**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure funds were reimbursed to the resident and/or representative or the state Office of Financial Recovery (OFR) within 30 days of resident discharge or death for 1 of 4 (Resident 57) residents reviewed for trust accounts. This failure caused a delay in reconciling residents accounts within the 30 days requirement. Findings included .Resident 57 was admitted to the facility on [DATE]. According to the nursing progress note, the resident passed away on 04/08/2025. In a record review of the facility's trust transaction history dated 07/15/2025, it was documented that Resident 57 had a balance of $378.67.In an interview on 07/18/2025 at 7:54 AM, Staff C, Business Office Manager, stated that any balances from resident's trust account must be returned to the resident within 30 days after discharge. If a resident passed away, then they were to submit the balance amount to the OFR. Reviewed Resident 57's trust transaction history with Staff C and they stated that have not submitted the funds for the resident as required. Refer to WAC 388-97-0340(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and/or implement individualized comprehensive care plans for 1 of 2 residents (Resident 27) reviewed for catheter use and 1 of 2 residents (Resident 8) reviewed for dementia care. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs placed residents at risk of unmet care needs and potential negative outcomes.Findings included.Review of an undated facility policy, titled, Comprehensive Person-Centered Care Planning, documented a comprehensive care plan would be developed to meet the residents medical and nursing needs and the IDT (interdisciplinary team) would review and/or revise the care plan after each assessment.<RESIDENT 8> Resident 8 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (memory impairment), anxiety disorder, and depression. Review of Resident 8’s Brief Interview for Mental Status (BIMS-an assessment to determine cognition) dated 03/10/2025 showed a score of 0/15 which was significant for severe cognitive impairment. In an interview on 07/17/2025 at 9:47 AM Staff M, Nursing Assistant Certified (NAC) stated they had worked with Resident 8 since they admitted . When asked what Resident 8’s dementia looked like for them, Staff M stated they became more confused at different times of the day especially in the evening. Staff M stated Resident 8 could be redirected by engaging in conversation about their daughter and plans for them to visit. Staff M stated they were not aware of any signage in the room to access when Resident 8 started speaking Dutch. Review of Resident 8’s care plan showed they had an alteration in their cognition and/or communication related to their dementia process, depression, and anxiety disorder. Resident 8’s goal was for them to be able to communicate basic needs daily. Interventions included asking yes/no questions, cue and/or reorient and supervise as needed, and monitor/document any changes in their cognitive function. In a separate care plan dated 07/14/2025 for communication, showed Resident 8’s first language was Dutch, and they reverted to speaking Dutch at times. Interventions included to anticipate Resident 8’s needs and to utilize signs provided by their family in Dutch to English translation to cue them when needed. On 07/17/2025 at 9:12 AM observed Resident 8’s room. There were no signs found in Resident 8’s room related to Dutch to English translation as described in the care plan. In an interview on 07/18/2025 at 9:59 AM Staff N, Licensed Practical Nurse (LPN)/Resident Care Manager, stated Resident 8 had been admitted to the facility with psychoactive (mood altering) medications because they were unsettled. Staff N stated Resident 8 was currently doing well and were tapering (gradually reducing) their psychoactive medications. Staff N stated Resident 8 exhibits their dementia by not making a whole lot of sense, visualizing something that is not there, or speaking Dutch. When asked about interventions for Resident 8’s dementia Staff N stated they like to watch television, staff to spend time with them, being around others, small group or reading magazines. Staff N stated they would often spend one on one time with Resident 8 and do a written question and answer activity. Staff N was unaware of the intervention for Dutch to English translation signage. Staff N stated they would need to update the care plan. <RESIDENT 27> Resident 27 admitted to the facility on [DATE]. During an interview on 07/15/2025 at 12:14 PM, Resident 27 stated they have had a urinary catheter (tube inserted into the bladder to drain urine) since admission to the facility but did not know why. Review of Resident 27’s care plan, printed on 07/16/2025, showed Resident 27 had a urinary catheter. The care plan did not show why the catheter was clinically unavoidable, the reason the resident had the catheter, nor what the follow up for the catheter was. During an interview on 07/17/2025 at 10:29 AM, Staff N, reviewed Resident 27’s urinary catheter problem on the care plan and reported the care plan was vague and they would have to follow up as to why the resident still had the catheter. During an interview on 07/18/2025 at 12:53 PM, Staff R, LPN/Minimum Data Set (MDS) Coordinator, reported the care plan should show the residents overall goals and how to take care of the resident. Staff R stated Resident 27’s care plan did not document why the catheter was clinically unavoidable. Refer to WAC 388-97- 1020(1), (2) (a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure professional standards were met for 2 of 5 residents (Residents 3 and 30) reviewed for unnecessary medication review. The facility failed to recognize and ensure parameters were followed for blood pressure medication administration and bowel constipation protocol for the resident and failed to notify the medical provider when the resident's blood sugar levels were beyond the ordered parameters. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs. Findings included . Review of the undated facility policy titled Blood Sugar Parameters stated the facility was to notify the provider for any blood sugar levels below 70 or above 450. Review of the undated facility policy titled House Bowel Protocol stated that milk of magnesium (medication for constipation) was to be given to residents if they had no bowel movement in three days, to give a glycerin suppository (medication for constipation inserted into the rectum) if no bowel movement for four days, and if no results from suppository the facility was to administer a enema (liquid inserted into the rectum). <RESIDENT 30> <BLOOD PRESSURE PARAMETER> Resident 30 admitted to the facility on [DATE] with diagnoses to include heart failure. According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 07/07/2025, Resident 30 was cognitively intact. Review of Resident 30’s 07/01/2025 - 07/15/2025 Medication Administration Record (MAR), showed Resident 30 had one antihypertensive medication (drugs used to treat high blood pressure) to be given twice a day. The order directed nurses to hold the medications for systolic blood pressure (top number of blood pressure reading) less than 110 or diastolic blood pressure (below number of blood pressure reading) less than 55. There was no blood pressures documented with the administration of the antihypertensive medication on the MAR. Review of Resident 30’s vital signs record, showed blood pressure: 07/01/2025 at 2:45 PM was 94/66mmHg (millimeters of mercury, unit of pressure measurement), 07/03/2025 at 12:28 AM was 105/57mmHg, 07/03/2025 at 10:48 AM was 109/67mmHg. Review of Resident 30’s entire electronic health record (EHR), showed no blood pressure documented from 07/04/2025 to 07/06/2024 and after 07/08/2025. In an interview on 07/18/2025 at 8:46 AM, Staff F, Registered Nurse (RN), stated nurses needed to follow the provider’s order and check the parameter if the order had specific instructions. Staff F stated they were not sure why the blood pressure was not documented. In a record review and joint interview on 07/18/2025 at 12:36 PM with Staff N, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), and Staff B, Director of Nursing Services, Staff N stated all nurses needed to follow the order and check blood pressures prior to administering antihypertensive medications. Staff N stated the order needed to be updated and the blood pressure should be documented with the medication in the MAR. Staff N stated the antihypertensive medication should be held on those days with out-of-range parameters. Staff B stated the expectation was to follow the provider’s order, to read the parameter and to hold the medication if the parameter was out of range. <BOWEL MOVEMENT> In an interview on 07/15/2025 at 11:53 AM, Resident 30 stated they had constipation, and had not received any bowel medication. Review of Resident 30’s care plan, print date 07/15/2025, showed the goal of the focus area for constipation was to have a normal bowel movement at least every two to three days, and one of the interventions was to follow the facility’s bowel protocol. Review of Resident 30’s bowel elimination record from 06/19/2025 - 07/18/2025, showed Resident 30 had no bowel movement from 07/01/2025 to 07/05/2025. Review of Resident 30’s MAR dated 07/01/2025 - 07/15/2025, documented MiraLAX powder (laxative powder to relieve constipation) was given on 07/04/2025 (no bowel movement on day four) with ineffective result; Milk of Magnesia suspension to be given for no bowel movement for three days was not administered; Glycerin rectal suppository for constipation If no bowel movement for four days was not administered; Fleet enema rectal insert for constipation if no result from Glycerin suppository was not administered. In an interview on 07/18/2025 at 8:52 AM, Staff F stated they had a bowel movement alert list from the EHR. Staff F stated the list showed residents who had no bowel movement for three days and nurses needed to follow the bowel medication orders and monitored the effectiveness. Staff F stated nurses needed to follow up with the provider if the medication was not effective. In an interview on 07/18/2025 at 12:49 PM, Staff B stated nurses should have started the bowel medication when Resident 30 had no bowel movement on day three and they expected nurses to follow the bowel protocol <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include diabetes mellitus (disease where the body cannot regulate sugar levels in the blood). The Quarterly MDS dated [DATE] showed the resident had mild cognitive impairment, and received insulin (medication inserted into the body to help regulate blood sugar levels) injections all seven days of look back period. Review of Resident 3’s physician orders dated 04/21/2025 documented to administer insulin injection per the sliding scale, and if blood sugar levels were above 400, to notify the medical provider. Review of Resident 3’s MAR from 05/01/2025 – 07/17/2025 showed the resident had blood sugars above 400 on 05/03/2025, 06/04/2025, 06/15/2025, 06/27/2025, and 07/09/2025. Review of Resident 3’s progress notes from 05/01/2025 – 07/17/2025, showed no documentation that the physician had been notified that the residents blood sugars had exceeded the ordered parameters. In an interview on 07/18/2025 at 9:33 AM, Staff F, stated they were educated to follow parameters that were listed on the resident orders. Staff F stated if the order specified to notify provider when outside the parameters they were to document in the progress notes. Staff F stated for blood sugar monitoring there should be a note about re-checking the blood sugar as well as a possible new order to administer extra insulin. In a joint interview on 07/18/2025 at 1:05 PM, Staff B, and Staff N, Staff N stated if a resident’s blood sugar was outside the facility parameter or the physician ordered parameters they were to call the provider, and made a progress note in the medical record. Staff B reviewed Resident 3’s blood sugars and agreed they were outside the parameters and the licensed staff should have notified the provider and documented in the medical record. 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 respiratory care and services were provided in accordance with physician's orders and accepted professional standards of practice for 2 of 2 residents (Resident 49 and 6) reviewed for respiratory care. The facility failed to ensure continuous positive airway pressure (CPAP, a form of non-invasive ventilation therapy used to facilitate breathing) orders were active and in place, to include the prescribed pressure settings, checking, refilling, and cleaning of the humidifier reservoir, and identifying what solution was to be used in the humidifier. Additionally, the facility failed to ensure oxygen (O2) was being administered per physician's orders. These failures placed residents at risk for ineffective breathing, decreased oxygen levels, respiratory infection and other respiratory complications.Findings included.Reviewed of an undated facility policy titled, CPAP Monitoring and Management, documented that CPAP machine settings and the mask tubing and adapter are to be cleaned per physician's orders. Review of an undated facility policy titled, Oxygen Administration, documented the facility will administer oxygen as ordered by the physician.<RESIDENT 6> Resident 6 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder and fibromyalgia (long term and chronic condition that causes pain and tenderness throughout the body). In an observation on 07/15/2025 at 12:08 PM, observed Resident 6 wearing a nasal cannula (device used to deliver supplemental O2 through the nose). In an interview and observation on 07/16/2025 at 11:42 AM, Resident 6 was wearing a nasal cannula, attached to an O2 concentrator, with the setting at 1.5 liters per minute (lpm). When asked about the settings for their O2, Resident 6 stated it should be 2 lpm. In an interview and observation on 07/17/2025 at 9:34 AM, Resident 6 was observed lying in their bed wearing a nasal cannula attached to a running O2 concentrator with settings at 1.5 lpm. When asked if they were getting enough O2, Resident 6 stated they could use more but did not want to ask for it because they thought the facility would start weaning them off the O2. In a review of Resident 6’s Medication Administration Record (MAR) for 07/01/2025 - 07/16/2025 showed an order start date of 05/31/2025 for oxygen at 2 lpm via nasal cannula to keep O2 saturations (level) above 90 percent (%) for shortness of breath as needed. In a review of Resident 6’s vitals (measurement of the body's basic functions) dated 07/07/2025 - 07/16/2025 showed their O2 saturations were checked consistently while the resident was using O2 since admission, all documented saturations were above 90%. In a review of Resident 6’s care plan dated 05/30/2025 showed they had altered respiratory status with difficulty sleeping related to sleep apnea (temporary pause in breathing). Interventions included O2 at 2 lpm as needed to keep their saturations above 90%. In an interview on 07/18/2025 at 10:36 AM Staff N, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated Resident 6 admitted with O2. Staff N was asked how Resident 6’s O2 saturations were assessed, when all vitals were documented during O2 use, Staff N did not answer the question. In an interview on 07/18/2025 at 10:42 AM Staff B, Director of Nursing Services (DNS), stated there was usually a range for the lpm on the orders for O2. Staff B stated they were unaware Resident 6’s settings were at 1.5 lpm. When asked how Resident 6’s O2 was maintained above 90%, Staff B stated they would need to discuss the order with the provider and adjust it accordingly. <RESIDENT 49> On 07/15/2025, at 9:51 AM, it was observed that Resident 49 had a CPAP machine on their nightstand. On 07/15/2025, at 2:43 PM, Resident 49 stated that they wore the CPAP every night and that the staff have never washed it. During an interview on 07/16/2025, at 11:14 AM, Resident 49 stated staff have not been washing the CPAP mask. During an observation and interview on 07/16/2025, at 1:18 PM, visually inspected the CPAP mask and noted visible debris on the mask. On 07/17/2025, at 8:46 AM, visually inspected CPAP mask and noted debris and oily substances. Resident 49 stated the CPAP mask had not been washed the prior day. On 07/16/2025, record review showed that there were no active orders in the medication administration record (MAR) regarding the CPAP for Resident 49. In an interview on 07/17/2025, at 9:48 AM, Staff J, Nursing Assistant Certified (NAC), stated the aides did not provide any care for the CPAP and that the nurse did everything for it. In an interview on 07/17/2025, at 9:54 AM, Staff F, Registered Nurse (RN), reported no orders or instructions regarding the CPAP were in the MAR. In an interview on 07/17/2025, at 2:39 PM, Staff B, stated their expectations for a resident with a CPAP were the orders which would include settings, maintenance, distilled water, and cleaning. Staff B reviewed the clinical record and was not able to locate any active orders for the CPAP. Surveyor observed CPAP mask and tubing with Staff B. Staff B stated that the CPAP mask had not looked like it had been cleaned. Staff B was not able to identify what the debris on the mask was, and they stated they saw some white stuff on there. Refer to WAC 388-97-1060(3)(j)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 4 residents (Resident 31) reviewed for transmission-based precautions (TBP), 1 of 4 residents (Resident 27) reviewed for bowel and bladder care, and 1 of 3 nurses (Staff F) reviewed for medication administration. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriate hand hygiene practices during perineal care (process of cleaning genitals and anal area), and failed to ensure there was a barrier in place during medication administration. These failures placed all residents and staff at risk of potential infection. Findings include . Review of the facility policy titled Enhanced Barrier Precautions (EBP), revised 02/2025, stated EBP was utilized to prevent the spread of potential multi-drug-resistant organisms (MDROs) .EBP was applied when resident had a wound .EBP instructs the staff to use gown and glove for any high contact care provided to the residents, face protection may be used if potential splash exposure .high contact areas include but not limited, to dressing, bathing, toileting, device care, and wound care. Review of facility policy titled Hand Hygiene, revised 02/2025, stated facility staff should ensure the staff are performing hand hygiene effectively as it was one of the most effective measures to prevent the spread of infection based on accepted standards of practice .hand hygiene should be performed if hands are visibly soiled, caring for residents with a known organisms, before and after using the restroom, before and after direct care with a resident, before and after wearing gloves, before and after handling of food, and before and after removing PPE. <ENHANCED BARRIER PRECAUTIONS> Resident 31 admitted to the facility on [DATE] with diagnoses to include fracture of their right lower leg with ankle wound. Review of Resident 31’s care plan dated 04/23/2025, documented they were on EBP related to their wound. In a continuous observation on 07/16/2025 at 1:15 PM, observed a sign on Resident 31’s door alerting staff of their EBP status. There was PPE cart outside Resident 31’s door which contained gloves, gowns, face masks and eye protection. Observed Staff W, Nursing Assistant Certified (NAC) enter Resident 31’s room and asked them if they were done with their meal. At 1:57 PM observed Staff W enter Resident 31’s room without any PPE and closed the door. Staff W exited Resident 31’s room at 2:00 PM without any PPE. In an interview on 07/16/2025 at 2:03 PM Staff W, NAC, stated they had assisted Resident 31 with toileting. In an interview on 07/21/2025 at 8:46 AM Staff L, NAC, stated Resident 31 preferred to use the urinal and at times the commode, but usually the bed pan for bowel movements. When asked if staff should be using PPE when assisting Resident 31 with toileting, Staff L stated because the wound was covered the EBP applied only to nurses but did not know for sure. <PERICARE> During an observation on 07/17/2025 at 7:10 AM, Staff J, NAC, provided perineal care to Resident 27. Staff J cleansed the genital area, removed their gloves, placed their contaminated hand into the box of gloves and then applied new gloves without doing hand hygiene. Staff J cleansed the buttocks area, removed their gloves, reached into the box of gloves and then applied new gloves without doing hand hygiene. During an interview on 07/17/2025 at 7:31 AM, Staff J stated they should have washed their hands or used hand sanitizer each time after removing their gloves. During an interview on 07/18/2025 at 1:30 PM, Staff Q, Infection Preventionist, stated staff should perform hand hygiene each time gloves were removed during perineal care: before starting task, after cleaning the buttocks and when completed with the task. <MEDICATION ADMINISTRATION> During an observation on 07/16/2025 at 11:42 AM, Staff O, Licensed Practical Nurse, used a glucometer (meter that measures sugar levels in the blood) inside a resident’s room. Staff O then brought the contaminated glucometer and the vial of glucometer strips from the room and placed them on top of the medication cart without a barrier. Staff O then used a disinfectant cloth to disinfect the glucometer but did not disinfect the medication cart. During an observation on 07/16/2025 at 11:46 AM, Staff O brought an insulin pen (device that contains insulin that can be injected) into a resident’s room and placed it on the overbed table without a barrier. Staff O applied gloves and then injected the insulin, put the pen back on the overbed table and removed their gloves and did hand hygiene. Staff O then exited the resident’s room and placed the insulin pen on top of the medication cart without a barrier. Staff O then unlocked the medication cart and placed the insulin pen inside without disinfecting the pen. Staff O did not disinfect the medication cart where the insulin pen had been sitting. During an interview on 07/16/2025 at 11:48 AM, Staff O stated used equipment were considered contaminated until they had been disinfected. Staff O reported they should have used a barrier under the insulin pen in the resident’s room and that they should have placed a barrier on top of the cart before placing items that had been used in a resident room. During an interview on 07/18/2025 at 1:30 PM, Staff Q stated the nurse should have used a barrier under the glucometer and insulin pen on the resident’s table and used a barrier before placing the used glucometer on top of the medication cart before it was sanitized. Refer to WAC 388-97-1320(1)(a)(c)(2)(a)(b)

Based on observation, interview and record review, the facility failed to have a system in place that ensured grievances were addressed and resolved in response to residents' verbal conveyance of concerns for 1 of 1 Resident Council groups and 1 of 1 sampled resident (Resident 27). The facility failed to track and investigate the concerns which led to residents repeatedly reporting the same care issues without resolution and placed them at risk of unidentified and unmet care needs, and diminished quality of life. Findings Included . Review of the undated facility policy titled Grievance Policy & Procedure, showed all grievance issues would be put into writing and brought to the Grievance Officer and would be addressed in an efficient manner. The administrator would contact the party initiating grievance to discuss and resolve any concerns. <RESIDENT COUNCIL> In an interview with Resident Council representatives on 07/16/2025 at 1:55PM: - * Resident 51 and Resident 47 stated the television (TV) noises, laughter and loud voices from staff at night was a continuous issue and was mentioned a few times during the previous meetings. Resident 51 stated the TV was loud almost every night and the TV headphones provided by the facility were not always accessible and uncomfortable to wear. Resident 47 stated the noise from TV's and the laughing and loud voices from the staff made it very hard to sleep at night. * Resident 12, Resident 50 and Resident 51 stated the food served in the facility was cold every meal every day. Resident 47 stated the concern was brought up in every Resident Council meeting since April of 2025 but there was still no change. Resident 13 stated they talked to the administrator about the food served cold, but the administrator did not say anything. Review of Resident Council meeting minutes, dated 04/23/2025, showed residents stated TVs were too loud at night and suggested the night shift nurses could conduct rounds to turn down the volume. There was no documentation about the cold food concerns. There was no documentation of resolutions for the cold food or noise at night. There were no attached grievance/concern forms related to these resident council concerns. Review of Resident Council meeting minutes, dated 06/04/2025, showed residents were still complaining of TV noise at night and the facility was to provide headphones. Residents also brought up night shift staff were boisterous, laughing and loud. There was no documentation about the cold food concerns. There was no documentation of resolutions for the cold food or noise at night. There were no attached grievance/concern forms related to these resident council concerns. Review of Resident Council meeting minutes, dated 07/02/2025, showed TV noise at night was still a problem and residents suggested that headphones be accessible to night shift staff so they could be provided to residents who were watching TV at night. The minutes did not reflect cold food concerns, but showed the kitchen was working on getting new temperature-controlled carts. There was no documentation of resolutions for the noise at night. There were no attached grievance/concern forms related to these resident council concerns. Review of the facility Grievance Resolution reporting log from January 2025 to June 2025, showed the facility had not logged the Resident Council’s concerns during the meetings, such as loud TVs, staff noise at night or cold food concerns. In an interview on 07/17/2025 at 11:55 AM, Staff P, Activity Director, stated they assisted Resident Council meetings and wrote the meeting minutes. Staff P stated they resolve the concerns themselves or pass the specific concerns to other departments. Staff P stated the concerns from Resident Council meetings were different from grievances and they did not complete the grievance forms or track their concerns. In an interview on 07/17/2025 at 1:47 PM, Staff D, Social Service Director, stated everyone could file a grievance concern form and they were responsible to resolve with residents in five to 10 days. Staff D stated they had not been notified of any concerns or received any grievance forms from Resident Council meetings. In an interview on 07/18/2025 at 10:22 AM, Staff A, Administrator, stated they expected the activity director to complete a grievance form from the voiced concerns from the Resident Council meetings and give copies to other departments’ heads, the social service director who was the Grievance Officer, and the administrator to review. Staff A stated they had not received any grievances from Resident Council meetings. Staff A stated they expected the grievances to be resolved within five to 10 days, and a resolution provided to the residents. Staff A stated the concerns brought up from the Resident Council meetings such as noises at night and food served cold were grievances and should be logged in the grievance log and complete a grievance form. Staff A stated the TV noise at night was an ongoing concern that the facility had been working on since April 2025. Staff A stated staff had been educated on noise levels at night, there was no grievance form related to that. Staff A stated they were aware of the cold food concerns, and they had not purchased the temperature-controlled carts. In a follow-up interview on 07/21/2025 at 10:42 AM, Staff A stated they were not aware of the staff noise at night which was brought up during the Resident Council meeting in June 2025 and there was no follow up documentation. Staff A stated they had not established the Resident Council meeting grievance process with the activity director. <RESIDENT 27> During an interview on 07/15/2025 at 11:17 AM, Resident 27 reported “it sounds like they are having a party out there at night.” During an observation on 07/17/2025 at 6:51AM, a walkie talkie located at the desk at the north nurse’s station was overheard from 10 feet away. The communication heard was loud and sounded like yelling. During an interview on 07/17/2025 at 11:07 AM, Staff B, Director of Nursing, reported they were not aware of any recent noise complaints at night and were not aware of any noise concerns from Resident 27. During an interview on 07/21/2025 at 10:42 AM, Staff A was asked about what follow up was done from the resident council meeting in June 2025 about staff being “boisterous and laughing during the night shift?” Staff A reported that they had not been notified about the concern from the resident council and no follow up had been done until noise concern was reported by surveyor on 07/17/2025. Reference WAC 388-97-0920 (4)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide complete and updated Notification of Medicare Non-Coverage (NOMNC - a document informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) for 4 of 4 sampled residents (Resident 4, 15, 25 and 55) reviewed for liability notice. This failure placed residents and/or their representatives at risk for not fully understanding their Medicare benefits and appeal rights and receiving inadequate information to make appeal decisions. Findings included .Review of the facility policy titled, Notice of Medicare non-coverage Letter (NOMNC), revised date 12/27/2024, showed the facility had to make sure the resident and/or representative understood the purpose and the contents of the notice, the appeal process and the associated time frames so they could make an informed decision on whether to appeal.Review of Center for Medicare and Medicaid Services (CMS) electronic web site (CMS.gov), shows the NOMNC form was last updated January/2025. <RESIDENT 4> Resident 4 admitted to the facility on [DATE]. Review of the NOMNC form signed by Resident 4 on 03/26/2025, documented there was no appeal organization’s name or telephone contact written on the form. The NOMNC form was approved by CMS on 12/31/2011 which was not the latest version. Review of Resident 4’s electronic health record (EHR), showed there was no documentation regarding whether Resident 4, or their representative were provided an explanation of NOMNC form. <RESIDENT 15> Resident 15 admitted to the facility on [DATE]. Review of the NOMNC form signed by Resident 15 on 07/02/2025, documented there was no appeal organization’s name or telephone contact written on the form. The NOMNC form was approved by CMS on 12/31/2011 which was not the latest version. Review of Resident 15’s EHR, there was no documentation regarding whether Resident 15, or their representative were provided an explanation of NOMNC form. <RESIDENT 25> Resident 25 admitted to the facility on [DATE]. Review of the NOMNC signed by Resident 25 or representative on 07/08/2025, documented there was no appeal organization’s name or telephone contact written on the form. The NOMNC form was approved by CMS on 12/31/2011 which was not the latest version. Review of Resident 25’s EHR, showed there was no documentation regarding whether Resident 25, or their representative were provided an explanation of NOMNC form. In a record review and interview on 07/18/2025 at 2:27 PM, Staff D, Social Service Director (SSD), stated they were responsible to issue and explain the NOMNC form to residents and/or representatives. Staff D stated they explained the appeal process and the appeal telephone contact information on the form. Staff D was not aware that the appeal organization’s name and the appeal telephone contact information was not written on the form. Staff D stated the form was not updated and the appeal information should be included within the form. <RESIDENT 55> Resident 55 was admitted to the facility on [DATE]. In a record review on 07/17/2025 at 9:32 AM, Resident 55’s NOMNC form documented there was no appeal organization’s name or telephone contact written on the form. The NOMNC form was approved by CMS on 12/31/2011 which was not the latest version. In an interview on 07172025 at 12:22 PM, Staff D stated that they were not aware that there was a newer version of the NOMNC form. Reference WAC 388-97-0300(1)(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility), provide a written notice to the resident and/or their representative and the ombudsman (independent and objective individual who investigates complaints against government agencies and other organizations) of a hospital transfer for 3 of 3 residents (Residents 14, 53 and 55) reviewed for hospitalization/discharge. These failures placed the residents at risk for lack of knowledge regarding their rights to a bed hold, monetary consequences, appeal rights, and available advocacy services, and possible unidentified or unmet care needs. Findings included .In a review of the facility policy titled Transfer or Discharge Notices, updated 07/13/2025, showed if a resident was transferred to the hospital a notice of transfer would be provided to the resident and representative as soon as practicable and a notice of facility bed hold and return policies would be provided to the resident and representative within 24 hours of emergency transfer.