 02/01/2023 at 3:25 PM, Resident 18 stated they had just one upper tooth and seven teeth on the bottom. They said they had not been offered a dental appointment since admission and would like help to go to a dentist. They said they did not have much pain but a little pain. They said they were lucky there was no nerve exposure now. A review of the care plan showed the facility had not developed a care plan related to dental issues. Review of the clinical record showed the resident had not seen a dentist or dental hygienist since admission. In an interview on 02/07/2023 at 9:58 AM, Staff I, Licensed Practical Nurse, stated they were not aware Resident 18 had missing teeth. In an interview on 02/07/2023 at 10:28 AM, Staff L, Registered Nurse/Resident Care Manager, stated that social services were responsible for dental and eye exams and as soon as a resident reported dental pain or issues, they would notify social services of their need for an appointment. In an interview on 02/07/2023 at 1:38 PM, Staff B, Director of Nursing Services (DNS) was informed of the lack of dental services, and care planning as well as inaccurate MDS assessments for Resident 18, the DNS stated they had had turnover with the MDS nurses. In an interview and observation on 02/08/2023 at 10:42 AM, Resident 18 was sitting in bed smiling, they commented, Funny how you guys come in and everything happens. I even have a dentist appointment tomorrow. Reference (WAC): 388-97-1060 (2)(c), (3)(j)(vii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed proper hand hygiene practices when care was provided to one of three residents (Resident 87) observed during personal care and during one of two meal delivery observations. These failures left residents at risk for the development and transmission of communicable disease and infection. Findings Included . Review of the facility undated policy titled, Hand Hygiene, showed that hand hygiene was to be performed prior to donning gloves and immediately after removing gloves. MEAL DELIVERY In an observation on 02/01/2023 at 1:14 PM, Staff N, NAC, donned (put on) new gloves without performing hand hygiene prior and delivered the meal tray to room [ROOM NUMBER]. Staff N exited the room, disposed of gloves and prior to completing hand hygiene put on a new pair of gloves. Staff N delivered a meal tray to room [ROOM NUMBER]. At 1:16 PM, Staff N donned new gloves with no hand hygiene completed and delivered a meal tray to room [ROOM NUMBER]A then to 505B. Staff N removed their gloves and closed the room door. At 1:17 PM, Staff N donned new gloves with no hand hygiene and delivered a tray to room [ROOM NUMBER]. Upon leaving the room, they could not locate a garbage can, so their gloves were removed out in the hall. At 1:18 PM, Staff N did not complete hand hygiene and donned new gloves and delivered a meal tray to room [ROOM NUMBER]. In an interview on 02/01/2023 at 1:18 PM, Staff O, who had been assisting Staff N with hall trays stated that they hand sanitized every time they opened or closed the hall cart door. Staff O said hand sanitizer should be used before putting gloves on and after removing them. In a similar observation on 02/01/2023 at 1:19 PM, Staff N donned new gloves with no hand hygiene performed prior to delivering the meal tray to room [ROOM NUMBER]. Staff N left the room and removed the gloves with no hand hygiene observed. Reference: (WAC) 388-97-1320 (1)(a), 1320 (1)(c) PERSONAL CARE RESIDENT 87 An observation and interview on 02/03/2023 at 11:38 AM, Staff R, Nursing Assistant Certified (NAC), and Staff S, NAC, were observed to provide incontinent care for the resident. Staff R and Staff S did not remove their soiled gloves after cleansing the resident's groin and buttocks, then they touched the resident's clean briefs, gown, bedding, pillow, bed controls, and bedside table. After the procedure, the staff were asked about their process when to change their soiled gloves prior to handling clean items. Staff R stated it would have made sense to have changed their gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations of potential abuse and/or neglect for seven of eight investigations reviewed for abuse and neglect. The facility failed to report four incidents of elopement for Resident 182 and failed to report verbal abuse from Resident 4 to Residents 12 and 21 to the appropriate reporting agency. The failure to report to the required state agency placed all residents at risk for unidentified abuse and/or neglect, continued lack of supervision, and a poor quality of life. Finding included . Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 10/2022, showed that reporting of all alleged violations to the Administrator . and to all other required agencies . when applicable within specified timeframes: - Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. - Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the facility's undated policy titled, Elopements and Wandering Residents, showed when a resident was found to have eloped, the facility would make the appropriate reporting requirements to the State Survey agency. ELOPEMENT RESIDENT 182 Resident 182 admitted to the facility on [DATE] with diagnoses to include Huntington's disease (progressive neurological disease), mood disorder, wandering, and dementia (memory loss). