Based on observation, interview, and record review the facility failed to assess and obtain consent prior to implementing bed rails for 2 (Residents 1 & 2) of 3 sample residents reviewed for bed rails. The failure to assess and obtain consent prior to implementing bed rails resulted in Resident 1 sustaining a cut to their eyebrow and placed Resident 2 at risk for injury. These failures placed all residents at risk for injury and other negative health outcomes. Findings included . <Resident 1> According to the 10/30/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 1 had diagnoses including an acute condition affecting their brain function that could cause confusion, memory loss, and personality changes. The MDS showed Resident 1 had severe memory impairment. The MDS showed Resident 1 had severely impaired vision and did not use bed rails during the assessment period. The 10/31/24 discharge MDS showed the resident was discharged from the facility and not available for observation or interview. Review of Resident 1's evaluation and documentation tabs in their clinical record showed no assessments indicating Resident 1 was assessed for safe use of bed rails. Resident 1's record showed no consent or risk and benefit documentation for use of the bed rails. Review of Resident 1's 10/25/2024 comprehensive care plan showed no care plan indicating the resident utilized bed rails. Review of an 11/01/2024 nurse progress note showed a care giver providing one-to-one supervision reported to the nurse Resident 1 hit their head on the bed handrail, resulting in a cut above the left eyebrow . In an interview on 11/05/2024 at 2:12 PM, Staff C (Registered Nurse) stated they recalled Resident 1 having bed rails on their bed. Staff C stated unit managers completed assessments and consents for bed rails. In an interview on 11/05/2024 at 2:20 PM, Staff B (Unit Manager) reviewed Resident 1's record and confirmed the resident did not have an assessment or consent for the bed rails. In an interview on 11/05/2024 at 3:20 PM, Staff A (Administrator) stated Resident 1 was moved to a private room as they required one-on-one supervision. Staff A stated the bed rails were accidentally left on the bed in the private room from the previous tenant. Staff A stated they expected assessments and consents to be obtained for bed rails prior to implementation. <Resident 2> According to the 11/04/2024 admission MDS, Resident 2 had no memory impairment. This MDS showed Resident 2 had a fall prior to their admission to the facility and did not have impairment to their range of motion but required substantial/maximal assistance with bed mobility. The MDS showed Resident 2 did not use bed rails. Review of Resident 2's 10/31/2024 comprehensive care plan showed no care plan indicating the resident utilized bed rails. Observation on 11/05/2024 at 1:00 PM showed Resident 2 lying in bed. Resident 2's bed had bilateral bed rails installed. Review of Resident 2's evaluation and document tabs in their record showed no assessments indicating Resident 2 was evaluated for safe use of bed rails. Resident 2's record showed no consent or risk and benefit documentation of the bed rails. In an interview on 11/05/2024 at 3:20 PM, Staff A stated it was their expectation assessments and consents were obtained prior to the use of bed rails. REFERENCE: WAC 388-97-1060(3)(g). .

Based on interview and record review, the facility failed to inform residents or their assigned representatives in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 residents (Residents 61 & 34) reviewed for unnecessary medications. The failure of facility staff to obtain consent for psychotropic medications prior to administration detracted from the residents' and/or their representative's ability to exercise their right to make an informed decision about proposed treatments, and prevented the residents and their representative from exercising their right to decline the treatments/therapies. Findings included . <Facility Policy> The facility's revised 10/04/2022 Psychotropic Medication policy showed residents who used psychotropic drugs would be educated on the risks and benefits of psychotropic drug use. <Resident 61> According to the 05/20/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool) Resident 61 had moderately impaired cognition (impaired memory and problem solving) and had diagnoses of schizophrenia (mental disorder affects a person's ability to think, feel and behave), anxiety, and depression. The MDS showed Resident 61 regularly used Antipsychotic (AP), Antianxiety (AA), and Antidepressant (AD) medications. Review of Resident 61's records showed no consent was obtained for the psychotropic medications prior to implementing the medications. In an interview on 07/23/2024 at 11:07 AM Staff B (Director of Nursing) stated they expected staff to explain risk and benefits for psychotropic medications to residents or their representative prior to implementing the treatments. Staff B reviewed Resident 61's record and stated there was no documentation for consent at the time of order for the psychotropic medications for Resident 61. Staff B stated staff should obtain consent prior to implementing the medications for Resident 61, but they did not.<Resident 34> According to 04/15/2024 admission MDS, Resident 34 had a diagnosis of dementia with agitation. The MDS showed Resident 34 received AP medication. Review of Resident 34's records showed a court order that appointed full guardianship and full conservator for Resident 34 on December 21, 2023. Review of Resident 34's record showed AP Medication Informed Consent, was consented to by Resident 34's family member over the telephone on 4/9/2024. Review of Resident 34's record did not show documentation that the risks and benefits of the medication were discussed, either verbally or written, with the resident or their representative/legal guardian, prior to the resident receiving the medication. During an interview on 07/24/2024 10:08 AM, Staff Q (Social Services Assistant- SSA) and Staff R (SSA) stated if a resident had a guardian, the guardian needed to consent to and be informed of risks and benefits for AP medications. REFERENCE: WAC 388-97-0260(1)(a)(b)(i)(ii)(iii). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the appropriate Advanced Directives (AD) in place for 2 (Residents 61 & 6) of 7 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, and offered assistance to formulate an AD (Resident 61 and 6), and to obtain guardianship for Resident 61. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> The 11/2017 Advanced Directives facility policy showed the resident and/or the resident's representative would be provided with written information regarding the resident's right to refuse or accept assistance with formulating an AD, and this information would be provided in a manner the resident could understand. Nursing staff would document the resident's decision about formulating an AD in the resident's record. Information about whether or not a resident had an AD would be displayed prominently in the resident's records and retrievable by any staff. Facility staff would periodically review the AD with the residents and/or the resident's representatives. <Resident 61> According to the [DATE] admission 5 Day Minimum Data Set (MDS - an assessment tool) Resident 61 had moderately impaired memory. Record review of Resident 61's face sheet showed Resident 61 was their own responsible party. There was no copy of an AD for Resident 61 in their record. There was no documentation showing the facility attempted to obtain guardianship for Resident 61. In an interview on [DATE] at 10:34 AM Staff D (Social Services Director) stated they did not obtain a copy of Resident 61's AD because Resident 61 was unable to make decisions and there was no appointed guardian for Resident 61. In an interview on [DATE] at 10:48 AM Staff B (Director of Nursing) stated Resident 61 had no AD in their record and had no appointed guardian at that time. Staff B stated the facility was working to appoint a guardianship for Resident 61 but was unable to provide any documentation.<Resident 6> Review of Resident 6's record showed a [DATE] letter of limited guardianship expired on [DATE]. According to Resident 6's [DATE] admission record a guardian was listed as the responsible party. Review of Resident 6's [DATE] consent documents showed Resident 6 had an AD. Review of Resident 6's record on [DATE] at 9:01 AM showed no documentation of an AD or current guardianship paperwork. During a joint interview on [DATE] at 9:33 AM Staff D stated Resident 6 had a guardian. Staff D and Staff A (Administrator) stated there should be one uploaded in Resident 6's record. During an interview on [DATE] at 9:53 AM Staff A stated they don't have the guardian paperwork for Resident 6. REFERENCE: WAC 388-97-0280(3)(c)(i-ii). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate a grievance for 2 (Resident 1 & 47) of 2 resident's reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform the resident of their findings and the actions taken, precluded the facility from identifying grievance trends and placed the resident at risk of feeling frustrated, unimportant, and with a decreased self-worth and quality of life. Findings included . <Facility Policy> According to facility policy titled, Resident Rights - Grievances, dated 08/2018, the facility would help residents/representatives file grievances and would investigate and take appropriate actions to address resident grievances. The policy showed grievances could be submitted in writing or orally. The policy showed the administrator has designated the Social Services representative in the facility as the Grievance Officer (GO). The policy showed the GO had the responsibility to oversee the grievance process, receive and track grievances through to their conclusion, and lead any necessary investigations. The policy showed upon receipt of a grievance, the GO would investigate the allegations and submit a written report to such findings to the administrator within five working days of receiving the grievance. This policy showed the GO would immediately report to the administrator any grievance that alleged violations related to potential neglect. <Resident 1> According to a 06/07/2024 Discharge Minimum Data Set (MDS- an assessment tool) Resident 1 had no memory impairment. The MDS showed Resident 1 was discharged to the hospital on [DATE] with a return anticipated. In an interview on 07/17/2024 at 10:52 AM Resident 1 stated they returned from the hospital, and they had two new gowns they had put in the drawer which they didn't lock because staff informed them, they would be returning to the same bed. Resident 1 stated when they returned from the hospital, they were admitted to the same room but in the bed by the door. Resident 1 stated they were previously in the bed by the window but now another resident was in that bed and all their potted plants were missing off the bay window. Resident 1 also stated their daughter had bought them a bunch of bottled waters and snacks and staff informed them they had thrown all of that away. In an interview and record review on 07/23/2024 at 9:51 AM Staff A (Administrator) provided a copy of a care partners routine visit checklist from 06/07/2024 that Staff H (Unit Manager) had completed. The checklist showed Resident 1, and their daughter reported missing items to Staff H. Staff A stated they never received a grievance form about the missing gowns, plants, and grocery items, but Staff H should have completed one at the time of the reported missing items. Staff A stated they usually read through all the care partners checklists as they are turned into them but had not due to being busy preparing for survey, so they were unaware of the missing items. <Resident 47> In an interview on 07/16/2024 at 11:45 AM, Resident 47 reported long call light response times during the night shift, 10:00 PM to 6:00 AM. Review of Resident 47's electronic health record on 07/20/2024 showed a quarterly/annual care conference note with a complaint from Resident 47 that the night shift, 10:00 PM to 6:00 AM, took too long to answer the call light. In an interview on 07/23/2024 at 9:12 AM Staff D (Social Service Director) stated they notified Staff A about the long call light response time complaint from Resident 47. In an interview on 07/23/2024 at 9:27 AM Staff A stated they were not informed and had not received a grievance form regarding the complaint about long call light response times on night shift by Resident 47. Staff A stated a grievance form should have been filled out so they could have investigated immediately. REFERENCE: 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 document they communicated necessary resident information to the receiving health care institution or provider for 2 of 7 residents (Resident 1 & 31) reviewed for hospitalizations. Failure to ensure necessary resident information was communicated to the hospital placed residents at risk for decreased quality of care, inadequate care/treatment, and decreased quality of life. Findings included . <Facility Policy> According to a facility policy titled, Admission, Transfer, & Discharge - Facility initiated Transfers, or Discharges, dated 11/2017, showed when the facility initiates a transfer or discharge of a resident, the facility would document in the resident's record appropriate information was communicated to the receiving health care institution or provider. The policy showed information would be provided to the receiving provider and will include the following: a. Contact information of the practitioner responsible for the care of the resident b. Resident representative information including contact information c. Advance Directive Information d. All special instructions or precautions for ongoing care, as appropriate e. Comprehensive care plan goals f. Other necessary information, including a copy of the resident's discharge summary as applicable, and any other documentation to support a safe and effective transition of care. <Resident 1> Review of Resident 1's 06/07/2024 Discharge Minimum Data Set (MDS- an assessment tool) showed the resident was transferred to an acute care hospital on [DATE]. Record review showed no documentation staff provided any information on Resident 1's health condition or any contact information to the receiving acute care hospital. <Resident 31> Review of Resident 31's electronic health record on 07/20/2024 showed a progress note the resident was transferred to the hospital on [DATE] and 06/04/2024. Review of Resident 31's 06/10/2024 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE]. Record review on 07/20/2024 showed no documentation staff provided any information on Resident 31's health condition or any contact information to the receiving acute care hospital regarding their discharges for 05/27/2024 or 06/04/2024. In an interview on 07/23/2024 at 11:37 AM, Staff H (Unit Manager) stated there was no documentation of a report provided to the receiving acute care hospital for Resident's 1 and 31 when they were sent to the hospital but there should be. Staff H stated it was important to give the receiving facility a thorough report about the resident so they could provide the appropriate care the resident needed. REFERENCE: WAC 388-97-0120(3)(a)(b). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system that ensured residents who were transferred to the hospital or went on therapeutic leave were provided a written notice of bed hold that specified the duration of the bed hold policy upon transfer or attempted to contact the resident and/or the resident representative within 24 hours from an emergency transfer for 2 (Resident 59 & 23) of 7 sampled residents reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while hospitalized . Findings included . <Facility Policy> According to the Admission, Transfer, and Discharge - Notice of Bed Hold Policy Before/Upon Transfer facility policy revised 11/2018, the facility would provide information regarding the resident's right to hold their bed at the time of transfer or within 24 hours of the transfer if the transfer was emergent. <Resident 59> According to the 05/29/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 59 was assessed to have impaired memory and thinking abilities. The MDS showed Resident 59's diagnoses included heart failure, a progressive memory loss disease, and weakness to one side of their body. The MDS showed Resident 59 received nutrition via a tube surgically placed in their stomach. Review of Resident 59's census documents showed Resident 59 was hospitalized from : - 11/20/2023 to 11/29/2023 - 12/04/2023 to 12/12/2023 - 02/07/2024 to 02/09/2024 - 03/01/2024 to 03/12/2024 Review of Resident 59's record on 07/23/2024 at 8:34 AM showed no documentation indicating a bed hold notification was provided to Resident 59 or their representative when they discharged to the hospital on [DATE], 12/04/2023, 02/07/2024, and 03/01/2024 as required. <Resident 23> Review of Resident 23's 04/16/2024 Quarterly MDS showed Resident 23 had no memory impairment and had complex medical conditions including diabetes (inability to control their blood sugars), wounds to their feet related to diabetes, and pressure ulcers. Review of Resident 23's census documents showed Resident 23 was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 23's records on 07/16/2024 at 1:44 PM showed no documentation indicating a bed hold notification was provided to Resident 23 when they discharged on 01/26/2024 as required. In an interview on 07/23/2024 at 10:20 AM, Staff I (Admissions Coordinator) and Staff J (Admissions Coordinator) had a binder in which they kept track of hospitalizations and bed hold notifications. Staff I and Staff J reviewed their binder and reviewed Resident 59 and Resident 23's records and confirmed the bed hold notifications were not completed as required. REFERENCE: WAC 388-97-0120(4). .

Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days from the date of determination for 1 (Resident 68) of 1 resident reviewed for significant changes in status. The failure to identify the need for a SCSA when Resident 68 had a decline in condition and was started on hospice services placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . According to the Resident Assessment Instrument manual (a document directing staff when assessments of resident status is required) a .SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains in the nursing home. <Resident 68> Review of Resident 68's 04/05/2024 Hospice Certification and Plan of Care showed Resident 68 admitted to hospice services on 04/05/2024 for a diagnosis of protein - calorie malnutrition and the inability to absorb nutrients from food. This certification showed Resident 68 was terminally ill with a life expectancy of less than six months. Review of Resident 68's Minimum Data Set (MDS - an assessment tool) assessments showed staff completed a Quarterly MDS on 05/29/2024. Staff identified Resident 68 was receiving hospice services on the 05/29/2024 Quarterly assessment. A SCSA was completed for Resident 68 on 06/20/2024, 76 days after the date of determination on 04/05/2024, which was the hospice provider's start of care date. In an interview on 07/23/2024 at 10:42 AM, Staff M (MDS Coordinator) reviewed Resident 68's records and MDS assessments. Staff M stated a SCSA should be completed when the resident started on hospice, but staff did not complete the SCSA as required. REFERENCE: WAC 388-97-1000(3)(b). .