<RESIDENT 4> Resident 4 re-admitted to the facility on [DATE]. Review of Resident 4’s progress notes from 06/11/2025 to 06/17/2025 showed they were hospitalized on [DATE]. No progress notes were found related to a bed hold being offered or notice of transfer/discharge being provided to Resident 4 or their representative. Review of Resident 4’s Electronic Medical Record (EMR) showed no documents for a bed hold, or a notice of transfer or discharge related to their hospitalization on 06/11/2025. In an interview on 07/17/2025 at 1:38 PM Staff D, Social Services Director, stated they sent a list to the ombudsman monthly only for planned discharges. When asked about the notice of transfer/discharge form, Staff D stated they completed them for planned discharges and deferred to nursing for any hospitalizations. In an interview on 07/17/2025 at 3:02 PM Staff H, Registered Nurse (RN) stated the facility had a hospital packet that was completed to include the bed hold and notice of transfer/discharge when a resident was sent to the hospital. Staff H stated they reviewed the bed hold and the notice of transfer with the resident if they were able and if not then the power of attorney/resident representative would be notified. On 07/17/2025 at 3:08 PM Staff I, Nursing Assistant Certified (NAC)/Unit Secretary provided a blank “Transfer to Hospital Packet”. Staff I stated the nurse would complete the packet and signed documents would be left for medical records to upload into the EMR. The packet included: - Directions to complete the packet, -Blank Bed Hold Policy form, -Blank Nursing Home Transfer or Discharge Notice, -Blank Status Report, -Blank Skilled Nursing Facility Transfer Form. On 07/18/2025 at 8:33 AM, Resident 4's signed Bed Hold and Notice of Transfer/Discharge form from their most recent hospitalization (June 2025) was requested. At 10:30 AM Staff D, provided a signed bed hold policy form for Resident 4 from their hospitalization on 2/5/2025. No other information was provided. On 07/18/2025 at 1:35 PM Staff A, Administrator, stated they were not aware a bed hold and notice for transfer/discharge was not done for Resident 4. Staff A stated a resident being hospitalized should have gotten a notice of transfer/discharge and a bed hold policy form. <Resident 53> Resident 53 was admitted to the facility on [DATE]. In a review of Resident 53’s EMR progress notes documented the resident was sent to the emergency room on [DATE]. The EMR did not show a copy of the notification of transfer to the State Ombudsman. In an interview on 07/18/2025 at 1:03 PM, Staff E, RN stated that they were not aware that they were supposed to notify the State Ombudsman regarding transfers/discharges. In an interview on 07/18/2025 at 1:09 PM, Staff B, Director of Nursing Services (DNS) stated that for a planned discharge, the Social Service Department notified the Ombudsman. Staff B stated for unplanned discharges and hospital transfers, the nurses were expected to complete the notification of transfer/discharge form and then Social Services would fax to the ombudsman. Staff B stated they discovered that they were not doing the correct process. <RESIDENT 55> Resident 55 was admitted to the facility on [DATE] and discharged to an adult family home on [DATE]. In a review of Resident 55’s EMR showed documentation that the resident discharged to an Adult Family home on [DATE]. There were no documents in the resident’s EMR regarding notification of discharge to the State Ombudsman. In an interview on 07/17/2025 at 12:22 PM, Staff D, stated the nursing department completed the transfer/discharge notification form and for planned discharges they completed the notification form and sent it to the State Ombudsman. Staff D stated they sent the notifications once a month. Staff D provided a list of residents that were discharged in the month of May and June, that they had sent monthly to the state ombudsman. Staff D did not provide documentation that the transfer/discharge notification form was sent to the state ombudsman for each of the facility discharges. Refer to WAC 388-97-0120(2)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that 4 of 6 residents (Resident 3, 8, 29 and 30) reviewed for the Preadmission Screening and Resident Review (PASSR - a federally required screening of all individuals for Intellectual Disability (ID) or Related Condition and a Serious Mental Illness (SMI) prior to admission) process. The facility failed to refer the PASSRs for further review and failed to ensure any recommendations were incorporated into the plan of care. These failures placed residents at risk for unidentified mental health care needs, lack of mental health services and diminished quality of life.Findings included.Review of the facility policy titled, PASRR screening for Mental Disorder/Intellectual Disability, showed a positive Level I Screen (PASRR indicates that individual requires a PASRR Level ll Referral) necessitates an in-depth evaluation of the individual by the state-designated authority. PASRR Level ll which must be conducted prior to admission to a nursing facility OR upon identification that the individual may need a level ll PASRR Referral while at the Nursing Facility .if a Level II is indicated the facility must ensure an evaluation is conducted and results of the evaluation are incorporated and developed into the residents' plan of care.<RESIDENT 30> Resident 30 admitted to the facility on [DATE] with diagnoses to include depression. Review of Resident 30’s Level I PASRR dated 11/22/2024, showed Resident 30 had SMI and required a level II evaluation. Review of Resident 30's EHR showed no Level II PASRR was completed prior to the admission to the facility. In an interview on 07/17/2025 at 1:40 PM, Staff D, Social Services Director stated they sent an email to the state PASRR Evaluator recently for Resident 30’s PASRR level II, no documentation of confirmation was provided. In an electronic communication on 07/17/2025 at 2:40 PM Collateral Contact 1 (CC1), state contracted PASRR Evaluator, showed they had not received any information regarding Resident 30 and their PASRR from 11/21/2024. <Resident 29> Resident 29 was admitted to the facility on [DATE] with diagnoses to include major depressive disorder. Review of Resident 29’s records showed a level l PASRR was completed 11/22/2024 and documented a level ll evaluation referral was required for SMI. PASRR level ll was not located in Resident 29’s Electronic Health Record (EHR). During an interview on 07/17/2025, at 9:01 AM, Staff D, stated Resident 29’s PASRR required a level ll evaluation. Staff D could not locate a completed PASRR level ll. <Resident 8> Resident 8 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (memory impairment), anxiety disorder, and depression. Review of Resident 8’s care plan dated 10/30/2023 showed had an invalidated level II Pre-admission Screening and Resident Review (PASRR) completed on 11/27/2023. Review of Resident 8’s progress notes from 11/01/2024 through 07/15/2025 showed no documentation referencing the PASRR and the current status. Review of Resident 8’s EHR showed their level I PASRR was redone on 11/21/2024 and they required a level II evaluation. In an interview on 07/17/2025 at 1:40 PM Staff D, stated they had started a new process in the facility related to PASRR’s. Staff D stated when a resident was admitted to the facility, they would review the PASRR and update the diagnoses if needed and if the resident required a level II, they would send them to the evaluator by email. Staff D stated they had reviewed all the long-term care residents PASRR’s and updated them as needed. Staff D stated they did not review their facility policy and procedure on PASRR’s and had email correspondence with the PASRR evaluator weekly. When asked the status of Resident 8’s PASRR completed 11/21/2024, they stated they had emailed it and were going to send an email to the evaluator this week to follow up. In an electronic communication on 07/17/2025 at 2:40 PM CC1 showed they had not received any information regarding Resident 8 and their PASRR from 11/21/2024. <Resident 3>Resident 3 was admitted to the facility on [DATE] with diagnoses to include depression, and borderline personality disorder (difficulties regulating emotions and impulses). Review of Resident 3’s admission PASRR Level II evaluation dated 12/19/2024 showed the resident had a positive Level I screen and had been referred for a mental health evaluation. The recommendations for the nursing facility were the following: the facility should ensure the resident had a space that was free and clear of obstacles and ensure the resident did not have disruptive roommate. The staff should approach in a calm and compassionate manner, female staff members only due to past trauma from men. Staff should provide care in pairs to ensure that the resident did not split or manipulate the staff. The resident would need a private space for tele-health appointments with their therapist. The resident had great fear of going outside and fearful of grass and dirt. Review of Resident 3’s medical record showed a “Trauma Screening Questionnaire” dated 06/03/2025 that showed the resident had a history of traumatic events in their child and adult life, had been physically or sexually assaulted, felt anxious or depressed, felt their traumatic experiences affected their current way of life, and were uncomfortable around men. In a review of Resident 3’s care plan, print date 07/17/2025, showed none of the recommendations from the Level II evaluation had been incorporated into the plan of care. In an observation and interview on 07/15/2025 at 10:31 AM, Resident 3 was sitting up in their bed. The room space was small, and lacked adequate space for their mobility device, there were personal items in boxes stacked up against the wall. The resident stated there was no space in their room, and felt boxed in a corner, as there was no access to a window. The resident expressed they had no privacy for appointments and were told they would have to go outside for their telehealth appointments. In an interview on 07/18/2025 at 8:56 AM, Staff X, Nursing Assistant Certified (NAC) stated they rely on the care plan and the Kardex (condensed version of care plan) for assessing what level of care to provide to each resident. In an interview on 07/18/2025 at 9:33 AM, Staff F, Registered Nurse (RN) stated that the management team was usually responsible for updates to the care plans for residents. In an interview on 07/18/2025 at 11:00 AM, Staff D, stated their role as it relates to PASRR was they would review all PASRR’s to ensure they were accurate, and if they required a Level II evaluation, they made the request. Staff D stated when a Level II evaluation was completed, they would review and incorporate any recommendations into the care plan for the resident. Staff D was not aware of the recommendations that had been made for Resident 3 that were included in the Level II evaluation. Staff D was not aware that Resident 3 had a fear of going outside, or a fear of men. Staff D stated the facility had completed a trauma screening for all residents in June 2025 and thought Resident 3 had no trauma. Staff D was shown the results of the Trauma Screen that was done on 06/03/2025, and stated they were not aware of those results. In an interview on 07/18/2025 at 1:05 PM, Staff N, License Practical Nurse (LPN)/Resident Care Manager (RCM) stated the comprehensive care plan was created by the interdisciplinary team, each member contributing to their section. Staff N stated social services were usually responsible for updating residents care plan as it pertained to mental health, and PASRR. In a joint interview on 07/21/2025 at 11:04 AM, Staff A, Administrator and Staff B, Director of Nursing both stated they were unaware that there had been a lack of follow up as it related to PASRR, and that PASRR Level II evaluation recommendations had not been incorporated into the care plan. Refer to WAC 388-97-1975(8)(10)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing) center and consistently complete resident's pre and post dialysis assessments for 2 of 2 resident (Residents 4 and 28) reviewed for hemodialysis (HD) services. The failure of inconsistent communication and collaboration between the facility and the dialysis center about what occurred during HD and the inconsistent completion of the pre, and post dialysis assessments placed the residents at risk for unidentified medical complications and other potential/negative health outcomes.Findings included .In a review of the facility policy titled, Dialysis (Renal), Pre- and Post-Care revised 02/2025 showed the policy included ongoing communication and collaboration with the dialysis facility regarding dialysis care and service.<RESIDENT 4> Resident 4 initially admitted to the facility on [DATE] with diagnoses that included diabetes, type two (a condition in which the body does not use insulin correctly or does not produce enough insulin leading to high blood sugar) and end stage kidney disease (kidneys no longer function). Review of Resident 4's care plan dated 02/10/2025, documented the resident required hemodialysis related to renal failure with the goal of having no signs/symptoms of complications from dialysis through the review date of 09/22/2025. Interventions included not to take blood pressure in the right arm, encourage the resident to attend their scheduled dialysis appointments, monitor and report any changes to the physician, and the resident had dialysis on Tuesdays, Thursdays and Saturdays. In an interview on 07/17/2025 at 2:29 PM, Staff O, Licensed Practical Nurse (LPN), stated dialysis communication packets are put together by the night nurse and left for the day nurse on the day of dialysis. Staff O stated when a resident returns from dialysis the paperwork goes to the resident care manager and sometimes the dialysis center would be called to get information if none were sent. In an interview on 07/17/2025 at 2:30 PM, Staff N, LPN/Resident Care Manager (RCM) stated they would locate where the information for pre and post dialysis communication was located. In a follow up interview on 07/17/2025 at 2:53 PM, Staff N, LPN/RCM stated there are User Defined Assessments (UDA) in the resident's electronic medical record (EMR) for pre and post dialysis assessments. Staff N stated a packet was made and sent to dialysis which included a face sheet, medication list, and the UDA- pre dialysis assessment and blank after visit summary (AVS). Staff N stated they had not received any AVS from dialysis for Resident 4. In a review of Resident 4's UDA's for pre and post dialysis assessments documented missing post assessments for 6/24/2025, 06/26/2025, 06/28/2025, 07/01/2025, 07/08/2025 and 07/10/2025. In a review of Resident 4's EMR documented dialysis run sheets (tracking clinical data during dialysis) from the dialysis center for 07/01-07/10/2025 and 07/16-07/19/2025. No other documentation found from the kidney center that Resident 4 attended. <RESIDENT 28> Resident 28 was admitted to the facility on [DATE] with diagnoses to include end stage kidney disease and diabetes mellitus type two. In a review of Resident 28's care plan dated 04/23/2025 documented they required HD related to their end stage kidney disease with the goal of having no complications from dialysis through the review date. Interventions included encouraging Resident 28 to attend their dialysis appointments, monitor labs and report to the doctor as needed. In a review of Resident 28's progress notes dated 04/28/2025 10:14 PM, documented they went to dialysis and did not return; a call was placed to the dialysis center at 10:30 PM and was informed they were sent to the hospital. In a review of Resident 28's order summary as of 04/23/2025, documented they had dialysis at the kidney center on Monday, Wednesday and Friday from 12:15 PM until 4:15 PM. In a review of Resident 28's UDA's for pre and post dialysis communication documentation, none were completed from 04/23/2025 through 05/05/2025. There was no post dialysis assessment done on 07/2/2025 and no pre dialysis assessment completed on 07/08/2025. In an interview on 07/21/2025 at 9:07 AM, Staff B, Director of Nursing Services stated there was a UDA that was completed prior to resident attending dialysis and when they returned. Staff B stated if there were any concerns during dialysis the dialysis center would send a note with the resident. Staff B stated medical records had been contacting the dialysis center weekly to get run sheets and was aware there were some missing. Staff B stated the run sheets contain information about the resident's weight, vitals and if any acute changes. In an interview on 07/21/2025 at 9:27 AM Staff A, Administrator, stated the facility does not have contracts with the dialysis centers used to provide HD to Resident 4 and 28. Staff A stated there was a consent to treat for each of the residents. No other information or documentation received related to Resident 4 or 28.Refer WAC 388-97-1900(1)(2)(a)(b)(5)

Based on interview, observation, and record review, the facility failed to provide appetizing and palatable food to 3 of 7 residents (Residents 1, 27 and 49) reviewed for food temperature and palatability. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life.Findings included .<RESIDENT 27> During an interview on 07/15/2025 at 11:18 AM, Resident 27 reported that the food was not served hot. During an observation and interview on 07/17/2025 at 8:50 AM, Resident 27 had just received their breakfast tray. Resident reported the biscuits and gravy tasted “OK.” Resident 27 stated the food would taste better if it was hot, but it was only warm. There was no heated plate warmer under the resident’s plate. The edge and the bottom of the plate were cool to the touch. During an interview on 07/18/2025 at 12:50 PM, Resident 27 was observed finishing their lunch meal. Resident 27 reported the food was just lukewarm, so they did not eat all of it. There was half of the main entrée left on their plate. Review of the July 2025 Resident council meeting minutes documented the Kitchen was working on getting temperature-controlled carts. <Resident 49> During an interview on 07/15/2025, at 12:37 PM, Resident 49 had their lunch tray and stated that, the food could be hotter. On 07/16/2025, at 8:47 AM, Resident 49 was served their breakfast tray. Observed breakfast sausage on the plate looked over cooked. During an interview on 07/16/2025, at 11:13 AM, when asked how their breakfast was, Resident 49 stated, it was okay, but the sausage was on the dry side. At 1:16 PM, when asked how lunch was, Resident 49 said the kitchen was out of the potato salad that they ordered and were served macaroni salad. Resident stated he sent the macaroni salad back because the noodles were not cooked thoroughly and was unable to chew the hard noodles. On 07/17/2025, at 8:47 AM, Resident 49’s breakfast tray was delivered to them. Resident stated at 8:51 AM that the breakfast was lukewarm. <RESIDENT 1> In an interview on 07/16/2025 at 8:13 AM, Resident 1 stated the food and delivery of the food reminds them of the military. Resident 1 stated they were on small portions and did not really want to have small portions. In an observation on 07/16/2025 at 8:19 AM, observed Resident 1’s breakfast tray to have fried eggs, a sausage patty which was overcooked with visible shriveled and hard edges and a donut. In an interview on 07/16/2025 at 8:35 AM, Resident 1 stated the sausage patty was overcooked and they were not able to cut it themselves and had assistance to cut it up before eating it. In an interview on 07/17/2025 at 1:40 PM Resident 1 stated the salmon for lunch was a dry. <TEST TRAY> In an observation of a lunch test tray on 07/17/2025 at 12:37 PM, was the last remaining tray in the final meal cart for lunch. The scheduled meal consisted of salmon, couscous with peppers and mushrooms, asparagus and chicken noodle soup. The alternative was a ham sandwich and macaroni salad. The meal was warm and there was no heated plate warmer. The salmon’s texture was dry, and the salmon skin had to be scrapped off. The soup lacked flavor and was bland, tasted like oil and water. The flavor improved with salt and pepper. The asparagus was overcooked and lukewarm, the tips of the asparagus were crunchy. The macaroni salad tasted like mayonnaise and pasta. <GREIVANCES> Review of a grievance dated 02/06/2025 at 10:00 AM showed a resident found a bread tie in their roast beef sandwich. In an interview on 07/21/2025 at 11:04 AM, Staff A, Administrator stated that they were unaware of the food concerns brought up by the residents and were unaware that the food was not palatable. Refer to WAC 388-97-1100(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff S) had the required qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.Findings included .In an interview on 07/16/2025 at 9:47 AM, Staff S, Dietary Manager (DM), stated they were not a certified DM. Staff S stated they were enrolled in the educational program to obtain their certification. Staff S stated the facility was using the certification of Staff T, Assistant DM, in place of their certification.In a review of the staff roster, undated, documented Staff S was the culinary director.\In a review of the facility assessment dated [DATE], documented Staff S as the certified dietary manager.In an interview on 07/21/2025 at 11:04 AM, Staff A, Administrator, stated Staff T was the dietary manager last year and thought the facility could use their certification until Staff S was certified.Refer to WAC 388-97-1160 (2)(3)(a)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one facility kitchens, and one of one snack/nourishment refrigerators. The failure to ensure cleanliness of the kitchen, label opened food/beverage items, wash hands, and ensure dishwashing temperature were maintained at the proper temperature. These failures placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.Findings included.<CLEANLINESS>On 07/17/2025 at 11:04 AM observed the dishwashing area to have a large hole (approximately 6 -8 inches) in the wall underneath the dishwashing basin. Observed a rusty gallon can (content unknown and not able to be determined), below pipes, underneath the dishwasher appeared to hold up one of the copper pipes. Observed a leak from underneath the handwashing station, which included a pool of discolored liquid directly underneath the sink drainpipe. Observed food debris and remnants and cracker wrappers on the floor in and around the dishwashing area.In an interview on 07/17/2025 at 11:04 AM Staff U, Dietary Aide, stated they had informed every one of the pool of liquid accumulated beneath the handwashing sink. Staff U stated they tried y to do a deep clean in the morning when they arrive and night shift was expected to complete a deep cleaning at night.In an interview on 07/15/2025 Staff V, Maintenance Director, stated there had been a report of cockroaches in the kitchen from kitchen staff. Staff V stated they contacted a pest control company, and the facility was currently on a weekly maintenance plan for pest control.<DISHWASHING STATION>In an observation on 07/15/2025 at 10:00 AM, the dishwashing temperature log showed missing entries for 07/11-07/12/2025. The temperature logged for 07/15/2025 was 127 degrees.In an interview on 07/15/2025 at 10:00 AM Staff S, Culinary Director, stated they had just seen the dishwasher log was missing a few entries.In a follow up visit to the kitchen on 07/17/2025 at 11:04 AM, observed the dishwasher temperature log showed the temperatures recorded for 07/16/2025 for AM at 118 degrees Fahrenheit and for the PM 116 degrees.In an interview on 07/17/2025 at 11:04 AM Staff U, who was operating the dishwasher, stated the dishwasher was a low temperature-chemical dishwasher, and the temperature was to get up to 130 degrees. Staff U stated they run the dishwasher empty a few times to get it up to temperature before running a load of dishes.In an interview on 07/17/2025 at 11:29 AM Staff S stated they were not aware of the temperatures logged on 07/16/2025. Staff S stated the employee working that day was new and English was their second language. Staff U stated they had educated their staff on running the dishwasher a few times empty, to get it to temperature.<FREEZER>In an observation on 07/15/2025 at 9:44 AM, observed a large amount of ice buildup in and around the door of the freezer.In an interview on 07/15/2025 at 9:44 AM, Staff S stated the facility had just completed maintenance on the freezer two to three weeks ago, and the door seals had not been installed and the maintenance director was coordinating the replacement of the seals.In an interview on 07/15/2025 at 10:20 AM Staff V, stated the door seals were not replaced when the freezer unit was replaced and were due to be delivered soon. Staff U stated they were aware the freezer door was icing up.<HAND WASHING>In an observation on 07/17/2025 at 12:09 PM, Staff S prepared a chopped sandwich for a resident's lunch tray. Staff S removed their soiled gloves and placed a new pair of gloves on their hands without completing hand hygiene. Staff S repeated this observation two more times within minutes of each other.<NOURISHMMENT REFRIGERATOR>On 07/16/2025 at 8:29 AM, observed the dining room nourishment refrigerator to contain opened and undated coconut water and vanilla boost shake.