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 10/16/2022, showed the resident had severe cognitive impairment and wandered daily. Review of the October 2022 incident reporting log showed Resident 182 had eloped on 10/21/2022. Review of the facility's investigation showed a staff member saw the resident sitting on a bench outside. The facility was unaware the resident had left the building. The elopement was not reported to the state reporting agency. Review of the November 2022 incident reporting log showed Resident 182 had eloped on 11/23/2022. Review of the investigation showed that another resident had called the facility to inform them they saw the resident walking down the street near the facility. Staff were unaware the resident had left the facility unattended. The elopement was not reported to the state reporting agency. Review of the December 2022 incident reporting log showed Resident 182 had eloped on 12/20/2022 and 12/30/2022. Review of the investigation dated 12/20/2022, showed that the resident was found on a floor of another facility that occupied the same building. Staff were unaware the resident had left the facility unattended. Review of the investigation dated 12/30/2022, showed the resident was found wearing no shoes or coat, walking down the street in inclement weather. The staff member observed the resident walking away from the building. The resident had to be returned to the facility by the local police department. Staff were unaware the resident had eloped. The elopements were not reported to the state reporting agency. In an interview on 02/03/2023 at 2:13 PM, Staff C, Licensed Practical Nurse (LPN)/ Resident Care Manager (RCM) stated that the Director of Nursing Services (DNS) was responsible for reporting to the state reporting agency. Staff C was unaware why the elopements were not reported to the appropriate reporting agency. In an interview on 02/06/2023 at 9:06 AM, Staff E, Nursing Assistant Registered (NAR), stated they were unaware they needed to report an elopement to the state reporting agency. In an interview on 02/06/2023 at 9:33 AM, Staff F, Nursing Assistant Certified (NAC), stated that the managers were responsible for reporting elopements to the state agency and that was out of their scope. In an interview on 02/06/2023 at 9:51 AM, Staff G, NAC, stated they were educated to notify management before they report any allegation to the state reporting agency. VERBAL ALTERCATION RESIDENT 12 Resident 12 admitted to the facility on [DATE] with diagnoses to include Huntington's disease, major depressive disorder, anxiety, and psychosis (a mental disorder that results in difficulties determining what is real and what is not real). The Quarterly MDS dated [DATE], showed the resident had severe cognitive impairment and no behaviors directed at others. The resident wandered 4 to 6 days. RESIDENT 4 Resident 4 admitted to the facility on [DATE] with diagnoses to include anxiety, traumatic brain injury, post-traumatic stress syndrome, and developmental delay. The Discharge MDS dated [DATE] showed the resident was short tempered and easily annoyed for 7 to 11 days. Review of the October 2022 incident reporting log showed Residents 4 and 12 had an altercation on 10/13/2022. The incident was not reported to the state reporting agency. VERBAL ALTERCATION RESIDENT 21 Resident 21 admitted to the facility on [DATE] with diagnoses to include dementia with behaviors, depression, anxiety, panic disorder, psychosis with delusions (false fixed belief). The Quarterly MDS assessment dated [DATE] showed the resident had severe cognitive impairment and no behaviors. Review of the October 2022 incident reporting log showed Residents 4 and 21 had altercations on 10/13/2022 and 10/30/2022. Neither altercations were reported to the state reporting agency. In an interview on 02/07/2023 at 9:43 AM, Staff I, LPN, stated in the event of a resident-to-resident altercation they would notify the hotline if hands were thrown. In an interview on 02/07/2023 at 10:28 AM, Staff L, Registered Nurse (RN)/RCM, said all staff were mandatory reporters. Staff L stated they needed to report resident-to-resident altercations and elopements to the hotline. Staff L said anything that could put a resident at harm would need to be reported. Staff L said they always let the DNS and Administrator know. In an interview on 02/07/2023 at 11:48 AM, Staff K, contracted agency LPN, showed this surveyor the resource binder they use when they have questions. Staff K stated for resident-to-resident altercations, they would first separate the residents. Staff K said if there were injuries, they would have to report it. If residents were swearing at another, they would still have to call the DNS for direction. In an interview on 02/07/2023 at 12:56 PM, Staff M, Activity Director, who witnessed the resident-to-resident altercation with Resident 4 and 21 on 10/13/2022, stated verbal abuse was someone yelling and swearing at a resident. Staff M confirmed they did not report the altercation to the hotline. Staff M said they reported it to social services and nursing. Staff M said if the DNS was not at the facility, then they would need to report it to the hotline. In an interview on 02/07/2023 at 1:15 PM, Staff B, DNS, acknowledged not all elopements involving Resident 182 were reported to the hotline. Staff B confirmed the resident-to-resident involving Resident 4 and 21 on 10/13/2022 was not reported to the hotline. Staff B said they thought Resident 21 did not have any psychosocial distress and per the purple book (state reporting guidelines), it did not need to be reported. The DNS was informed the incident progress note dated 10/13/2022, and the incident investigation showed Resident 21 reported they were very upset. The DNS was informed that Resident 21 still recalled the incident with Resident 4 and was relieved the resident was gone. Reference: (WAC) 388-97-0640 (4) (6)(a)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct thorough investigations for seven of eight investigations reviewed for allegations of abuse and/or neglect. The facility failed to conduct a thorough investigation that identified the root cause, triggers and all contributing factors related to the continued elopement of a resident (Resident 182) and verbal abuse of a resident (Resident 21). This failure placed all residents at risk for unidentified abuse and/or neglect, lack of supervision, and potential harm or injury. Findings included . Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 10/2022, showed the facility would: - Initiate an immediate investigation that included identifying staff responsible - Interview all possible responsible person such as alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations -Provide a complete and thorough investigation. Review of the Nursing Home Guidelines, known as, The Purple Book, Sixth Edition, (October 2015), revealed verbal abuse was any use of oral, written or gestured language that willfully includes threats and/or disparaging & derogatory terms to or about residents or their families, within hearing distance of any resident regardless of their age, ability to comprehend, or disability; threats of harm; saying things to frighten a resident. Further, The Purple Book directs facility staff that the resident's record must include enough information about the incident to enable staff to identify, plan for and meet the resident's needs which would allow staff to appropriately plan for and meet the resident's needs. Included the guidelines for Prevention and Protection, Incident Identification, Investigation and Reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. RESIDENT 182 Resident 182 admitted to the facility on [DATE] with diagnoses including Huntington's disease (progressive breakdown of nerve cells in the brain), mood disorder, wandering, and dementia (memory loss). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 10/16/2022, showed the resident had severe cognitive impairment. Review of the October 2022 facility incident reporting log showed Resident 182 had eloped on 10/21/2022. Review of the investigation showed a staff member leaving the facility at the end of their shift saw the resident sitting on a bench outside, the facility was unaware the resident had eloped. The investigation lacked any witness statements from staff or other residents. The investigation lacked evidence on how the resident had eloped, how long they had been gone from the facility, and what could be done to prevent further reoccurrence. Review of the November 2022 facility incident reporting log showed Resident 182 had eloped on 11/23/2022. Review of the investigation showed that another resident had called the facility to inform them they saw the resident walking down the street near the facility. The investigation lacked any witness statements from staff or other residents. The investigation lacked evidence on how the resident had eloped, how long they had been gone from the facility, and what could be done to prevent further reoccurrence. Review of the December 2022 facility incident reporting log showed Resident 182 had eloped on 12/20/2022, 12/30/2022 and 12/31/2022. Review of the investigation dated 12/20/2022 showed that the resident was found on a floor of another facility that occupied the same building, staff were unaware the resident had eloped. The investigation lacked any witness statements from staff or other residents. The investigation lacked evidence on how the resident had eloped, how long they had been gone from the facility, and what could be done to prevent further reoccurrence. Review of the investigation dated 12/30/2022 showed the resident was found walking down the street, wearing no shoes or coat. The resident was returned to the facility by the local police department. Staff were unaware the resident had eloped until observed by a staff member leaving work for the day. The investigation lacked evidence on how the resident had eloped, a timeline of how long they had been gone from the facility, and what could be done to prevent further reoccurrence. Review of the investigation dated 12/31/2022 showed the resident was found by the police several blocks away from the facility. The facility was unaware the resident had eloped. The investigation lacked evidence on how the resident had eloped, a timeline of how long they had been gone from the facility, and what could be done to prevent further reoccurrence. In an interview on 02/03/2023 at 2:13 PM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated they were responsible for the investigations completed for the resident elopements dated 12/20/2022, 12/30/2022, and 12/31/2022. Staff C confirmed the investigations were not complete. In an interview on 02/07/2023 at 10:28 AM, Staff L, Registered Nurse (RN)/RCM said they had worked when a resident eloped. Staff L stated that Resident 182 was a big elopement risk and they had to keep eyes on her often. Resident 182 would be there, then just go off the unit and be missing. Staff L stated Resident 182 had been found on floors 1, 6 and 7 multiple times. Staff L stated that Resident 182 was found outside several times, and sometimes Resident 182 was several blocks away. Staff L reported the facility did not initiate one on one supervision until the last elopement, before they were hospitalized . In an interview on 02/07/2023 at 1:15 PM, Staff B, Director of Nursing Services, stated when Resident 182 was found on another floor, they had not done an incident report and it was not reported. Staff B did acknowledge that Resident 182 being on another floor was an elopement. Staff B stated they did not provide one on one supervision for Resident 182 because they did not have staff. Staff B acknowledged the incident investigations lacked witness statements, timelines, and a means to prevent reoccurrence. Staff B confirmed no timeline was created for the investigation and the incident investigations were not consistently initiated or complete. INVESTIGATION 10/10/2022 RESIDENT 12 Resident 12 admitted to the facility on [DATE] with diagnoses to include