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed accurately for 1 (Resident 61) of 5 residents reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Facility Policy> According to the facility's revised 08/2018 Resident Assessment - PASRR for Mental Disorder (MD) and Intellectual disability policy, all residents must have a PASRR screening prior to admission, and the facility would keep a copy of the screening in the resident's record. The policy showed the facility's Social Services department was responsible for ongoing maintenance of accurate PASRR screenings and PASRR screening should be updated as needed to reflect changes both positive and negative to a resident's mental health status. This policy showed if a PASRR level I was positive, with any MD or a related condition, the resident would be referred to the appropriate State designated authority for a PASRR level II review. <Resident 61> According to the 05/20/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool) Resident 61 had moderately impaired cognition (impaired memory and problem solving) and had diagnoses of schizophrenia and anxiety. The MDS showed Resident 61 regularly used Antipsychotic (AP), and Antidepressant (AD) medications during the assessment period. Review of the 05/16/2024 and 06/07/2024 psychiatry progress notes showed Resident 61 had diagnoses of schizophrenia, anxiety, and major depression disorder, and received AP, Antianxiety (AA), and AD medications. The psychiatrist recommended staff to continue administering AP, AA, and AD medications as ordered, and continue monitoring behaviors for depression and psychosis. Review of the July 2024 Medication Administration Record (MAR) showed Resident 61 received routine AP, AD, and AA medications every day as ordered related to their diagnoses. Review of the 05/15/2024 Level 1 PASRR showed Resident 61 was identified with serious mental illness indicator for Schizophrenia and Anxiety disorder diagnoses, and Level 11 PASRR evaluation was not required. Resident 61's diagnosis of major depression was not checked on the Level 1 PASRR. In an interview on 07/23/2024 at 1:27 PM, Staff D (Social Services Director) stated Resident 61's Level 1 PASRR was updated on 05/15/2024 and Level 11 PASRR was not indicated. Staff D reviewed Resident 61's MAR that Resident 61 received AP, AA, and AD medications every day. Staff D reviewed Resident 61's Level 1 PASRR and stated the form was inaccurate and required revision to check the major depression disorder diagnosis and the resident should be referred for a Level 11 evaluation. Staff D stated they should have reviewed the Level 1 PASRR for accuracy at admission time, but they did not. REFERENCE: WAC 388-97-1915 (1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). <Resident Refusals> <Resident 67> According to the 05/09/2024 Quarterly MDS, Resident 67 admitted to the facility on [DATE] and had no memory impairment. The MDS showed Resident 67 received pain medications to relieve pain and had no rejection of care during the assessment period. Review of Resident 67's July 2024 POs directed staff to administer a laxative powder twice daily for constipation. Review of the July 2024 MAR showed Resident 67 refused to take the laxative medication on twenty out of thirty-four opportunities. Review of Resident 67's record showed no documentation the provider was notified related to Resident 67's refusal of the laxative medication. In an interview on 07/17/2024 at 1:22 PM, Staff G (UM) stated if any resident refused care or treatment, Staff G expected staff to document the refusals in the resident's record and notify the providers. In an interview on 07/23/2024 at 10:04 AM, Staff B reviewed Resident 67's record and stated Resident 67 refused to take the medication nearly every day and there was no documentation staff notified the provider regarding Resident 67's refusals. Staff B stated staff should discuss with the resident the reason for the refusals, notify the provider, and document in Resident 67's record, but they did not. Based on interview and record review, the facility failed to ensure services provided met professional standards of practice for 4 (Residents 66, 32, 59, & 67) of 20 residents reviewed. The nursing staff's failure to follow and/or clarify Physician Orders (POs), and notify the provider of resident refusals of treatment, placed residents at risk for unmet care needs, and potential negative outcomes. Findings included . <Clarifying Physician Orders> <Resident 66> According to the 05/08/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 66 received nutrition through a feeding tube (a tube surgically placed in the stomach used to administer artificial nutrition). Review of Resident 66's order summary on 07/23/2024 at 12:45 PM showed Resident 66 had a 02/29/2024 diet order of NPO (nothing by mouth). Review of Resident 66's March 2024 through July 2024 Medication Administration Records (MARs) on 07/23/2024 at 12:45 PM showed Resident 66 had a 03/10/2024 PO for an anti nausea medication, a 03/26/2024 PO for a muscle relaxant, a medication to reduce itching, and a 03/27/2024 PO for a medication to reduce high blood pressure. These orders instructed staff to administer the medications to Resident 66 by mouth. During an interview on 07/23/2024 at 12:45 PM Staff P (Unit Manager - UM) stated Resident 66 received all their medications through the feeding tube. Staff P reviewed Resident 66's July 2024 MAR and confirmed the four medications were ordered to be administered by mouth. Staff P stated this was a mistake. <Following Physician Orders> <Resident 66> Review of Resident 66's June 2024 and July 2024 MAR on 07/18/2024 at 12:45 PM showed a 03/07/2024 PO for a medication to reduce high blood pressure to be held on Tuesday, Thursday, and Saturday mornings prior to dialysis. Review of the June 2024 and July 2024 MAR showed the medication was administered on those days to Resident 66 and not held as ordered by the physician. During an interview on 07/23/2024 at 12:52 PM Staff P stated the medication was not being held as ordered. <Resident 32> According to the 06/26/2024 Quarterly MDS, Resident 32 was understood and could understand others in conversation. The MDS showed Resident 32 had pain and received scheduled and As Needed (PRN) pain medications. Review of Resident 32's 07/18/2024 order summary showed a 05/17/2024 PO for an opioid medication to be administered every six hours PRN for pain. The PO did not instruct staff at what level to administer the opioid medication. The order summary showed a PO for an over-the-counter pain medication to be administered every eight hours PRN for a pain level of 1-5 on a numerical pain scale. Review of Resident 32's 07/2024 MAR showed staff administered the PRN opioid medication for a pain level of 2 and 4. This MAR showed staff administered the PRN over-the-counter pain medication for a pain level of 6. Review of Resident 32's 06/2024 MAR showed staff administered the PRN opioid medication on two occasions for a pain level of 2, on two occasions for a pain level of 3, and on one occasion for a pain level of 5. This MAR showed staff administered the over-the-counter pain medication for a pain level of 7 on one occasion. Review of Resident 32's 05/2024 MAR showed staff administered the PRN opioid medication on two occasions for a pain level of 2. In an interview on 07/23/2024 at 1:15 PM, Staff B (Director of Nursing) stated it was their expectation staff followed parameters when administering medications to residents. <Resident 59> According to the 05/29/2024 Annual MDS, Resident 59 had severe cognitive impairment. This MDS showed Resident 59 had a feeding tube and received more than half of their daily nutrition via the feeding tube. Review of Resident 59's 07/17/2024 order summary showed a 03/19/2024 PO for the tube feeding to be administered at 50 Milliliters (mls) per hour for 20 hours via a pump. This PO directed staff to start the tube feeding at 8:00 PM and stop the feeding at 4:00 PM the following day. The PO summary showed an additional 03/12/2024 order directing staff to document the amount of tube feeding formula and water administered to Resident 59 every eight hours. Observation on 07/17/2024 at 8:40 AM showed Resident 59 in bed receiving their tube feeding. The pump showed 3,324 mls were administered. Observation on 07/18/2024 at 8:58 AM showed Resident 59 in bed receiving their tube feeding. The pump showed 4,126 mls were instilled at that time. Similar observations were made on 07/22/2024 at 5:57 AM, the pump showed 5,830 mls were instilled. Review of Resident 59's 07/2024 Treatment Administration Record (TAR) showed at 6:00 AM on 07/17/2024, staff documented 660 mls were administered, less than three hours prior to the pump showing 3,324 mls were administered. The TAR showed staff documented at 6:00 AM on 07/18/2024, 660 mls were administered, three hours prior to the observation of 4,126 mls administered. On 07/22/2024 at 6:00 AM, staff documented 660 mls were administered despite the 5:57 AM observation showing 5,830 mls were administered. In an observation and interview on 07/24/2024 at 8:26 AM, the pump showed 1,366 mls were administered. Staff C (Assistant Director of Nursing) observed the pump and confirmed it showed 1,366 mls were administered. Staff C reviewed the 07/2024 TAR and confirmed staff documented 660 mls were administered at 6:00 AM, just two and a half hours earlier. In an interview on 07/24/2024 at 10:53 AM, Staff B stated they expected staff to look at the tube feeding pump and accurately document the amount of tube feeding administered to Resident 59. Staff B stated they expected staff to clear the pump readings in order to obtain the accurate amount of tube feeding Resident 59 received each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 61) of 3 sampled residents reviewed for communication, including language and speech, were provided a functional system to address their communication needs. Failure to identify and provide services which enhanced and or ensured effective communication, placed residents at risk for unmet care needs, social isolation, and a diminished sense of well-being. Findings included . <Resident 61> According to the 05/20/2024 admission 5 Day Minimum Data Set (an assessment tool), Resident 61 admitted to the facility on [DATE], had impaired memory, was never able to understand others, and had unclear speech. The assessment showed Resident 61 had no behavior or rejection of care during the assessment period. Observations on 07/16/2024 at 9:40 AM, and 07/17/2024 at 11:59 AM showed Resident 61 was lying in their bed in their room. During an interview on 07/17/2024 at 11:59 AM, Resident 61 mumbled and was unable to make themselves understood to the surveyor. During observation and interview on 07/18/2024 at 12:45 PM, Resident 61 was lying in their bed with head of bed up and Staff S (Certified Nursing Assistant) was feeding Resident 61 their lunch. Staff S stated Resident 61 would only shake their head for yes or no and did not speak clearly to make their needs known. There was no communication book or board observed in Resident 61's room. Review of the 05/24/2024 Communication Care Plan (CP) showed Resident 61 had a communication problem and nursing interventions instructed the staff to anticipate Resident 61's needs, ask yes or no questions of the resident, OT/PT (Occupational Therapy/Physical Therapy) was to evaluate Resident 61's ability to use a communication board, and use a computer or sign language as an alternate communication to speech. In an interview on 07/23/2024 at 10:51 AM, Staff B (Director of Nursing) stated Resident 61 could not talk and communicated with staff by shaking their head for yes or no. Staff B stated they tried a communication binder but the binder did not work. Staff B reviewed Resident 61's record and stated staff did not document the resident's inability to use the communication binder. Staff B stated they would provide OT documentation. In an interview on 07/23/2023 at 1:10 PM, Staff T (Rehab Director) stated Resident 61 was evaluated and treated by a Speech Therapist only for swallowing issues, not for communication or speech. In an interview on 07/23/2024 at 3:13 PM, Staff B provided Speech Therapist notes which showed Resident 61 was not evaluated for speech or communication. Staff B did not provide the OT evaluation or treatment documentation for communication problem as documented in the CP. REFERENCE: WAC 388-97-1620 (2)(a)(v). .