<DRY STORAGE>During the initial tour on 07/15/2025 at 9:44 AM the dry storage was observed to contain opened/unlabeled items including three different types of dry cereal and two bags of pasta.In an interview on 07/18/2025 at 1:48 PM, Staff A, Administrator, stated the facility was on the scheduled to replace the dishwasher and complete a deep cleanof the kitchen. Staff A stated they were aware of the need for a deep clean of the dishwashing area but were waiting for the replacement of the dishwasher.Refer to WAC 388-97-1100(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor the preferences of one of one resident (Resident 26) reviewed for Activities of Daily Living. Failure to provide staff to assist Resident 26 with recreational meal intake 7 days a week placed them at risk for decreased quality of life. Findings included . Resident 26 admitted to the facility on [DATE], with diagnoses to include a stroke affecting their ability to swallow and maintain adequate nutrition from oral intake. Review of current physician orders dated 04/19/2023, showed Resident 26 with an order for tube feeding (tube directly into the stomach) to meet 100% of their nutritional needs. Resident 26 had been assessed as being able to safely tolerate some oral intake daily with 1:1 (one to one staff to resident ratio) supervision related to their impaired swallowing. Review of the Speech Therapy Discharge Recommendations dated 06/21/2024 showed a recommendation to continue one recreational meal per day. Review of Resident 26's physician's orders dated 06/21/2024 showed: General diabetic diet, Pureed, Nectar thick liquids. Review of Resident 26's care plan dated 06/21/2024 showed: May only have lunch Monday through Friday with 1:1 supervision. In an interview 07/31/24 at 1:33 PM, Staff G, Nursing Assistant Certified (NAC)/ Restorative Aide (RA), stated they were the primary staff that assisted Resident 26 with their daily recreational meal. Staff G stated the reason the resident only had a recreational meal Monday through Friday was because they only work Monday through Friday and there was no staff on the weekends to supervise the resident. Staff G stated this was how the schedule was. Staff G stated Resident 26 did not usually eat very much during the meal, but they liked the socializing part of it. In an interview on 07/31/2024 at 3:36 PM, Resident 26 stated they only had lunch Monday through Friday and they had the potential for upchucking (vomiting), so the staff had to monitor them. Resident 26 stated they would go every day if they could but there were not enough aids to do that. In an interview on 08/06/2024 at 2:14 PM, Staff I, NAC/Unit Clerk,/Scheduler, stated when they did the schedule, they do not schedule any Restorative staff or Bath aids on the weekends, and that was how they had been trained to do the scheduling. Staff I was not aware of any limitations with providing resident assistance such as with Resident 26's meals. In an interview on 08/07/2024 at 10:04 AM, Staff B, Director of Nursing Services stated the facility interviewed residents about their preferences related to schedules. Staff B stated they were aware of the scheduling of the staff and that the facility had ensured that the Restorative programs and resident baths were completed and if a resident had a need or request on the weekend that the staff on the floor were assigned to complete that task. Staff B did not have further information regarding Resident 26 only having their recreational meal set up for Monday through Friday, reportedly due to no staff not available to assist them. Refer to WAC 388-97-0900 (3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure a homelike dining environment was provided during one of one dining observations. Failure to ensure licensed nurses refrained from administration of medications during resident meals placed residents at risk for diminished dignity and decreased quality of life. Findings included . Definition: Reasonable Person Concept: a standard used to determine whether an individual's actions or responses align with what a hypothetical reasonable person would do under similar circumstances. It defines the behavior expected of an ordinary, prudent, and rational individual. Resident 5 admitted to the facility on [DATE] with diagnoses to include dementia. Review of the Quarterly Minimum Data Set assessment dated [DATE] showed the resident could not complete the interview questions related to cognition. The staff assessment for cognition showed the resident had memory impairment and impaired decision making. Review of the facility policy titled Medication Administration (revised 07/2024), on 08/06/2024 showed licensed staff were to administer resident's medications in the privacy of their room. Other rooms may be suitable if the resident was alone and privacy could be preserved, or, if the resident requested, then the staff would accommodate. Review of Resident 5's current care plan on 08/05/2024 showed the resident had cognitive impairment and there were no preferences noted that the resident had requested to have their medications administered in the dining room. Applying the reasonable person concept, a resident would not desire to have a bitter tasting spoonful of medication during their meal and in front of other residents and staff. In an observation on 07/31/2024 at 1:05 PM, Staff C, Registered Nurse (RN), entered the assisted dining room with a cup of medications and was observed to walk over to Resident 5, who was in the middle of eating their meal, placed a spoonful of crushed medications in their mouth and then left the dining room. The group dining rooms were closed after 07/31/2024 due to an infectious outbreak so no further group dining observations were possible. In an interview on 08/06/2024 at 10:40 AM, Staff C, RN stated their practice for residents that require assistance with their meals or were cognitively impaired, that the meals were the best time to give residents their medications because they would be most likely to take them. Staff C stated they waited until the food was there and then brought Resident 5's medications to them. In an interview on 08/07/2024 at 10:17 AM, Staff B, Director of Nursing Services, was made aware of the observation and interview with Staff C which showed this was their usual practice with cognitively impaired residents. Staff B stated there needed to be further education done. Reference (WAC) 388-97-0880 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident grievances were filed and addressed for 1 of 1 resident (Resident 11) reviewed for grievances. The failure to address and resolve resident grievances placed residents at risk for diminished dignity, unresolved missing property and diminished quality of life. Findings included . Review of the facility's policy on 08/02/2024 titled, Grievances, showed a grievance report would be initiated for all concerns, the resident would be communicated with, and an attempt was made to resolve the grievance within 5 days. There would be follow up with the resident or representative about the grievance to ascertain satisfaction with the resolution of the reported concern. Resident 11 re-admitted to the facility on [DATE] and was alert and oriented. Review of the record showed the resident had a recent prior stay 03/21/2024 through 05/16/2024. In an interview on 07/31/2024 at 11:05 AM, Resident 11 stated they ended up back in the hospital and readmitted to the facility a couple of months ago. Resident 11 stated they had a roommate during their prior stay in March, who was inconsiderate with their loud television volume and encroaching on their space in the room. Resident 11 stated they had verbalized the concern to the staff several times and asked to move rooms which they did a few days later. Resident 11 stated they were missing a pair of plaid lounge pants that had been missing for at least a month. Resident 11 stated the laundry person was still looking for them, but they had not received any updates. Resident 11 stated there had been a nursing assistant (Staff K) that they requested not to have provide care to them because they were unsanitary and just did not like their care, but they stated that the staff member did come back and care for them on two days after they requested not to have them. Resident 11 stated Staff K confronted them about it stating, do you have a problem with me? which Resident 11 stated made them upset and they told Staff K to get out of their room. Resident 11 stated they did not say anything about Staff K coming back to their room until they were in the resident council meeting at the end of July (July 23, 2024). Review of the prior 6 months of the facility grievance logs on 08/05/2024 showed no grievances found for Resident 11 related to missing property or a roommate concern. The log showed a grievance for Resident 11 that was dated 07/01/2024 and labeled as handwashing. In an interview on 08/05/2024 at 9:20 AM, Staff D, Laundry Manager, stated they were aware of Resident 11's missing lounge pants, stating Resident 11 had told them they were missing and stated they thought maybe they got mixed up with the briefs and got thrown away. Staff D stated they had not personally ever seen the lounge pants Resident 11 mentioned and added that sometimes residents did not want their clothing labeled, so items could get lost. Staff D was able to state the process for filling out a grievance when a resident reported a concern but stated they had not completed a grievance for the missing pants for Resident 11 yet. Review of the 07/01/2024 grievance report on 08/05/2024 showed that Resident 11 did not want Staff K to be their aid anymore because they did not wear gloves and the resident did not want to get an infection. The documented action taken was Staff K received education on infection prevention and included copies of the in-service education provided to Staff K. The grievance was signed by Staff J, Infection preventionist, and a therapy (witness) on 07/02/2024, stating that the resident could not sign due to wet nails. The grievance form did not include further follow up with the resident or a conclusion to ascertain satisfaction with the reported concern, including whether Staff K would or would not provide any further care to Resident 11. The grievance was not signed as being completed and was not signed by the Director of Nursing or Administrator. Staff K was no longer a current employee. Review of Resident 11's July 2024 care record on 08/05/2024 confirmed that Staff K had documented providing care to Resident 11 on two days following the grievance report, on 07/09/2024 and 07/11/2024. In an interview on 08/06/2024 at 10:30 AM, Staff J, Infection Preventionist, stated they had received the grievance form and completed the in-service with Staff K. Staff J stated they had verbally reviewed what they had done with Resident 11 and they were okay with the education, but they still did not want Staff K to be their aid, (Resident 11) was not comfortable, they said. Staff J stated they forgot to mark the box on the grievance that stated the resident was notified of the action taken and satisfied with the outcome. In an interview on 08/06/2024 at 2:14 PM, Staff I, Scheduler, stated they were aware that Staff K was not supposed to be scheduled to care for Resident 11, but stated sometimes staff would be assigned to a certain section, but they would just trade a resident, such as if one resident on a section preferred only female aids, they may have a male aid on that section but they would just trade one resident with another aid who was female. Staff I stated they recalled it being sometime in July that there had been an allegation and even though Staff K was assigned on that section, they knew they were not supposed to have Resident 11 and were supposed to trade with another staff. In an interview on 08/07/2024 at 10:17 AM, Staff B, Director of Nursing Services stated there should have been grievances for the missing item and noisy roommate concern but had not been aware of those issues. They reviewed grievances every day in their stand-up meeting. Staff B stated that they had not been aware that Staff K had Resident 11 on their care assignment on those dates. Staff B stated that they had provided education to Staff K related to the grievance and when they had done their investigation regarding the allegation that Staff K had come back to the room stating, do you have a problem with me?, they had denied that allegation, and they had not been able to substantiate it. Staff B stated they became aware of that allegation at the July 23,2024 resident council meeting, and it was reported as an allegation of potential abuse. Staff B stated they have been working on their grievance process but needed to continue education. Refer to WAC 388-97-0460(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, - a systematic process to interpret the triggered information from the Minimum Data Set assessment to assess the potential problem and determine if the area should be care planned), holistically analyzed the plan of care for 1 of 6 sampled residents (Resident 30) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on their individualized needs. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, showed the RAI consists of three basic components: the Minimum Data Set (MDS - and assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information). Once a CAA 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. Resident 30 admitted to the facility on [DATE] with diagnoses to include fracture of the right upper leg. Resident 30 was admitted to hospice services on 03/15/2024. Review of Resident 30's Annual CAA assessment, dated 03/25/2024, showed they triggered for functional abilities. The CAA worksheet for functional abilities showed no evidence a comprehensive analysis of findings was thoroughly completed and did not contain Resident 30's goals, preferences, strengths, needs or input from the resident or their representative. The CAA contained a narrative that read, Continue to care plan to slow or minimize decline in ADL's (Activities of Daily Living). In an interview on 08/07/2024 at 10:28 AM Collateral Contact 2 (CC 2), contracted Registered Nurse, stated they are completing the MDS's for the facility to include the CAA and care plans. CC 2 stated they had daily telephonic meetings with the facility's Resident Care Manager (RCM) and Director of Nursing Services (DNS) to discuss the residents. CC 2 stated the process for completing CAAs included a review of information that was gathered from notes and their sources and do a shorter description to proceed to the care plan. Cross Reference to: CFR 483.21(a), (a)(1)(i)(ii), F655 - Baseline Care Plan CFR 483.21(b), (b)(1),(c)(3)(i - iv), F656 - Develop/implement Comprehensive Care Plan CFR 483.21(b),(b)(2)(i-iii), F657 - Care Plan Timing And Revision Refer to WAC 388-97-1000 (1)(a)(2)(q)(5)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure care plan interventions were implemented for 1 of 3 sampled residents (Resident 13) reviewed for accidents. This failure placed residents at risk for injury, and decreased quality of life. Findings included . Resident 13 readmitted to the facility on [DATE] with diagnoses to include fall, high blood pressure, fracture of right upper leg. In an interview and observation on 07/31/2024 at 2:54 PM, Resident 13 stated they had fallen out of their bed around eight months ago. Resident 13 stated they had been asleep in their bed when they had moved the bed control and started to fall over to the right side and fell from their bed. During the observation a blue foam wedge was noted at the foot of Resident 13's bed. Review the incident report, dated 01/02/2024, showed that Resident 13 sustained a fall at 2:45 AM and was assisted back to bed after they refused to be sent to the hospital. The incident report showed Resident 13 voiced being disproportionate in their hip and legs which had them leaning to the right side which led to the fall while they were asleep. Resident 13's care plan was updated. The incident summary dated 01/05/2024, showed therapy assessed Resident 13 and determined the cause of the fall was related to their poor trunk control. Resident 13 was assessed by therapy, and they recommended a positioning wedge be placed under the resident's right hip/leg and secured with a strap that is attached to the bed frame. In a follow up interview and observation on 08/07/2024 at 11:15 AM, Resident 13 stated the blue wedge was to assist them in not falling out of bed. Resident 13 was observed to use their cane to pull the blue wedge from the foot of their bed to them and positioned it under their right hip/leg. There was no strap observed on the wedge. Resident 13 stated the wedge worked well as an arm rest. Resident 13 stated they had not used the wedge the night before and required no reminders from staff to use it. Review of Resident 13's care plan dated 01/04/2024 and revised 06/12/2024 showed they were at high risk for falls and they had a positioning wedge with secure strap for safety and comfort to be positioned on their right side (hip/leg). The care plan directed staff to notify the nurse if the wedge was not secured and to unstrap the wedge while Resident 13 was awake and per their request. There was no information in the care plan that addressed Resident 13's poor trunk control. Review of Resident 13's treatment administration record for July 2024 showed no information about the use of the positioning wedge. In an interview on 08/07/2024 at 9:14 AM Staff I, Nursing Assistant Certified (NAC), stated they would need to review the information on Resident 13's [NAME] (tool that directs an NAC on specific care needs of a resident). Staff I stated Resident 13 had a positioning wedge with a strap for safety and comfort. When asked what the safety and comfort reasons were, Staff I stated Resident 13 had a wound and it was to keep them comfortable. Staff I stated Resident 13 had leaned over too far while in bed and that was scary for them. Staff I stated the staff check on Resident 13 daily and provide care and repositioning if needed. Staff I stated Resident 13 was not utilizing their wedge when last checked. When asked about the strap to the wedge, Staff I stated they did not know if there was a strap. In an interview on 08/07/2024 at 12:06 PM Staff B, Director of Nursing Services, stated they were not aware Resident 13 did not want to use the strap for the wedge. No other information was provided. This is a repeat citation from 10/16/2023. Refer to WAC 388-97-1020 (1)(2)(a)(b)(e)(5)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 3> Resident 3 admitted to the facility on [DATE], with diagnosis to include congestive heart failure, atrial fibrillation, morbid obesity, and sleep apnea. Review of the quarterly Minimum Date Set (MDS-an assessment tool) assessment completed on 07/12/2024 showed Resident 3 was cognitively intact. Resident 3 was not on tube feeding (a way to provide nutrition when a person cannot eat or drink safely by mouth) or a mechanically altered diet. In an interview on 07/31/2024 at 10:35 AM, Resident 3 stated they had partials for their upper teeth that had been sent to the dentist to be repaired. Resident 3 stated they were having a hard time chewing meat. Review of Resident 3's diet order dated 02/02/2024, showed the resident was to receive a regular diet and texture with thin liquids. Review of Resident 3's current care showed a focus area of ADL self-care performance deficit related to fatigue initiated on 04/18/2023. Interventions for oral care showed Resident 3 had an upper partial, their own bottom teeth and required assistance by staff with the task of oral care, initiated on 09/14/2023. In an interview on 08/02/2024 at 09:57 AM, Staff L, Certified Nursing Assistant (CNA) stated Resident 3 did not have a partial. Staff L reviewed Resident 3's [NAME] and stated: I stand corrected, resident has an upper partial and wears it. Staff L stated Resident 3 does their own oral care. In an interview on 08/02/2024 at 10:18 AM, Staff M, Registered Nurse (RN) stated Resident 3 was wearing their upper partial when they had checked on the resident. In an interview and observation on 08/02/2024 at 10:21 AM Resident 3's mouth was observed and showed no upper partials in place. Resident 3 stated their partials were sent to a dentist to be repaired before the COVID pandemic and had not been returned. In an interview on 08/05/2024 at 11:05 AM, Staff O, Licensed Practical Nurse (LPN) stated that Resident 3 did not have their partials but was going to the dentist to get fitted with one. Staff O stated they would review the care plan. In an interview on 08/02/2024 at 11:38 AM, spoke to Staff N, LPN/Resident Care Manager, stated they were working with European Dentures and [NAME] Dental in replacing the partials. Resident 3 had an appointment scheduled on 09/24/2024 and their clerk was calling the clinic to see if they can move up the appointment and would continue to keep trying. Staff N stated they and the nurses update the care plan. Staff N confirmed Resident 3 was not currently wearing a partial. This is a repeat citation from 10/16/2023. Refer to WAC 388-97-1020 (1)(2)(a)(b)(e)(5)(a)(b) Based on interview and record review, the facility failed to revise comprehensive care plans for 2 of fourteen sampled residents (Residents 3 and 20), reviewed for care plan revisions. The failure to revise care plans for dental services and discharge planning placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <RESIDENT 20> Resident 20 admitted to the facility on [DATE] with diagnoses to include above the knee amputation of the right leg, diabetes mellitus Type 2 (a condition where the body has a problem regulating blood sugar), and high blood pressure. In an interview on 07/31/2024 at 3:23 PM, Resident 20 stated they had planned to move to the Assisted Living Facility (ALF) next door. Resident 20 stated they had sold some property and were now not able to move to the assisted living. Resident 20 stated they were trying to contact someone at Home and Community Services (HCS) to work it all out. Review of Resident 20's care plan initiated 08/09/2022 and revised on 08/04/2023 showed that they wished to discharge home and would consider an Adult Family Home as a secondary option. The goal was Resident 20 would verbalize understanding of the discharge plan. Interventions included, establishing a pre discharge plan with the resident and evaluate the progress and revise the plan as needed. In an interview on 08/06/2024 at 2:25 PM Staff E, Social Services Director, stated Resident 20 was supposed to move to the ALF last month, but was over resourced and was trying to get that sorted out. Staff E stated that they email/speak with the case worker at HCS weekly and received notification that Resident 20 was over resourced on 07/17/2024 and had last spoke with the case worker on 07/31/2024. Staff E stated the last care conference for Resident 20 was on 06/13/2024. Staff E stated the care plan was not updated, however there were detailed progress notes in Resident 20's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 21> Resident 21 admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type 2 (a condition where the body has a problem regulating blood sugar), chronic pain and high blood pressure. Review of Resident 21's Medication Administration Record (MAR) for July 2024 showed they were prescribed a medication to manage their high blood pressure. The order was for Amlodipine Besylate Tablet 0.5 milligrams (mg) by mouth for high blood pressure and to hold the medication if Resident 21's systolic blood pressure was below 100 millimeters of mercury (mm Hg). The order was dated 10/04/2023 and discontinued on 07/19/2024 and the MAR showed had documented blood pressures. The July 2024 MAR showed the same order dated 07/20/2024 with no documented blood pressures. Review of Resident 21's August 2024 MAR showed an order for Amlodipine Besylate Tablet 0.5 milligrams (mg) by mouth for high blood pressure and to hold the medication if Resident 21's systolic blood pressure was below 100 millimeters of mercury (mm Hg). The August MAR contained no documented blood pressures from 08/01/2024 through 08/05/2024. Review of Resident 21's provider progress note dated 07/18/2024 showed the provider ordered an A1C (lab test that measures the average level of blood sugar over the previous three months). Review of Resident 21's electronic medical record showed there were no labs were completed for A1C on 7/18/2024. A review of Resident 21's progress notes dated 08/02/2024 that a lab slip was completed for an A1C, 15 days after it was ordered by the provider. In an interview on 08/06/2024 at 2:00 PM Staff B, Director of Nursing Services (DNS) stated they had changed times on medications to broaden the range in which medications could be administered and the blood pressure monitor was somehow left off. Staff B stated the blood pressure monitor was placed back on after they caught the error. Staff B stated the blood pressure should have been taken prior to the administration Amlodipine for Resident 21. Staff B stated the provider for Resident 21 had placed the order for their A1C in the wrong section of the electronic health record and would not have been processed by the nursing staff as this was not their practice. In an interview on 08/07/2024 at 12:06 PM CC 3, facility consultant, stated the transition to the electronic medical record was difficult and contributed to the errors. CC 1 stated the nurse managers were responsible for ensuring provider notes were and processed. CC 1 stated the provider notes were not fully integrated and were previously scanned into the medical record, causing a delay in availability of the note to the nurse manager by a few days. Refer to WAC 388-97-1620 (2)(b)(i)(ii) Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were implemented for 2 of fourteen residents (Residents 21 and 26) reviewed. Failure to follow physician's orders for labs and medication parameters for Resident 21 and to follow Speech Language Pathologist (SLP) recommendations for Resident 26 placed the residents at risk for delay in treatment and potentially adverse outcomes. Findings included . <RESIDENT 26> Resident 26 admitted in 2023 and had diagnoses which included a stroke affecting their ability to swallow and maintain adequate nutrition from oral intake. Resident 26 had physician's order for a tube feeding (tube directly into the stomach) to meet 100% of their nutritional needs. Resident 26 had been assessed as being able to safely tolerate some oral intake daily with 1:1 (one to one staff to resident ratio) supervision related to their impaired swallowing. Review of the Speech Therapy Discharge Recommendations dated 06/21/2024 showed the resident required verbal cues for swallow strategies and stated: Continue one recreational meal per day with the following swallow strategies to facilitate safety and efficiency: rate modification, alternate liquids/solids, bolus size modification, chin tuck, hard throat clear, resident swallow, effortful swallow and no straws. Review of Resident 26's physician's orders and care plan dated 06/21/2024 on 08/01/2024 showed: General diabetic diet, Pureed, Nectar thick, may only have lunch Monday through Friday with 1:1 supervision. The care plan and resident [NAME] (care directive to nursing assistants) did not include the speech therapy strategies. In an observation on 08/01/2024 at 12:55 PM, Resident 26's tray was noted to have a piece of paper with handwriting on it that stated only (Resident 26 initials) and NTL (nectar this liquids) in mugs. There was no other information on the resident's tray. In an observation on 08/01/24 12:56 PM, Staff G, Nursing Assistant Certified (NAC) stated the Speech Therapist had given them verbal instructions about the swallow precautions for Resident 26 stating the resident had a strong cough and would cough and clear their throat or stop themself and they would remind them. Resident 26 added that they were supposed to swallow hard. In an observation 08/02/2024 at 1:19 PM, Staff H, NAC was observed sitting with Resident 26. Resident 26 was noted to accept a sip of a handled mug and was noted to swallow without tucking their chin. Staff H did not cue the resident. Resident 26 coughed and held a napkin to their mouth. Staff H asked the resident you ok? but did not cue the resident with the recommended interventions. Resident 26 accepted one more bite of a thickened food and coughed again. Staff H had not cued the resident to tuck chin or swallow hard. Staff H handed Resident 26 a box of tissues but did not say anything. In an interview on 08/07/2024 at 10:04 AM, Staff B, Director of Nursing Services, stated swallow precautions and recommendations should be on the resident's [NAME] (care directive to nursing assistants) which they were expected to review for the residents on their care assignment. Staff B was made aware of Resident 26's swallow precautions not being found on their [NAME] and not consistently observed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living for 2 of 2 sampled dependent residents (Residents 26 and 30) reviewed for activities of daily living (ADL's). Facility failure to provide residents, who were dependent on staff for assistance with hygiene including oral care and meal assistance placed residents at risk for diminished quality of life. <RESIDENT 30> Resident 30 admitted to the facility on [DATE] with diagnoses that included fracture of the right upper leg. Review of Resident 30's Minimum Data Set (MDS-an assessment tool) dated 06/18/2024 showed they required supervision or touching assistance with eating and partial/moderate assistance to complete their oral hygiene. In an interview on 07/31/2024 at 10:54 AM Resident 30's representative, Collateral Contact 1(CC 1), stated the resident spent most of their time in bed. CC 1 stated Resident 30 was assisted by staff with their meals, had their natural teeth (which were barely there) and had difficulty eating. Review of Resident 30's current care plan, initiated 03/14/2024 and revised/updated on 06/12/2024 showed they required set up assistance for meals. The care plan identified Resident 30's oral care routine consisted of brushing teeth and rinse every AM, PM and nightly. The care plan did not identify how much care the resident required for their oral care routine. In a continuous observation on 08/01/2024 starting at 12:33 PM observed Resident 30 in their bed, their head to right. There was a cup and a pink pitcher with straw on Resident 30's overbed table. At 12:39 PM Resident 30's meal arrived on a tray and was placed overbed table and consisted of multiple drinks in cups. On 08/01/2024 at 1:35 PM Staff V, Nursing Assistant Certified (NAC) entered Resident 30's room and asked them if they wanted something to drink or eat. Staff V stated to them that they were sleepy. Staff V asked the resident several times if wanted something to eat or drink or if they could take the tray. Staff V stated that she was going to leave the tray for a few more minutes and left Resident 30's room. During the continuous observation on 08/01/2024 from 12:33 PM until 2:24 PM Resident 30 received no assistance with their meal and received no care. Resident 30's meal tray remained in their room, untouched, and no assistance was provided to them. During an observation on 08/02/2024 at 10:15 AM, Resident 30 was observed lying in their bed, the head of their bed elevated. There was visible brown matter observed under all their fingernails, their scalp was oily with multiple dried skin debris in their hair. There were several cups on the overbed table with different liquids in them. Resident 30's teeth were covered in a film with white debris and matter visibly built up in between their teeth. On 08/02/2024 at 10:45 AM in a continuous observation from 10:15 AM to 11:56 AM, Resident 30 had the same cups of liquid on their overhead table, untouched. At 11:13 AM Staff T, Registered Nurse, entered Resident 30's room and left with two cups of liquid. At 11:21 AM Staff T returned to Resident 30's room and stated aloud they brought fresh milk. At 11:42 AM Staff P, NAC, entered Resident 30's room, asked if they were hungry and reassured them, they had water and milk. At 11:56 AM, at the end of the continuous observation, Resident 30 was lying in bed with the water and milk on their bedside table and received no assistance with oral hygiene or drinking. In an interview and observation on 08/02/2024 at 11:45 AM observed Resident 30 in their bed, their teeth unbrushed with visible debris in between their teeth. Resident 30 stated they had not had their teeth brushed in the last two days. Resident 30 had multiple cups of liquid on their overbed table to include a full glass of brown liquid, a half a glass of amber colored liquid, a full glass of clear liquid, and three quarters full glass of white liquid. Resident 30 had white crusty like matter on their right side of their cheek/chin. In an interview on 08/07/2024 at 9:33 AM Staff T, RN, stated the NACs were to assist Resident 30 with oral hygiene every shift and every time after they eat. Staff T stated Resident 30 required set up for and oral hygiene and if they don't do it then the NACs would assist them. Staff T described Resident 30 as being super motivated at times and other times not. In an interview on 08/07/2024 at 9:37 AM Staff S, NAC stated Resident 30 does not like to get out of bed. Staff S stated Resident 30 had dementia which was getting worse. Staff S stated Resident 30 is receptive to care. Staff S stated Resident 30 was particular about what they eat and drink and enjoyed cookies, milk and juice. Staff S stated when they start their shift, they make sure to change out the milk and juice because they are not sure if they had been out for more than 24 hours. Staff S stated that Resident 30 required set up, but more supervision for oral hygiene and needed supervision for eating. In an interview on 08/07/2024 at 9:49 AM Staff P, NAC, stated Resident 30 didn't really eat, but enjoyed milk which they sometimes spilled. Staff P stated they do not do Resident 30's oral hygiene and that the nurse would do it. Staff P stated Resident 30 did not need assistance with eating, but they help them when they see the resident needs it. <RESIDENT 26> Resident 26 admitted in 2023 and had diagnoses which included a stroke resulting in impaired swallow and a gastrostomy tube (tube directly into the stomach) for nutrition, left sided weakness, blindness to the left eye and dependence of staff for activities of daily living such as oral care. Review of the current care plan on 08/04/2024 showed the resident required one person assistance for oral care using glycerin swabs and assistance with mouth rinsing. The care plan did not include a problem specific to risk for dry mouth or specify a frequency for oral care. Review of Resident 26's current physician orders dated 07/31/2024, showed an order for glycerin (Oral swabs coated with glycerin, which activated saliva glands and helped keep the mouth moist.) swabs for mouth care as needed. There was no documentation in the clinical record that this had been done. In an observation on 07/31/2024 at 3:18 PM, Resident 26 was in their room with their eyes closed and their mouth hanging open. The residents lips were dry and flaky and their tongue was coated in white matter. In an observation and interview on 7/31/2024 at 3:41 PM, Resident 26 was noted moving their tongue over a flaky loose piece of skin on their lower lip. Their lips were dry and flaky, and their tongue had thick white matter visible. The resident stated the staff rarely helped them with swabbing their mouth. They stated their mouth was always dry (a common occurrence in people with tube feedings who do not eat and drink normally throughout the day.) Resident 26 stated they thought there was a medication they were supposed to get for their mouth because they used to have an infection in their mouth. There was a cup of pink toothettes (oral swabs- non glycerin) noted in a cup on top of the dresser on the opposite side of the room. In an interview on 08/05/2024 at 2:00 PM, Staff P, NAC, stated Resident 26 was able to swab their mouth if they handed them the swab and stated they should offer them one every day and after they eat in case they had anything left in their mouth. They said they used the toothettes, the pink ones. In an interview on 08/07/2024 at 10:04 AM, Staff B, Director of Nursing, stated oral care should be done for resident 26 upon rising, after meals related to their swallow issues, and at night. Refer to WAC 388-97-1060 (2)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents 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 for 2 of 5 residents (Resident 21 and 30) reviewed. The facility failed to ensure Resident 21's alternating air mattress was set at the labeled setting and Resident 30 received routine repositioning. These failures placed the residents at increased risk of unmet care needs and potential skin breakdown. Findings included . Review of the facility policy titled Repositioning residents dated 08/2022 and revised 07/2024 showed it was the facility's policy to reposition residents for comfort and skin integrity. The policy identified repositioning was critical for a resident who was immobile or dependent upon staff for repositioning. The policy general guidelines included the following interventions: 1.A turning/repositioning program includes a continuous consistent program for changing the residents position and realigning the body. A program is defined as specific approach that is organized, planned, documented, monitored and evaluated. 