Huntington's disease, major depressive disorder, anxiety, and psychosis (a mental disorder that results in difficulties determining what is real and what is not real). The Quarterly MDS dated [DATE], showed the resident had severe cognitive impairment and no behaviors directed at others. The resident wandered 4 to 6 days in the lookback period. RESIDENT 4 Resident 4 admitted to the facility on [DATE] with diagnoses to include anxiety, traumatic brain injury, post-traumatic stress syndrome, developmental delay. The Discharge MDS dated [DATE] showed the resident was short tempered and easily annoyed for 7 to 11 days of the 14-day lookback period and his decision making was severely impaired. Review of the October 2022 facility reporting log showed Resident 4 and 12 had two residents to resident altercations in the hallway. One altercation occurred on 10/10/2022 at 12:32 PM and another occurred on 10/13/2022 at 12:35 PM. Review of the facility investigation revealed Resident 4 was sitting in their wheelchair at the nursing station when Resident 12 approached. Resident 4 began yelling obscenities at Resident 12. Resident 12 responded by also using profanities. The summary showed that due to Resident 4's inability to refrain from potential further negative interactions, the plan was to move him on 10/17/2022 (a week later) to another floor. The summary included reminding resident 4 to not use foul language towards other residents. The summary included a witness report written by Staff C that revealed Resident 4 was yelling F you at Resident 12 who was bent over and giving Resident 4 the middle finger. Resident 4 repeatedly said, F her, I hate her. Staff C wrote that Resident 4 was unable to tell them what happened as they were too upset at the time. A witness report written by Staff Y, RN, revealed they heard Resident 4 yelling slut, whore from the staff room. The staff member wrote they told the resident they would have to go back to their room if they continued with this language. A statement written by Staff O, NAC, showed they heard the verbal altercation between residents who reside in room [ROOM NUMBER] and 417. Staff O redirected the resident of room [ROOM NUMBER]. Another statement written by Staff Y, the following day showed the incident occurred at 11:30 AM rather than 12:32 PM and Resident 4 yelled at Resident 12, You slut, whore, damn b***h. Staff Y wrote that Resident 12 said, He made fun of me for asking for diapers. A reasonable person would not want to be swore at, called names, or made fun of. The progress notes for both residents did not include necessary details of the incident nor the plan to prevent reoccurrence. The investigation failed to clarify inconsistencies. Review of the incident reports showed the facility did not identify the circumstances that may have contributed to the verbal abuse. The care plan was revised to redirect Resident 4 if swearing occurred although the resident had severely impaired decision-making skills. Also, the staff were to move him to another room the next week. Resident 12 was ambulatory, and Resident 4 was able to self-propel and transfer in their wheelchair independently. Their rooms were close together. There was no education to staff including agency staff to attempt to keep both residents away from each other. INVESTIGATION 10/13/2022 RESIDENT 21 Resident 21 admitted to the facility on [DATE] with diagnoses to include dementia with behaviors, depression, anxiety, panic disorder, psychosis with delusions (false fixed belief). The Quarterly MDS assessment dated [DATE] showed the resident had severe cognitive impairment and no behaviors. RESIDENT 4 Resident 4 admitted to the facility on [DATE] with diagnoses to include anxiety, traumatic brain injury, post-traumatic stress syndrome, developmental delay The Discharge MDS dated [DATE] showed the resident was short tempered and easily annoyed for 7 to 11 days of the 14-day lookback period. Review of the October 2022 facility reporting log showed Resident 4 and 21 had two resident-to-resident altercations occurring on 10/13/2022 at 12:15 PM and 10/30/2022 at 12:02 PM in the hallway. The incident report for Resident 4 completed by the Staff Z, RN, on 10/13/2022, showed the LN was on a lunch break and was told the resident had a verbal altercation with another resident. The physician was noted to be notified on 10/17/2022, 4 days later. The witness area showed no witnesses found although someone had to report to Staff Z, that the incident occurred. The incident report for Resident 21, completed by Staff L showed they were not present for the altercation. The statement showed that the incident was reported as; at 12:15 PM, Resident 21 was standing at the nurse's station when Resident 4 turned the corner and spotted Resident 21. Resident 4 began yelling F**k you bitch, f**king b***h, and c**t loudly and repeatedly. Resident 21 stated they were very upset and would not tolerate being spoken to like that. The immediate action take did not include a plan to prevent reoccurrence. Review of the witness statement written by Staff M, Activity Director, showed they were escorting Resident 4 in their wheelchair when they yelled out c**t. Staff M asked who they were talking to, and they pointed at three female residents at the nurse's station. The statement did not state who the other two female residents were so they could be assessed and monitored for psychosocial harm. Review of witness statement by Staff F, NAC, included they did not see the incident, but Resident 21 told them about it and asked who they could talk to about it. Staff F documented Resident 4 seemed to be getting more agitated. Review of the witness statement dated 10/13/2022 from Staff O showed that Resident 21 wanted a lawyer and that Resident 4 had used improper language towards them. Resident 