**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 (ADL), related to cleanliness and grooming for 2 (Residents 61 & 62) of 20 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 61), and nail care (Resident 62), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life. Findings included . <Facility Policy> According to the facility's 11/2017 Quality of Life- Activities of Daily Living policy, the facility would provide ADLs in accordance with resident's comprehensive assessment, Care Plan (CP), and resident preferences to ensure a resident's ADL abilities do not diminish unless decline in function was unavoidable. <Shaving> <Resident 61> According to the 05/20/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 61 admitted to the facility on [DATE], had impaired memory, and required maximal assistance with personal hygiene. The MDS showed Resident 61 had no behavior of refusing care during the assessment period. Observations on 07/16/2024 at 9:40 AM, 07/17/2024 at 11:59 AM, and 07/18/2024 at 9:51 AM showed Resident 61 was in bed and had long facial hair. According to the 05/16/2024 ADL self-care performance deficit CP, Resident 61 was dependent on staff for personal hygiene including shower and oral care. In an interview on 07/23/2024 at 11:52 AM, Staff B (Director of Nursing) stated they expected staff to check all resident's preferences related to ADLs and provide assistance as needed every morning. Staff B stated staff should have shaved Resident 61's facial hair as they allowed. If the resident refused, staff should document the refusals. Staff B reviewed Resident 61's record and stated the facility should have documented Resident 61's preferences and provided assistance with shaving their facial hair, but they did not. <Resident 62> According to the 06/16/2024 admission MDS, Resident 62 admitted to the facility on [DATE] and had no memory impairment. The MDS showed Resident 62 required one person assistance with personal hygiene and had no rejection of care behavior during the assessment period. Observations on 07/16/2024 at 10:31 AM, 07/17/2024 at 8:30 AM, and 07/18/2024 at 2:12 PM, showed Resident 62 had long fingernails, and facial hair. In an interview on 07/19/2024 at 12:33 PM, Resident 62 stated they did not have a razor to shave their facial hair. Resident 62 stated they needed help to clip fingernails. According to the 06/10/2024 ADL self-care performance deficit CP, Resident 62 required maximal assistance from staff with personal hygiene, including shower and oral care. In an interview on 07/23/2024 at 11:52 AM, Staff B stated staff should have shaved Resident 62's facial hair during morning care, but they did not. Staff B stated Staff should provide the assistance with ADLs to Resident 62 to clip their fingernails weekly and as needed, but they did not. REFERENCE: WAC 388-97-1060(2)(C). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Air Mattress Settings> <Resident 59> According to the Annual 05/29/2024 MDS, Resident 59 had severe cognitive impairment. The MDS showed Resident 59 had weakness to one side of their body and required substantial/maximal assistance from staff to move in bed. The MDS showed Resident 59 was at risk for developing pressure ulcers or injuries. The MDS showed Resident 59 had a pressure reducing device for their bed. Observation on 07/18/2024 at 9:10 AM showed Resident 59 lying in bed. In an interview at that time, Resident 59 stated they were uncomfortable because the bed was very firm and was hurting their legs. Observation of the bed at that time showed Resident 59 was lying on an air mattress. The air mattress was set to 300 LBS [pounds], normal pressure. Review of Resident 59's weights showed on 07/17/2024, staff obtained Resident 59's weight and documented the resident weighed 147 pounds. Review of Resident 59's 07/17/2024 order summary showed there were no orders for the resident's air mattress. There were no directions to staff regarding what setting the mattress should be on or how often the settings should be verified. Review of Resident 59's .risk for impairment to skin integrity . CP revised on 11/29/2023 showed the resident had an air mattress. The CP did not give directions to staff regarding what setting the mattress should be on or how often the settings should be verified. In an observation and interview on 07/18/2024 at 9:23 AM, Staff B stated air mattress settings were determined by the resident's weight unless a resident had a specific preference for the air mattress setting. Staff B stated instructions regarding the air mattress should be in the resident's CP. At that time, Staff B looked at Resident 59's mattress settings and confirmed the mattress was not on the proper setting given the resident's current weight. REFERENCE: WAC 388-97-1060 (1). Based on observation, interview, and record review, the facility failed to ensure 3 of 20 residents (Residents 41, 67, & 59) reviewed, received the necessary care and services in accordance with professional standards of practice, and the comprehensive person-centered care plan. The facility failed to complete weekly skin checks and provide the treatment for 2 of 4 residents (Residents 41 & 67) reviewed for non-pressure ulcers and failed to accurately set air mattress setting according to resident's weight for 1 of 4 residents (Resident 59) reviewed for air mattress setting. These failures placed residents at risk for decline in medical status, unmet care needs, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's revised 08/2018 Quality of Care policy, the facility would ensure care plans included resident care needs and described the services and care required; ensure residents with non-pressure-related skin ulcers/wounds were assessed by a clinician, including documentation of underlying conditions contributing to ulceration, characteristics of the wound edge and wound bed, location, shape and condition of surrounding tissues; ensure treatment of such conditions were in accordance with physician orders and incorporated appropriate preventive measures. <Non-Pressure Skin> <Resident 41> According to the 06/12/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 41 admitted to the facility on [DATE], cognitively intact and had diagnoses including below the right knee amputation, asthma, and reduced blood circulation to body parts. The assessment showed Resident 41 had unhealed pressure ulcers, other wounds included infection of the foot, and open lesions other than ulcers, rashes and cuts. Resident 41 required maximal assistance for bed mobility, toileting, and shower. Review of the 07/15/2024 weekly skin assessment showed Resident 41 had no new skin issues. The facility staff documented no skin concern at that time. Observations on 07/16/2024 at 10:23 AM showed Resident 41 was lying in bed with left lower leg exposed (blanket pulled up to shins and no sock in place on left foot). Multiple opened and scabbed areas observed on left shin and left foot toes were macerated with debris between toes. On 07/17/2024 at 9:15 AM, Resident 41 was again observed lying in bed with left lower leg exposed and the skin issues were still present on left shin and left foot toes. Resident 41 stated they had those open sores on left shin and infection on their left foot for a while. Resident 41 stated the facility nurses were aware of the skin issues on left leg, but they did not apply any treatment on left lower leg or foot. Observation on 07/18/2024 at 9:39 AM of wound care provider and nursing staff providing the wound care to Resident 41's pressure wounds showed Resident 41 had multiple open and scabbed areas on left shin and left foot toes were still macerated and brown debris between the toes. The wound care provider assessed left shin wounds, measured 8.2 centimeter (cm) X 2.2 cm and left toes were assessed with fungal infection. Record review showed no indication the facility was treating or monitoring Resident 41's left shin wounds and left toes fungal infection. Review of the July 2024 Treatment Administration Record (TAR) showed facility failed to treat or monitor Resident 41's skin issues on left shin and toes. In an interview on 07/18/2024 at 10 :01 AM, Staff G (Unit Manager) stated Resident 41 was admitted with cellulitis on left lower leg and these wounds were not new. Staff G reviewed Resident 41's record and stated there was no treatment order for the left shin wounds. Staff G stated they did not know about Resident 41's left foot toes fungal infection. In an interview on 07/23/2024 at 11:23 AM, Staff B (Director of Nursing) stated they expected the facility staff to complete weekly skin check and document accurately in resident's record. Staff B stated staff should notify the provider for any skin issue to receive a treatment order and documentation in TAR as ordered. Staff B stated no matter it was pressure ulcer or non-pressure ulcer, staff should have completed weekly skin check accurately and documented in resident's record, but they did not. Staff B stated there should be treatment order for Resident 41's skin issues on left shin and toes, but there was not. <Resident 67> According to the 05/09/2024 Quarterly MDS, Resident 67 admitted to the facility on [DATE] with left lower leg cellulitis and had no memory impairment. The MDS showed Resident 67 had skin tears and infection on left foot. Observation on 07/17/2024 at 10:58 AM showed Resident 67 had bruises on left arm and dry skin tears on left hand. Resident 67's left foot was observed wrapped with dressing. Review of the 02/13/2024 Skin integrity Care Plan (CP) instructed nurses to perform and document weekly skin checks, and to notify the provider for any skin issues. Review of Resident 67's record showed the last weekly skin check was performed on 06/12/2024. After 06/12/2024, there was no weekly skin check was performed or documented in Resident 67's record. In an interview on 07/23/2024 at 10:01 AM, Staff B stated they expected the facility staff to perform and document weekly skin check in all residents record every week. Staff B reviewed Resident 67's record and stated staff should have completed weekly skin check and documented in Resident 67's record, but they did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 41) of 5 residents reviewed for Pressure Ulcers (PU's) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure of the facility to consistently complete weekly skin assessment, assess skin integrity to identify PUs timely, and implement interventions to include updating the Care Plan (CP), placed Resident 41 at risk to develop new PU, and diminished quality of life. <Facility Policy> According to the facility's 08/2018 Quality of Care- Skin Integrity policy, the facility would assess residents upon admission and thereafter, to identify if the resident had existing PU's or was at risk for developing PUs. A resident at risk for developing PUs would have individualized interventions implemented to prevent new PUs from developing. The policy showed the resident's CP would reflect the treatment strategies for residents identified with PUs and preventative interventions for residents identified at risk for developing PU's. The policy showed repositioning was an effective intervention for treatment and prevention of PU's and would be addressed in the resident's comprehensive CP. <Resident 41> According to the 06/12/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 41 admitted to the facility on [DATE], cognitively intact and had diagnoses including below the right knee amputation, asthma, high blood sugars, pressure ulcers, and peripheral vascular disease (reduced blood circulation to body parts). According to the assessment, Resident 41 had stage 3 (full thickness tissue loss) PU's on their right and left buttocks and was at risk for developing new PU's. Resident 41 required maximal assistance for bed mobility, rolling from back to left and right side in bed, toileting, and showering and Resident 41 had no behavior of rejection of care during assessment period. Review of the 06/12/2024 CAA (Care Area Assessment) showed Resident 41 required a special mattress to reduce or relieve pressure related to PU's. Review of Resident 41's record showed the facility was aware Resident 41 had existing PU's and was at risk for developing new PU's but failed to evaluate the need for and implement additional pressure relief until 07/18/2024 to heal the existing PU's and to prevent new PU's According to the 06/06/2024 nursing admission skin assessment, Resident 41 admitted with two stage 3 PU's. A review of Resident 41's June and July 2024 weekly skin assessments showed the facility failed to complete the weekly skin assessments consistently as ordered. The 06/11/2024 PU CP showed Resident 41 had coccyx PU and was at risk for PU development related to immobility. Nursing interventions included instructions for staff to administer treatment as ordered, avoid positioning the resident on their back, to follow facility policy for the prevention/treatment of skin issues, to perform and document weekly skin checks, and to notify the provider for any skin breakdown. Review of The 07/11/2024 contracted wound care provider's progress note showed Resident 41 remained fully dependent on nursing staff for repositioning and offloading. Observations on 7/16/2024 at 8:52 AM, 11:00 AM, and 12:54 PM, on 07/17/2024 at 9:15 AM, 11:00 AM, 1:04 PM, and 3:00 PM, on 07/18/2024 at 8:11 AM and 9:35 AM showed Resident 41 was lying on their back in bed. Resident 41's left lower leg had multiple open and scabbed sores, a left medial foot (base of the big toe) with dark purple spot, and left foot toes with maceration and debris between the toes. Observation on 07/18/2024 at 9:39 AM of the wound care provider and nursing staff providing the wound care to Resident 41's wounds showed right buttock and left buttock wounds. The observation showed Resident 41 had a dark purple spot on their left medical foot. The wound care provider and nursing staff did not acknowledge the left medial foot wound and left the room. In an interview on 07/18/2024 at 10:22 AM, Resident 41 stated they stayed in bed all the time because they had bed sores. Resident 41 stated they had only one leg and needed assistance from staff to reposition in bed. Resident 41 said they were lying on their back in bed all the time. In an interview and observation on 07/18/2024 at 1:01 PM, Staff B (Director of Nursing) Staff B stated Resident 41 was admitted with PU's and non PU's due to poor blood circulation. Staff B assessed Resident 41's left medial foot and confirmed Deep Tissue Injury (DTI- discolored intact skin due to damage or underlying soft tissue from pressure) on the base of big toe, measured 2.0 cm X 1.0 cm. Staff B stated all these wounds were unavoidable related to Resident 41's diagnoses. In an interview on 07/23/2024 at 10:07 AM, Staff B stated weekly skin assessment, early identification of skin impairment and implementing PU prevention timely were important to maintain skin integrity to prevent new PU from developing. Staff B stated they were aware of Resident 41's PU's on their buttocks and expected staff to reposition Resident 41 in bed every 2-3 hours and as needed. Staff B stated the left medial foot DTI was a new PU and staff should have identified during wound rounds, documented in Resident 41's record, and notified the provider but they did not. Staff B reviewed Resident 41's record and stated staff should have completed weekly skin checks every week and document in the resident's record, but they did not. Staff B stated Resident 41 was admitted with PU's and staff should have ordered an air mattress and heel floater in Resident 41's bed to prevent new in-house PU from developing, but they did not. REFERENCE: 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 ensure the resident environment was free of accident hazards for 1 of 8 (Resident 68) sample residents reviewed for accident hazards. The failure to assess devices such as wedges placed Resident 68 at risk for accidents, injury, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's Quality of Care - Accident Hazards/Supervision/Devices policy dated 07/2018, the facility would provide an environment that was free from accident hazards. This policy showed risks and benefits of assistive devices that could pose an entrapment risk would be considered prior to implementing the device. <Resident 68> According to the 06/20/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 68 had severely impaired thought processes. The MDS showed Resident 68 had a progressive memory loss disorder and was receiving end-of-life services. This assessment showed Resident 68 admitted to the facility on [DATE] and had two or more falls since their admission to the facility. Observation on 07/16/2024 at 1:21 PM showed Resident 68 lying in bed with three pillows and one wedge cushion positioned under the right side of the mattress and the bed frame. One pillow was positioned under the left side of the mattress and the bed frame. Similar observations were made on 07/17/2024 at 11:03 AM. On 07/18/2024 at 12:21 PM, the wedge cushion was positioned between the right side of the mattress and bed frame. In an interview at that time, Staff E (Licensed Practical Nurse) stated the wedge was positioned under the mattress to keep the resident from falling out of bed. On that same date at 12:33 PM Staff F (Certified Nursing Assistant) stated the wedge and pillows were placed under the mattress to keep Resident 68 from falling out of bed. Similar observations of the pillows and/or wedge positioned between the mattress and bed frame were made on 07/19/2024 at 1:37 PM, 07/22/2024 at 9:31 AM and 07/23/2024 at 10:51 AM. In an interview on 07/23/2024 at 1:54 PM, Staff B (Director of Nursing) stated the pillows and wedge cushion should not be placed between the mattress and the bed frame because they could restrain the resident in bed and prevent them from freely moving about. Staff B stated there was no assessment completed to determine if the pillows and wedge did or did not restrain Resident 68's movement. REFERENCE: WAC 388-97-1060(3)(g). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain consent for Bed Rails (BR) for 3 (Residents 1, 297, & 20) of 3 residents reviewed for BR's. Facility failure to attempt alternatives before implementing BR's, assess residents for safe use of BR's, or obtain informed consent for the use of BR's placed all residents at risk for harm or injury and other negative health outcomes. Findings included . <Facility Policy> According to a facility policy titled, Resident Rights Planning and Implementing Care, dated 11/2017, the residents had the right to be informed of their treatment and care. The policy stated staff would inform residents in advance of the treatment risks and benefits, options, and alternatives. According to a facility policy titled, Quality of Care - Bed Rails, the facility would attempt alternative measures prior to utilizing BR's and if it was determined the alternative measures were not effective, the facility would assess the resident for risks of entrapment. The policy showed staff would obtain consent from the resident/representative prior to installing the BR's. The policy showed if BR's are utilized, the resident would be re-assessed at routine intervals to verify the ongoing need for the BR's and they would be used for the shortest time necessary to meet the residents needs. <Resident 1> According to 06/07/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 1 did not have BR's. The MDS showed Resident 1 had no memory impairment. Review of a 06/19/2024 revised Care Plan (CP) showed Resident 1 had BR's on their bed. In an observation on 07/16/2024 at 11:06 AM, Resident 1 had BR's attached to both sides of their bed. Review of Resident 1's Electronic Health Records (EHR) on 07/20/2024 showed no consent was obtained for the bilateral BR's. In an interview on 07/23/2024 at 9:53 AM, Staff H (Unit Manager - UM) stated they screened residents for BR's, but they did not obtain consent from the resident. Staff H stated it is important to involve the residents in their care, so they are making their own decisions. Staff H stated they could see why it was important to get the residents consent before initiating treatments. <Resident 297> According to a 07/22/2024 admission MDS, Resident 297 did not have BR's. The MDS showed Resident 297 had no memory impairment. During an observation and interview on 07/17/2024 at 1:47 PM., Resident 297 had BR's attached to both sides of their bed. Resident 297 stated they did not know why the BR's were on their bed. Review of Resident 297's EHR on 07/20/2024 showed no Physician Order (PO) for bed rails, no BR screening/evaluation, and no consent for the BR's. In an interview on 07/23/2024 at 11:39 AM, Staff H stated they did not obtain a PO, complete a BR screening/evaluation, or get Resident 297's consent for the BR's to both sides of their bed, but they should have. Staff H stated the BR's were probably already on the bed when they admitted to the facility and were not removed. <Resident 20> According to a 05/06/2024 Annual MDS, Resident 20 did not have bed rails attached to their bed. The MDS showed Resident 20 had no memory impairment. According to 05/02/2024 revised Activity of Daily Living CP, Resident 20 had BR's attached to both sides of their bed. Resident 20 also had a revised 05/06/2024 mobility bars to bed CP. In an interview on 07/17/2024 at 10:17 AM Resident 20 stated they did not sign a consent for the BR's to be on their bed and the BR's were on their bed when they readmitted to the facility on [DATE]. Review of Resident 20's EHR showed an enabler bar screening evaluation and PO dated 01/01/2024 for the bilateral BR's. Resident 20's EHR had no consent from the resident. In an interview on 07/24/2024 at 10:04 AM Staff G (UM) stated Resident 20 had bilateral BR's to their bed but they did not obtain consent for these BR's. Staff G stated it was important to obtain resident consent for BR's to ensure they wanted the BR's. REFERENCE WAC: 388-97-0260, -1060(3)(g). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 32> According to the 06/26/2024 Quarterly MDS, Resident 32 had diagnoses of a progressive memory loss disorder, anxiety, and depression. The MDS showed Resident 32 took antianxiety and antidepressant medications during the assessment period. This MDS showed Resident 32 did not have behaviors during the assessment period. Review of Resident 32's 07/18/2024 order summary showed a 01/16/2023 order for staff to administer an antianxiety medication to the resident three times daily. This order summary showed a 12/19/2023 order for staff to administer an antidepressant medication to Resident 32 once daily. Review of a pharmacist consultation report provided by the facility on 07/22/2024 at 11:30 AM showed the pharmacist reviewed Resident 32's records each month. This report showed in May of 2024, the pharmacist made recommendations regarding Resident 32's medication regimen. Review of Resident 32's records showed no May 2024 MRR was available in the resident's records. At this time, Staff B reviewed Resident 32's record and confirmed the May 2024 MRR was not in the record. In an interview on 07/22/2024 at 12:20 PM, Staff B provided the MRR form dated 05/08/2024, stating they called the pharmacist to have the form sent over. Review of the MRR showed the pharmacist recommended Resident 32 be placed on the facility's psych meeting schedule to discuss a gradual dose reduction of Resident 32's psychotropic medications. Staff B stated this recommendation was not implemented because the MRR form was not received by Staff B until now. REFERENCE: WAC 388-97-1300(1)(c)(iii). <Resident 67> According to the 05/09/2024 Quarterly MDS, Resident 67 admitted to the facility on [DATE] and had diagnoses of high blood sugars, heart failure, and a left lower leg infection. The assessment showed Resident 67 had no memory impairment and no behaviors or rejection of care during the assessment period. Record review showed a 03/20/2024 pharmacy recommendation to decrease the dosage for a smoking cessation patch for 14 days and then to discontinue altogether after the 14 days. Another recommendation advised staff to decrease the frequency of Resident 67's blood sugar checks from twice daily to once daily related to the resident having stable blood sugars. Under the Physician's response section, the provider checked I accept the recommendations and signed the form on 03/24/2024. The recommendations were not noted by a facility nurse until 04/10/2024 (16 days later). Review of Resident 67's Physician's Orders (POs) showed the order to discontinue the smoking patch and to reduce blood sugar checks were not carried out until 04/10/2024. In an interview on 07/23/2024 at 10:08 AM, Staff B indicated the order should be carried out the day the provider approved the recommendations. Staff B reviewed Resident 67's record and stated staff should have carried out the provider's recommendations in time but they did not.Based on interview and record review, the facility failed to ensure licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records and that recommendations were reviewed and carried out in a timely manner for 3 of 5 residents (Residents 32, 67, & 34) whose medication regimens were reviewed. This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects, and negative outcomes. Findings included . <Facility Policy> According to the facility's Pharmacy Services - [MRR] policy dated 11/2017, the facility would develop a system by which medication irregularities would be acted on in order to minimize adverse consequences to the resident. This policy showed the pharmacist would conduct monthly MRRs. Any irregularities would be provided in a separate report and reviewed by the physician, medical director, and director of nursing. The irregularities would be responded to in a timely manner dependant on the nature of the concern. The policy showed the pharmacist recommendations were considered part of the resident's record. <Resident 34> According to a 04/15/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 34 had a diagnosis of non-Alzheimer's Dementia (a progressive disease that destroyed memory and other mental functions) and used an antipsychotic medication during the assessment period. Review of a pharmacist consultation report provided by the facility on 07/21/2024 at 10:54 AM, showed the facility's pharmacy consultant reviewed Resident 34's medication records each month. This report showed in May 2024 and June 2024, the pharmacist made recommendations regarding Resident 34's medication regimen. Review of Resident 34's records showed no May or June 2024 MRR was available in the resident's records. In an interview on 07/23/2024 at 1:59 PM, Staff B (Director of Nursing) stated the facility should have each month's MRR for all residents in their record. Staff B reviewed Resident 34's record and confirmed the May and June 2024 MRRs were not in Resident 34's record. Staff B provided the MRR form for June 2024 with recommendations. Staff B stated they could not locate Resident 34's May 2024 MRR record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 32> According to the 06/26/2024 Quarterly MDS, Resident 32 had diagnoses of anxiety and depression. The MDS showed Resident 32 took medications to treat their anxiety and depression, and did not display any behaviors during the assessment period. Review of Resident 32's 07/18/2024 order summary showed Resident 32 was taking an AA medication three times per day since 01/16/2023, for nearly 18 months. The order summary showed a 12/19/2023 PO for an AD medication to be administered once daily to Resident 32. A 07/05/2024 PO directed staff to administer an anticonvulsant medication twice daily for behaviors and to give a double dose of the anticonvulsant at bedtime for behaviors. Review of Resident 32's records showed the Interdisciplinary Team (IDT) last reviewed the resident's psychotropic medication use on 12/13/2023. This form showed the IDT did not recommend a GDR of the AA medication at that time because Resident 32 was having worsening verbal agitation, anxiety, and calling out. The team recommended to re-assess the resident quarterly. No other IDT assessments were available in the resident's record indicating Resident 32 was re-assessed quarterly as recommended. Review of Resident 32's 05/08/2024 pharmacy consult report summarized the resident was receiving AA, AD, anticonvulsant, and over the counter sleep aide medications. This report showed the last time Resident 32's medications were reviewed by the IDT was 12/12/2023. The report showed the pharmacist recommended Resident 32 be placed on the IDT's schedule to discuss GDRs of their medications. Review of a 06/18/2024 psychiatry provider progress note showed Resident 32 had a GDR of their antidepressant medication on 12/20/2020, over three years ago, and a GDR of the anticonvulsant medication on 05/12/2022, over two years ago. Review of a 07/05/2024 psychiatry provider progress note showed the psychiatrist was following up with Resident 32 for agitation, impulsivity, and difficulty being redirected. This note showed the psychiatrist recommended staff increase the anticonvulsant medication Resident 32 was taking for behaviors. The psychiatrist indicated Resident 32 was to continue all other medications without changes. Review of Resident 32's 07/07/2024 physician visit note showed the physician acknowledged the resident was taking an AA medication three times daily. The physician documented Resident 32 should continue the medication and that the resident was being followed by psychiatry. There was no rationale documented for continuing the medication as ordered. Review of Resident 32's behavior monitor documentation for 07/01/2024 to 07/21/2024 showed staff documented the resident had behaviors on 4 of the 42 opportunities. Review of Resident 32's June 2024 behavior documentation showed staff documented the resident had behaviors on 6 of 60 opportunities. Review of Resident 32's May 2024 behavior documentation showed staff documented the resident had behaviors on 4 of 62 opportunities. Review of Resident 32's comprehensive progress notes from 07/29/2023 to 07/22/2024 showed no documentation indicating a GDR of the antianxiety medication should be attempted or why a GDR was contraindicated. In an interview on 07/23/2024 at 12:59 PM, Staff B stated GDRs were important for maintaining the resident's quality of life. Staff B stated it was important to monitor resident behaviors to evaluate if the psychotropic medication could be reduced. Staff B stated they expected GDRs to be attempted and/or physician documentation indicating a reason why a GDR was contraindicated or not. REFERENCE: WAC 388-97-1060(3)(k)(i). Based on interview and record review, the facility failed to ensure 2 (Residents 24 & 32) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic (medication that affected behavior, mood, thoughts, or perception) medications. This failure left residents at risk for unnecessary medications, adverse side effects, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's Pharmacy Services - Psychoactive Medication policy revised 10/04/2022, showed the facility implemented Gradual Dose Reductions (GDRs) unless contraindicated, prior to initiating, or instead of continuing a psychotropic medication. The policy showed supportive documentation included but was not limited to consideration of other factors addressed prior to initiating a psychotropic medication or in conjunctions with GDRs. <Resident 24> According to the 07/01/2024 Medicare 5 Day Minimum Data Set (MDS - an assessment tool), Resident 24 admitted to the facility on [DATE] and had a diagnosis of bipolar disorder (mental illness causing unusual shifts in a person's mood), anxiety disorder, and depression. Resident 24 received Antianxiety (AA), Antidepressant (AD), and Antipsychotic (AP) medications during the assessment period, and was assessed with no behavior or rejection of care during the assessment period. Review of Resident 24's July 2024 Physician Orders (POs) showed a 06/26/2024 order for an AA medication to be administered every 12 hours as needed for anxiety. Review of Resident 24's Medication Administration Record (MAR) showed Resident 24 received the as needed AA medication 6 times in 5 days of June and 13 times in 16 days of July 2024. In an interview on 07/22/2024 at 10:02 AM, Staff D (Social Services Director) stated as needed AA medications should be ordered for a limit of 14 days. Staff D stated staff should have clarified the order with the provider to have stop date. In an interview on 07/23/2024 at 10:27 AM, Staff B (Director of Nursing) stated as needed AA medications should be ordered for only 14 days. Staff B stated if a resident had behaviors affecting the resident, staff should communicate with the provider and the provider should document in the resident's record the reason for extending an AA medication. Staff B reviewed Resident 24's record and stated staff should clarify the order and should obtain a stop date for the as needed AA medication after 14 days, but they did not.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 1 of 5 nurses (Staff N - Licensed Practical Nurse) to properly administer 2 of 25 medications for 1 (Resident 203) of 8 residents observed during medication pass resulted in a medication error rate of 8%. This failure placed residents at risk for adverse side effects and/or not receiving prescribed medications as ordered. Findings included . <Facility Policy> Review of the facility's General Dose Preparation and Medication Administration policy revised 01/01/2013 showed the facility staff administering the medication should ensure the resident's consumption of the medication. <Staff N> Observation on 07/18/2024 at 9:02 AM showed Staff N preparing to administer morning medications to Resident 203. Staff N brought Resident 203 their morning medications. As Resident 203 took their medications, 2 medication tablets dropped in the resident's lap. Staff N did not notice and started to leave the resident's room. At that time, the surveyor stopped Staff N and asked if Resident 203 missed any medication tablets. Staff N went to Resident 203, found two tablets in the resident's lap, and handed the resident the tablets to take. In an interview on 07/18/2024 at 9:08 AM, Staff N stated they did not notice Resident 203 dropped the two tablets in their lap. Staff N stated they usually made sure the resident swallowed their medications before they left Resident 203's room but did not that time. REFERENCE: WAC 388-97-1060(3)(k)(ii). .

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured for 3 (Resident 90, 23, & 52) of 21 sample residents observed with medications in their rooms. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed, self-administration of medications by residents. Findings included . <Facility Policy> According to the facility's Storage and Expiration of Medications, Biologicals, Syringes, and Needles policy revised 10/31/2016, the facility would store bedside medications or biologicals in a locked compartment within the resident's room. This policy showed the facility would not provide bedside medications or biologicals without a Physician's Order (PO). <Resident 52> Observation on 07/18//2024 at 8:38 AM showed Resident 52 in bed. The facility's contracted wound team entered Resident 52's room to provide a treatment to Resident 52's skin. Resident 52's windowsill contained several skin treatments and ointments including a tube of antibiotic ointment, wound cleansing spray, a medicated topical cream, and a prescription lotion used to treat dry/scaly skin. The wound team and facility staff applied the medicated treatments from the windowsill to Resident 52 and placed the various ointments and creams back on the windowsill when the treatment was completed. <Resident 90> Observation on 07/18/2024 at 9:49 AM showed Staff O (Registered Nurse) administer morning medications to Resident 90. At that time, a large bag of Over The Counter (OTC) cough suppressant lozenges were observed on Resident 90's nightstand. Record review showed no assessment or PO indicating Resident 90 was safe to self-administer the OTC cough suppressant lozenges. In an interview on 07/18/2024 at 1:22 PM, Staff O stated they did not notice the bag of OTC cough suppressants. Staff O went to Resident 90's room and confirmed the OTC medication on the nightstand. Staff O confirmed Resident 90 would need a PO to keep the OTC cough suppressants in their room for self-administration. Staff O stated the medications should be in a locked drawer. <Resident 23> Observation on 07/18/2024 at 1:06 PM showed Resident 23 lying in bed watching TV. Beneath the TV was a dresser that contained several wound treatment supplies stored on top of the dresser. The top of the dresser contained three bottles of wound cleanser spray, a bottle of an antifungal powder, skin preparation wipes, 2 bottles of a topical gel used to kill bacteria in wounds, 2 bottles of medical grade wound dressing gel, and one tube of antimicrobial wound gel. In an interview on 07/18/2024 at 1:30 PM, Staff P (Unit Manager) stated once staff took medicated treatment supplies into a resident's room, those treatment supplies stayed in the room with the resident. In an interview on 07/19/2024 at 9:43 AM, Staff B (Director of Nursing) stated medicated treatment supplies should not be left at a resident's bedside. Staff B stated OTC cough lozenges should not be left at a resident's bedside. Staff B stated those items were considered a medication and should not be unattended at a resident's bedside. REFERENCE: WAC 388-97-1300(2). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 7 of 7 residents (Residents 94, 31, 1, 20, 26, 23, & 59) reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> A facility policy titled, Admission, Transfer, and Discharge - Notice Requirements Before Transfer/Discharge, dated 07/2018, showed a notice of transfer must be provided to the resident/representative when an emergency transfer to an acute care facility is ordered. <Resident 94> Review of Resident 94's 05/10/2024 Discharge Minimum Data Set (MDS- an assessment tool) showed the resident was transferred to an acute care hospital on [DATE]. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 94 and/or their representative regarding their discharge. <Resident 31> Review of Resident 31's Electronic Health Record (EHR) on 07/20/2024 showed a progress note the resident was transferred to the hospital on [DATE] and 06/04/2024. Review of Resident 31's 06/10/2024 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE]. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 31 and/or their representative regarding their discharge for 05/27/2024 or 06/04/2024. <Resident 1> Review of Resident 1's 06/07/2024 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE]. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 1 and/or their representative regarding their discharge. <Resident 20> Review of Resident 20's 12/23/2023 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE]. Review of Resident 20's 05/03/2024 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE]. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 20 and/or their representative regarding their discharges on 12/11/2023 or 04/28/2024. <Resident 26> According to 09/10/2023 Discharge MDS, Resident 26 discharged to an acute care hospital on [DATE] with a return anticipated. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 26 and/or their representative regarding their discharge on [DATE].