2.Frequency of repositioning a bed-or chair-bound resident should be determined by: a. The type of surface used. b. The condition of the skin. c. The overall condition of the resident. d. The response to the current repositioning schedule. e. Overall treatment objectives 3. Residents who are in bed and not on an alternating air mattress should be on a repositioning schedule. <RESIDENT 21> Resident 21 admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus Type 2 (a condition where the body has a problem regulating blood sugar), chronic pain and high blood pressure. In an interview on 07/31/2024 at 8:59 AM, Resident 21 stated their mattress was an air mattress and it moved her back and forth and around to the point they are stuck in the middle of the bed. In a follow up interview at 11:58 AM Resident 21 stated their mattress makes a noise and maintenance has looked at it several times without finding a problem. On 07/31/2024 at 11:58 AM observed the air mattress pressure pump (a pump that inflates and deflates the mattress) hooked to the back of Resident 21's foot board of their bed. The pump was set to 450/25. There was a sticker on the pump that read 300/15. On 08/02/2024 at 10:49 AM observed the air mattress pump with the settings on 450/25. Review of Resident 21's progress notes dated 02/06/2024 showed the staff found an open area to the residents sacral area (the bone at the bottom of the spine) and an alternating pressure mattress was ordered for wound prevention. Review of a skin incident report dated 02/06/2024 showed a nursing assistant observed a skin impairment on Resident 21 and notified their nurse. The nurse assessed the resident's skin, and they were found to have an open area on the sacral region measuring 0.5 centimeters (cm) by 1 cm. Interventions initiated included ordering an alternating pressure mattress. Review of Resident 21's current care showed a focus area At risk for pressure ulcer development related to immobility and other comorbidities initiated on 05/17/2023 and revised on 06/29/2024. Interventions included an alternating pressure mattress with the setting at 300/15 (300=amount of pressure-firmness/15=cycle time), initiated on 02/08/2024, revised on 06/12/2024. The staff tasked with implementing/monitoring this intervention included nursing assistants and nurses. In an interview on 08/07/2024 at 9:14 AM Staff I, Nursing Assistant Certified (NAC), stated they do not adjust the settings on the alternating pressure mattress pump for Resident 21. Staff I stated the nurses were responsible for the adjustment of the settings. Staff I stated they ensure the pump is functioning and there are no kinks in the hose that enters the mattress. In an interview on 08/07/2024 at 12:06 PM Staff B, Director of Nursing Services, stated the required settings were marked on the pump and were they not aware the settings were not set accurately. Staff B stated Resident 21's skin was intact. <RESIDENT 30> Resident 30 admitted to the facility on [DATE] with diagnoses to include fracture of the right upper leg. Resident 30 admitted to hospice services on 03/15/2024. In an interview on 07/31/2024 at 11:00 AM Resident 30's representative, Collateral Contact 1(CC 1), stated the resident spent most of their time in bed. In an observation on 07/31/2024 at 12:24 PM, Resident 30 was lying in their bed, on their back, with pillows positioned on their sides. On 08/01/2024 at 12:33 PM observed Resident 30, in their bed, on their back, their right foot on top of a pillow and their left heel on the bed. Resident 30 had a pillow tucked under their left side and their head of bed was elevated. In a continuous observation on 08/01/2024 from 12:33 PM until 2:24 PM Resident 30 received no assistance from staff with repositioning or care. Review of Resident 30's current care plan showed a focus area ADL self-care performance deficit related to impaired balance, right hip fracture and pain, initiated on 03/14/2024 and revised on 07/29/2024. Interventions included the resident required extensive assistance of one staff for repositioning and turning in bed. The care plan contained no elements of a repositioning schedule or addressed Resident 30's heels. In an interview on 08/07/2024 at 9:37 AM Staff S, NAC, stated Resident 30 is repositioned every 2 hours to keep them off their hip and buttocks. Staff S stated they rolled Resident 30 toward the window and use a pillow under their hip/upper thigh. Staff S stated they always elevate Resident 30's heels by use of a pillow under their calves to relieve pressure. In an interview on 08/07/2024 at 9:49 AM Staff P, NAC, stated they reposition Resident 30 every two to three hours. Staff P stated Resident 30 often sleeps and wants to be pulled up all the way with their feet positioned higher than their head. Staff P stated that they placed pillows on each side of Resident 30's. Refer to WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 1 of 4 NAC's (Staff K) files reviewed who had been employed at the facility longer than one 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 . Staff K was hired on 07/06/2023. Review of Staff K's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff K. Review of the staff roster printed on 07/31/2024 on the first day of survey showed various hire dates for staff beginning on 06/12/1987 to 07/26/2024. In an interview on 08/06/2024 at 12:59 PM, Staff J, Staff Development Coordinator said they would be doing new performance evaluations, but everyone's start date was May 1st and they were all new employees. In an interview on 08/06/2024 at 2:48 PM, Staff B Director of Nursing Services said all staff completed new hire paperwork on 05/01/2024 so they needed to do the performance evaluations again. In a phone interview on 08/07/24 at 10:08 AM, Staff Q, Credentialing Compliance Coordinator said they were responsible for completing new hire paperwork. Staff Q said the facility had a new owner on May 1st, but they were not sure if staff were keeping their original hire dates, or the May 1st hire date. Staff Q said the prior administrator told them to ask the new administrator, but they hadn't asked Staff A, Administrator yet. Refer to WAC 388-97-1680 (2) (a-c) .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens, 1 of 1 snack/nourishment refrigerators and 2 of 3 halls observed. The failure to monitor and document safe kitchen refrigerator temperatures, label opened food/beverage items, discard expired food items in the kitchen and unit refrigerators, ensure dishwashing temperature were maintained at the proper temperature, and cover desserts during meal delivery. These failures placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food. Findings included . <KITCHEN REFRIGERATOR> On 07/31/2024 at 8:54 AM during the initial kitchen tour, observed an undated sandwich in a bag on the first shelving unit, a thickened dairy beverage that was opened and undated, three trays of condiments, a pitcher of lemonade with a use by date of 07/29/2024, a pitcher of iced tea prepared 7/23/2024 with no use by date in the refrigerator. There was a stack of temperature logs taped to the front of the refrigerator door multiple areas of missing documentation. In an interview on 7/31/2024 at Staff W, dietary staff, stated the condiments had been used for salads from the night before and should have been dated. Staff W stated when items are placed in the refrigerator they should be dated. Staff W removed the sandwich in the baggie and three trays of condiments and threw them in the garbage. In an interview on 08/05/2024 at 9:45 AM Staff X, Dietary Manager (DM), stated the temperature logs were completed in the morning and evening. Staff X stated they were aware of the missing entries to the evening portion of the logs and had spoken to the staff responsible about it. <DISHWASHER> In a follow up visit to the kitchen on 08/05/2024 at 9:45 AM, observed the dishwasher temperature log filled out completely with the temperature documented at 120 degrees Fahrenheit (F). Observed the dishwasher temperature after a load of dishes were washed and the temperature reached 100 degrees F, outside of the required 120 degrees F. In an interview on 08/05/2024 at 9:45 AM, Staff X, DM, stated they were unaware the dishwasher had not been heating to the required 120 degrees F and would contact maintenance and their vendor. Staff X stated the dishwasher used a chemical sanitization process. In a follow up interview on 08/05/2024 at 2:42 PM Staff X stated the water booster heater was adjusted which attached to the dishwasher and the temperature exceeded the 120 degrees F. <MEAL DELIVERY> On 07/31/2024 at 12:47 PM observed meal trays being delivered to resident rooms on the 100 hall. During the observation there was Jello, uncovered, on the trays being delivered. On 07/31/2024 at 12:33 PM observed meal trays being delivered to resident rooms on the 300 hall. During the observation there was Jello, uncovered, on the trays being delivered. In an interview on 07/31/2024 at 12:49 PM Staff H, Nursing Assistant Certified, stated the Jello on the meal trays should have been covered. On 08/05/2024 at 12:30 PM observed a dessert being placed on a tray uncovered. When asked Staff X, DM, if the dessert should be covered, they stated they should. <UNIT REFRIGERATOR> In an observation in the assisted dining room on 07/31/2024 at 12:30 PM, the nourishment refrigerator was observed to contain a plastic container of oats with no name or date, a zip lock bag of cheese slices with no date, a bottle of ketchup in the door with an expiration date of 7/7/2024, and two bags of muffins and pastries with a resident name but no date. In an observation on 08/01/2024 at 9:28 AM, the nourishment refrigerator had been moved from the assisted dining room to the main dining room. There was a new temperature log taped to the front of the refrigerator for the month of August. Inside the refrigerator, it was observed that the same items remained from the day prior (expired ketchup in the door, unlabeled cheese slices, container of oats, muffins and pastries.) In an interview on 08/01/2024 at 9:25 AM, Staff H, Certified Nursing Assistant, stated the kitchen brought down nourishments and put them in the refrigerator and if residents had personal snacks, the staff would label them with name and date and put them in the refrigerator. Staff H stated they did not know who was responsible to check to ensure items were labeled and to remove old or expired items but they thought it was the kitchen. In an observation on 08/05/2024 at 8:58 AM, the refrigerator contained the same expired and unlabeled items (expired ketchup in the door, unlabeled cheese slices, container of oats, muffins and pastries.) Additionally, there was now an unlabeled, undated plastic container of white rice and there were observed to be two boxes of Capri Sun drinks in the cupboard which had expiration dates of December 2023. In an observation and interview on 08/06/2024 at 12:56 PM, the nourishment refrigerator was observed with Staff F, Dietary Aide, who stated they checked and logged the refrigerator temperatures, made sure the refrigerator was clean, and looked to make sure there was enough of the different types of snacks for the residents every day. Staff F stated they were supposed to check for labels and dates and if items were not properly labeled, old or expired they were supposed to throw them out. Staff F confirmed the kitchen staff were supposed to do this every day and noted the observed items needed to be thrown out. Staff F did not know why the items had remained in the refrigerator days in a row without anyone noticing they were expired or not properly labeled or dated. Reference WAC: 388-97-1100 (3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adherence to infection prevention and control practices. The facility failed to properly don (put on) and doff (take off) personal protective equipment (PPE) for 1 of 1 (Resident 23) reviewed for aerosol contact precautions related to Coronavirus Disease 2019 (COVID-19, an infectious disease-causing respiratory illness symptoms including cough, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak, and failed to cover clean linens during transport. The facility also failed to properly store oxygen (O2) tubing for 1 of 1 resident (Resident 3) reviewed for O2 therapy. These failures placed residents at risk for contracting infection and diminished quality of life. Findings included . In a review of the Facility Assessment, undated, showed the facility was prepared to manage the treatment of COVID-19 infection for their residents by following the COVID-19 Protocol. The facility assessment protocol showed staff would use PPE to protect eyes, nose, and mouth and to prevent contamination of clothing and hands. The minimum PPE for care of residents with respiratory illness (suspected or known COVID-19) included, gown, gloves, N-95 respirators or masks (if available) and eye protection (goggles or face shields). <Resident 3> Resident 3 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (a condition that causes the heart not to pump blood efficiently), atrial fibrillation (irregular heart rate that effects blood flow), obstructive sleep apnea (OSA) [a sleep disorder in which breathing repeatedly stops and starts]. Review of the quarterly Minimum Date Set (MDS-an assessment tool) dated 07/12/2024, showed Resident 3 was cognitively intact and used oxygen (O2) at night due to OSA. Review of a physician's order dated 10/04/2022, showed Resident 3 had an order to receive O2 at 2 liters per minute (lpm) via nasal cannula (NC) [a tube that delivers oxygen] at night secondary to OSA. In an interview and observation on 07/31/2024 at 10:44 AM, Resident 3 stated that they used oxygen at night. An O2 concentrator machine was observed at the resident's bedside and the oxygen tubing was undated and lying on the floor. In an interview/observation on 07/31/2024 at 10:56 AM, Staff P, Nursing Assistant Certified (NAC) stated Resident 3 used O2 at night and the nurse turns the O2 off. Staff P stated the O2 tubing was not supposed to be on the floor. Staff P picked up the O2 tubing from the floor, rolled it and placed it on top of the concentrator. Staff P stated that was how the tubing was stored. In an observation on 08/01/2024 at 2:01 PM, Resident 3's O2 tubing was observed rolled and stored on top of the concentrator. The O2 tubing was dated 07/11. In an observation on 08/02/2024 at 09:41 AM, Resident 3's O2 tubing was rolled and placed on top of the concentrator. The O2 tubing was dated 07/11. In an interview on 08/02/2024 at 10:00 AM, Staff M, Registered Nurse (RN) stated, Resident 3 used O2 at night and the nurse applies and removes the O2 tubing. Staff M stated the O2 tubing was changed, dated, and initialed weekly or when visibly soiled. Staff M stated, the O2 tubing used to be stored in a Ziploc bag, but the bag disappears, so staff just rolls it and puts it on the top of the concentrator. Staff M stated it was not good practice to store O2 tubing on top of the concentrator. In an interview on 08/06/2024 at 09:55 AM, Staff B, RN/Director of Nursing Services stated, if O2 tubing was found on the floor it should be replaced and stored in a plastic bag when not in use. <Facility> In an observation on 07/31/2024 at 11:55 AM, Staff D, Laundry Manager was observed transporting clean clothing protectors and towels uncovered. In an observation on 08/02/2024 at 09:59 AM, Staff U, laundry staff, was observed walking in the hall carrying clothing protectors against their body uncovered. In an interview on 08/02/2024 at 10:04 AM, Staff U stated clean linens and clothing protectors should be covered when transported in the hallway. In an interview on 08/07/2024 at 09:25 AM, Staff D stated laundered items should be covered when being transported through the facility. <RESIDENT 23> In an observation on 08/01/2024 at 12:36 PM, Staff S, NAC was observed entering Resident 23's room. The wall next to Resident 23's door had signage posted that showed they were on aerosol contact precautions. Staff S entered Resident 23's room wearing only an N95 respirator (a type of face mask recommended for COVID-19) to deliver the resident's meal tray. In an interview on 08/01/2024 at 12:36 PM Staff S, NAC, stated they were not aware Resident 23 had aerosol contact precautions. Staff S stated they should have gowned and gloved. When asked if they should change their mask after exiting Resident 23's room, Staff S stated they were not aware they needed to change their mask. During an observation on 08/01/2024 at 1:04 PM, Staff P, NAC, was observed donning PPE they were wearing a surgical mask, put on gloves and a gown and entered Resident 23's room. Staff P exited Resident 23's room and doffed the gown outside the resident's door, rolled up the gown, removed the gloves, and threw away the gown and gloves down the hallway. In an interview on 08/01/2024 at 1:04 PM Staff P, NAC, stated they should wear a mask, gloves and a gown. When asked what type of mask they should wear, Staff P pointed to the PPE supply bin that contained N95 masks, next to Resident 23's door. Staff P stated they were not wearing the proper mask when they entered Resident 23's room. In an interview on 08/06/2024 at 11:56 AM Staff J, Infection Preventionist-Licensed Practical Nurse (LPN) stated the expectation for donning and doffing PPE, for staff who enter rooms with aerosol contact precautions, was to follow the instructions on the posted signs step by step. Refer to WAC 388-97-1320(1(a)(c)(2)(b(3)(4)

Based on record review, and interview the facility failed to develop, implement and maintain an in-service training program to ensure 1 of 4 Nursing Assistant's (Staff K) reviewed for the required 12 hour of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk for potential unmet care needs. Findings included . Review of the Facility Assessment, undated, showed the facility utilizes the following training topics during all staff in-services or department meetings at multiple times throughout the year: - Communication - effective communications for direct care staff with residents/family. Resident's rights and facility responsibilities - educate staff members on the rights of the resident and the responsibilities of a facility to properly care for its residents. - Abuse, neglect, and exploitation - educate staff on: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. - Infection control - education of staff on infection prevention and control standards, policies, and procedures, including proper hand hygiene and the use of personal protective equipment (PPE) in following isolation precautions as necessary. - Culture change (that is, person-centered and person-directed care). - Required in-service training for nurse aides (CNAs and NARs). ln service training must: be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. -lnclude dementia management training and resident abuse prevention training. <EMPLOYEE FILE REVIEW> Review of the emplolyee file for Staff K, NAC, showed they had 6.3 hours of training rather than documented evidence of the required 12 hours of in-servicing. Review of the in-service records showed the facility failed to document how long the in-service lasted or the time it started. In an interview on 08/06/2024 at 12:59 PM, Staff J, Staff Development Coordinator stated they were working on the education piece to ensure the staff had the 12 hours of education. At 3:00 PM, Staff J said they were able to locate the 12 hours for the other 4 NACs requested but not for Staff K. Staff K said the expectation was for NACs to have at least 12 hours of education yearly. Refer to 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 advanced notice when Medicare coverage ended. The facility did not issue a Notification of Medicare Non-Coverage (NOMNOC) at least two calendar days before coverage for Medicare services ended, as required, for 1 of 3 residents (Resident 40) reviewed for required liability notices. This failure prevented the resident from exercising the right to appeal and dispute the termination of Medicare covered care. Findings included . Review of the Centers for Medicare & Medicaid Services (CMS) form titled, Instructions for the Notice of Medicare Non-coverage (NOMNC), on 10/13/2023, showed the Medicare provider or health plan must give an advanced, completed copy of the NOMNC to beneficiaries/enrollees receiving skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services, not later than two calendar days before the termination of services. Resident 40 admitted to the facility on [DATE] with diagnosis to include heart disease. Review of the 5-day Minimum Data Set (MDS- assessment tool) assessment, dated 06/23/2023, showed the resident was cognitively intact and able to make their needs known. Review of Resident 40's medical record showed there was no documentation the resident had received a completed NOMNC form prior to skilled services ending. During an interview on 10/13/23 10:51 AM, Staff J, Health Information Manager (HIM), stated they had looked through Resident 40's clinical records and were unable to locate a completed NOMNC form. Staff J stated the business office manager typically gets a copy once the form was completed, stating they had not previously kept NOMNC in the resident's medical/clinical records, but rather with the financial records in the business office. During a joint interview and record review on 10/13/23 10:58 AM, Staff S, Business Office Manager (BOM), stated it was the responsibility of the medical records department to complete these forms when required. After review of Resident 40's records, Staff S stated there was not a NOMNC form completed for the resident, and it should have been. Staff S was unable to provide any further information as to why the form was not completed as required. Refer to WAC 388-97-0300(1)(e) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 19> Resident 19 admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus type 2 (medical condition which the body doesn't use insulin properly), and a fracture of the right femur (broken right leg). In a review of Safety Assessment/Consent signed by Resident 19, dated 8/17/2023, noted that resident alert and impulsive, had unsteady or disrupted gait, needed assistance with ambulation, had a history of falls with interventions that indicated use of bed and chair alarms as to prevent falls. The alternative to the use of alarms were noted to be watched closely to prevent falls. In a review of Resident 19's care plan, dated 8/29/2023, showed the resident used a chair and bed alarm and directed the staff to ensure the device was in place and that was working properly. There was no additional information found in the care plan that addressed Resident 19's use of bed and/or chair alarms. In an interview on 10/10/23 at 9:40 AM Resident 19 stated that they have bed and chair alarms to let the staff know when they get out of bed or their wheelchair. Resident 19 stated that the alarms are annoying. On 10/11/2023 at 1:10 PM, Resident 19's bed alarm sounding, and Resident 19 was observed sitting in their w/c next to their bed. Staff M, NAC, entered Resident 19's room and turned off the bed alarm. In a brief interview at 10/11/2023 at 1:10 PM, Staff M stated Resident 19 had placed their hand on their bed and removed the alarm causing the alarm to sound. In an interview on 10/13/2023 at 10:16 AM, Staff R, Licensed Practical Nurse (LPN), stated they did not know how often the use of bed/chair alarms were reassessed for use. Staff R stated Resident 19 was a fall risk and still attempted to get up, which was then documented in the resident's clinical record. Staff R stated the use of the alarm was a good reminder for Resident 19 and the resident had not complained about the noise of use of the alarms. In an interview on 10/13/23 03:16 PM Staff E, LPN, stated that they had advocated to have bed alarms discontinued. Staff E, stated that they completed an audit of care plans and physician orders for residents with alarms and found that there were none but has since been fixed. In an interview on 10/16/2023 at 12:15 PM Staff D, LPN/Resident Care Manager (RCM), when asked how often bed/chair alarms were being assessed for residents that have an alarm, stated that the assessments were lacking. Refer to WAC 288-97-0620(1) Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and review the need for bed and wheelchair alarms for 2 of 2 residents (Resident 37 and 19) reviewed for restraints. This failure placed the residents at risk for injury and decreased quality of life. Findings included . Review of facility Policy titled, Use of Alarms in Fall Prevention/Wander guard, dated 12/05/2018, showed: - Alarm Usage: LN's (Licensed Nurses) will assess resident for fall risk at time admission. If at risk, LNs will determine need for alarms and indicate on plan of care type of alarm, times, and location of alarm. - Responsibilities to alarms: Placement & functions: It is the responsibility of the caregiver, NAC (Nursing Assistant Certified) or LN, to place alarm and assure it is in good working order at all times indicated in care plan. - It is the responsibility of team charge nurse to observe and check for proper placement of alarms on all his/her residents needing alarms. - Monitoring will be signed for every shift <RESIDENT 37> Resident 37 admitted to the facility on [DATE] with diagnoses that included dementia and seizure disorder. Review of the resident's admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/02/2023, showed the resident had severe cognitive impairment, impaired balance, required extensive assistance with transfers and had history of falls prior to admission to the facility. In an observation and interview on 10/10/2023 at 10:29 AM, Resident 37's pressure sensor alarms were in place on the resident's bed and wheelchair (w/c). The resident was unable to express awareness or comment regarding their use due to their severe cognitive impairment. Review of a physician order, dated 09/04/2023, showed Resident 37's chair alarm to be checked for proper function every shift. Orders did not include specific type of device or time/frequency of use or the use of an alarm on the resident's bed. In an interview on 10/10/2023 at 10:29 AM with Staff Z, Nursing Assistant Certified (NAC), stated Resident 37 did not use their call light and the alarm would alert staff that the resident was trying to get up and the staff would see what the resident needed. Staff Z stated usually the resident needed to go the bathroom. Record review of Resident 37's care, dated 09/04/2023, showed interventions were initiated that directed the nurse to check to ensure the chair alarm was working properly. There was no additional information found in the care plan that addressed Resident 37's use of bed and chair alarms, or directives for monitoring of effectiveness or potential complications of their use. In an interview on 10/13/2023 at 1:31 PM, Staff B, Registered Nurse (RN)/Interim Director of Nursing Services, stated they completed a form prior to the use of safety devices and obtained informed consent from families. Staff B stated the form had an assessment and lists the risks and benefits that were discussed with the families. In a joint record review of Resident 37's electronic and paper records, this form was not found for this resident.