21 commented they were frustrated that Resident 4 had used aggressive language and talked about their genitalia. Review of the facility's incident investigation for 10/13/2022 at 12:15 PM, identified that Resident 21 had a known behavior to come out of their room and ask Resident 4 to be quiet when they were yelling. The investigation showed that Resident 4 was unprovoked and began yelling profanities at Resident 21. The investigations included that Resident 21 was very upset. The summary showed that Resident 4 was subsequently moved to the 5th floor. The investigation failed to include two other female residents in the investigation who were present. These residents were not assessed for injury. Review of the progress notes showed Resident 4 was not moved to the 4th floor until 10/17/2022. The room move had it occurred after the initial 10/10/2022 incident could have mitigated this incident that occurred between residents with a known history of not liking each other. The progress notes for Residents 4 and 21 did not include necessary details of the incident nor the plan to prevent reoccurrence. Review of the incident report showed the facility did not identify the circumstances that may have contributed to the verbal abuse. The care plan was revised to redirect Resident 4 if swearing occurred although the resident had severely impaired decision-making skills. Also, the staff were to move him to another room the next week. Resident 21 was ambulatory, and Resident 4 was able to self-propel and transfer in their wheelchair independently. Their rooms were close together. INVESTIGATION 10/30/2022 Review of the incident investigation occurring on 10/30/2022 at 12:02 PM, showed a NAC brought Resident 4 down to the 4th floor to be weighed. While Resident 4 was wheeled past Resident 21's room, they yelled at Resident 21 and Resident 21 then yelled back. The plan at the end of the summary was to borrow a scale. The investigation did not indicate a means to prevent reoccurrence by keeping the residents away from each other. There was no education to staff included to reduce the likelihood of reoccurrence. In an interview on 02/01/2023 at 11:20 AM, Resident 21's representative/collateral contact 1 (CC1) stated that there was a resident who would run around yelling his penis hurt. CC1 stated they were notified by the facility that both residents were yelling nose to nose. In an interview on 02/07/2023 at 9:43 AM, Staff I, LPN, stated when completing incident reports, they would get witness statements from all staff present that shift even if they were not the specific aide for that resident. Staff I commented, Often there will be information from other staff you need. In an interview on 02/07/2023 at 10:29 AM, Staff L stated who ever witnessed the incident will start the incident report. Staff L said the initial plan to maintain resident safety was implemented by the nurse immediately. Staff L was unaware of the other female residents present for the 10/13/2022 incident. Staff L was unaware of why there was a delay in moving Resident 4 off the unit. In an interview on 02/07/2023 at 11:48 AM, Staff K, Agency Nurse, stated if residents were swearing at another there should be a room move that shift to keep the residents separate. In an interview on 02/07/2023 at 12:56 PM, Staff M stated verbal abuse was somebody yelling or swearing at another resident. Staff M acknowledged she was present for an altercation between Resident 21 and Resident 4 in October. Staff M could not recall who the other two female residents were. This failure to identify a time trend, utilize this information to make adjustment in supervision and training, and to communicate to staff best practices to mitigate hazards to residents which placed all residents at risk for abuse, mistreatment, and psychological harm. In an interview on 02/07/2023 at 1:09 PM, Staff B was asked about the other two female residents who were present during the incident that occurred on 10/13/2022 between Resident 4 and 21. Staff B stated maybe those residents did not hear anything. Staff B did not know who the other residents were and acknowledged there was no incident report for them nor were they placed on alert for monitoring for psychosocial distress. Reference: (WAC) 388-97-0640 (6)(a)(b) .

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent (%) during observation of medication administrations. There were six errors made in the total of 30 opportunities resulting in a medication error rate of 20%. The failure to administer the correct medications in the correct doses placed residents at risk for adverse side effects, a decreased quality of life and possible harm. Findings included . Review of the facility's undated policy titled Medication Administration showed that licensed nurses were to: - Identify resident by photo in the Medication Administration Record (MAR). - Compare medication label with the MAR to verify resident name, medication, form, dose, route, and time. - To document medication administration after the medication is given. Review of the facility's undated policy titled Insulin Pen showed insulin pens would be primed prior to each use. In an observation on 02/03/2023 at 8:43 AM, Staff P, Licensed Practical Nurse (LPN) was unable to locate Lactulose (medication for constipation or liver disease) to give to Resident 7 as prescribed. OMITTED MEDICATION Review of Resident 7's MAR, dated February 2023, showed that Resident 7 was to receive Lactulose (laxative) two times daily. In an observation on 02/03/2023 at 8:43 AM, Lactulose was not prepared or administered to Resident 7. Staff P, LPN, could not locate the medication and omitted it. Staff P did not look in the emergency kit or medication storage for the missing medication. In a follow up interview on 02/03/2023 with Staff