<Resident 23> Review of Resident 23's 09/17/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 23's 09/28/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 23's 01/24/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 23's records on 07/16/2024 at 1:44 PM showed no documentation staff provided written notifications to Resident 23 regarding their rights related to their 09/17/2023, 09/27/2023, or 01/24/2024 discharges as required. <Resident 59> Review of Resident 59's 07/12/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's 07/25/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's 10/27/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's 11/20/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's 12/04/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's 02/07/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's 03/01/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's 04/29/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on [DATE]. Review of Resident 59's records on 07/23/2024 at 8:34 AM showed no documentation staff provided written notifications to Resident 59 or their representative regarding their rights related to their 07/12/2023, 07/25/2023, 10/27/2023, 11/20/2023, 12/04/2023, 02/07/2024, 03/01/2024, or 04/29/2024 discharges as required. In an interview on 07/23/2024 at 9:22 AM Staff A (Administrator) stated they did not have a process for written transfer notifications, so they were not being provided to any of the residents transferred to the hospitals. Staff A stated it was important to provide a written transfer notification to ensure the resident or resident representative was informed of the reason for transfer and to ensure the transfer was in alignment with the resident's stated goals for care and preferences. REFERENCE: WAC 388-97-0120 (2)(a-d). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 68> Review of the 05/29/2024 Quarterly MDS showed Resident 68 had severe impairment to their thinking abilities. This MDS showed Resident 68 was receiving hospice (end of life care) and had a life expectancy of less than six months. Review of Resident 68's Comprehensive CP on 07/23/2024 at 1:30 PM showed the CP was not revised to include goals or interventions related to Resident 68's hospice services. There were no instructions to staff indicating what care and services hospice staff provided to Resident 68. There were no instructions to staff regarding what measures to implement for Resident 68's comfort or directions for coordination between hospice and the facility. In an interview on 07/23/2024 at 1:35 PM, Staff B stated it was important for CPs to be updated and revised to ensure staff were providing the correct care for residents. Staff B reviewed Resident 68's CP and confirmed it needed to be updated to reflect Resident 68's hospice status. <Resident 32> Review of the 06/26/2024 Quarterly MDS showed Resident 32 had one fall since their admission to the facility. This MDS showed Resident 32 had no behaviors or rejection of care during the assessment period. Review of Resident 32's 07/02/2024 revised Fall CP showed an intervention directing staff to keep Resident 32's bed in a low position. Observations on 07/17/2024 at 9:18 AM and 07/22/2024 at 9:29 AM showed Resident 32 lying in bed. Resident 32's bed was not in the low position. In an observation and interview on 07/23/2024 at 2:03 PM, Resident 32 was lying in bed with the bed not in the low position. At that time, Resident 32 stated they did not like their bed in the low position because it affected their sleep. At that time, Resident 32 grabbed their bed controller and demonstrated how they could independently raise their bed up and down. In an interview on 07/23/2024 at 1:17 PM, Staff B stated Resident 32's bed should be in the lowest position, but the resident was able to position their bed independently. Staff B stated the CP should be updated to identify Resident 32's non-compliance with their plan of care, but the CP was not. REFERENCE: WAC 388-97-1020(5)(b). Based on observation, interview, and record review, the facility failed to ensure Care Plans (CPs) were accurately reviewed and revised to reflect current resident status and needs as required for 5 (Residents 41, 61, 6, 68, & 32) of 20 residents reviewed for CP's. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . <Facility Policy> Review of the facility's Quality of Care policy, revised 08/2018, showed the resident's CP would reflect person-centered care and include resident choices, preferences, goals, concerns, and needs. The CP would describe the care and services staff would provide to the resident so the resident could attain or maintain their highest practicable physical, mental, and psychosocial well-being. <Resident 41> According to the 06/12/2024 admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 41 admitted to the facility on [DATE] with two pressure ulcers (PUs). Resident required maximal assistance with bed mobility and toileting needs. Review of Resident 41's record showed Resident 41 had PUs on right buttock and left buttock. Review of the 06/11/2024 Skin CP showed Resident had a coccyx PU and was at risk for new PU development. Nursing interventions included Resident 41 preferred to be repositioned with two staff members. Observations on 07/18/2024 at 9:39 AM during wound care showed Resident 41 had PU on right buttock and left buttock. There was no PU on Resident 41's coccyx area. In an interview on 07/18/2024 at 10:22 AM, Resident 41 stated staff did not offer or assist the resident to reposition in bed. In an interview on 07/18/2024 at 10:45 AM, Staff G (Unit Manager - UM) stated Resident 41 had PUs on their right and left buttock. In an interview on 07/22/2024 at 10:02 AM. Staff B (Director of Nursing) stated they knew the facility had a CP issue. Staff B stated Resident 41 did not have a PU on coccyx area and the CP is inaccurate. Staff B stated nursing staff should have reviewed the CPs and updated according to the resident's status, but they did not. <Resident 61> According to the 05/20/2024 admission 5 Day MDS, Resident 61 admitted to the facility on [DATE] and had moderately impaired memory. Review of the 05/16/2024 Medication CP showed Resident 61 received Intravenous (IV- needle inserted into a vein to provide medication or fluids) medications and nursing interventions included instructions for nursing staff to monitor IV dressing site every shift. Review of the July 2024 medication administration record showed Resident 61 received no IV medication. Observation on 07/18/2024 at 9:21 AM showed no IV insertion site or dressing on Resident 61's body. In an interview on 07/18/2024 at 11:21 AM, Staff E (Licensed Practical Nurse) reviewed Resident 61's record and stated Resident 61 had no IV medication orders. In an interview on 07/22/2024 at 10:02 AM, Staff B stated the CP was not accurate. Staff B stated nursing staff should have reviewed the CPs and updated according to the resident's status, but they did not.<Resident 6> According to the 06/07/2024 Quarterly MDS Resident 6 was independent with lying to sitting on side of bed, sit to stand, chair-to-bed/bed-to-chair transfer, toilet transfer, and walked ten feet. This MDS showed Resident 6 had intact cognition. During an interview on 07/16/2024 at 9:07 AM Resident 6 stated they transferred from their bed to their wheelchair or walker and back to their bed independently. Review of Resident 6's Potential for Alteration in Activities of Daily Living CP on 07/18/2024 at 8:46 AM showed the CP had contradicting information. One intervention stated the resident required supervision or partial assistance of one staff for transferring. Another intervention stated Resident 6 was able to transfer on their own. Review of Resident 6's bedside [NAME] on 07/18/2024 at 9:00 AM showed Resident 6 required substantial to maximal assistance by one staff to turn and reposition in bed, was independent with bed mobility, was able to transfer on their own, and required supervision or partial assistance of one staff for transferring. During an observation on 07/18/2024 12:16 PM Resident 6 went from lying in bed to sitting on the edge of their bed independently. During an interview on 07/23/2024 at 11:21 AM Staff P (UM) stated Certified Nursing Assistants used the CP and [NAME] for information on what care to provide for each resident. Staff P stated it was important to update or revise CPs to ensure proper care was provided to the residents. During an interview on 07/23/2024 at 11:28 AM Staff P stated Resident 6 was mostly independent with bed mobility and transfers. Staff P stated the CP and [NAME] should be revised to reflect Resident 6's current care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment/services for 7 of 8 residents (Residents 47, 20, 40, 41, 61, 32, & 59) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Facility Policy> According to a facility policy titled, Quality of Care Restorative Nursing Programs, revised 06/2018, showed Restorative Nursing Programs (RNP) would be developed and/or formalized by a supervising nurse. <Resident 47> According to a 05/31/2024 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 47 had functional limitation in ROM to both arms and both legs. The assessment showed Resident 47 did not have any memory impairment. The MDS showed Resident 47 had medically complex conditions which included, but were not limited to, depression, generalized muscle weakness, difficulty in walking, and fibromyalgia (chronic disorder characterized by pain, stiffness, and tenderness). Review of a 02/23/2024 Activity of Daily Living (ADL) Care Plan (CP), Resident 47 required substantial/maximal assistance from staff with bathing/showering, bed mobility, dressing, and toilet use. The CP showed Resident 47 required two staff maximal assistance with a mechanical lift machine for transfers. In an interview on 07/16/2024 at 11:56 AM Resident 47 stated they were unable to raise either arm up to shoulder level and unable to bend both of their knees to a 90-degree angle. Resident 47 stated they were informed by therapy they can't work with therapy, and they could not have restorative nursing services until they were approved for Medicaid insurance. In an interview on 07/24/2024 at 9:52 AM Staff G (Unit Manager - UM) stated Resident 47 was assessed to have limited ROM to both arms and both legs. Staff G stated Resident 47 should have started a RNP to prevent ADL decline, but they were not. Staff G stated they did not assess residents for RNP's and believed therapy was responsible for these recommendations. Staff G stated it was important when a resident with limited ROM finished working with therapy to continue exercises with a RNP, so they did not become contracted or develop a decrease in their ROM and mobility. <Resident 20> According to a 05/06/2024 Annual MDS, Resident 20 had no memory impairment. The MDS showed Resident 20 was [AGE] years old and originally admitted on 06/2023 with a rehospitalization in December 2023 and April 2024. The assessment showed Resident 20 had diagnoses of, but not limited to, generalized muscle weakness, and difficulty in walking. Review of a 06/10/2024 nursing admission assessment/evaluation showed Resident 20 required assistance from one staff with walking daily. In an interview and observation on 07/17/2024 at 10:06 AM Resident 20 stated their right shoulder had limited ROM. Resident 20 demonstrated the inability to raise their right arm on its own by using their left hand to lift their right arm up and stated they could not even raise their right arm up to shoulder height anymore. Resident 20 stated when staff gave me the power chair, they stopped physical therapy and walking with me. Resident 20 stated walking was the one thing they really looked forward to, but staff had not been walking with them anymore. In an interview on 07/19/2024 at 10:07 AM, Staff B (Director of Nursing) stated the RNPs were removed by the higher-ups. Staff B stated the facility did not have any dedicated staff to provide RNPs to residents and was told the RNPs would be incorporated/performed by all Certified Nursing Assistants (CNA) during the provision of ADL care. Review of Resident 20's records on 07/24/2024 there was no assessment of their right arm/shoulder in the resident's chart showing the decrease in their ROM. A daily task for staff to document they assisted Resident 20 with walking 10 feet every shift showed activity did not occur for the months of October, November, December in 2023, and January, February, March, April, May, June and July 2024. In an interview on 07/24/2024 at 10:14 AM Staff G stated Resident 20 had limited ROM to their right shoulder. Staff G stated staff were to assist Resident 20 with walking daily and they should be on a RNP to prevent a decline in their level of function and ROM, but they were not. Staff G stated there was no documentation staff assisted Resident 20 with daily walking.<Resident 32> According to the 06/26/2024 Quarterly MDS, Resident 32 had clear speech, was understood and could understand others in conversation, and had some impairment with their thinking/processing abilities. The MDS showed Resident 32 had limited ROM to one side of their upper extremities and to both lower extremities. The MDS showed Resident 32 did not receive restorative nursing services during the assessment period. In an interview on 07/17/2024 at 9:22 AM, Resident 32 stated they used to have a RNP but it stopped a while ago and the resident was unsure why the program ended. Review of Resident 32's .limited physical mobility . CP showed a 07/10/2022 revised intervention directing staff to assist the resident in completed upper and lower extremity ROM exercises five to seven times per week. Review of Resident 32's May 2024, June 2024, and July 2024 task report, showed staff did not offer or provide Resident 32 their RNP as care planned. <Resident 59> According to the 05/29/2024 Annual MDS, Resident 59 was understood and able to understand others in conversation. This MDS showed Resident 59 had severely impaired thinking/processing abilities. This MDS showed Resident 59 had limited ROM to one side of their upper body and one side of their lower body. The MDS showed Resident 59 did not receive RNP services for their limited ROM during the assessment period. Observation on 07/17/2024 at 8:48 AM showed Resident 59 lying in bed on their left side toward the wall. A palm protector was observed in Resident 59's left hand Review of Resident 59's limited physical mobility CP revised 11/29/2023, showed Resident 59 had generalized weakness related to a stroke and weakness to one side of their body. This CP showed a goal for Resident 59 to remain free of complications related to their immobility including contractures. Resident 59's ADL - self-care performance deficit . CP showed Resident 59 was totally dependent on staff for turning/repositioning in bed, dressing, bathing, toilet use, transfers, and personal hygiene. This CP had no directions to staff regarding the palm protector and did not indicate Resident 59 was receiving a RNP despite have limited ROM. In an interview on 07/24/2024 at 10:43 AM, Staff B stated the CNAs were expected to provide walking assistance for resident who could walk. Staff B stated other activities such as encouraging a resident to brush their hair was considered active ROM. Staff B stated the CNAs were not documenting these activities. Staff B stated they did not have a list of residents who had formal RNPs in place. Staff B stated they expected CNAs to be trained to perform RNP tasks but they were not trained. REFERENCE: WAC 388-97-1060 (3)(d). <Resident 41> According to the 06/12/2024 admission 5 Day MDS, Resident 41 admitted to the facility on [DATE], cognitively intact and had a diagnosis of below the right knee amputation. The assessment showed Resident 41 had impairment on both upper and lower extremities with functional limitation in ROM and was required maximal assistance for bed mobility rolling from back to left and right side, toileting, and shower. Resident 41 had no rejection of care during the assessment period. Review of the 06/07/2024 ADL CP showed Resident 41 required two staff members for repositioning in bed and for locomotion. Observations on 07/16/2024 at 10:13 AM and 12:55 PM, on 07/17/2024 at 9:10 AM, and 07/18/2024 at 12:23 PM showed Resident 41 lying in their bed on their back. In an interview on 07/18/2024 at 12:23 PM, Resident 41 stated they had only one leg and they need two staff members to get them out of bed and even to reposition in bed. Resident 41 stated they worked with therapy till end of June 2024 and after that Resident 41 did not receive any exercise. In an interview on 07/23/2024 at 11:26 AM, Staff B stated the facility did not have any dedicated RNPs to residents and was told the RNPs would be performed by all CNAs during care and sometimes activity department would perform exercise program with a group of residents. Review of Resident 41's record showed a daily task for staff to document they assisted Resident 41 with walking 10 feet every shift and staff documented activity did not occur every day. In an interview on 07/23/2024 at 1:10 PM, Staff T (Rehab Director) stated Resident 41 received rehab services from 06/06/2024 thru 06/30/2024 until insurance covered the services. Staff T stated Resident 41 had limited ROM and would benefit from more therapy or RNP to prevent a decline in their level of function and ROM, but the facility did not have RNP. <Resident 61> According to the 05/20/2024 admission 5 Day MDS, Resident 61 admitted to the facility on [DATE], had limited ROM on right arm and required maximal assistance with personal hygiene, bed mobility, and toileting. The MDS showed Resident 61 had no behavior of refusing care during the assessment period. Review of the 05/16/2024 ADL CP showed Resident 61 was dependent on staff for ADLs and locomotion. Observations on 07/16/2024 at 9:40 AM, 07/17/2024 at 11:59 AM, 07/18/2024 at 2:45 PM showed Resident 61 was lying in their bed and was trying to get out of bed. In an interview on 07/23/2024 at 11:14 AM, Staff B stated the facility did not have any dedicated RNPs to residents and was told the RNPs would be performed by all CNAs during care. Staff B stated CNAs were assisting Resident 61 with ADLs and feeding all meals. Review of Resident 61's record showed a daily task for staff to document they assisted Resident 61 with walking 10 feet every shift and staff documented activity did not occur every day. In an interview on 07/23/2024 at 1:10 PM, Staff T stated Resident 61 was non weight bearing status on right their arm. Staff T stated Resident 61 had limited ROM and would benefit from a RNP to prevent a decline in their level of functioning and ROM, but the facility did not have a RNP.<Resident 40> According to a 06/13/2024 Quarterly MDS, Resident 40 was understood and could understand others in conversations and had intact cognition. The MDS showed Resident 40 had functional limitation in ROM to both legs, used a wheelchair for mobility, was dependent on staff assistance with rolling side to side, bathing, and chair/bed-to-chair transfers. The MDS showed Resident 40 had no rejection of care and did not receive a RNP during the assessment period. The revised 12/28/2023 limited physical mobility CP directed staff to provide a Nursing Rehab/Restorative: Active Assist ROM program for Resident 40 three to six days per week and a Nursing Rehab/Restorative: Mobility program three times per week. During an interview on 07/16/2024 at 8:50 AM Resident 16 stated staff assisted them to get out of bed about once a week. Resident 40 stated staff don't assist them with any exercises. During an interview on 07/23/2024 at 11:19 AM Staff P (Unit Manager) stated this facility does not have a RNP, the CNAs are expected to provide this service when a resident needs it. Staff P reviewed Resident 40's revised 12/28/2023 limited physical mobility CP and stated it directs staff to provide Resident 40 with restorative exercises. Staff P reviewed Resident 40's task documentation for July 2024 and stated there were no tasks listed for staff to sign off on, therefore Resident 40 did not receive these interventions.