Based on interview and record review, the facility failed to implement their Abuse Prohibition policy by not ensuring reference checks were conducted prior to hire for 3 of 5 employees (Staff X, AA, and BB) reviewed for reference checks. These failures placed residents at risk for abuse, neglect, unmet care needs, mistreatment by staff and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse/Neglect Policy and Procedure, undated, showed no resident would be subjected to abuse, mistreatment .The procedure showed prior to hiring, staff would be screened, and professional references would be verified by the facility representative and documented. Staff X was hired on 11/10/2022 as a Nursing Assistant Certified (NAC). Review of Staff X's employee file showed there were no professional or personal reference checks completed. Staff AA was hired on 05/03/2023 as a NAC. Review of Staff AA's employee file showed there were no professional reference checks completed. Staff BB was hired on 09/14/2004 as a Registered Nurse. Review of Staff BB's employee file showed no professional or personal reference checks completed. In an interview on 10/11/2023 at 11:13 AM, Staff A, Administrator, was informed there were no professional reference checks for Staff X, AA, and BB. Staff A said they had met with human resources to inform them they need to acquire three professional references prior to hiring. This is a repeat deficiency from 08/18/2022. Refer to WAC 388-97-0640(1)(2)(b)(4)(5)(a)(6)(a)(b)(c) .

**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 for 1 of 2 residents (Resident 11) reviewed for abuse and neglect. This failure to report to the required state agency resulted in lack of timely investigations and placed all residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect. Findings included . A review of the facility policy titled, Abuse/Neglect Policy and Procedure, undated, showed staff were directed to report to the hotline suspected abuse/neglect/exploitation and misappropriation, immediately or within two hours. Resident 11 admitted on [DATE] with diagnoses to include stroke with left side hemiparesis (weakness) and hemiplegia (partial or nearly complete paralysis), and depression. In an interview on 10/09/2023 at 10:23 AM, Resident 11 stated they had an issue with Staff AA, Nursing Assistant Certified (NAC) when they laughed and were physical with them. When asked what that meant, Resident 11 said Everyone knows about it. [Staff AA] uses [their] hip to move me because I don't move my leg fast enough. I have had a stroke. [Staff AA] makes fun of me and laughs when I tell them my concerns about them. I do not feel safe with them, and the prior Administrator knew that. But now they have [Staff AA] taking care of me again. I do not want them to care for me, they make fun of me. Resident 11 said [Staff D, Licensed Practical Nurse (LPN)/Nurse Manager] knows I do not want [Staff AA] to touch me, I told them personally and [Staff AA] still cares for me. Resident 11 stated Staff AA does not treat me with respect. I do not feel safe with them. The resident stated staff were aware of this, but Staff AA was reassigned to care for them again. In an interview on 10/09/2023 at 11:00 AM, Staff B, interim Director of Nursing (DNS), was informed about Resident 11's allegation of abuse. In an interview on 10/11/2023 at 12:15 PM, Staff A, Administrator, said they had terminated Staff AA and they informed Staff B to call the hotline and report the 10/09/2023 allegation. Staff A said that Staff B asked them if they really needed to report this today. Staff A said they told Staff B they should have called the allegation in on Monday. Review of the incident investigation from 10/09/2023, showed the state abuse hotline was called on 10/11/2023, two days later after the allegation was made. Cross reference with CFR 483.12 (a)(1) F600 - Freedom from Abuse, Neglect, and Exploitation This is a repeat deficiency from 08/18/2022. Refer to WAC 388-97-0640 (2)(b)(5)(a)(6)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 8> Resident 8 was admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes, depression, and Chronic Obstructive Pulmonary Disease (COPD) (constriction of airways and difficulty breathing). Review of Resident 8's admission MDS assessment, dated 10/03/2023, showed they had no diagnoses of a PU (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Review of Resident 8's admission summary progress note, dated 09/28/2023, showed the resident was admitted with an open sacral (bottom of the spine) pressure area measuring 8 centimeters (cm) x 3cm. In an interview on 10/16/2023 at 10:04 AM, Staff G stated if a resident had a PU on admit, it should be documented on admission. Staff G stated if the nurse writing the note did not stage the wound, then they would not know how to add the information to the MDS assessment. Staff G acknowledged they had not documented Resident 8's PU on the admission assessment. <RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnoses to include depression and heart failure. Review of the Resident 31's diagnoses list in the electronic medical record showed no diagnosis of Post Traumatic Stress Disorder (PTSD - a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations.). Review of Resident 31's admission MDS assessment, dated 08/12/2023, showed the resident had a diagnosis of PTSD. In an interview on 10/13/2023 at 1:45 PM, Staff D, Licensed Practical Nurse (LPN)/ Nurse Manager (NM), stated they were unaware of how the MDS coordinator gathered the information for the MDS assessments. Staff D stated nurses were to obtain diagnoses off admission orders, or the provider list of diagnoses. In an interview on 10/16/2023 at 10:04 AM, Staff G stated they would not know about Resident 31's diagnosis of PTSD. Staff G stated social services would know about Resident 31's diagnoses, adding they ([NAME] G) was sure Resident 31 had a psychiatric diagnosis. In an interview on 10/16/2023 at 10:28 AM, Staff C, Social Services, stated a diagnosis should come from a clinical document. PTSD diagnoses came from a nurse at the facility that the resident was previously at. Staff C stated that depression was the only psychiatric diagnosis listed on Resident 31's history and physical, and hospital documentation. In a joint interview on 10/16/2023 at 1:00 PM, Staff D stated resident's diagnosis needed to come from a provider. Staff B, Director of Nursing Services, acknowledged in agreement. Staff B and D were asked to provide documentation related to Resident 31's diagnosis of PTSD. No further information was provided from the facility. Refer to WAC 388-97-1000(1)(b) Based on interview and record review, the facility failed to accurately assess 3 of 6 sampled residents (Residents 33, 8, and 31) reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding health conditions including their fall history, skin pressure ulcers (PU's), and physician documented diagnoses place residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . <RESIDENT 33> Resident 33 was admitted to the facility on [DATE] with diagnosis of anoxic (lack of oxygen) brain damage that caused severe impairments in cognition and physical functional movements. Review of Resident 33's most recent MDS assessment, dated 07/03/2023, indicated the resident had no falls since admission or since their prior assessment. Review of Resident 33's medical records and the facility incident reporting logs showed the resident had falls in the facility on 08/03/2023, 08/10/223, 08/25/2023, 08/28/2023, and 09/25/2023. In a joint interview/record review on 10/16/2023 at 9:22 AM, Staff G, Registered Nurse (RN)/MDS coordinator, stated they did not see documentation related to the multiple falls in Resident 33's clinical record or the facility's risk management records when they were gathering information to complete MDS assessment for Resident 33.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnosis to include major depressive order. Review of Resident 31's admission MDS assessment, dated 08/12/2023, showed the resident had diagnoses of depression, anxiety, and post-traumatic stress disorder (PTSD - a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashbacks, and avoidance of similar situations.). Review of Resident 31's PASRR, dated 08/05/2023, and completed by hospital staff, showed the resident had a mood disorder, which was listed as depression and no Level II was indicated. The document also showed the resident had depression and was stable taking Cymbalta (antidepressant). There was no documentation of anxiety or PTSD. Review of Resident 31's hospital discharge documents, dated 08/05/2023, showed the resident had a diagnosis of depression. There was no documented diagnoses of anxiety or PTSD. Review of Resident 31's Electronic Medical Record (EMR) on 10/13/2023 at 1:33 PM, showed no documentation of anxiety or PTSD diagnoses, and were added to the resident diagnosis list in September 2023. In an interview on 10/13/2023 at 1:45 PM, Staff D, Licensed Practical Nuse/Nurse Manager, stated they take the resident's diagnoses from the hospital records when they admitted . Staff D stated they reviewed the PASRR form on admission for new residents and then Social Services and MDS staff would review. In an interview on 10/16/2023 at 10:04 AM, Staff G, Registered Nurse/MDS coordinator, stated they did not know how anxiety and PTSD were added to Resident 31's diagnoses. Staff G stated these diagnoses were documented in the MDS assessment. In an interview on 10/16/2023 at 10:28 PM, Staff C stated a new PASRR evaluation should be completed when there was an addition of a new psychiatric diagnoses and a new PASRR had not been completed for Resident 31. Refer to WAC 388-97-1915(4) Based on observation, interview and record review, the facility failed to refer 2 of 5 sampled residents (Resident 10 and 31) reviewed for Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) for a Level II (an evaluation to determine whether the resident requires specialized rehabilitation services) evaluation after Resident 10 exhibited hallucinations, delusions and possible serious mental disorder diagnosis. This failure increased residents' risk for experiencing fear, anxiety and having unmet behavioral health care needs. Findings included . <RESIDENT 10> Review of Resident 10's record indicated the resident admitted on [DATE] with diagnoses including bipolar disorder (a serious mental illness characterized by extreme mood swings), dementia without behavioral disturbance, psychotic disturbance (a group of serious illnesses that affect the mind), mood disturbance and anxiety. Review of the admission Minimum Data Set (MDS-assessment tool) assessment, dated 09/29/2023, documented the resident had severe cognitive impairment and experienced potential indicators of psychosis (a condition that affects how the brain processes information and causes a resident to lose touch with reality) including hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions tor beliefs that are firmly held, contrary to reality). Review of the PASRR assessment completed by hospital staff, dated 09/25/2023, prior to admitting to the facility, documented Resident 10 had mood disorder and anxiety disorder but no credible suspicion of SMI and therefore a Level II PASRR was not required. Review of a progress note, dated 10/02/2023 at 10:15 AM, showed Resident 10 was having delusions and thought someone was hiding in their closet, heard dogs barking, thought they saw their family car in the parking lot waiting for them. Review of a progress note dated 10/02/2023 at 12:27 PM, Staff C, Social Services, showed Resident 10 was experiencing delusions and hallucinations. Review of a MDS note, dated 10/02/2023 at 1:18 PM, noted Resident 10 was having a psychotic disturbance with current visual and auditory hallucinations and delusions. In an observation on 10/16/2023 at 2:08 PM, Resident 10 was in their wheelchair in their room and was visiting with their family member. Resident 10 asked if their family member could come to lunch and said that they were right here (no one was present). The resident immediately became anxious and started calling out their family members name repeatedly then said they were just here. In an interview on 10/16/2023 at 10:29 AM, Staff C said they were unaware Resident 10 was experiencing new delusions and hallucinations although they had completed a progress note about them on 10/02/2023. Staff C stated they could send off a referral for a Level II evaluation later today. Staff C stated when they were first hired three months ago, they could not locate multiple PASRR's, so they started completing new ones. Staff C said they had sent the PASRR evaluator new admissions and a couple of other resident's evaluations at a time as to not overwhelm them. Staff C said they watched the Point Click Care (electronic charting system) dashboard for changes of condition, for new psychiatric medications or diagnoses and then sent those identified changes along to the state PASRR evaluator. Staff C said it was their focus to make sure the PASRR's were accurate. Staff C commented that Pretty much everyone is on the list to be sent to (PASRR evaluator).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to make a referral for the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individual's wo are being referred to a Medicaid-certified nursing facility) for a Level II (an evaluation to helps determine resident placement and the need for specialized services needed prior to admitting to a facility) evaluation for 1 of 5 sampled residents (Resident 34). This failure placed the resident at risk for unidentified mental health care needs, lack of mental health services and a diminished quality of life. Findings included . Resident 34 admitted to the facility on [DATE] with diagnosis that included dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 34's PASRR Level I (a screening to determine if a resident may have a SMI/ID related condition and if positive a Level II PASRR is required), dated 05/23/2023, showed a serious mental health illness indicator was marked as YES for a mood disorders. Review of Resident 34's Minimum Data Set (MDS - an assessment tool) assessment, dated 06/07/2023, showed an active diagnosis to include bipolar disorder (a serious mental illness characterized by extreme mood swings). During an interview on 10/11/2023 at 3:21 PM Staff C, Social Services Director, stated they were the individual responsible to ensuring that residents are referred for Level II evaluations. Staff C initially stated Resident 34's primary diagnosis was dementia, and this was the reason why a referral for a Level II evaluation did not occur. After reviewing the PASARR Level I, Staff C stated Resident 34 required a referral for a Level II evaluation. Refer to WAC 388-97-1915(1)(2)(a-c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 34 admitted to the facility on [DATE] with diagnoses that included fracture of the right leg (broken right leg), hypertension (high blood pressure, and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of the PASSR, dated 05/23/2023, showed Resident 34 showed signs of a serious mental illness, had a primary diagnosis of dementia, and required an additional evaluation. Review of Resident 34's Minimum Data Set (MDS - an assessment tool) assessment, dated 06/07/2023, showed an active diagnosis to include bipolar disorder (a serious mental illness characterized by extreme mood swings). Review of Resident 34's care plan showed no information regarding the PASRR Level I (a screening to determine if a resident may have a SMI/ID related condition and if positive a Level II PASRR is required), was completed prior to admission and the need for a Level II evaluation was to be completed. During an interview on 10/11/2023 at 3:21 PM, Staff C, Social Services Director, stated they were the individual responsible to ensure residents were referred for Level II evaluations. Staff C stated Resident 34's primary diagnosis was dementia, and this was the reason why a referral for a Level II evaluation did not occur. After reviewing the PASRR Level I, Staff C, stated Resident 34 required a referral for a Level II evaluation. In an interview on 10/16/2023 at 10:19 AM Staff G, Registered Nurse/MDS Coordinator, stated they complete the CAA process that carried over to the care plan. Staff G stated they look at the PASRR when they had completed the MDS and CAA process and stated they had missed Resident 34's PASRR form. This is a repeat citation from 08/18/2022. Refer to WAC 388-97-1020 (1)(2)(a) Based on interview, and record review, the facility failed to develop and implement comprehensive care plans for 1 of 6 sampled residents (Resident 34) reviewed for comprehensive care plans. The failure to develop and implement a Pre-admission Screening and Resident Review (a screening assessment for possible serious mental health disorders or intellectual disabilities) Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) care plan placed residents at risk for unmet care needs, and a diminished quality of life. Findings included .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 35> Resident 35 was admitted to the facility on [DATE] with diagnoses to include congestive heart failure and weakness. In an interview on 10/09/2023 at 11:22 AM, Resident 35 stated they had a current skin rash that was being treated by the facility nurses. Review of Resident 35's care plan, showed the resident required a skin inspection when clothing or brief changed. There were no specific interventions or mention of Resident 35's current skin rash. Review of Resident 35's [NAME] (a guide to help direct resident care to the nursing assistant certified), dated 10/09/2023, showed there was no information related to their current skin rash. Review of Resident 35's September and October 2023 Medication Administration Records, showed they started diphenhydramine 25 milligrams three times daily related to bilateral shoulder and back rash. Review of Resident 35's September and October 2023 Treatment Administration Records, showed no monitors were in place for their current skin rash. In an interview on 10/13/2023 at 1:45 PM, Staff D stated if a resident has a rash or other skin concerns, they expect to find that information on the care plan. Staff D stated the previous DNS would update care plans and that was why they believe care plans have not been updated, the nurses were not used to updating. This is a repeat citation from 08/18/2022. Refer to WAC 388-97-1020(5)(b) Based on interview and record review, the facility failed to review and revise care plans for 3 of 6 sampled residents (Resident 20, 10, and 35) reviewed for care planning. These failures placed the residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life. Findings included . Review of the facility's, Care plan policy and procedure, revised 08/08/2019, showed the care plan was to include the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. <RESIDENT 20> Resident 20 admitted on [DATE] with diagnoses which included antibiotic resistant infection to their right hip prosthesis, breast cancer, neuropathy (nerve disease that impairs sensation and movement), chronic pain syndrome, high blood pressure, and chronic anemia. The resident had not pressure ulcers. Review of the progress note, dated 08/29/2022, showed there was an incident regarding new skin issues. The note revealed two new open areas, one in right upper inner upper thigh measuring 0.6 centimeter (cm) by 1.5 cm by 0.2 cm depth and one in the left inner upper thigh wound that measured 0.4 cm by 1.5 cm and depth 0.2 cm. An order was received for a hydrocolloid dressing (dressing for mildly draining pressure ulcers) to be started on those two areas. Review of the care plan on 10/10/2023, showed on 04/03/2023, a new care plan problem was developed, and Resident 20 had a stage 3 (full-thickness skin loss of skin) pressure ulcer (PU) to their left superior thigh. The care plan did not include the right superior thigh PU. The care plan was incomplete and failed to include cause of the PU or the residents risk factors. The interventions listed were not resident centered and directed nurses to administer medications and treatments as ordered, follow facility policies and protocols for prevention and treatment of skin breakdown and monitor/document/report as needed any changes in skin appearance, color, wound healing, signs of infection, wound side (length X width X depth), and the stage of the PU. Review of the hypertension care plan, dated 01/22/2020, showed Resident 20 had a Peripherally Inserted Central Catheter (PICC line, a type of intravenous line) in their left arm so they were to have no blood pressures on their left arm. In an joint interview on 10/16/2023 at 12:20 PM, Staff D, Licensed Practical Nurse/Nurse Manager, said Staff G, Registered Nurse/MDS Coordinator, was overall responsible for the care plan and the nurses tried to help with revisions. Staff B, interim Director of Nursing Services (DNS), and Staff D said they were aware care plans were not consistently revised. Staff D stated they try to review and revise the care plans. In an interview on 10/16/2023 at 10:03 AM, Staff G usually stated the nurse managers revised the care plans or they would ask them to. Staff G said Resident 20 had not had a PICC line for a long time and that should not be on the care plan. Staff G said that each wound should be included on the care plan. Staff G said they had acknowledged the care plans were not resident centered six weeks ago started going over a couple care plans a week to ensure accuracy. <RESIDENT 10> Resident 10 admitted on [DATE] with dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder (a serious mental illness characterized by extreme mood swings) and depression. Review of the hospital Discharge summary, dated [DATE], showed Resident 10 had a history of falls. Review of a progress note on 10/03/2023 at 11:58 PM, showed Resident 10 was found on the floor in their room. The resident stated they fell while trying to go to the bathroom. The resident sustained a one-inch hematoma to their right elbow and reported lower back and left arm pain. Review of the care plan on 10/16/2023, showed Resident 10 was at risk for falls related to confusion, deconditioning, gait/balance problems, and they were unaware of safety needs. The goal was for the resident to be free of falls through 01/26/2024. The care plan did not include the fall that occurred on 10/03/2023 nor measures to prevent reoccurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 34> Resident 34 admitted to the facility on [DATE] with diagnoses that included fracture of the right leg (broken right leg), hypertension (high blood pressure), and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 34's Care Area Assessment (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned) for activities dated 06/08/2023, showed the resident was at risk for alteration in activities and prior to admission they were involved in group activities. Review of Resident 34's care plan, dated 06/08/2023, showed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs due to severe cognitive-communicative because of dementia. The goal for Resident 34 was to maintain involvement in cognitive stimulation and social activities. Interventions included one-on-one bedside/in-room visits and activities. Observations on 10/10/2023 at 9:44 AM, 10/11/2023 at 10:18 AM, 10/12/2023 at 11:38 AM, 10/13/2023 at 9:32 AM, and 10/16/2023 at 9:29 AM, showed Resident 34 was in their bed with their eyes closed. Observation on 10/12/2023 at 11:55 AM, Resident 34 was observed in their room on their bed. Staff Y, Nursing Assistant Certified (NAC), offered Resident 34 something to drink and asked them how they were feeling. Resident 34 stated several times that they were dead. Staff Y left Resident 34's room stating that they would leave them alone. In an interview on 10/13/2023 at 1:03 PM Staff D, Licensed Practical Nurse (LPN), described Resident 34 as pleasant. Staff D stated the resident liked to go outside and sit. Staff D stated the Activities Department offered activities to residents, but anyone could offer them. Staff D stated Resident 34 could be offered puzzles, a walk, television program and offered choices was important. In an interview on 10/16/2023 at 11:03 AM, Staff I, Activities Director, stated they do not recall Resident 34 by name. Staff I stated they would provide Resident 34's activity participation log, which was not received. This is a repeat citation from 08/18/2022. Refer to WAC 388-97-0940(1) Based on observation, interview and record review, the facility failed to ensure 2 of 2 sampled residents (Resident 10 and 34) reviewed for activities, received an ongoing program of activities to meet the individual residents' interests and needs. This failure placed the residents at risk for a decreased quality of life. Findings included . <RESIDENT 10> Resident 10 was admitted to the facility on [DATE] with diagnoses to include depression, dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), anxiety, and chronic obstructive pulmonary disease (COPD - causes airway blockage and difficulty breathing). Review of Resident 10's admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/29/2023 