P, they stated that they were still unable to find the Lactulose for Resident 7. Staff P inaccurately documented that Resident 7 had received their scheduled Lactulose on the morning of 02/03/2023 INSULIN PEN In an observation on 02/03/2023 at 9:14 AM, Staff P was getting ready to administer two types of insulin (short and long-acting insulin's) to Resident 135. Staff P was observed to not prime either insulin pen resulting in the resident not receiving the correct doses of insulins. Staff P was observed to click the lantus (long acting insulin) pen 6 times for 6 units of insulin, without the 2 clicks to prime the pen. Staff P was observed to click the Humalog (short acting insulin) 2 clicks for 2 units of insulin, without the 2 clicks to prime the insulin pen. In an interview on 02/03/2023 at 9:18 AM, Staff P confirmed they did not prime the insulin pens for Resident 135. Staff P stated that sometimes the licensed nurses on the previous shift will prime the insulin pen before the next shift to help. WRONG RESIDENT In an observation on 02/03/2023 at 9:21 AM, Staff P was observed to sign the MAR for Resident 282's insulins. Staff P went into Resident 132's room and told the resident they were there with their insulin. Resident 132 asked Staff P if it was a vaccine and Staff P replied that it was not. Staff P reiterated that it was their insulin and the resident stated it was not for them. Staff P then asked the roommate, Resident 133, and they stated that they did not take insulin either. Review of Resident 132's MAR dated February 2023 showed that this resident did not have insulin ordered. Review of Resident 133's MAR dated February 2023 showed that this resident did not have insulin ordered. In an interview on 02/03/2023 at 9:38 AM Staff P, stated that they call out the first name of the resident and if they answer, that was how Staff P verified that it was the correct resident to give medication to. Reference: (WAC) 387-97-1060(3)(k)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff's failure to administer medication in accordance with professional standards of practice, and the seven rights of medication administration, including Right medication, Right time, Right dose and Right Resident, resulted in avoidable significant medication errors for 8 of 9 Resident's (7, 11, 18, 22, 132, 134, 135, and 282.) Resident 7 did not receive two ordered medications by the manufacturer's instructions for prefilled insulin syringes, the facility failed to ensure the correct procedure was followed prior to administering insulin via a prefilled syringe for 2 of 2 residents (135 and 282) observed to receive insulin during medication pass. This had the potential for the resident not to receive the correct amount of insulin needed in order to control blood sugars. The facility failed to ensure that licensed nurses (Staff P) observed during medication administration and (Staff J), understood and followed nursing professional standards for safe and accurate administration of medications. Staff P administered medications or attempted to administer medications to 4 of 4 Resident's (7, 132, 133, and 135) without verifying the resident's name or identity. Resident's (11, 132, 133, and 134) received their medications late. In addition, Resident 133 received partial ordered medications. Resident 18 received Resident 135's medications. These failures placed Resident 18 at risk for adverse side effects from non-prescribed medications including dizziness, lethargy, confusion, falls, injury, and/or respiratory compromise. Further, Staff P attempted to administer insulin to non-diabetic Resident's 132 and 133. This failure could have resulted in hypoglycemia, coma, or death. Findings included . Review of the undated facility policy titled Medication Administration showed medications were to be administered by licensed nurses as ordered and in accordance with professional standards of practice .The policy directed licensed nurses to identify the resident by the photo in the MAR (medication administration record). According to [NAME] Drug Guide for Nurses 2017, there were seven rights of medication administration for keeping resident's safe. Medication safety can be managed by consistently using the seven rights of drug administration: right drug, right route, right dose, right time, right patient, right response, and right documentation. Review of the Manufacturer's Instructions provided by the facility for the prefilled insulin syringe directed the needle unit to be attached to the prefilled syringe. The needle unit was then to be primed with 2 units of insulin to clear air from the needle and then administer the dose as ordered. RESIDENT 18 In an interview on 02/01/2023 at 3:10 PM, Resident 18 stated their nurse this morning (identified as Staff J, LPN,) gave them the wrong medicine. Resident 18 showed the surveyor a clear medication cup, stating she gave me this. The cup had (name of another resident) and 506 B labeled on it with black marker. Resident 18 stated the nurse may have been from agency or from another floor. They said they took a few of the pills and then questioned the nurse about the medications. The resident said then the nurse told me, Oh, you're not the one with the mole. Resident 18 said they gave me (Resident 135)'s Benadryl and a pain pill, not sure what else. Resident 18 said they reported this to (Staff E, Nurses Aide Registered [NAR]). The resident said the nurse returned to them and said remember I just gave you your medication. Resident 182 said, but I hadn't my morning medications yet. No, you didn't give me any of my medications. The nurse told me it will be better tomorrow. I guess she will be back tomorrow. Now I am worried. Resident 18 said they did not take everything that the nurse gave them when they realized the cup said (Resident 135) and a different room number on it. In an interview on 02/02/2023 at 9:42 AM, Staff A, Administrator, asked about the request for a medication error report for Resident 18. Staff A stated they were unaware of any medication errors on 02/01/2023. Staff A was informed Resident 18 reported they received medications labeled with Resident 135's name and room number yesterday. Additionally, Staff A was informed Resident 18 also had two stacks of clear medication cups they had been keeping that had their name and/or room number on them, suspicious for pre-pouring medications. Staff A acknowledged there was no reason for writing names or room numbers on medication cups if the med's were to be administered right away. They stated they would go investigate it. In a resident council interview on 02/02/2023 at 2:30 PM, Resident 21 stated the nurses do not verify her by name or check their name band when they give her med's. She said she gets her medications with her name on it most of the time. Resident's 7, 16, 23, 29 and 6 interjected and confirmed they received their medications in cups with their room numbers on them and the nurses do not check their names or arm bands prior to giving them their medications with the exception of Staff T, Licensed Practical Nurse (LPN). Review of Staff J's employee file showed there was prior enforcement on her LPN license. The background check showed the facility needed to complete a Character Completing and Suitability (CCS) on her. There was no CCS completed for her in her file. In an interview on 02/07/2023 at 1:29 PM, Staff B, Director of Nursing Services, stated they had requested the agency do a background check on staff. Staff B stated she had really never thought about doing the CCS as Staff J was not a facility employee. Staff A acknowledged they needed to make sure agency staff could be around vulnerable adults. Review of the facility investigation of the medication error for Resident 18 on 02/01/2023, showed the facility identified six additional errors involving Staff J, LPN. Medication errors were identified for Resident 11 who received his medications late, Resident 133 who received some of his medications and they were 2.5 to 3.5 hours late, Resident 132 received his 9 AM cardiac medication at 12:50 PM, Resident 134 received his 9:00 AM medications late 10:58 AM and Resident 22 received his 9:00 AM medications at 11:30 AM. RESIDENT 7 In a medication pass observation on 02/03/2023 at 8:43 AM, Staff P, LPN was observed preparing medications for Resident 7. Review of the MAR showed the resident was to receive Lactulose (a medication used for constipation and liver disease) and Metoprolol (a blood pressure medication). Staff P could not locate the medications and omitted those medications. Staff P did not go look in the medication room for the missing medications. In an observation on 02/03/2023 at 9:00 AM, there was an unlabeled medication cup with two unidentified tablets in them in the top drawer of the medication cart. RESIDENT 135 In an observation and interview on 02/03/2023 at 9:14 AM, Staff P, LPN, was preparing Lantus and Humalog insulin pens for administration. Staff P failed to prime the insulin pens. At 9:18 AM, Staff P stated that sometimes the prior shift would prime the pens to help the next shift out. Both insulin pens were not primed, resulting in an inadequate dose administered. RESIDENT 282 In an observation on 02/03/2023 at 9:21 AM, Staff P, LPN signed the MAR for Resident 282's Lispro and Lantus insulin. Staff P then went into room [ROOM NUMBER], walked up to Resident 132 and said they were there with their insulin. Resident 132 asked if the syringe was a vaccine and the Staff P responded No. Staff P again stated they were there to give them their insulin and the Resident 132 stated it was not for them. Staff P then asked Resident 132's roommate, Resident 133 if the insulin was for them. Resident 132 stated, Neither one of us take insulin. Staff P responded, One of you in here gets insulin. Resident 133 informed the nurse there used to be a resident in that room that took insulin. Staff P then walked out to their medication cart and looked at their census sheet. At 9:24 AM, they went to room [ROOM NUMBER] and administered the insulin to Resident 282. Resident 282 told the nurse they had asked for pain medication an hour ago. Staff P stated nobody had told them that. Staff P left the room without inquiring more about their pain or assessing them. In an interview on 02/03/2023 at 9:38 AM, Staff P, LPN was asked about how they identified the residents to ensure the correct resident. Staff P stated they call out the resident's name and if they answer that is how they verified. When asked about their process if the resident was confused or less alert, they said they would look at their face picture in the electronic medical record. Staff P confirmed the medication cup with two tablets in the top of the cart had no resident name or room number identified. She stated the medication cup was there when she came on shift. In an interview on 02/07/2023 at 9:43 AM, Staff L, LPN, stated they had been responsible for the whole 5th floor until the day of survey at which time, Staff J was assigned to split the floor. Staff L stated this was Staff J's first shift working by herself. Reference: (WAC) 388-97-1060 (3)(k)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 28 In an interview and observation on 02/02/2023 at 2:16 PM, Resident 28 stated that the meals are horrible. The resident stated the meals just do not taste good and are usually not very warm. Resident 28's lunch tray was observed to be untouched. Resident 28 commented that they looked at it and did not want it. In an interview on 02/03/2023 at 8:31 AM, Resident 28 stated they offer scrambled eggs most mornings that