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, and served under sanitary conditions. Facility staff failed to: consistently perform hand hygiene when preparing resident meal trays; label food items and discard expired food items from unit refrigerators; keep the kitchen dishwasher machine free from grime and debris build up; and maintain accurate documentation for the dishwasher temperature and chlorine chemical logs. These failures contributed to an unsanitary kitchen environment, placed residents at risk for food borne illness, and/or contaminated food. Findings included . <Facility Policy> Review of the facility's Food and Nutrition Services - Food Safety policy dated 07/2018, showed facility staff would use good hygienic practices when handling food. This policy showed facility staff would follow manufacturer's guidelines based on the type of dishwasher used to sanitize dishware and chemical solutions would be checked for concentration levels at least once per shift. Review of the facility's Food's Brought by Family/Visitors policy revised 02/2014 showed perishable foods would be stored in the refrigerator and the container would be labeled with the resident's name and use by date. The policy showed the nursing staff were responsible for discarding perishable foods on or before the use by date. <Meal Tray Service> Observation on 07/19/2024 at 11:59 AM showed kitchen staff plating resident meals for the day's lunch service. Staff U (Dietary Aide) was placing drinks, desserts, and silverware rolled in napkins on the resident trays. Staff U was observed to have their hairnet placed behind their ears leaving hair around their eyes and forehead not contained within the hairnet. Staff U was observed to use their gloved hands to wipe their hair out of their eyes and wipe sweat away from their face using the back of their gloved hand and/or the thumb side of their hand on five occasions throughout the plating of resident meals. Staff U did not remove their gloves and perform hand hygiene during the meal service and continued wearing the contaminated gloves while touching resident drink cups, dessert plates, and rolled napkins containing silverware. During the lunch service observation on 07/19/2024 at 12:22 PM, Staff V (Dietary Manager) was assisting with the plating of the lunch meal. Staff V wiped their face with their forearm and then rested their forearm on a large, uncovered bin of lettuce. Staff V's watch band was resting in the bin of lettuce. Staff V then used their gloved hands to adjust their shirt, walked away from the tray line, obtained a large stack of trays, and continued assisting with putting toppings like cheese and lettuce on plated lunch meals. Staff V did not change their gloves or perform hand hygiene after touching their face or shirt. <Dishwashing Machine> Observation on 07/16/2024 at 8:40 AM of the facility's dishwasher machine showed the machine was a low temperature dishwasher machine. A sign near the machine, above the dish sink showed the dishwasher temperature should be between 120-140 degrees Fahrenheit (F) and the chemical test strips should have a result of 50-100 Parts Per Million (PPM) of chlorine (chemical used to ensure proper sanitization of dishes washed in a low temperature dishwasher machine). The sign instructed staff to dip the chlorine test strip on droplets of water leftover on dishes after a dishwashing cycle was completed. Observation of the top of the dishwasher machine at that time showed a large amount of rust colored debris, crumbs, and grime build-up. Observation on 07/16/2024 at 8:49 AM showed Staff W (Cook) and Staff V running a test cycle on the dishwasher machine. Staff W placed dishware in the dishwasher machine, took a chemical test strip and placed it on a dish, closed the dishwasher, and ran a cycle. When the cycle was complete, the chemical test strip was washed off the dish and down into the drain. Staff W and Staff V repeated the same process again and the chemical test strip was washed away in the machine by the end of the cycle. On the third attempt, the instructions on the sign on the wall were pointed out the the kitchen staff. At that time, staff performed the chemical test strip per the instructions. Staff V's test strips remained unchanged, indicating the chlorine chemical was ineffective. In an interview at that time, Staff V stated they were having issues with their test strips and needed to obtain new ones. Observation on 07/16/2024 at 9:03 AM of a cycle of the dishwasher machine showed the machines temperature during the wash cycle was 150 degrees F and the rinse cycle was 157 degrees F. Review of the facility's July 2024 Dish Machine Log showed on 74 dishwashing cycles, the facility staff documented the dishwasher temperature was above 140 degrees F temperature for the low temperature machine. This same log showed staff documented the PPM of chlorine was greater than the indicated 50-100 PPM range on 30 occasions. The bottom of the Dish Machine Log showed directions to staff that a low temperature dishwasher machine's wash and rinse cycle should be between 120-140 degrees F. There was a spot on the form reading: Manufacturer's Recommended PPM with a blank area to be filled in. This was left blank. In an interview on 07/16/2024 at 8:50 AM, Staff V confirmed the discrepancies on the Dish Machine Log. Staff V confirmed the dishwasher temperature was high during the test cycle and the machine needed to be checked. <Unit Refrigerators/Freezers> Observation on 07/22/2024 at 5:26 AM of the [NAME] Hall unit refrigerator/freezer showed a sign on the door directing staff that the refrigerator was for resident items only. The sign showed the food items must have a name, date, room number, and the item must be tossed after three days. Observation of the freezer showed a coffee mug containing an opened, unlabeled ice cream sandwich with a bite taken out of it. The back of the freezer contained an unlabeled and undated plastic cup with a slice of cake and a spoon. The freezer contained one ice cream cake dated 06/19/2024 and another ice cream cake dated 04/17. Observation on 07/22/2024 at 5:43 AM showed the East Hall unit refrigerator/freezer contained three yogurts with a handwritten date of 06/29, a piece of cake unlabeled and undated, and three meals in food storage containers and/or fast-food bags without resident names or dates. The refrigerator contained a grocery bag with three food containers. The bag had a resident name but no date. The refrigerator also contained an undated pizza box and a grocery bag that had two chicken breasts, a package of four yogurts, and two bags of store-bought hard-boiled eggs. The bag was unlabeled and undated. In an interview on 07/23/2024 at 11:53 AM, Staff A (Administrator) stated it was their expectation staff changed gloves and performed hand hygiene after touching their face. Staff A stated they expected staff disposed of food in unit refrigerators after three days. REFERENCE: WAC 388-97-1100(3), -2980. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: consistently performed Hand Hygiene (HH) before and after resident care/contact; apply/remove Personal Protective Equipment (PPE) in accordance with the Transmission Based Precaution (TBP- implement precautions based on the means of transmission in order to prevent or control infection) signs posted outside of resident rooms; and implement interventions to prevent Legionnaires disease (a serious severe respiratory infection caused by inhalation of bacteria growing in the water system) within the facility. The facility was unable to provide documentation of completed McGeer's or Loeb's infection surveillance criteria forms for each resident with an infection who received, or was currently on, an antibiotic. These failures placed all residents and staff at risk for contracting and/or spreading infections, possible future antibiotic resistance, and a decreased quality of life. Findings included . <Facility Policies> According to a facility policy titled, Infection Prevention and Control Program (IPCP), revised 06/08/2022, the IPCP would utilize a system for prevention, identifying, reporting, investigating, and controlling infections, and communicable disease. The policy showed the program would provide infection surveillance to assist in identification of infections and communicable diseases before they can spread. The policy showed the program would provide guidance to staff on TBP to be followed, PPE use, and HH practices. The policy showed resident room assignments would be made while taking into consideration resident diagnoses and risk factors such as not placing residents with active contagious infections in a room with residents who are at greater risk of contracting an infection. This policy showed when a resident had an infection or was potentially infectious, the infection would be tracked, and interventions would be implemented to minimize the additional risks to the residents. The policy showed the facility would monitor for proper HH, use of PPE and TBP, and proper infection prevention techniques were used during wound care. According to an undated facility policy titled, Legionnaires' Disease, the maintenance director would keep logs to assure that routine preventative measures were being done for the prevention of Legionnaires Disease. According to a facility policy titled, Infection Prevention and Control Antibiotic Stewardship, revised 03/2019, the facility would utilize McGeer's and Loeb's criteria for infections and antibiotic use. <Legionella Prevention> Record review on 07/19/2024 showed no documentation of Legionella prevention. In an interview on 07/19/2024 at 8:44 AM Staff L (Maintenance Director) stated they did not know where Legionella was at higher risk of development and did not have monitoring or prevention techniques for Legionella in place. In an interview on 07/22/2024 at 8:57 AM Staff C (Infection Preventionist) stated they were not involved with the facilities Legionella prevention process. <Hand Hygiene> During an observation and interview on 07/18/2024 at 12:19 PM, Staff K (Certified Nursing Assistant - CNA) entered room [ROOM NUMBER] to bring the resident their lunch. Staff K was observed, without gloves, to move the over the bed table to the resident, assisted the resident to sit up, and set their meal tray up for them. Staff K exited room [ROOM NUMBER] without performing HH, collected room [ROOM NUMBER] lunch tray from the meal cart and proceeded to room [ROOM NUMBER]. Staff K setup 216-1 lunch tray for the resident and the resident requested fresh ice water, so Staff K collected the water pitcher and exited room [ROOM NUMBER] to collect fresh ice water for the resident at the ice machine without performing HH. Staff K then collected room [ROOM NUMBER]'s lunch tray from the meal cart and brought to room [ROOM NUMBER] without gloves or performing HH, cleared and moved the over the bed table over the resident, and setup their meal tray. Staff K collected dirty cups and glasses from room [ROOM NUMBER] and exited the room without performing HH. Staff K stated they only had to perform HH if they contacted a resident or provided care, otherwise they did not have to perform HH. In an interview on 07/19/2024 at 1:28 PM both Staff B (Director of Nursing) and Staff C stated they expected staff to perform HH before entering a room or exiting a room, between dirty and clean cares, before and after glove change, before and after resident contact, and between passing meals to residents. <Resident 41> Observation on 07/18/2024 at 9:26 AM showed Resident 41 had a bowel movement and Staff G (Unit Manager) was holding Resident 41 on their side and Staff X (CNA) was providing incontinency care to Resident 41 in their bed. Staff X was wearing gloves on both hands during providing the care. Staff X removed the dirty brief and cleaned the resident, removed one glove from their right hand and still had another glove on right hand (was wearing double gloves on right hand), did not wash their hands, grabbed the clean brief with the same gloves and put on the resident, grabbed the clean linens and fixed Resident 41's bed, put dirty linens in a bag, removed their gloves, washed their hands and left the room with the soiled linens in a bag. In an interview on 07/18/2024 at 9:39 AM, Staff X stated they were wearing double gloves on right hand because Resident 41 had Bowel movement everywhere in their bed. Staff X stated after they cleaned the resident, they removed the dirty glove from right hand and continued with changing the clean brief and linens in Resident 41's bed. Staff X stated they should have removed the dirty gloves and washed their hands between dirty to clean care, but they forgot to do so. In an interview on 07/18/2024 at 1:33 PM, Staff B stated they expected staff not to wear double gloves during any care and to perform HH before entering a room or exiting a room, between dirty and clean cares, before and after glove change. <Transmission Based Precautions> <room [ROOM NUMBER]> Observation on 07/16/2024 at 1:36 PM showed room [ROOM NUMBER] door had two signs posted: one for Enteric Barrier Precautions (EBP) for bed one and another Contact Precaution sign for bed two. Contact Precaution sign was directed staff to wear gown and gloves before entering the room. Observations on 07/17/2024 at 9:57 AM showed Staff Y (Licensed Practical Nurse - LPN) went to room [ROOM NUMBER] to administer medications to the resident. Staff Y was not wearing the gown while administering medications to the resident inside the room. In an interview on 07/17/2024 at 10:00 AM, Staff Y stated they should have followed the sign posted outside the door to wear gown and gloves, but they forgot to do so. In an interview on 07/18/2024 at 8:42 AM, Staff B stated they expected staff to follow the sign posted outside the door. <room [ROOM NUMBER]> Observation on 07/16/2024 at 11:30 AM showed room [ROOM NUMBER] door had sign posted for Contact Enteric Precautions with instructions for the staff to follow: Prior to entering the room- wash or gel hands, use soap and water upon leaving the room. Wear gown and gloves. In an interview on 07/16/2024 at 11:36 AM, Staff E (LPN) stated Resident in room [ROOM NUMBER] had C-Diff (Clostridium Difficile- contagious bacterial infection of the colon) infection and staff had to follow the sign posted on the door. Observation on 07/16/2024 at 12:05 PM showed Staff S (CNA) was delivering lunch hall trays in resident's rooms. Staff S went to deliver tray in room [ROOM NUMBER], did not wear gloves or gown when entered the room, delivered the meal tray, came outside the room, and sanitized their hands. In an interview on 07/16/2024 at 12:08 PM, Staff S stated they only had to wear gown and gloves if they contacted a resident or provided care, otherwise they did not have to wear PPE. In an interview on 07/18/2024 at 8:38 AM, Staff B stated their expectation from staff is to follow the sign posted outside the door and to wear PPE as instructed on the sign, but they did not. <McGeer's/Loeb's Infection Surveillance Criteria> In an interview on 07/19/2024 at 1:59 PM Staff B and Staff C stated they used the McGeer's and Loeb's criteria for their antibiotic stewardship/surveillance program. Review of ABO stewardship records on 07/22/2024 showed no McGeer's or Loeb assessment documentation for a sample of six residents that had taken or were currently on antibiotics. In an interview on 07/22/2024 at 8:09 AM Staff C stated the McGeer's and Loeb's criteria was documented in different software. Staff C stated it does not have the McGeer's or Loeb's documentation of the assessments and only showed a box to check yes /no if they met the criteria. Staff C stated they did not have documentation to support they completed the McGeer's or Loeb's assessment on any of the residents, so they did not have the symptoms documented that supported they met these criterions. Refer to F812 - Food Procurement, Store/Prepare/Serve - Sanitary Refer to F881 - Antibiotic Stewardship REFERENCE: WAC 388-97-1320(1)(c)(2)(b). .