showed that the resident required extensive assist of one or two staff with their Activities of Daily Living (ADL - dressing, transfers, bed mobility, walking/locomotion, bathing personal hygiene, toileting and eating). Review of Resident 10's care plan showed they were dependent on staff for meeting emotional, intellectual, physical, and social needs, initiated 10/02/2023. A care plan goal was to maintain involvement in cognitive stimulation, social activities as desired, initiated 10/02/2023. The care plan directed staff to ensure the activities the resident attended would be compatible with their physical and mental capabilities and they were to be invited to scheduled activities. Review of Resident 10's [NAME] (a guide for nursing assistant certified to care for a resident), dated 10/13/2023, showed staff were to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. Review of Resident 10's Electronic Medical Record (EMR) showed no documented activity notes. Observations on 10/09/2023 at 11:22 AM, 2:00 PM, and 2:52 PM, Resident 10 was observed sitting up, their television off, no music or activity items present. Observation on 10/10/2023 at 1:53 PM, Resident 10 was observed to be awake and sitting up in bed, television off, no music or activity items present. Observation on 10/11/2023 at 1:53 PM, Resident 10 was observed to be awake and sitting up in bed, television off, no music or activity items present. Observation on 10/11/2023 at 3:19 PM, Resident 10 was observed to be sitting on edge of their bed, television off, and no music or activity items present. Observation on 10/12/2023 at 10:27 AM, Resident 10 was observed sitting up in their wheelchair (w/c), television off, and no music or activity items present. Observation on 10/12/2023 at 3:08 PM, Resident 10 was observed in their w/c in their room as a group activity with a singer took place. Observations on 10/13/2023 at 1:46 PM and 2:40 PM, Resident 10 was observed sitting in their room staring into their empty closet, their stuffed cat was out of their reach, television off, and no music or activity items present. In an interview on 10/16/2023 at 10:03 AM, Staff G, Registered Nurse (RN)/MDS nurse, stated they were temporarily responsible to interview residents about their activity preferences. Staff G stated Resident 10 would be a long-term care resident and they would personalize their activity care plan. Staff G acknowledged Resident 10 had not gone to any activities. Staff G stated they know they need to focus on activities for cognitively impaired residents. In an interview on 10/16/2023 at 10:54 AM, Staff C, Social Services (SS), stated Resident 10 goes to most activities. Staff C was made aware of the above observations and provided no further information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide proper treatment to maintain vision for 1 of 1 resident (Resident 19) reviewed for vision. This failure placed the resident at risk for frustration, decline in the ability to see, and diminished quality of life. Findings included . Resident 19 admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus type 2 (medical condition in which the body doesn't use insulin properly), fracture of the right femur (broken right leg). Review of Resident 19's Minimum Data Set (MDS - an assessment tool), dated 06/07/2023, showed the resident had adequate vision. Review of Resident 19's care plan, dated 08/08/2023, had no problem, goal, or intervention identified for their vision. In an interview on 10/10/2023 at 9:17 AM, Resident 19 stated they have floaters in their eyes and needed to see the optometrist. Resident 19 stated they could not recall the last time they had seen the optometrist. In an interview on 10/13/23 at 9:52 AM, Staff D, Licensed Practical Nurse (LPN), stated Resident 19 had been seen by the optometrist and had their cataracts removed. Staff D was unable to locate documents in the resident's clinical record related to the visits to the optometrist, then faxed the optometrist office on 10/13/2023. Review of the optometrist progress note, dated 04/21/2023, showed Resident 19 was seen for complaints of seeing spots/floaters. The plan showed the resident should be referred to a retinal consult for further evaluation, a Yag (type of laser eye surgery that's used to treat a specific complication of cataract surgery consult). In an additional interview on 10/13/23 at 12:58, PM Staff D stated they did not know if the referral and consult had taken place for Resident 19. Review of progress notes from 01/01/2023 to 10/10/2023, showed no notation of Resident 19's complaints of their vision, visits with the optometrist or notation of the referral/consult that was part of the plan noted on 04/21/2023 note from the optometrist. Refe to WAC 388-97-1060(3)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to thoroughly assess and document pressure ulcers (PU's) weekly, maintain clear and accurate PU documentation, and develop and implement an individualized care plan for 1 of 2 sampled residents (Resident 20) reviewed for PU's. This failure placed residents at risk for deterioration of their PU's and a diminished quality of life. Findings included . Review of the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, showed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing PU, for example, immobility, recent weight loss, and a history of PU's. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b. Pain assessment. c. Resident's mobility status. d. Current treatments, including support surfaces. e. All active diagnoses. The physician will help identify medical interventions related to wound management. The physician will help staff characterize the likelihood of wound healing, based on review of pertinent factors. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicate, extensive, or poorly-healing wounds. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing intervention. The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed a PU/Pressure Injury (PU/PI) definition and stages as: -A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction). -Stage 3 PI is full-thickness skin loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (new connective tissues and microscopic blood vessels) and epibole (rolled wound edges) are often present. Slough (nonviable tissue) and/or eschar (dead or devitalized tissue) may be visible. Undermining (destruction of tissue or ulceration extending under the skin edges) and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). Resident 20 admitted on [DATE] with diagnoses which included antibiotic resistant infection to their right hip prosthesis, breast cancer, neuropathy (nerve disease that impairs sensation and movement), and chronic pain syndrome. The resident was non-weight bearing related to a right hip prosthesis removal. Review of Resident 20's medical record from 08/29/2022 through 10/13/2023, showed the resident had reoccurring PU's on their right and left upper inner thighs, and coccyx. Review of Resident 20's care plan, dated 04/03/2023, showed a new care plan problem was developed, and identified the resident had a stage 3 PU to their left superior thigh. Interventions directed nurses to administer medications and treatments as ordered, follow facility policies and protocols for prevention and treatment of skin breakdown and to monitor/document/report as needed any changes in the skin appearance, color, wound healing, signs of infection, wound side (length X width X depth), and the stage of the wound. Review of a progress note, dated 04/04/2023, showed Resident 20 had a stage 3 left superior thigh PU and was followed by a contracted wound care provider. Review of a progress note, dated 04/29/2023, showed Resident 20 had chronic shear denuded like areas related to self-care and moisture with incontinence. There were three small areas each approximately 1 cm round on the right buttock and two small areas on the left buttock measuring approximately 1 cm. The resident declined to have an alternating pressure mattress as it limited their bed mobility. The resident was provided with barrier cream per their request to their buttocks. Review of the Quarterly Minimal Data Set (MDS - an assessment tool) assessment, dated 07/01/2023, showed Resident 20 was cognitively intact, was at risk for developing PU's, had a current stage 3 PU that was not present on admission, moisture-associated skin damage (MSAD - a general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture), was frequently incontinent of bowel and always incontinent of bladder. Record review no skin assessments were documented in Resident 20's record from 04/30/2023 to 07/06/2023. Review of a progress note, dated 07/07/2023, showed Resident 20 had two abraded (scraped or worn areas from friction) on their right inner buttock that measured 1.0 cm by 1.0 cm, and on their left inner buttock that measured 2.0 cm by 1.0 cm. The note indicated there was a current treatment order in place. Review of a visit note, dated 07/27/2023, showed Staff N, Medical Director, did not include an assessment of the PUs. The note showed the resident had not been too active and was able to sit up in bed. Review of Collateral Contact 2's (CC2), Advanced Registered Nurse Practitioner, visit note, dated 09/12/2023, showed Resident 20 was seen for follow up of their PU's. The resident was found sitting in their bed reporting their current pain regimen was not treating their pain. Staff documented the PU's had redness to bilateral posterior thighs and left buttock. There were no measurements of the wound. The resident was provided education regarding offloading their pressure and getting out of bed. The resident told them it was hard with them being in pain all the time. The note added resident was bedbound at baseline. Review of the clinical record showed no contracted wound care visit from 03/13/2023 until 09/21/2023. Review of the annual MDS assessment, dated 09/26/2023, showed Resident 20 had two stage 3 PU's that were not present on admission. The resident rejected care one to three days during the assessment period. They did not receive a turning and repositioning program or nutrition or hydration interventions to manage skin problems. Observations on 10/09/2023 at 9:34 AM and 10:14 AM, Resident 20 was observed sitting in their bed with their legs outstretched. The resident said they had to deal with PU's to the back of their legs and the nurses were treating them. The resident said their pain was normally a six or an eight on the 1-10 pain scale. They said their left knee and hip caused them much pain and they received scheduled pain medications. Observations on 10/10/2023 at 9:23 AM and 2:57 PM, Resident 20 was sitting up in their bed with their legs outstretched listening to music. Observations on 10/11/2023 at 9:24, 12:00 PM and 1:56 PM, Resident 20 was sitting up in their bed with their legs outstretched. Observations on 10/12/2023 at 10:28 AM, and 2:05 PM, Resident 20 was observed sitting in their bed with their legs outstretched. The resident said they spent their days sitting up in their bed. Review of a wound care providers visit note, dated 10/12/2023 (received electronically from the facility on 10/17/2023), showed Resident 20 did not want an air flow mattress. The provider had a long discussion concerning offloading the wounds for wound healing. Assessment of the wounds revealed the right superior thigh stage 3 PU measuring 4.0 cm by 2.0 cm by 0.1 cm and a left superior thigh stage 3 PU measuring 1.2 cm by 1.5 cm by 0.1 cm. The left and right wound healing was stalled (making no improvement). During a wound care observation on 10/13/2023 from 11:45 AM until 2:10 PM, Staff B, interim Director of Nursing Services (DNS), performed wound care to Resident 20. Staff B stated the surgical hip wound was present on admit but the PU's to the posterior thighs were not. There were no dressings present on the resident's posterior thighs. The right posterior hip PU wound bed was pink granulating (red and moist) tissue measuring 4.0 cm by 4.0 cm. The left hip PU measured approximately 2.0 cm by 2.0 cm and contained pink granulating tissue. Staff B said the facility tried to measure the wounds weekly, and was unsure if the resident was followed by their contracted wound provider. Resident 20 stated that they were seen by the wound provider. In an interview on 10/13/2023 at 3:19 PM, Staff E, Licensed Practical Nurse (LPN)/Infection Preventionist, stated Resident 20 was stubborn and difficult to deal with, had a lot of mental disorders that caused them to not do anything that was offered. Staff E said the resident had refused the contracted wound provider. After the refusal, Staff E said they set up a care conference with the resident and their spouse on resolving the wounds. Staff E said the resident did their own peri care without hand hygiene and had contracted an antibiotic resistant infection. Staff E said there was no air mattress in place as the resident did not want one. Staff E said they had not offered the resident another type of mattress or any other interventions. Staff E said they asked Staff C, Social Services, to set up another care conference. Staff E said they had offered mental health services to come in and tried to help the resident and encourage them to get out of bed. Staff E said the resident does not leave their bed except every six months. Staff E said they had never provided the resident with PU education materials. In an interview on 10/16/2023 at 10:03 AM, Staff G, Registered Nurse (RN)/MDS Coordinator, stated each wound should be addressed on the care plan. Staff G stated the expectation was the nurses document their weekly skin checks in the progress notes. In a joint quality assurance interview on 10/16/2023 at 1:09 PM, Staff B stated they were unsure if there was an incident reports for the facility acquired PU's. Staff B stated the nurses were to document weekly skin checks in the progress notes. Staff B said Resident 20 refused an air mattress and their PU's had resolved and then came back. Staff B said the resident had allowed an air mattress in the past when they last had pressure wounds but not now. Staff B said they were unsure what type of mattress the resident had and did not offer different mattresses to increase acceptability. Staff B said they encourage Resident 20 to get out of bed, was incontinent, and the moisture led to further skin issues. Staff B and Staff D stated there should be a more complete care plan and documentation on Resident 20's the wounds. They were unaware the right posterior thigh stage 3 PU was not included on the care plan. They were informed the clinical record and care plan lacked resident's risk factors, interventions, and preventative measures. Staff B, stated they had been the facility wound nurse responsible to do wound rounds, document and follow up on wound healing. Staff B stated Staff Q, former Administrator, removed them from that duty. In an observation on 10/16/2023 at 2:18 PM, Resident 20 was in the shower. Inspection of their recently sanitized mattress showed a navy top with grey bottom mattress from a national supplier. In an interview on 10/16/2023 at 2:07 PM, Staff T, Nursing Assistant Certified, said Resident 20 accepted care from them. Staff T said they had just returned from extended time off and the current PU's to the back of their legs used to be blisters. In an interview on 10/16/2023 at 2:11 PM, Staff F, RN, stated they were supposed to document weekly skin checks in the progress notes. Staff F was unsure what type of mattress Resident 20d was on, but they had been on an air mattress at one time. In an interview on 10/16/2023 at 2:13 PM, Staff U, RN, stated Resident 20 had been on an air mattress, but they did not like it and felt like they were sitting on a balloon. Staff U stated the resident was on a regular mattress now. Review of fax from the facility, dated 10/17/2023 at 3:21 PM, showed a progress note indicated Resident 20 was on a type of bariatric mattress. Review of the mattress literature, dated May 2017, contained a warning that showed this mattress was not intended for stage 3 or 4 PU's. This is a repeat deficiency from 08/18/2022. Reference (WAC) 388-97-1060 (1)(2)(3)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 19> Resident 19 admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus type 2 (medical condition in which the body doesn't use insulin properly), and fracture of the right femur (broken right leg). Review of Collateral Contact 2 (CC2), Advanced Registered Nurse Practitioner, progress notes from 01/2023 to 10/10/2023 showed Resident 19 was seen for a post hospital visit on 05/23/2023. The note dated 05/23/2023, showed the resident should use the toilet prior to bedtime as their last three falls were from middle of the night restroom use and with current wrist fracture. In a note, dated 09/13/2023, CC2 recommended fall precautions per facility protocols for safety. Review of Resident 19's care plan, dated 08/18/2023, showed Resident 19 was at high risk for falls due to poor safety awareness, Parkinson's disorder with tremors, weakness, narcotic use, pain, and bi-polar 1 disorder (mental illness that causes extreme mood swings from mania to depression). Interventions included the resident was to have their purse on their bed (to avoid overreaching), use of chair and bed alarm, personal belongings within reach, low position, and their call light within reach. Review of the Morse Fall Scale Assessment (fall risk assessment tool that predicts the likelihood of a person falling), dated 04/05/2023, 05/24/2023 and 08/17/2023 show Resident 19 was a high fall risk. Review of Resident 19's Minimum Data Set (MDS-An assessment tool) assessment, dated 08/23/2023, showed the resident had a fall in the last two to six months and a fall that led to a fracture in the last six months. Review of the Care Area Assessment (CAA-an assessment of a specific care or medical issue) for falls, dated 08/25/2023, showed Resident 19 was a high fall risk, had a hip fracture on 05/16/2023, muscle weakness, unsteady gait, and cognitive communication deficits. Review of progress note, dated 10/01/2023, showed Resident 19's bed was in the low position as a fall prevention measure. Resident 19 was observed on 10/10/2023 at 9:18 AM and 3:05 PM in their bed (not in a low position) and a fall mat next to their bed. Resident 19's purse was not within their reach. Resident 19 was observed on 10/13/2023 at 9:35 AM in their bed (not in a low position) and a fall mat next to their bed. Resident 19's purse was not within their reach. In an interview on 10/13/2023 at 10:16 AM Staff R, Licensed Practical Nurse (LPN), stated Resident 19 was a fall risk, was unable to state when the resident last fell, and the resident had sustained a fracture of their hip during one of their falls and had a urinary tract infection at the time. Staff R stated fall interventions for Resident 19 included having their bed in the low position, fall mat next to their bed, and use of bed/chair alarms. Staff R, when asked if Resident 19's bed was in a low position, went to the resident's room and stated that it was not and promptly lowered Resident 19's bed. <RESIDENT 34> Resident 34 admitted to the facility on [DATE] with diagnoses that included fracture of the right leg (broken right leg), high blood pressure, and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 34's care plan, dated 05/31/2023, showed the resident was at a high risk for falls due to confusion, deconditioning, incontinence, and poor safety awareness. The care plan interventions showed the resident needed a safe environment with floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, the bed in low position, personal items within reach, and frequent safety checks with reminders not to self-transfer and use of the call light. Review of Resident 34's progress notes, dated 06/08/2023, showed the resident had a fall while attempting to use the bathroom. Review of the Care Plan interventions, updated on 06/08/2023, included anticipating and meeting Resident 34's needs, encourage use of the front wheel walker with ambulation (walking), offer diversional activities such as puzzles, crafts, and socialization in area of high supervision, and offer toileting before meals, at bedtime and as needed. Review of progress notes, dated 06/09/2023, showed Resident 34 was checked on frequently with room rounds. On 10/11/2023 at 1:06 PM, Resident 34 was observed using their four wheeled walker. Resident 34 was wearing red slip-on shoes with a heel, one foot had a sock on, and the other foot did not. There was a napkin and liquid on floor in front of Resident's bed. Resident removed an incontinent brief from their dresser drawer, took small shuffling steps, and entered the bathroom. Resident 34's bed was approximately two feet above the floor, not in the lowest position. The resident's room had a strong odor of urine. In an interview on 10/16/2023 at 10:02 AM Staff M, Nursing Assistant Certified (NAC), stated Resident 34 was not a fall risk and did not have a fall mat or bed or chair alarms. Staff M stated Resident 34 often refused care for showers and assistance with incontinence. This is a repeat citation from 08/18/2022. Refer to WAC 388-97-1060(3)(g) Based on observation, interview and record review, the facility failed to ensure safety and mobility interventions were developed, implemented, and consistently provided as directed in the care plan for three of four residents (Resident 19 and 34) reviewed for falls. This failure placed the residents at risk for avoidable falls with injury and diminished quality of life. Findings included . Review of a facility policy titled, Falls and FaII Risk, Managing, dated March 2018, showed that staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility policy showed position-change alarms would not be used as the primary or sole intervention to prevent falls, rather to identify patterns and routines of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 1 of 1 residents (Resident 34) who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. This failure placed residents at increased risk of urinary tract infections and decreased quality of life. Findings included . Resident 34 admitted to the facility on [DATE] with diagnoses that included fracture of the right leg (broken right leg), high blood pressure, and unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 34's Minimum Data Set (MDS - an assessment tool) assessment, dated 06/07/2023, showed that they were frequently incontinent and not on a toileting program. In a review of the Care Area Assessment (CAA - an assessment of a specific care or medical issue), dated 06/08/2023, showed Resident 34's incontinence would be addressed in the care plan. There was no description or complete assessment as to the rationale of adding incontinence to Resident's care plan. Review of Resident 34's care plan showed: - As of 05/30/2023, required two staff for assistance in incontinent care. - As of 06/08/2023, had functional bladder incontinence with a history of Urinary Tract Infection. Interventions on the care plan included Resident 34 wearing disposable briefs, staff offering Resident 34 the use of the beside commode, staff checking and changing Resident 34 every two hours, encouraging fluids, documenting intake, output, and offering toileting to Resident 34 upon arising, before meals, and at night. - As of 09/11/2023, Resident 34 was noted to have deficits in self-care performance in completing Activities of Daily Living (ADL- a term used in healthcare to refer to people's daily self-care activities). Resident 34 was to receive prompted toileting upon arising, and before and after meals through a nursing restorative program. Review of progress notes for Resident 34, dated 01/01/2023 to 10/11/2023 showed: - On 06/01/2023, 06/02/2023, 06/03/2023, 06/08/2023, 06/09/2023, 6/10/2023, 06/21/2023 and 06/22/2023 Resident 34 required incontinent care of one-person moderate assistance and the resident used briefs for comfort and dignity. - On 09/16/2023, the resident was noted to have had a small bowel incontinence in which they refused care. - There was no other information found in the progress notes regarding Resident 34's restorative toileting program, their incontinence, or their intake (measurements of fluids that enter the body) or output (measurements of fluid that leave the body). Observations on 10/10/2023 at 9:44 AM and 2:45 PM, and 10/11/2023 at 9:31 AM , Resident 34's room had a strong smell of urine and no bedside commode. On 10/11/23 at 1:06 PM, Resident 34 was observed using their four wheeled walker. Resident 34 was wearing red slip-on shoes with a heel, one foot had a sock on, and the other foot did not. There was a napkin and liquid on floor in front of the resident's bed. Resident 34 removed an incontinent brief from dresser drawer, took small shuffling steps, and entered the bathroom. There was a strong odor of urine coming from the resident's room. On 10/11/2023 at 1:22 PM, observed Resident 34's call light on. Staff Z, Nursing Assistant Certified (NAC), entered the resident's room, the call light was turned off, and Staff Z left the resident's room less than a minute after entering. The resident's room had a strong smell of urine present. In