don't have much flavor. Resident 28 said, I think they are the kind that just pours out of the box. In an interview on 02/07/2023 at 2:39 PM, Staff W, Registered Dietician, stated they had heard concerns from residents about food being cold, especially when the kitchen used disposable plates. Reference: (WAC): 388-97-1100 (1)(2) RESIDENT INTERVIEWS RESIDENT 26 Resident 26 was admitted on [DATE] with a diagnosis of diabetes. An interview on 02/01/2023 at 12:05 PM, Resident 26 stated that the food was cold, there was no variety to the menu, and they received items with high amounts of carbohydrates. Resident 26 stated that they were worried about their diabetes because they frequently could not eat the food that was provided. Resident 26 stated that they had completed a grievance. Review of the grievance from Resident 26, dated 01/26/2023, showed that food was cold, and that food was served on paper (disposable) plates. The resolution on the grievance showed that staff were to reheat the meal for Resident 26. During an observation on 02/01/2023 at 1:25 PM, a sign was noted on the refrigerator in the 4th floor nourishment room that showed staff were not to re-heat food or drinks up in the microwave. In an interview on 02/02/2023 at 1:30 PM, Staff O, Nursing Assistant Certified (NAC), stated that if a resident complained of cold food, they would call the kitchen to get them a new tray. Staff O stated that they cannot reheat food in the microwave for safety reasons. In an interview on 02/06/2023 at 1:22 PM, Staff Q, NAC, stated that they would need to call the kitchen if a resident complained of cold food because they had no safe way to check the temperature of the food. In an interview on 02/06/2023 at 1:25 PM, Staff E, Nursing Assistant Registered, stated that the kitchen had provided meals on paper plates twice in the last 3 months. Staff E stated that the first time it lasted for a couple of days, but the second time it lasted for 10-12 days. Staff E stated that staff were not to reheat food in the microwave and would need to contact the kitchen if a resident stated their food was cold. In an interview on 02/07/2023 at 9:23 AM, Staff H, dietary manager, stated that they were not aware of the sign that showed staff were not to reheat food. Staff H also confirmed that the kitchen had been serving meals on disposable dishes for 10 days. Based on interview and record review, the facility failed to ensure food was palatable, attractive and at temperatures acceptable to 7 of 8 residents (6, 7, 16 23, 26, 28, and 29) reviewed for dietary services. The facility served several meals on disposable dishes which affected the temperature, attractiveness, and palatability of the meal. Failure to ensure meals were palatable and served at the correct temperature could lead to weight loss, affect chronic medical conditions, and diminish the resident's quality of life. Findings included . RESIDENT COUNCIL MINUTES OCTOBER 2022 Review of the resident council minutes for 10/25/2022, showed a concern of meals being delivered late. DECEMBER 2022 Review of the resident council minutes for 12/27/2022, showed a concern of food being served cold at times. RESIDENT COUNCIL MEETING RESIDENT 6 In an interview on 02/02/2023 at 2:12 PM, Resident 6 stated the facility had food issues. They stated they specifically asked for a certain meal yesterday and did not receive what they ordered. Resident 6 stated the only good food here was the chef salad. RESIDENT 29 In an interview on 02/02/2023 at 2:13 PM, Resident 29 stated they received their meals late. They said the food was cold as the kitchen did not adhere to the posted mealtimes. Resident 29 stated the facility should be temping and retaining the heat to the food when it was being delivered to the floors. RESIDENT 7 In an interview on 02/02/2023 at 2:13 PM, Resident 7 stated meals were served cold and on cardboard. The resident said they wondered if the facility had fired the dishwasher. The resident said they had a whole week of cold eggs and cold breakfast. RESIDENT 23 In an interview on 02/02/2023 at 2:18 PM, Resident 23 stated the kitchen put paper plates in the clam shell system. They said they were told there was a 2-hour window for meal delivery and sometimes meals were served at the end of the threshold. They stated meals were served lukewarm at best. They said they were disappointed there was just the main meal and one alternate to select from. The resident said they recently received a hamburger patty and bun and a slice of lettuce on a separate plate with no condiments. The resident asked the group if they would like to eat a hamburger with only lettuce and no tomato, onion, or condiments. RESIDENT 16 In an interview on 02/02/2023 at 2:20 PM, Resident 16 said their food is often delivered cold.

Based on interview and record review, the facility failed to ensure nursing assistant competencies were assessed and completed yearly, for four of four staff (F, R, S, and U) employee files reviewed. This failed practice had the potential to negatively affect the competency of the nursing assistants and impact the quality of care provided to residents. Findings included . Staff F, Nursing Assistant Certified (NAC), had a hire date of 10/12/2014. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff R, NAC, had a hire date of 02/15/2021. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff S, NAC, had a hire date of 06/12/2020. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. Staff U, NAC, had a hire date of 08/17/2015. A review of the employee file showed no documentation of a yearly skills checklist having been performed in the last year. In an interview on 02/06/23 at 10:55 AM, Staff V, Staff Development Coordinator, acknowledged staff competency evaluations were not done. Reference: (WAC) 388-97-1680 (2)(b)