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of Antibiotics (ABO), reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 6 of 6 sample residents (Resident 204, 80, 77, 64, 47, & 3) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABO's. Findings included . <Facility Policy> According to a facility policy titled, Infection Prevention and Control ABO Stewardship, revised 03/2019, the program would validate that antibiotics were prescribed for the correct indication, the correct dose, the correct route and the correct duration. The policy showed the program would implement a data gathering system and analyze the collected data to ensure unnecessary ABO prescribing did not take place. The policy showed the facility would monitor the use of ABO's using the McGeer's (a set of signs and symptoms that verify active infection) and Loeb's (tool used to assess antibiotic appropriateness) criteria as a guide for protocols for prescribing ABO's. This policy showed when a resident was admitted on an ABO regimen, the facility would review for appropriateness of the ABO. The policy titled, Antibiotic Stewardship Program, revised 04/2022, showed documentation related to the ASP, including meeting minutes, tracking information, and logs would be maintained in a binder to facilitate comparisons and review. The policy showed within 48 -72 hours following initiation of an ABO, an ABO Time-Out Checklist would be completed and reviewed with the prescriber. Record review on 07/22/2024 showed incomplete and inaccurate antibiotic line listing for the facility's ASP. Review of the ASP showed no documentation of a positive McGeer's or Loeb's criteria to meet the need of ABO use for Residents 204, 80, 77, 64, 47, or 3. The facility was unable to provide accurate and complete ABO line listing documentation from the last survey to the current survey. <Residents 204> Review of Resident 204's records showed two ABO's that were not documented on the ASP line listing and had no documentation of McGeer's or Loeb's data. <Residents 80> Review of Resident 80's records showed they had completed an ABO without any documentation of symptoms that met McGeer's or Loeb's criteria. <Residents 77> Review of Resident 77's records showed they had completed an ABO without any documentation of symptoms that met McGeer's or Loeb's criteria. <Residents 64> Review of Resident 64's order summary showed they were admitted on an ABO for colitis (inflammation of the colon), but review of hospital history and physical showed the colitis was resolved and Resident 64 was placed on the ABO for Pneumonia (inflammation of the lungs). Review of Resident 64's hospital records showed a chest X-ray which was clear of pneumonia. <Residents 47> Review of Resident 47's records showed they had completed an ABO without any assessment or ABO time-out. <Residents 3> Review of Resident 3's records showed they had completed an ABO without any assessment or ABO time-out. In an interview on 07/22/24 at 8:09 AM Staff C (Infection Preventionist) stated they did not maintain an ASP binder with meeting minutes, tracking information, and logs for comparison and review. Staff C stated they did not have the ASP up to date and did not have residents who are on ABO's, or were on an ABO, logged for July 2024. Staff C stated they had three job titles, Assistant Director of Nursing, Staff Development Coordinator, and Infection Preventionist, which made it difficult to keep up with their workload. Staff C stated they did not complete a McGeer's or Loeb's assessment on any resident that used to be or was currently taking an ABO. Staff C stated the facility had a software with a question . meets McGeer's or Loeb's criteria? Yes or no, but the software did not document the data that qualified the resident to take an ABO. Staff C stated it was important to complete a McGeer's & Loeb's assessment to ensure the resident was receiving the correct ABO and to ensure the ABO was necessary. REFERENCE: WAC 388-97-1060(3)(k)(i),-1320(2)(a-c). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notices (SNF-ABN) and/or a Notice to Medicare Provider Non-Coverage (NOMNC) for 2 of 3 residents (Resident 102 & 262) reviewed for SNF ABN and NOMNC notification. The failure to provide residents information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program. Findings included . The 09/20/2022 Resident Rights of Medicaid/Medicare Coverage Liability facility policy showed the facility will issue a NOMNC to the resident or representative at least two days before the end of a Medicare covered Part A stay or when all therapy services were ending. The policy showed a SNF-ABN will be issued to inform the resident or representative of potential liability for non-covered services if the resident decided to remain in the facility after skilled coverage ended. <Resident 102> Review of Resident 102's undated SNF Beneficiary Protection Notification Review completed by the facility staff showed Medicare Part A services started on 03/21/2023 and the facility initiated the end of coverage on 04/20/2023 with unused benefit days remaining. The form showed the SNF-ABN was not provided to Resident 102 or their representative, showed Staff did not complete. Review of Resident 102's full medical record showed they remained in the facility after Medicare benefits ended and continued to receive skilled services. The medical record did not contain a SNF-ABN notice issued or signed by Resident 102 or their representative to inform of financial liability for continued skilled services. During an interview on 04/25/2023 at 3:31 PM, Staff P (Business Office Coordinator) stated Resident 102 admitted to the facility on [DATE] with Medicare Part A Services. Staff P stated the Medicare Part A coverage ended on 04/21/2023 and Resident 102 remained in the facility. Staff P stated Resident 102 should have received a NOMNC and SNF-ABN notice. When looking at Resident 102's record, Staff P stated there was no SNF-ABN notice and no documentation in the record that Resident 102 or their representative received information regarding their responsibility for costs and services. During an interview on 04/27/23 at 8:45 AM, Staff A (Administrator) stated when a Resident's skilled services are ending the costs and services should be discussed with the resident and/or their responsible party. Staff A stated a SNF-ABN should have been, and was not, provided to Resident 102 when they remain in the facility after Medicare A benefits ended. <Resident 262> Review of Resident 262's undated SNF Beneficiary Protection Notification Review completed by the facility staff showed Medicare Part A services started on 02/25/2023 and the end of coverage was on 04/20/2023. The form showed a NOMNC was not provided to Resident 262 or their representative. Review of a 03/17/2023 progress note showed Resident 262 discharged home. Review of Resident 102's full medical record showed no documentation of who initiated the discharge. Review of the 03/13/2023 Discharge Planning and Summary, completed by social services staff, showed a NOMNC was not provided to Resident 262. Review of an undated Discharge checklist showed NOMNC/Last coverage date marked N/A. In an interview on 04/27/2023 at 9:45 AM, Staff P stated Resident 262 admitted to the facility on [DATE] with Medicare Part A Services. Staff P stated the Medicare Part A coverage ended on 03/17/2023 and Resident 262 discharged home. When looking at Resident 262's record, Staff P stated there was no documentation if the discharge was resident or facility initiated and there was no documentation the NOMNC was issued. Staff P stated a NOMNC should have been, and was not, issued to Resident 262. REFERENCE: WAC 388-97-0300(1)(e), (5), (6). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to: ensure 1 (Resident 82) of 1 residents reviewed for positioning was positioned correctly in their wheelchair; ensure care was coordinated with hospice services for 1 (Resident 78) of 1 residents reviewed for hospice services. Facility failure to ensure correct positioning left Resident 82 at risk for discomfort, and negative health outcomes. The facility's failure to coordinate care with hospice left Resident 78 at risk for receiving unnecessary care. Findings included . <Resident 82> In an interview on 04/28/2023 at 11:22 AM, Staff A (Administrator) stated there was no facility policy addressing wheelchair positioning. Staff A stated the facility used the [NAME] (Nursing) Manual which contained a section titled Measure it: Proper Wheelchair Fit is Key to Ensuring Function while Protecting Skin Integrity dated December 2014. This section showed, Users remain seated in wheelchairs during a variety of functional activities. For these users, a wheelchair goes beyond a means of conveyance and is used as the base of support while eating, exercising, recreating, working, learning, and any other activity in which one participates . Consideration of posture includes both wheelchairs and seating systems, which consist of a seat cushion and back/trunk support. Wheelchairs are chairs, so it is important to provide structural support for the trunk, pelvis, and extremities. According to the 03/04/2023 quarterly Minimum Data Set (MDS - an assessment tool), Resident 82 had diagnoses including a left femur (thigh bone) fracture, difficulty walking, repeated falls, spinal stenosis (narrowing of the spinal canal that can put pressure on the spinal cord and the nerves within the spine) and dementia. The MDS showed Resident 82 was rarely or never understood, and did not exhibit any mood or behavioral indicators, such as rejecting care, and required extensive assistance of one person for transfers, locomotion on and off the unit, dressing, toilet use, and hygiene. The MDS showed Resident 82 was not steady, and only able to stabilize with assistance for balance during transitions and walking. Resident 82's Physician's Orders included an 08/09/2022 order for PT [Physical Therapy] to eval and treat for wheelchair. The 08/09/2022 Physical Therapy PT Evaluation & Plan of Treatment showed pertinent diagnoses/conditions of repeated falls, hip fracture and abnormal posture, and included goals for Resident 82 to be able to sit in appropriate seated system with spine and hips in a neutral position. Resident 82 was dependent on staff for the application of the footrests on the wheelchair. Resident 82's revised 09/15/2022 limited physical mobility . care plan (CP) included a goal to ensure the resident remained free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. The CP included interventions to: maintain current level of mobility; locomotion - the resident required extensive assist of (1) staff for locomotion; locomotion - the resident used a manual wheelchair for locomotion; PT, OT [Occupational Therapy] referrals as ordered; the resident was weight bearing; Provide supportive care, assistance with mobility as needed/document assistance as needed. There was nothing on the CP to indicate Resident 82 did not allow staff to apply the footrests to the wheelchair. The following observations showed Resident 82 sat in their wheelchair in a slightly reclined position without support for his legs or feet on three of the four days of the survey period with their legs dangling, and unsupported: -On 04/25/2023 at 12:05 PM, Resident 82 sat in their wheelchair in their room in a reclined (tilted back) position. The resident's feet dangled eight inches above the floor. There was no support for his legs or feet. -On 04/25/2023 at 12:26 PM, Resident 82 was observed in the same position with their feet dangling above the floor. -On 04/25/2023 at 2:21 PM, Resident 82 was observed in the same position with their feet dangling above the floor. -On 04/25/2023 at 3:30 PM, Resident 82 was observed in the same position with their feet dangling above the floor. -On 04/26/2023 at 08:30 AM, Resident 82 was observed sitting in their wheelchair in their room in a reclined position with their feet dangling eight inches above the floor -On 04/26/2023 at 12:11 PM, Resident 82 was in the same position with their feet dangling above the floor. -On 04/27/2023 at 2:07 PM, Resident 82 was asleep tilted back in their wheelchair. Their feet were dangling 12 inches above the floor. In an interview conducted outside Resident 82's room on 04/27/2023 at 2:07 PM, Staff Z (Licensed Practical Nurse - LPN) stated Resident 82 did not always allow staff to put the footrests on the wheelchair. Staff Y (Certified Nursing Assistant - CNA) was observed to enter the room at 2:08 PM and put the legs rests on the wheelchair. Resident 82 did not object, smiled and stated in a pleasant manner they were waiting their turn. Staff Z stated Resident 82 should have the leg/footrests applied to the wheelchair because it would not be comfortable to have his legs dangling. In an interview on 04/26/2023 at 3:42 PM, Staff Y stated Resident 82 required extensive assistance with activities of daily living and was able to stand but lost their balance. Staff Y stated Resident 82 was not safety conscious, and their chair was typically slightly reclined. Staff Y stated there were footrests for the chair that should be applied when Resident 82 was in the chair and Resident 82 was not able to propel the wheelchair. In an interview on 04/28/2023 at 12:45 PM, Staff W (PT) stated they worked with Resident 82 several times and completed their wheelchair evaluation. Staff W stated the wheelchair was the resident's personal customized chair. Staff W stated the resident should be upright in the chair for eating but could be tilted back for comfort and to relieve pressure. Staff W stated the leg rests should be on the chair to support Resident 82's legs. Staff W stated the footrests could be released if Resident 82 got tired of their legs being bent and could be repositioned as needed for comfort, but the footrests should then be reapplied. Staff W stated when they turned the chair over to nursing, they gave instruction to the nurses and aides on the whole wheelchair system including use of the footrests. In an interview on 04/28/2023 at 1:35 PM, Staff C (Regional Nurse Consultant) stated the footrests provided support, but staff should do what Resident 82 wanted and what was comfortable for the resident. Staff C stated it could be the issue could be the approach nursing staff took when applying the footrests and stated Resident 82 was generally passive and allowed staff to provide care. <Resident 78> According to the 04/02/2023 Significant Change MDS, Resident 78 had diagnoses including depression, stroke and diabetes, and received hospice services. Review of Resident 78's record showed no orders in place for Hospice services, and Resident 78's comprehensive CP did not include a hospice CP. Resident 78's medical record did not include evidence of hospice visits. In an interview on 04/27/23 at 11:11 AM Staff B (Director of Nursing - DON) stated each resident's CP should be current and contain pertinent information for the provision of care. Staff B stated Resident 78's medical record lacked evidence of coordination of care between the facility and hospice including Resident 78's orders for hospice, a hospice CP, and hospice clinical documentation. REFERENCE: WAC 388-97-1016(1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review the facility failed to ensure residents with urinary catheters received appropriate treatment and services for 2 of 4 (Residents 37 & 75) residents reviewed for indwelling urinary catheters. The failure to obtain and follow physician orders for catheter care placed residents at risk for infection and diminished quality of life. Findings included . The 04/2021 facility policy for Urinary Catheterization, showed a resident with an indwelling urinary catheter will have a rationale for use, monitor for changes, a care plan with interventions, and physician orders for changing catheters and drainage bags. <Resident 37> The 01/24/2023 admission Minimum Data Set (MDS, an assessment tool) showed Resident 37 admitted to the facility on [DATE] with the diagnosis of diabetes, pressure ulcers and a urinary tract infection. Resident 37 was assessed as cognitively intact, able to make daily decisions and had an indwelling urinary catheter. Review of a 01/17/2023 Physician Orders (PO) showed Resident 37 had an indwelling urinary catheter for pressure ulcer healing. The PO included the tube size and directions for catheter care each shift. There were no directions for when or if the catheter should be changed or removed. Review of Resident 37's 04/2023 Care Plan (CP) showed the catheter was used for protection of pressure ulcers. The CP did not instruct staff when to change the catheter. During an interview and observation on 04/25/2023 at 9:45 AM, Resident 37 was lying in bed, awake. An indwelling urinary catheter was observed connected to the side of their bed. The inside of the tubing showed a white crusted substance from where it entered the resident all the way to the drainage bag. Resident 37 stated they admitted to the facility with the catheter. Resident 37 stated staff had not discussed removing the catheter. In an interview on 04/27/2023 at 7:42 AM, Resident 37 stated the indwelling urinary catheter was not changed since coming to the facility three months ago. In an observation and interview on 04/28/2023 at 8:35 AM, Staff D (Resident Care Manager) observed the catheter tubing and confirmed the entire tubing was covered in a white crusted substance. While reviewing Resident 37's medical record, Staff D stated there was no PO to change the catheter. Staff D stated the facility standard was to have a PO to change the catheter each month. Staff D stated the catheter tubing, should have been, and was not changed. During an interview on 04/28/0223 at 10:51 AM, Staff C (Regional Nurse Consultant) stated nurses were expected to verify at admission that there is an order to change indwelling urinary catheters. Staff C stated, This process has been a challenge. <Resident 75> The 02/23/2023 Annual MDS showed Resident 75 admitted to the facility on [DATE] and had a diagnosis of benign prostatic hyperplasia [an enlarged prostate that can block the flow of urine out of the bladder and can cause urinary tract infections], and kidney stones. Resident 75 was assessed with moderate impaired cognition and had an indwelling urinary catheter. A 03/01/2023 PO showed one PO for a Coude catheter (specialized shaped catheter) size 18F, change monthly on the first of the month. A 03/05/2023 PO showed another PO for a standard catheter size 22F, change monthly on the fifth of the month. Review of the March 2023 and April 2023 Treatment Administration Record (TAR) showed nursing staff documented that the Coude catheter was changed on 03/01/2023 and 04/01/2023, then removed and the standard catheter was inserted on 03/05/2023 and 04/05/2023, twice in each month. During an observation and interview on 04/28/2023 at 11:29 AM, Staff C reviewed the PO and TAR for Resident 75 and confirmed the nursing staff changed the catheter on the first and the fifth of both March and April. Staff C stated Resident 75 should not have two catheter changes in a month and the staff should have questioned the PO. REFERENCE: WAC 388-97-1060(3)(c). .

. Based on interview and record review, the facility failed to maintain a system of records for accurate reconciliation of narcotic drugs for 1 of 3 medication carts. The failure to accurately count and verify the inventory of controlled substances - narcotic drugs through reconciliation at shift change, placed residents at risk for potential financial loss, not receiving narcotic pain medication, and possible drug diversion. Findings included . Review of the 01/01/2023 facility policy Inventory Control of Controlled Substances showed the facility would ensure the incoming and outgoing nurses counted all controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily, and document the results. In an observation and interview on 04/28/2023 at 11:35 AM, Staff S (Licensed Practical Nurse) was at the [NAME] Medication Cart when a random narcotic reconciliation was completed. The narcotic ledger book showed page 91 had two doses of oxycodone remaining on the card. There was no card of oxycodone for page 91 for Resident 3 present on the medication cart. Staff S stated there was no card for page 91 and the two doses of oxycodone were not accounted for Resident 3. Staff S stated the two doses had been administered and not documented in the narcotic ledger book. In an interview on 04/28/2023 at 12:13 PM, Staff C (Regional Nurse Consultant) reviewed the ledger book and stated the book did not match the number of oxycodone available for Resident 3's use. Staff C stated the nurses at shift change did not correctly reconcile the medication count as required. REFERENCE: WAC 388-97-1300(1)(b)(ii), (3)(a), (4)(a)(i). .