an observation at 10/12/2023 at 2:58 PM, Staff K, Housekeeping was observed in the resident's room cleaning. Resident 34 was speaking to Staff K and directed Staff K to clean urine up from in front of their bed. Resident 34 walked, shuffling, without the use of a walker, into the bathroom, the light in the bathroom was off and the door was open. Observations on 10/13/2023 at 9:32 AM and 10/16/2023 at 9:29 AM, Resident 34's room had a strong smell of urine and no bedside commode. In an interview on 10/16/2023 at 9:53 AM, Staff M, NAC, stated Resident 34 was both continent and incontinent of urine and their status varied. Staff M stated the resident refused care and was supported with incontinent care in the form of changing clothing and taking showers. Staff M stated they were able to help Resident 34 in the middle of breakfast around 9:00 AM with changing the resident's clothing and sheets. Staff M stated the interventions for Resident 34 included to encourage the resident, offer care, come back later, or have another aide to come assist. Staff M stated they had noticed a strong odor of urine in the resident's room. Staff M stated the nurse was often outside of the resident's room and knew Resident 34 refused showers often. Staff M stated they do not think that the resident was on a restorative program. This is a repeat citation from 08/18/2022. Refer to WAC 388-97-1060(3)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with professional standards of practice for 1 of 1 sampled resident (Resident 32) reviewed for enteral nutrition. The facility failed to ensure orders were processed and transcribed accurately which placed the resident at risk for inadequate nutrition, hydration, and weight loss. Findings included . Review of a facility policy titled, Enteral Nutrition, dated 2001 and revised November 2018, showed complete orders for enteral nutrition should include: the enteral nutrition product, the delivery site (tip placement); the specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.), the administration method (continuous, bolus, intermittent); the volume and rate of the administration, and the volume/rate goals and recommendations for advancement toward these; and instructions for flushing (solution, volume, frequency, timing and 24-hour volume). Resident 32 was admitted to the facility on [DATE] with diagnoses that included non-traumatic cerebral hemorrhage (stroke from ruptured blood vessel causing bleeding inside the brain) that affected their ability to swallow, history of gastric/jejunum stricture (narrowing of connection between stomach and small intestine) and placement of jejunostomy feeding tube (feeding tube placed into their jejunum/small intestine.) Review of Resident 32's current physician orders, showed the following order: Fibersource High Nitrogen (HN - a brand of liquid food) with equal amounts of water for example if one 1.5 can of Fibersource equals 375 cc (cubic centimeter) of liquid food, add additional 375 cc water for 50% solution to water. Note: routine water flush was 35cc/hr (hour). Review of the written orders showed they were incomplete and did not include delivery site, specific access device, administration method, or volume and rate of administration. Review of Resident 32's nutrition progress note, dated 09/25/2023, Collateral Contact 3 (CC3), Registered Dietician (RD), showed the current tube feeding order was Fibersource HN 240cc diluted with equal amount of water once every shift and 65 cc water every hour. CC3 recommended that the Fibersource HN be increased to 1.5 cans, diluted 1:1 with water every shift for total of 90 cc/hr and the additional water flush could be decreased to 35 cc/hr. In an observation on 10/12/2023 at 10:06 AM, Resident 32 was observed sitting up in their bed with the feeding tube connected to a feeding bag and they were receiving formula via a pump. The setting on the pump was observed and showed it was set at 60 cc per hour with water flush set at 35cc per hour. In a joint interview and record review on 10/12/2023 at 10:28 AM, Staff F, Registered Nurse, stated they were not aware of any changes in Resident 32's tube feeding orders and confirmed the resident was getting their tube feeding formula at a rate of 60 cc per hour at that time. Staff F reviewed the current Medication Administration Records (MAR) and was unable to state what the rate of administration of the tube feeding should be from the order listed on the MAR. Staff F stated that the written order did not include the cc's per hour, and it should. In a joint interview/record review on 10/12/23 at 10:45 AM, Staff D, Licensed Practical Nurse/Nurse Manager, stated the tube feeding orders for Resident 32 were incomplete and did not show that the tube feeding rate of administration had been increased from 60 cc to 90 cc per hour as recommended by the dietitian on 09/25/2023. Staff D stated the order had not been followed up on as recommended. Refer to WAC 388-97-1060(3)(f) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 19> Resident 19 admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses to include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus type 2 (medical condition in which the body doesn't use insulin properly), and fracture of the right femur (broken right leg). Review of Resident 19's care plan, dated 08/18/2023, showed staff were to encourage Resident 19 to take sustained deep breaths with the use of an incentive spirometer (handheld medical device used to help improve the functioning of the lungs) every two hours while awake. Review of Resident 19's October 2023 MAR, showed an order for the licensed nurse to encourage use of incentive spirometer every two hours as tolerated every shift starting 08/18/2023. There were three boxes used to document for Day Shift, Evening Shift, and Night Shift. There were check marks in the boxes of each shift from 10/01/2023 through 10/13/2023. In an interview 10/11/2023 at 2:07 PM Staff U, Registered Nurse, stated they had offered Resident 19 the incentive spirometer around 10:00 AM to 11:00 AM, but Resident 19 was not interested. In an interview on 10/12/2023 at 3:00 PM, Staff R, LPN stated they started their shift at 6:00 AM. Staff R stated they had not offered Resident 19 the incentive spirometer yet. Staff R could not provide information on how often Resident 19 was offered the incentive spirometer or if Resident 19 was offered the medical device every two hours. Staff R stated the resident had not refused the use of the incentive spirometer and described Resident 19 as cooperative. On 10/11/2023 at 9:24 AM, Resident 19's incentive spirometer was observed on their overbed table within their reach. On 10/12/2023 at 11:34 AM and 3:00 PM, Resident 19's incentive spirometer was observed on their dresser out of their reach. Refer to WAC 388-97-1060(3)(j)(vi) Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were followed according to professional standards of practice for 2 of 3 residents (Residents 8 and 19) reviewed for respiratory care. The failure to transcribe and/or follow physician's orders for respiratory care and routinely change oxygen tubing placed the residents at risk of unmet care needs, respiratory infections, and related complications. Findings included . <RESIDENT 8> Resident 8 was admitted to the facility on [DATE], with diagnoses to include heart failure, atrial fibrillation (a fast irregular heart rate), and chronic obstructive pulmonary disease (COPD - group of diseases that cause airflow blockage and breathing problems). Review of Resident 8's admission Minimum Data Set (MDS - an assessment tool) assessment, dated 10/03/2023, showed no documentation the resident used oxygen. Review of Resident 8's care plan, initiated on 09/25/2023, showed the resident was oxygen dependent and had an intervention for oxygen per the provider's order. Review of Resident 8's 09/01/2023 through 10/13/2023 Medication Administration Records (MAR), showed they were to receive three liters per minute of oxygen through a nasal cannula (tube from oxygen machine to nose). Review of Resident 8's provider (MD, Nurse Practitioner, or Physician Assistant) orders, dated 10/09/2023, showed the resident was to receive oxygen three liters per minute through a nasal cannula to maintain oxygen level above 92%. Observations on 10/09/2023 at 9:24 AM, 9:49 AM, 10:51 AM, and 11:12 AM, Resident 8 was observed to be on oxygen and the oxygen tubing was not dated. Observation on 10/10/2023 at 09:33 AM, Resident 8 was observed to be lying in bed with their oxygen on and the oxygen tubing was not dated. In an interview on 10/13/2023 at 1:45 PM, Staff D, Licensed Practical Nurse (LPN/Nurse Manager (NM), stated Resident 8 was admitted on oxygen and there should have been orders to change the oxygen tubing weekly and the tubing should be dated and initialed at time of the change. Staff D looked in Resident 8's electronic medical record and found new orders to change oxygen tubing weekly. Staff D acknowledged Resident 8 did not have orders to change oxygen tubing weekly until 10/10/2023. In an interview on 10/16/2023 at 2:15 PM, Staff A, Administrator, stated residents on oxygen should have orders to change oxygen tubing weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 34> Resident 34 admitted to the facility on [DATE] with a diagnosis of unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 34's Care Area Assessment (CAA - an assessment of a specific care or medical issue) for activities, dated 06/08/2023, showed the resident was at risk for an alteration in activities and prior to admission was involved in group activities. Resident 34 was noted to have severe cognitive communication deficits, multiple medical conditions, and had socially inappropriate behaviors. Review of Resident 34's care plan, dated 06/08/2023, showed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs due to severe cognitive-communicative because of dementia. The goal for Resident 34 was they would maintain involvement in cognitive stimulation and social activities. Interventions included one-to-one bedside/in-room visits and activities. Observations on 10/10/2023 at 9:44 AM, 10/11/2023 at 10:18 AM, 10/12/2023 at 11:38 AM, Resident 34 was in their bed with their eyes closed. Observation on 10/12/2023 at 11:55 AM, Resident 34 was in their room on their bed. Staff Y, Nursing Assistant Certified (NAC), offered the resident something to drink and asked them how they were feeling. Resident 34 something to drink and asked them how they were feeling. Resident 34 replied, several times, that they were dead. Staff Y was observed leaving Resident 34's room stating that they would leave them alone. Observation at 10/12/2023 at 11:43 AM, Staff CC, Laundry, entered Resident 34's room, offered resident a clothing protector for lunch and left the resident's room in less than a minute. Observation at 2:58 PM, observed Staff K, Housekeeping, in resident's room cleaning. Resident 34 was speaking to Staff K, stating that there were flies in their room and that they (themselves) might as well die. Observations on 10/13/2023 at 9:32 AM, Resident 34 was in their bed with their eyes closed. In an interview on 10/13/2023 at 1:03 PM Staff D, Licensed Practical Nurse (LPN)/Nurse Manager, stated Resident 34 liked to go outside and sit. Staff D stated all staff were responsible to offer activities to the residents and dementia specific care for Resident 34. Staff D stated the resident could be offered puzzles, a walk, television program, and offering choices was important. Staff D stated Resident 34 was to be offered choices for care, food and something to drink. When asked what the facility's dementia care guidelines were, Staff D, deferred to Social Services and stated the nursing staff interact with residents with dementia to the best of their abilities. In observations on 10/16/2023 at 9:29 AM, Resident 34 was in their bed with their eyes closed. In an interview on 10/16/2023 at 10:19 AM Staff G stated Social Services was responsible for assessing and completing the MDS section for residents related to dementia. In an interview on 10/16/2023 at 10:29 AM, Staff C stated that they were responsible for the care plan for residents that had dementia and required dementia care. Staff C stated they gathered information, discussed concerns regarding specific residents in care conferences, and morning meetings with the nursing staff. Staff C initially stated Resident 34 had family involvement and then stated Resident 34 did not have any family involved in their care. Staff C described Resident 34 as persnickety and liked things on their own terms. Staff C stated the approach with Resident 34 was important because if the staff push too much, the resident likely would react by screaming. When asked how Social Services interacted with the Activities Department to support Resident 34, Staff C deferred to the Nursing Certified Assistants. In an interview on 10/16/2023 at 11:03 AM Staff I, Activities Director, stated that they were not involved in the care planning process and were not currently completing MDS assessments. Staff I stated that for residents that had memory/cognitive issues, they provided sensory items, puzzles, and music. Refer to WAC 388-97-1040 (1)(a-c) Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided to 2 of 2 residents (Resident 10 and 34) reviewed for dementia care. Failure to implement resident-specific interventions to address the resident's hallucinations (where someone sees, hears, smells, tastes or feels things that don't exist outside their mind) and delusions (unshakeable belief in something that isn't true, or likely to happen), placed the residents at risk for having unidentified and/or unmet care needs, avoidable decline, and diminished quality of life. <RESIDENT 10> Resident 10 admitted on [DATE] with dementia without behavioral disturbance, anxiety, mood disturbance, depression, and bipolar disorder (a serious mental illness characterized by extreme mood swings). Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 09/29/2023, showed the resident experienced hallucinations (the perception of the presence of something that is not actually there that may be auditory or visual or involve smells, tastes, or touch) and delusions (fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary) and had significant cognitive impairment. Review of the care plan developed on 10/02/2023, showed Resident 10 was dependent on staff for meeting their emotional, intellectual, physical, and social needs related to severe cognitive deficits and immobility. The interventions were not resident centered. In an interview and observation on 10/16/2023 at 2:08 PM, Resident 10 was in their wheelchair in their room with a portable phone in their hand. The resident talked about lunch and asked if their family member could join, they reached out to their bed and said their son was right here (the resident's family was not in the resident's room). Resident 10 then became anxious and started repeatedly calling out (their family members name). Resident 10 said they were just here. In an interview on 10/16/2023 10:03 AM, Staff G, Registered Nurse/MDS coordinator, said when a resident had dementia it would be a care plan under cognition. Staff G said they included interventions on how to communicate with those with cognitive impairment. Staff G said social services should do that section, but they did a lot of it themselves. In an interview on 10/16/2023 at 10:29 AM, Staff C, Social Services, said the care plan should include interventions to help the staff care for those residents with cognitive impairment. They said they would include interventions like explaining care ahead of time, providing care one step at a time, and ways to distract or redirect to get tasks done. In an interview on 10/16/2023 at 1:23 PM, Staff B, interim Director of Nursing Services, said they knew dementia care was an issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnosis to include depression. Review of Resident 31's admission MDS assessment, dated 08/12/2023, showed the resident had diagnoses of depression, anxiety, and Post Traumatic Stress Disorder (PTSD - a serious mental illness characterized by extreme mood swings). Review of Resident 31's hospital discharge documents, dated 08/05/2023, showed the resident had a diagnosis of depression, there was no diagnoses of anxiety or PTSD documented. Review of the Resident 31's electronic medical record on 10/13/2023, showed an anxiety disorder had been added to the resident's diagnosis list on 09/05/2023. Further review of the medical record showed the PTSD diagnosis was not added to the diagnosis list and there was no physician documentation related to the anxiety or PTSD diagnosis. Review of Resident 31's August 2023 Medication Administration Record showed the resident was prescribed scheduled lorazepam (anti-anxiety medication) 0.5 milligrams (mg) three times daily on 08/23/2023 and buspirone (anti-anxiety medication) 15 mg twice daily for anxiety on 08/30/2023. On 8/11/2023 Paxil (anti-anxiety medication) 10 mg was prescribed daily for anxiety. On 08/22/2023, the Paxil dosage was doubled to 20 mg daily. In an interview on 10/13/2023 at 1:45 PM, Staff D stated Resident 10's diagnoses come from their chart records, provider diagnoses list, or clinical documentation. Staff D stated they did not know where Resident 31's diagnosis of anxiety came from, and that the resident was on multiple medications for anxiety. In an interview on 10/16/2023 at 10:04 AM, Staff G, Registered Nurse/MDS coordinator, stated they wound not know how anxiety was added Resident 31's diagnoses. Staff G stated the diagnosis of anxiety was documented in Resident 31's MDS assessment, dated 08/12/2023. Staff G stated Social Service staff would know about Resident 31 diagnoses. In an interview on 10/16/2023 at 10:28 AM, Staff C, Social Services, stated diagnoses should come from a clinical document. Staff C stated they remember discussing anxiety as a diagnosis for Resident 31 with the provider and clinical team and decided not to add the diagnosis. Staff C stated they did not see clinical documentation related to diagnosis of anxiety for Resident 31. In an interview on 10/16/2023 at 1:00 PM, Staff D stated they had talked about not adding diagnoses that were not provided by a provider (Medical Doctor, Nurse Practitioner, Physician Assistant). Requested any additional information or documentation related to the diagnosis of anxiety and use of multiple anti-anxiety medications. No further information provided. Refer to WAC 388-97-1060 (3)(k)(i) Based on observation, interview, and record review, the facility failed to ensure adequate indications for use, failed to ensure target behaviors were individualized and monitored, failed to complete necessary assessments, and failed to address pharmacist recommendations related to psychotropic medication use for 2 of 5 residents (Resident 10 and 31) reviewed for unnecessary medications. These failures placed residents at risk for a decreased quality of life, medication side effects, and did not promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Findings included . Review of a facility policy titled, Psychotropic Medication Monitoring, dated 11/27/2006, showed before starting psychoactive medications to address the problem on the care plan and social services would write management approaches and target behaviors. If unable to manage behaviors with management approaches, contact the physician. Ask for a mental health order, and if medication was ordered do not give until resident/family understood the risks/benefits and agrees to the medication. For anti-psychotic medications, complete an AIMS (Abnormal Involuntary Movement Scale) before starting the medication and repeat the test 1 month and 2 months after the medication was started, then every 6 months thereafter. Notify the physician of significance in AIMS score. Social Services was to start target behavior flow records on medication profile to monitor target behaviors and side effects. <RESIDENT 10> Review of Resident 10's record indicated the facility admitted the resident on 09/25/2023 with diagnoses including bipolar disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the admission Minimum Data Set (MDS - assessment tool) assessment, dated 09/29/2023, documented Resident 10 had severe cognitive impairment and experienced potential indicators of psychosis including hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions tor beliefs that are firmly held, contrary to reality). Review of the admission physician orders, showed Resident 10 was prescribed donepezil (a medication used to treat confusion) 10 milligrams (mg) by mouth at bedtime for dementia, quetiapine (an antipsychotic medication) 150 mg at bedtime for agitation related to bipolar disorder, buspirone (an antianxiety) 30 mg by mouth at 8:00 and 8:00 PM for anxiety, and zoloft (an antidepressant) 100 mg twice a day at 8:00 AM and 8:00 PM for depression. Review of Resident 10's progress note, dated 09/25/2023 at 5:12 PM, showed the following order was outside of the recommended dose or frequency: bupropion hcl (XL) oral tablet extended release 24-hour 150 mg's. Give 1 tablet by mouth two times a day for Depression. This dose failed a general dose range check based on drug inputs and/or the patient information provided. Bupropion dose should be adjusted based on renal (kidney) function and manual screening is required. Review of Resident 10's clinical record showed no labs were obtained to check renal function for bupropion dosing. Review of Resident 10's progress note, dated 09/25/2023 at 5:14 PM, showed the following order was outside of the recommended dose or frequency: Sertraline HCL (zoloft) oral tablet 100 mg, give one tablet by mouth two times a day for depression. The frequency of two times per day exceeded the usual frequency of daily. Review of the pharmacist's medication regimen review, dated 09/26/2023, revealed Resident 10 was taking the following antidepressant medication, Sertraline and bupropion XL which may be considered therapeutic duplication. Some clinical conditions or situation may require several adjuvant medications together. The pharmacist recommended the facility assess and document the benefits and risks of combination antidepressant therapy. The review was noted by Staff D, Licensed Practical Nurse/Nurse Manager. Review of the clinical record showed there was no assessment or documentation about the risks of taking two different antidepressant medications. Review of the facility's binder of pharmacy consults revealed two additional pharmacist consults regarding psychoactive medications that were not present in the medical record: - Resident 10 had an order for the as needed (PRN) antipsychotic medication quetiapine 150 mg nightly and every evening as needed for agitation. This order must be limited to 14 days. A new order for the PRN antipsychotic may be written if the prescribing practitioner directly examines and assesses the resident and documents clinical rationale for new order. The pharmacist recommended to discontinue the PRN antipsychotic medication, have the provider (physician, nurse practitioner or physician assistant-certified) directly examine and assess the resident if the order continued, and document clinical rational and write new order if appropriate every 14 days. - Resident 10 was taking the antipsychotic mediation quetiapine 150 mg nightly and PRN. Monitor the resident for movement disorders with an Abnormal Involuntary Movement Scale (AIMS) that was recommended upon initiation of the medication, during dosage changes, and then at least every 6 months. Review of Resident 10's clinical record showed there was no documentation about addressing the pharmacy consults. Review of the multidisciplinary care conference, dated 09/27/2023 and located in the assessment tab of the clinical record, showed a completely blank care conference for Resident 10. The task was initiated but not completed. Observation on 10/09/2023 at 10:12 AM, Resident 10 was in bed asleep. Observations on 10/10/2023 at 9:20 AM and 2:44 PM, Resident 10 was in bed asleep. Observations on 10/11/2023 at 9:24 AM and 12:04 PM, Resident 10 was in bed asleep. In an interview and observation on 10/11/2023 at 3:19 PM, Resident 10 was awake sitting on the edge of their bed, stating they were tired but otherwise felt okay. In an interview on 10/16/2023 at 10:29 AM, Staff C, Social Services, said the facility had weekly psychotropic meetings, but they did not keep minutes of the meetings. Staff C stated they would complete a progress note if the resident was discussed. Staff C said Staff D kept track of psychotropic medications, and gradual dose reductions. Staff C said Resident 10 was on two antidepressants and high doses of quetiapine and BuSpar. Staff C said they had asked Staff N, Medical Director, to do a medication review and look at the doses for Resident 10. Staff C said Resident 10 was out of control at the hospital and they threw a bunch of medications at (Resident 10). In an interview on 10/16/2023 at 1:09 PM, Staff D was asked about the psychoactive medications, duplicative therapy, and pharmacist recommendations. Staff D stated they had informed Staff N, Medical Director, to address that but did not document that.

Based on interview and record review, the facility failed to ensure dental services were provided for 1 of 2 Medicaid sampled residents (Resident 11) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to wear ill-fitting dentures. These failures placed residents at risk for difficulty chewing and a decreased self-image and diminished quality of life. Findings included . Review of Resident 11's 09/13/203 Quarterly Minimum Data Set (MDS - an assessment tool), an assessment tool, showed the resident was cognitively intact, required physical assistance with hygiene including oral care. The resident was edentulous (had no natural teeth) and did not have loosely fitting dentures. Review of the activities of daily living (ADL) care plan, dated 09/20/2023, Resident 11 had upper and lower dentures and needed assistance with oral care. Staff were directed to remove and clean dentures at bedtime. The care plan indicated the resident used a denture adhesive daily. During an interview on 10/09/2023 at 10:41 AM, Resident 11 reported their dentures did not fit good anymore. The resident said they were using denture adhesive and swallowed too much of it and it upset their stomach. The resident stated lately they were needing to use denture powder after every meal. The resident said they would love a denture appointment. Review of Resident 11's dental consult, dated 10/07/2022, showed the dentist recommended and referred Resident 11 to a denturist. A handwritten note showed the resident would like to have their dentures realigned. The consult was noted by a nurse on 10/14/2022. Review of a progress note on 10/14/2022 at 3:23 PM, showed Resident 11 had been seen by the dental hygienist on 10/07/2022 and the resident would like their dentures realigned. Review of the clinical record did not include any follow up about Resident 11 request and dentist recommendation for denture realignment. In an interview on 10/11/2023 at 12:31 PM, Staff L, Nursing Assistant Certified/Unit Secretary, stated they were unaware Resident 11 needed to see a denturist or that there had been previous referrals for the resident. In an interview on 10/11/2023 at 1:45 PM, Staff L provided a fax from the dentist which included another consult, that was not present in the clinical record from 05/09/2023, showed Resident 11 would like to have their bottom denture relined to fit better. Review of Resident 11's dental consult, dated 05/09/2023, showed the dentist recommended and referred Resident 11 to a denturist. A handwritten note showed the resident would like to have bottom denture realigned to fit better. Area of concern showed ill-fitting lower denture. During an interview on 10/16/2023 at 1:09 PM, Staff B, Director of Nursing Services, was informed Resident 11 had two dental consults that showed the resident wanted her dentures relined and did not receive timely dental services. This is a repeat citation from 08/18/2022. Refer to WAC 388-97-1060(1)(3)(j)(vii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a homelike environment for 3 of 3 resident care areas (100 hall (to include room [ROOM NUMBER] and 402), 200 hall and 300 hall) and 2 of 2 residents rooms (Resident 20 and 33) reviewed for environment. The facility failed to ensure the carpet in the hallways were clean and maintained, walls repaired, privacy curtains laundered, and comfortable sound levels were maintained for the residents. The facility's failure to provide maintenance and housekeeping services and management of noise level placed residents at risk for diminished rest and quality of life. Findings included . <NOISE> In a continuous observation on 10/11/2023 from 1:29 PM to 2:03 PM, Resident 33 called out 28 times Help Me, which could be heard down the 200 hall. In a continuous observation on 10/11/2023 from 2:13 PM to 3:45 PM, there was frequent loud banging into the walls heard from the kitchen. In observations on 10/12/2023 at 11:44 AM and 2:31 PM, there was loud banging noise emitting from the kitchen. In a continuous observation on 10/12/2023 at 10:35 AM to 11:03 AM, Resident 33 called out four times. In a continuous observation on 10/13/2023 at 9:15 AM to 9:58 AM, loud frequent banging noises was heard almost constantly from the kitchen. In a continuous observation on 10/13/2023 from 1:40 PM to 2:36 PM, loud frequent banging nose and doors slamming were heard almost constantly from the kitchen. In an interview 10/13/2023 at 9:36 AM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager, commented the kitchen was loud. Staff D stated sometimes they go into the kitchen and told them to quiet down. In an observation on 10/13/2023 at 9:46 AM at the East Nurses Station (across from room [ROOM NUMBER] and 402), there was loud banging noises coming from the kitchen. In a brief interview on 10/13/2023 at 9:46 AM, Staff D stated the kitchen was loud, and they have had to ask the kitchen to quiet down. <HALLS> Observation on 10/12/2023 at 11:49 AM, a sit to stand machine (a machine used to transfer a resident from one surface to another), wheelchair, medication cart, stool, trash can, Hoyer (a machine used to transfer residents from one surface to another), a clean laundry/linen cart and Enhanced Barrier Precautions (containing personal protective equipment for resident care) cart lined the hallway of the 200 hall. <GRIEVANCE> Review of grievance/concern, dated 08/14/2023 at 10:30 AM, showed that a prior resident reported being tired of the guy yelling help day and night. <CARPET> In an observation on 10/12/2023 at 2:34 PM, the carpet throughout the facility was heavily worn in all places except for the edges closest to the walls. In an interview on 10/16/2023 at 9:48 AM Staff H, Maintenance Director, stated the facility had tile carpet and they have steamed cleaned in front of kitchen a couple weeks ago and replaced some tiles, but the area was a high traffic and gets dirty quick. Staff H stated they think the carpet might be about [AGE] years old. Staff H stated they had spoken to the prior administrator about replacing the carpet, but not since then. Staff H stated the carpet was spot cleaned prior to the maintenance assistant leaving about two weeks ago. <PRIVACY CURTAINS> In an observation on 10/09/2023 at 09:18 AM, in room [ROOM NUMBER], privacy curtain noted to be soiled with areas of dried brown substance smears. In an observation on 10/12/2023 at 2:31 PM, room [ROOM NUMBER]'s privacy curtains remained soiled with dark pink stain, brown dried stains, and dirt smudges. Resident 20 was asked how often their privacy curtains were changed or laundered, the resident stated the facility had measured them a few months ago and talked about replacing them. The resident said they couldn't recall when they were last changed. This is a repeat deficiency from 08/18/2022. Refer to WAC 388-97-0880 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 19> Review of incident investigations for Resident 19, showed the resident fell on [DATE], 05/15/2023, and 09/18/2023, showed the investigations were not complete and accurate. Review of the incident investigation, dated 05/10/2023, contained conflicting information regarding the time of the incident, the note written on 05/11/2023 noted that Resident 19's fall occurred at 9:40 AM and the incident report noted the time at 4:18 PM on 05/10/2023. The incident report notes indicated Resident 19's fall was a non-injury fall and was unwitnessed. Documentation was not located to indicate an injury was ruled out after Resident 19 voiced pain in their left hip. Abuse and neglect were ruled out per the notes in the incident report; however, no evidence was located in the resident's medical record or incident report to support a thorough analysis of this finding. Review of an incident investigation, dated 05/15/2023, indicated Resident 19 had an unwitnessed fall at 5:00 PM. The incident report indicated the resident was found to have a right hip fracture. The notes section in the incident report referred to notes attached, which was the nurse progress note from 05/15/2023 noting the fall. The progress note indicated Resident 19 was found lying on the floor on their back after their roommate yelled out for help. The incident report did not address how potential abuse and/or neglect was ruled out. Review an incident report, dated 09/18/2023, showed Resident 19 had a witnessed fall at 11:00 PM. The description of the incident indicated the resident was found to be lying on their right side when the nurse walked by the resident's room. The description of the incident was contradictory to a witnessed fall. Abuse and neglect were ruled out per the notes in the incident report; however, no evidence was in the resident's medical record or incident report to support a thorough analysis of this finding. The incident report lacked the components of a complete and thorough investigation. <INTWERVIEWS> In an interview on 10/09/2023 at 11:33 AM, Staff A, Administrator, stated all grievances were not logged prior to June 2023. In an interview on 10/16/2023 at 10:29 AM, Staff C, Social Services, stated they had training when hired on abuse and neglect. Staff C stated that if there is an allegation of abuse or neglect, they interviewed like residents. Staff C stated they manage the grievance process and made sure all the steps were taken, log the grievances, and manage them. Staff C stated the team decided at the morning meeting if a grievance was an allegation of potential abuse or neglect or just a grievance. Staff C explained the team talked about what was written on the grievance and if it was determined that it was an allegation then they would discuss it with Staff B and Staff D, Licensed Practical Nurse/Nurse Manager. An interview was done on 10/16/2023 at 12:15 PM, with Staff A, Staff B, and Staff D. Staff B explained the difference between a grievance and an allegation was a grievance was something that does not hurt a patient (resident) and an allegation could include a resident alleging that a staff member was rough with them. Staff D stated Staff P had completed all the incident reports and they (Staff D) was not allowed to be involved in the process. Staff B stated they were just hired as interim DNS a week prior and was doing the best they could. Staff A stated the integral parts of an investigation included: interviews with the resident in question, witness statements, and staff interviews. Staff A stated Staff P was not following through with grievances and incident reports with poor oversight. Staff A stated that they would be doing investigations differently and they (Staff A) would not be signing off on them until all the information was complete and included. This is a repeat deficiency from 08/18/2022. Reference: (WAC) 388-97-0640 (6)(a) <RESIDENT 33> Review of the facility's incident reporting logs for August, September, and October 2023, showed Resident 33 had fallen in the facility on 08/03/2023, 08/25/2023, 09/25/2023, and 10/05/2023. Review of the investigation report, dated 10/05/2023 at 10:30 PM, showed Resident 33 was found by staff lying on the floor mat next to the bed. The investigation was incomplete. It was unclear how the facility ruled out potential abuse and/or neglect due to the resident's repeated falls in the facility. Based on interview and record review, the facility failed to facility failed to implement their abuse/neglect policy and procedure, thoroughly investigate falls, allegations of potential abuse and/or neglect to identify the root cause and all contributing factors related to an allegation for 11 of 12 investigations (3, 93, 22, 25, 94, 24, 91, 11, 10, 33, and 19) reviewed. Failure to thoroughly investigate allegations of abuse and/or neglect placed residents at risk for additional abuse/neglect. Findings included . Review of the facility policy titled, Abuse/neglect Incident Policy and Procedure, undated, revealed the facility was to identify, correct and intervene in situations in which abuse, neglect was more likely to occur. All incidents will be thoroughly investigated upon discovery of the incident. If a staff to resident incident is suspected, the staff is removed from the area or facility. The hotline is to be notified within 2 hours. The staff were directed to seek to determine by analyzing facts, interview the alleged resident victim, all residents in the same hall or set, interview witnesses including potential witnesses, roommates, alleged suspect and take appropriate action to safeguard further incidents during the investigation process. Complete a comprehensive record review, document what was done and who was trained. A thorough investigation requires a review (who, what, why, when, where and how questions) as applicable to the incident and as is necessary to come to a reasonable conclusion. <RESIDENT 3> Review of a grievance/concern, dated 07/24/2023, showed Resident 3's family member reported Resident 3 reported they fell on Saturday 07/22/2023, the facility was short staffed and call lights were not being answered during the evening and night shift for over an hour. The resident's family member reported the resident was getting a urinary tract infection every month related to the call light not being answered and lack of cleaning thoroughly. A bruise was noted to the resident's right hand/wrist. The action taken showed day and evening staff were interviewed and no fall was reported. The call light audit was pulled. Resident 3's grievance was not investigated as a potential neglect allegation. There was no evidence the facility ensured the grievance was investigated thoroughly to rule out the allegation of potential neglect or a plan to prevent reoccurrence. Review of the clinical record showed Resident 3 was not assessed or documentation regarding these concerns or the bruising. <RESIDENT 93> Review of a grievance/concern, dated 07/25/2023, showed Resident 93 reported they waited an hour and a half for their call light to be answered on more than one occasion. The follow up/outcome showed the resident wanted their call light answered timely and a call light audit was scheduled for follow up. Resident 93's grievance was not investigated as a possible neglect allegation. There was no evidence the facility ensured the grievance was investigated thoroughly and include a plan to prevent reoccurrence. It was unclear how the allegation of neglect had been ruled out. Review of a grievance/concern, dated 08/09/2023, showed Resident 93 reported they waited an hour and a half for their call light to be answered on more than one occasion. The follow up/outcome showed resident wanted their call light answered timely and a call light audit was scheduled for follow up. Resident 93's grievance, dated 08/09/2023, was not investigated as a possible neglect allegation to rule out neglect regarding long call wait times and the resident's needs not being met timely. There was no plan for reoccurrence. <RESIDENT 22> Review of a grievance/concern, dated 08/11/2023, showed Resident 22 was asked if anyone had ever been rough with them when giving care. Resident 22 responded, Yes, they push on my bare bottom. I do not know their names and it happens at nighttime. Action taken was staff education and care plan update. Resident 22's grievance was not investigated as a possible abuse allegation. There was no evidence how the facility ruled out potential abuse and did not include a plan to prevent reoccurrence. Review of Resident 22's clinical record showed no documentation the resident had been assessed, monitored, or placed on alert charting regarding the allegation of potential physical abuse. <RESIDENT 25> Review of a grievance/concern, dated 07/25/2023, showed Resident 25 stated they waited too long for their call light to be answered. Action taken was to meet with the resident, complete a call light audit, and staff coaching. There was no evidence the facility ensured the grievance was investigated thoroughly to rule out the allegation of potential neglect or a plan to prevent reoccurrence. Review of a grievance/concern, dated 08/28/2023, showed Resident 25 stated they turned their call light on at 2:00 AM that morning and did not get help until 3:00 AM. There were call light reports printed confirmed that the call light was on for 61 minutes. There was no evidence the facility ensured the grievance was investigated thoroughly and include a plan to prevent reoccurrence. It was unclear how the allegation of potential neglect was ruled out regarding the resident's call light wait time. Review of the clinical record showed no documentation Resident 25 was assessed or monitored regarding the allegation of potential neglect. Review of a grievance/concern, dated 09/27/2023, showed Resident 25 made a complaint about Staff AA, Nursing Assistant Certified (NAC), not answering their call light promptly and they did not want this aide to help them. The follow up was for Staff AA to no longer care for Resident 25. There was no evidence the facility ensured the grievance was investigated thoroughly to rule out the potential abuse and/or neglect when Resident 25 identified a specific staff member and not wanting the staff member to care for them. <RESIDENT 94> Review of an incident report, dated 07/27/2023 at 2:33 AM, showed Resident 94 had been found on the floor lying on a pillow on their back next to their bed. The resident was assessed for injury and stated their hip and knee hurt. The immediate action taken was to ensure the fall alarm and mat were in place. It was unclear if these devices were present at the time of the fall. Review of a progress not, dated 07/27/2023 at 12:19 PM, showed the night nurse reported Resident 94 had a non-injury fall. The resident's family member requested nursing send them out to the hospital for further evaluation related to the fall. Resident 94 was sent to the hospital via ambulance. Review of a progress note, dated 07/27/2023 at 6:16 PM, showed Resident 94 had a lumbar 2 (L2 - a bone in the lower back), but the hospital could not say if it was from the fall last night. Review of the incident investigation lacked evidence Resident 94's fall thorough to indicate the root cause of how Resident 94 sustained a L2 fracture. There was no plan to prevent reoccurrence. <RESIDENT 24> Review of a grievance/concern, dated 08/11/2023, showed Resident 24 was asked if they had any concerns with care. They stated Yes, call light response time for yesterday, I waited hours to be helped. Action taken was staff education and a call light audit was pulled. There was no evidence the facility ensured the grievance was investigated thoroughly and included a plan to prevent reoccurrence. It was unclear how the allegation of neglect was ruled out. <RESIDENT 91> Review of a grievance/concern, dated 08/11/2023, showed Resident 91 stated call light times were longer and their wheelchair was being moved out of their reach. Review of the attached call light report showed two call lights were on for 50 minutes. Resident 91's grievance was not thoroughly investigated as a possible abuse or neglect allegation. It was unclear how the facility ruled out the allegation of potential abuse or neglect. There was no plan to prevent reoccurrence. Review of a grievance/concern, dated 08/20/2023, showed Resident 91 reported to them they had called the police and the state on the night shift and told them they were being neglected and their call light was not being answered. The resident stated Staff BB, Registered Nurse (RN), removed their wheelchair and reported to the state they were confined. Action taken was this was reported to Staff O, former Administrator, and Staff P, former Director of Nursing Services (DNS). The follow up/outcome showed no further information. Resident 91's grievance was not investigated further regarding the allegation of possible neglect and possible involuntary seclusion (regarding keeping their wheelchair out of reach). There was no evidence the facility ensured the grievance was investigated thoroughly to rule out the allegation of potential neglect and possible involuntary seclusion) or a plan to prevent reoccurrence. Review of a grievance/concern, dated 08/25/2023 at 12:30 PM, showed Resident 91 requested a staff member not provide care for them. There was no evidence the facility investigated the grievance thoroughly when Resident 91 identified a specific staff member not to provide care. It was unclear how an allegation of potential abuse and or neglect was ruled out. Review of a grievance/concern, dated 08/30/2023, showed Resident 91 complained about their call light not being answered for three hours. Action taken was resident was placed on alert to monitor behavior. There was no evidence the facility ensured the grievance was investigated thoroughly and include a plan to prevent reoccurrence. It was unclear how the allegation of neglect was ruled out the allegation of potential neglect. Review of a progress note, dated 08/30/2023 at 2:56 AM, was included showed the resident was upset and complained about their call light and threatened the staff they would call the police and 911 and even the state. This grievance was not escalated to a possible neglect allegation. There was no evidence the facility ensured the grievance was investigated thoroughly and included a plan to prevent reoccurrence. It was unclear how the allegation of neglect was ruled out. <RESIDENT 11> Review of an incident investigation, dated 10/09/2023, showed Resident 11 had an allegation of potential mental and physical abuse regarding Staff AA who transferred them roughly onto the toilet and then laughed at them. The resident was interviewed and said they requested not to have this aide care for them, and they cared for them one more time. Review of Resident 11's clinical record showed there were not placed on alert charting, an assessment, monitoring or any documentation about the allegation. In an interview on 10/16/2023 at 4:00 PM, Staff B, interim DNS, stated they were gathering statements now, a week after the allegation had been reported to them. <RESIDENT 10> Review of an incident cover sheet for falls showed Resident 10's name and fall occurring on 10/03/2023 at 8:15 PM. There was no incident report included. A questionnaire was attached along with a progress note that showed the resident was found on the floor. The resident stated they fell while trying to go to the bathroom. The resident sustained a one-inch hematoma on their right elbow. Included, in the packet was a skin sheet that had a handwritten note that showed no injury. The investigation conclusion on the back page was blank. It was unclear how the facility ruled out potential abuse or neglect regarding the resident falling while attempting to use the bathroom. There was no plan to prevent reoccurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 19> Resident 19 admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), diabetes mellitus type 2 (medical condition in which the body doesn't use insulin properly), and a fracture of the right femur (broken right leg). Review of Resident 19's MDS assessment, dated 08/23/2023, showed the resident used a bed and chair alarm (any physical or electronic device that monitors resident movement and alerts the staff when movement is detected) were used daily. Review of the CAA's for falls, dated 08/25/2023, showed Resident 19 was a high fall risk, had a hip fracture on 05/16/2023, muscle weakness, unsteady gait, and cognitive communication deficits. There was no documented input from the resident regarding the care area. The description of the impact of falls on the resident was minimal and referred to the current fall care plan, occupational therapy, physical therapy, speech therapy, plan of care and progress notes. The CAA lacked the components of a complete and thorough CAA. There was no notation of Resident's use or need of alarms or the rationale. In a review of progress note labeled MDS note, dated 08/25/2023, showed Resident 19's current diagnosis and the MDS was completed based on observations, record review and staff interviews. There were no other details provided as what information was collected from observation, the resident, staff or through record review. In an interview on 10/16/2023 at 10:19 AM, Staff G stated they complete the CAA process with minimal information, does not fill out the CAA's in details, and would benefit from reading the facility's policy and procedures again on the CAA process. <RESIDENT 34> Resident 34 admitted to the facility on [DATE] with diagnoses that included fracture of the right leg (broken right leg), hypertension (high blood pressure). In an interview on 10/16/2023 at 10:19 AM Staff G stated that they complete the CAA process. Staff G stated they look at the PASARR when they completed the MDS assessment and CAA process, and they had missed Resident 34's PASRR was positive for mental illness and required a Level II evaluation. In a joint interview on 10/16/2023 at 12:20 PM, Staff B, interim Director of Nursing Services, and Staff D, Licensed Practical Nurse/Nurse Manager, were informed the CAA's were not complete. Staff B and D said they were unaware they were issues with the CAA process. Refer to WAC 388-97-1000 (1)(a)(2)(q)(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's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 5 of 9 residents (10, 11, 20, 19 and 34) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included . Review of the facility's policy, Care Area Assessments, revised November 2019, showed CCA's are used to help analyze data obtained from the [NAME] Data Set (MDS - an assessment tool) and to develop individualized care plans. Triggered care areas are evaluated by the interdisciplinary team to determine the underlying causes, potential consequences, and relationships to other triggered are areas. CAA documentation explains the basis for the care plan. The documentation should include: a. Causes and contributing factors for the triggered areas. b. The nature of the condition or issue (i.e., what exactly is the problem and why is it a problem?). c. Complications contributing to (or caused by) the care area. d. Risk factors related to the condition. e. Factors that should be considering in developing the care plan (including reasons to care plan or not to care plan particular findings). f. Any need for further evaluation by the physician or other healthcare provider. g. Resources and tools used for decision-making. h. Conclusions that arose from the care area assessment process; and i. Completion of Section V of the MDS (the CAA summary - provides a location for documentation of the care areas that have triggered from the MDS, and a decision made during the CAA process if the care area should be care planned or not). <RESIDENT 10> Resident 10 admitted on [DATE] with diagnoses to include dementia without behavioral disturbance, severe protein-calorie malnutrition, bipolar disorder, and a stage I pressure ulcer of sacral region (tailbone area). The admission MDS assessment, dated 09/29/2023, included the following triggered CAA's: psychotropic drug use, pressure ulcer (PU), nutritional status, cognitive loss/dementia, falls, psychosocial well-being, mood state, and communication. Review of the MDS assessment, dated 09/29/2023, showed the CAA's did not contain comprehensive summaries or analysis that included the current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. The CAA's had documentation of Resident 10's diagnoses, but no assessment of how those diagnoses affected the specific care areas. <RESIDENT 11> Resident 11 admitted on [DATE] with diagnoses to include stroke with hemiparesis and hemiplegia, limitation in activities and weakness. The Annual MDS assessment, dated 06/13/2023, included the following triggered CAA's: falls, dental, and activity of daily living (ADL)/rehabilitation potential. Review of the annual MDS assessment, dated 06/13/2023, showed the CAA's did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. The CAA's had documentation of Resident 11's diagnoses, but no assessment of how those diagnoses affected the specific care areas. <RESIDENT 20> Resident 20 admitted on [DATE] with diagnoses to include displaced (absent) right femur (thigh bone), chronic pain syndrome, breast cancer, limitation of activities due to disability, anxiety, and major depressive disorder. The Annual MDS assessment, dated 09/26/2023, included the following triggered CAA's: PU/injury, nutrition, pain, ADL functional/rehabilitation potential, and behavioral symptoms. Review of the Annual MDS assessment, dated 09/26/2023, showed the CAA's did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, limitations, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. The CAA's had documentation of Resident 20's diagnoses, but no assessment of how those diagnoses affected the specific care areas. In an interview on 10/16/2023 at 10:03 AM, Staff G, Registered Nurse (RN)/MDS Coordinator, stated they were responsible for the MDS and CAA process for the facility. Staff G said they did not put a whole lot of information into the CAA's and would refer to therapy or provider notes rather than fill out the whole plan of care. Staff G said they could review the facility policy again.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent (%). Ten During observation of 27 opportunities for error, 10 medication errors were identified for 2 of 4 residents (Resident 8 and 16) observed during 27 medication administration opportunities that resulted in a medication error rate of 37.03%. This failure placed residents at risk for side effects, unmanaged pain, altered medication effectiveness and the possibility to receive medications outside of the scheduled time it was to be given. Findings included . During a medication administration observation on 10/13/2023 at 9:36 AM, Staff F, Registered Nurse (RN), prepared Resident 8's scheduled 8:00 AM medications. Medications prepared and given to Resident 8 included: - Pantoprazole (Acid reflux/indigestion), - Metolazone (diuretic), - Nicotine patch (smoking cessation), and - Methadone (pain medication) Review of Resident 8's October 2023 Medication Administration Record (MAR), showed Resident 8 was to receive those four scheduled medications at 8:00 AM. In a medication administration observation on 10/13/2023 at 9:52 AM, Staff F prepared Resident 16's scheduled 8:00 AM medications. Medications prepared and given to Resident 16 included: - Sodium chloride (supplement), - Sertraline (antidepressant), - Pantoprazole (acid reflux/indigestion), - Metformin (Diabetes/blood sugar management) - Plavix (blood thinner/stroke prevention), and - Aspirin (stroke prevention). Review of Resident 16's October 2023 MAR showed that Resident 16 was to receive those six scheduled medications at 8:00 AM. In an interview on 10/13/2023 at 1:45 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager (NM), stated medications were administered within an hour before or after the scheduled medication times, 8:00 AM medications could be given from 7:00 AM to 9:00 AM. In a joint interview on 10/16/2023 at 12:15 PM with Staff B, RN/Interim Director of Nursing Services, and Staff D, LPN/NM, Staff B stated medications scheduled for 8:00 AM should be given between one hour before or after the scheduled time; 8:00 AM medications should be given between 7:00 AM and 9:00 AM. Staff B stated not all residents would be able to get their medications at 8:00 AM and times may have to be changed. This is a repeat citation from 08/18/2022. Reference WAC: 388-97- 1060 (3)(k)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BREAKS IN INFECTION CONTROL PRACTICES> In an observation on 10/12/23 at 2:58 PM Staff K, Housekeeping, was in Resident 34's room using a fabric cloth and wearing gloves, wiped the bottom of overbed table. Staff K then used the same cloth to wipe the top of the over bed table. Resident 34 told Staff K that there was urine on the floor in front of the bed. Staff K was observed to use the used fabric cloth in their hands, wipe the urine off the floor and exited the resident's room. Staff K placed the soiled cloth under their left arm, removed their gloves, then placed the contaminated towel on the housekeeping cart, and did not perform any hand hygiene. Observation on 10/13/2023 at 11:06 AM, Staff F was observed in room [ROOM NUMBER], a room with an enhanced barrier precautions (EBP) sign posted outside. Staff F took off their isolation gown, pushed their (Staff F's) eyeglasses in place, then pushed Resident 32 out of their room in their wheelchair, without performing hand hygiene. Observation on 10/13/2023 at 11:40 AM, Staff B asked Staff F if they had hand sanitizer on them. Staff F checked their pockets and responded no. Staff B informed Staff F to go grab some. Observation on 10/13/2023 at 11:31 AM, Staff L, Nursing Assistant Certified (NAC)/ Unit Secretary, removed their isolation gown in room [ROOM NUMBER] with an EBP sign posted outside. There was no hand hygiene performed after removing the yellow reusable isolation gown. In a co-interview on 10/16/2023 with Staff A, Administrator, and Staff B and Staff A stated the expectation was that all staff should know how to wash their hands in between care and change gloves. Staff B stated the infection preventionist ensured all staff does their hand hygiene. Staff A stated that there were handwashing clinics in the facility where staff were watched performing hand hygiene to make sure they were washing their hands properly. Staff B stated there were enhanced barrier precautions signs outside of resident's room where staff were expected to read precautions that were to be implemented prior to and after entering a resident's room. Staff B stated the facility had numerous in-services regarding hand hygiene and staff would repeat these hand washing two to three time. Staff were tested and watch for proper hand washing technique and if it was not done right, they would repeat until it was done properly. Staff B provided no information regarding Staff K and what was observed. This is a repeat citation from 08/18/2022. Refer to WAC 388-97-1320(1)(a)(c) RESIDENT 8 In an observation and interview of wound care on 10/13/2023 at 11:45 AM, Staff F, Registered Nurse (RN), was observed to complete wound care for Resident 8. Staff F, with gloved hands, removed Resident 8's coccyx dressing, with contaminated gloves washed the wound with saline, and then applied a new dressing. Staff F was not observed to perform hand hygiene during dressing change. When asked about infection prevention and process for wound care, Staff F stated they should have changed gloves and performed hand hygiene in between removing the old dressing and placing the new dressing. In an interview on 10/13/2023 at 1:45 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager (NM), stated they should perform hand hygiene before wound care, between any wound care steps, and when wound care was completed. Staff D stated hand hygiene should be performed multiple times during a dressing change. In an interview on 10/16/2023 at 1:00 PM, Staff B stated that hand hygiene should be performed during wound care and that they had sanitizer bottles for nurses to keep in their pockets to be able to complete hand hygiene. Based on observation, interview, and record review the facility failed to ensure the Infection Prevention and Control Program (IPCP), specifically hand hygiene and donning/doffing personal protective equipment, was followed during wound care for 2 of 2 residents (Resident 20 and 8) and standard infection control measures were followed for 3 of 10 staff (Staff K, F, and L) observed for standard infection control practices. These failures placed residents at risk for exposure to infections and a decreased quality of life. Findings included . <WOUND CARE> RESIDENT 20 In a wound care observation on 10/13/2023 from 11:45 to 12:10 PM, Staff B, Registered Nurse (RN)/Director of Nursing Services, performed wound care to Resident 20. Staff B placed a barrier on the over bed table and set up the dressing supplies necessary for the wound care. While the resident was repositioning in bed, the TV remote fell near the barrier and dressing supplies. With gloved hands, Staff B moved the TV remote and opened the clean dressing supply packages. Staff B grabbed household scissors from the resident's nightstand, without sanitizing them, and placed them on the towel barrier next to the clean dressing supplies. At 11:54 AM, Staff B removed the soiled dressing from the resident's right hip, then removed the packing (applied packing material to a deep wound to absorb drainage and protect the area) from the wound with their gloved hand. Staff B then took off their gloves, applied a new dressing, placed one hand on the dressing and placed the tape along the four edges barehanded. Staff B did not perform hand hygiene or change gloves in between changing the resident's right hip dressing, the left posterior thigh pressure ulcer (PU), or the right posterior thigh PU. In a follow up interview on 10/13/2023 at 2:37 PM, Staff B inquired as to how the wound care observation went. Staff B was informed they had touched the TV remote with their glove then proceeded to open up dressing supplies, cut tape with household scissors not cleaned, placed dressing to residents right hip ungloved and completed wound care on two sites without hand hygiene and glove change. In an interview on 10/16/2023 at 12:20 PM, Staff B stated hand hygiene was to be completed before donning gloves and after glove removal. Staff B acknowledged many resident rooms did not have sinks in them, so they would have the administrator address the quantity and placement of wall mounted hand sanitizers in the rooms and hallways.