. Based on interview and record review, the facility failed to identify and monitor resident-specific behaviors for the use of Antipsychotic (AP) medication and document the rationale for the use of an as needed (PRN) AP medication. The facility failed to implement non-pharmacological interventions for 1 of 5 residents (Resident 361) reviewed for unnecessary medications. This failure placed residents at risk for unmet behavior needs and a diminished quality of life. Findings included . The 10/04/2022 facility policy Psychoactive Medications showed prior to initiating psychotropic medications (medication affecting mental function), the facility would identify rationale for use and implement non-pharmacological interventions. The policy showed PRN psychotropic medication use was limited and only used when the medication was required. The 04/17/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 361 had diagnoses of depression, dementia with behaviors and a nervous system disorder. Resident 361 was assessed with severe cognitive impairment for daily decision making and received an AP medication during the assessment period. The 04/11/2023 behavior Care Plan (CP) showed Resident 361 was resistive to care in the evenings related to dementia and increased confusion. The intervention directed staff to anticipate and meet Resident 361's needs, explain all procedures to Resident 361 before starting, and allow Resident 361 time to adjust to change. The CP did not show any resident-specific target behaviors or non-pharmacological interventions for the use of the AP medication. Review of the 04/19/2023 Physician Order (PO) showed 25 milligrams (mg) of an AP medication to be administered by mouth nightly at 9:30 PM. A second 04/19/2023 PO showed 12.5 mg of the same AP to be administered PRN after 9:30 PM for dementia with behaviors. A 04/18/2023 9:57 PM progress note from Staff E (Registered Nurse-RN) showed Resident 361 was observed attempting to self-transfer and crawl to the floor. The note showed Staff E provided one on one supervision to Resident 361 next to the medication cart. During an interview on 04/25/2023 at 1:56 PM, Resident 361's Representative (RR) stated Resident 361 had delusions since admission, but behaviors were improving. Resident 361's RR stated when Resident 361 first came to the facility they would get very agitated and totally delirious. The RR stated the only thing that helped Resident 361 was to hold their hand. During an interview on 04/28/2023 at 7:38 AM, Staff E stated Resident 361 was on the AP medication since admission for delusions, hallucinations, and seeing things on the walls. Staff E stated they cared for Resident 361 on 04/18/2023 and 04/19/2023 when Resident 361 was having delusions and removing their shirt. Staff E stated Resident 361 needed supervision for their behaviors and was placed next to the nurse medication cart on evening and night shift. Staff E stated Resident 361's behaviors did not improve with supervision. Staff E stated the PRN AP medication was administered at 1:01 AM. Staff E stated they did not document in the record Resident 361's behaviors or rationale for administering the PRN AP medication. In an interview on 04/28/2023 at 8:45 AM, Staff D (Resident Care Manager) stated when a resident was admitted with a PO for an AP medication, the staff would discuss identified behaviors with the resident or resident representative and document the behaviors in the resident's record. Staff D stated resident-specific trigger behaviors should be on the CP and available to the nurses and nursing assistants. Staff D stated when a nurse administered a PRN AP medication, the resident's behaviors were expected to be documented in the progress notes. In an interview on 04/28/2023 at 10:51 AM, Staff C (Regional Nurse Consultant) stated when a resident was admitted with an AP medication, the resident or their representative was interviewed, and a psych history was obtained. Staff C stated generic behaviors were documented on the CP. Staff C stated psychotropic medications were reviewed with the psychiatrist weekly, but not all residents were reviewed, only new admissions and residents due for a dose reduction. Staff C reviewed Resident 361's records and stated there was no documentation the AP medication was reviewed in the weekly meetings for effectiveness. Staff C reviewed the CP and stated the CP did not list resident-specific behaviors for the AP medication use. Staff C stated nurses were expected to document in the resident's record the resident behaviors and non-pharmacological interventions used whenever a PRN psychotropic medication was administered. REFERENCE: WAC 388-97-1060(3)(k)(i). .

. Based on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 161 & 162) of 4 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required. Findings included . <Resident 161> Record review showed Resident 161 was discharged on 01/17/2023. Review of trust fund records showed the resident had a balance of $60.41, which was not transferred to the OFR until 12/12/2022, 11 months after discharge. <Resident 162> Record review showed Resident 162 was discharged on 05/22/2022. Review of trust fund records showed the resident had a balance of $431.52, which was not transferred to the OFR until 10/31/2022, five months after discharge. In an interview on 04/27/2023 at 2:48 PM, Staff P (Business Office Coordinator) stated trust funds should be dispersed to the OFR within 30 days of a resident's discharge. Staff P confirmed the funds for Resident 161 and 162 should have, but were not dispersed within 30 days as required. REFERENCE: WAC 388-97-0340(5). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide a written notice of transfer/discharge to the State Office of the Long-Term Care Ombudsman (LTCO) for 2 of 3 residents (Residents 110 & 109) reviewed for discharge. The failure to have an established system of discharge notification to the LTCO placed all discharged residents at risk for lack of information about discharge, access to an advocate who could inform them of their options and rights, and risk for a diminished quality of life. Findings included . <Resident 110> A [DATE] progress note showed Resident 110 had a resident-initiated discharge from the facility to a private home. A [DATE] release form showed Resident 110 left the facility against medical advice. <Resident 109> A [DATE] progress note showed Resident 109 was deceased . A [DATE] release form showed Resident 109 was discharged and transferred to a funeral home. In an interview on [DATE] at 8:21 AM, Collateral Contact (CC) from the LTCO stated there was no notification of discharge for Residents 110 or 109. The CC stated there was no documentation of monthly notification for any discharged residents from the facility for [DATE], [DATE], February 2023, or [DATE] as required. In an interview on [DATE] at 11:22 AM, Staff A (Administrator) stated the facility did not provide documents that showed the LTCO was notified of resident discharges in 2023 or the end of 2022. Staff A stated the facility did not have an intact system to notify the LTCO when residents discharged . REFERENCE: WAC 388-97-0120(2)(a-d). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide the bed-hold notice (a document detailing the duration, cost, and conditions of return, when holding a bed while the resident was at the hospital) for 2 of 2 residents (Residents 57 & 62) reviewed for hospitalization. This failure placed residents at risk for being uninformed and unable to exercise the right to hold their bed while in the hospital. Findings included . The 11/2018 Facility Policy for Notice of Bed Hold showed residents were notified of the bed hold policy at the time of transfer or within 24 hours if the transfer was an emergency. The policy showed the bed hold notification was provided regardless of payment source, and included the reserve bed payment policy, and information related to the resident's ability to return to the facility. <Resident 57> Review of Resident 57's January 2023, February 2023 and April 2023 progress notes showed Resident 57 was transferred to the hospital on [DATE], 01/26/2023, 02/24/2023, and 04/19/2023. There was no documentation in the record that Resident 57 or their representative was informed of the bed hold policy. <Resident 62> Review of Resident 62's March 2023 progress notes showed Resident 62 was discharged to the hospital for a surgical procedure on 03/01/2023. There was no documentation in the record that Resident 62 or their representative was informed of the bed hold policy. In an interview on 04/27/2023 at 2:55 PM, Staff A (Administrator) stated when a resident goes to the hospital, the facility makes a call to the resident to offer a bed hold and the staff was expected to document the conversation in the progress notes. On 04/28/2023 at 11:22 AM, Staff A stated there was no documentation that a bed hold was offered to Residents 57 or Resident 62 and the facility system of offering bed holds was not intact. REFERENCE: WAC 388-97-0120(4)(a-c). .

. Based on observation, interview, and record review the facility failed to ensure food served to residents was palatable, attractive and at a safe and appetizing temperature for 8 of 34 sampled residents (Resident 23, 39, 37, 20, 54, 40, 65, & 35) and 22 residents who attended the food committee. The failure to obtain and act on feedback from residents regarding food and failure to ensure food temperatures were maintained during transport from the kitchen to the resident placed residents at risk for decreased intake, weight loss, and diminished quality of life. Findings included . The 07/2018 facility policy Food and Nutrition Services Food and Drink showed the facility will prepare food and drink in methods that conserve nutritive value, flavor, and appearance. Food and drink will be palatable, attractive and at a safe, appetizing temperature. On 04/25/2023 at 9:00 AM, Resident 23 stated the eggs were always lukewarm and burnt on the bottom. Resident 23 stated they had previously talked with a manager about the cold burnt eggs, and the manager wrote down the complaint and said they would talk with the kitchen supervisor. Resident 23 stated they received burnt eggs and toast again this morning. On 04/25/2023 at 9:20 AM, Resident 39 stated, The food sucks, breakfast did not have any flavor and the food was not hot when it was delivered to the room. On 04/25/2023 at 10:03 AM, Resident 37 stated the food was not hot when delivered to their room. Resident 37 stated the food tasted awful and the vegetables and noodles were over-cooked. On 04/25/2023 at 2:59 PM, Resident 20 stated, The food is bad for everybody. Resident 20 stated the food is hard and they could not cut it with a knife. On 04/25/2023 at 2:48 PM, Resident 54 stated, The food is garbage. Resident 54 stated the food was not hot and it did not taste good. On 04/25/2023 at 3:13 PM, Resident 40 stated Nothing really tasted good and the food was like cardboard. On 04/25/2023 at 12:40 PM, Resident 65 stated, The food is horrible. Resident 65 stated, The meat was really hard and even a man could not cut it with a knife. In an observation and interview on 04/25/2023 at 1:09 PM, Resident 35 was served a chicken salad sandwich, potato chips, cold broccoli salad, vegetable soup and a cookie. The broccoli salad consisted of a couple large chunks of a faded green broccoli in a thin white dressing. Resident 35 stated they could not chew the large chunk of broccoli with white stuff, and it tasted old. Resident 35 stated the soup was not hot and had no flavor, and Every day the food sucks. Review of the 02/22/2023 Food Committee meeting minutes showed 15 residents attended. A concern was noted regarding breakfast, the eggs had a greenish tint to them, and several residents agreed. Another concern was noted the eggs were cooked too long. A grievance was created for the eggs. Review of the 04/19/2023 Food Committee meeting minutes showed seven residents attended. The meeting minutes revealed, 'We have got to get better cooks.' Was the first comment made in this meeting. Residents are all in agreement that food needs improvement. Observations in the kitchen on 04/27/2023 from 7:55 AM to 8:38 AM during the tray line showed the breakfast meal consisted of scrambled eggs, pancakes with margarine, syrup, one sausage patty, oatmeal, and beverages including milk and juice. Equipment observed included use of a plate warmer, insulated bases, lids, and heated pellets that were placed between the insulated base and the plate. Six non-insulated metal carts were loaded with residents' meal trays. On 04/27/2023 at 8:38 AM, the last cart was loaded and was delivered from the kitchen to the 100 hallway. The pancakes were 156 degrees F and the eggs were 162 degrees F. The other foods were also above 130 degrees F. Observation and interview on 04/27/2023 at 8:58 AM showed the last tray in the 100 hall was served to residents, 20 minutes after the food left the kitchen. Staff V (Dietary Manager measured the temperatures of foods and stated the pancakes were 117 degrees Fahrenheit (F) and the eggs were 121 degrees F. Staff V stated the hot food temperatures should be between 130 - 135 degrees F when served to residents. Staff V confirmed the pancakes and scrambled eggs were not hot enough and were not at the required temperature for serving. In an interview on 04/27/2023 at 8:46 AM, Staff V stated they were aware of the resident food complaints and thought the problem was resolved. Staff V stated they were not currently conducting temperature audits on test trays. During an interview on 04/28/2023 at 10:14 AM, Staff A (Administrator) stated the food was improving, however, it was not where it should be yet. Staff A stated weekends were the biggest problem. REFERENCE: WAC 388-97-1100(1)(2), -1120(4). .

. Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and exiting staff as identified in the Facility Assessment. The failure to ensure new staff received orientation and were evaluated for skill sets within their scope of practice, evaluate staff skills annually, and provide annual training on abuse/neglect, mandated reporting, resident rights, communication, person-centered care, dementia care, and behavioral health, for 9 of 10 (Staff J, K, L, M, N, BB, G, Z, and I) staff placed residents at risk for unmet needs, inadequate quality of care and diminished quality of life. Findings included . Review of the undated Facility Assessment (FA) showed the facility evaluated the resident care needs and identified staff training requirements to provide person-centered care and services the facility residents required. The FA showed staff would receive orientation upon hire and receive annual education on the topics of abuse/neglect, resident rights, dementia, mental health and behaviors, hospice care, and catheter care. The FA showed nurses and nurse aides received annual competency skills checks in identified areas of resident care they provided. The 09/20/2022 Training Requirements facility policy showed the facility developed and implemented a training program for new and existing staff. The training program was consistent with the expected duties and roles of staff and the identified needs on the FA. The policy showed identified training would be provided in orientation for new staff and was repeated annually for exiting staff. <Nursing Assistant Training Records> Review Staff J's (Certified Nursing Assistant- CNA) employee file showed a hire date of 09/19/2022. Review of Staff J's training records showed no documented orientation training, no evaluation of CNA skills set competency, no documented training in abuse/neglect, mandated reporting, resident rights, person-centered care, or response to resident behaviors. Review Staff K's (CNA) employee file showed a hire date of 01/13/2023. Review of Staff K's training records showed no documented orientation training, no evaluation of CNA skills set competency, no documented training in abuse/neglect, mandated reporting, communication, person-centered care, dementia care, or response to resident behaviors. Review Staff L's (CNA) employee file showed a hire date of 02/10/2022. Review of Staff L's 2022-2023 training records showed no documented orientation training, no documented training in person-centered care, or response to resident behaviors. Review Staff M's (CNA) employee file showed a hire date of 07/07/2022. Review of Staff M's training records showed no documented orientation training, no evaluation of CNA skills set competency, no documented training in abuse/neglect, mandated reporting, resident rights, communication, person-centered care, dementia care, or response to resident behaviors. Review Staff N's (Registered Nursing Assistant) employee file showed a hire date of 04/27/2022. Review of Staff N's training records showed no documented orientation training, no evaluation of nursing assistant skills set competency, and no documented training in mandated reporting, resident rights, person-centered care, or dementia care. Review Staff BB's (CNA) employee file showed a hire date of 03/29/2023. Review of Staff BB's training records showed no documented orientation training, no evaluation of CNA skills set competency, no documented training in abuse/neglect, mandated reporting, communication, person-centered care, dementia care, or response to resident behaviors. <Licensed Nurse Training Records> Review Staff G's (Licensed Practical Nurse- LPN) employee file showed a hire date of 02/08/2023. Review of Staff G's training records showed no documented orientation training, no evaluation of LPN skills set competency, and no documented training in abuse/neglect, mandated reporting, resident rights, communication, person-centered care, dementia care, or response to resident behaviors. Review Staff Z's (LPN) employee file showed a hire date of 11/21/2005. Review of Staff Z's 2022-2023 training records showed no annual evaluation of LPN skills set competency, and no annual documented training in abuse/neglect, mandated reporting, resident rights, communication, person-centered care, dementia care, or response to resident behaviors. <Social Services Training Records> Review Staff I's (Social Services Assistant) employee file showed a hire date of 08/14/2022. Staff I had no orientation or training records on file. During an interview on 04/27/2023 at 3:59 PM, Staff F (Staff Development Coordinator) stated the staff training records could not be located. On 04/28/2023 at 8:37 AM, Staff F provided training records for Staff J, K, L, M, N, BB, G, and Z. Staff F stated these staff did not receive the required training. Staff F stated the facility was developing the staff orientation program, the annual staff training and a skills competency program. In an interview on 04/28/2023 at 2:46 PM, Staff A (Administrator) stated the training program for staff was not intact. REFERENCE: WAC 388-97-1680. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interview, and record review the facility failed to ensure 1 out of 1 walk-in freezers was maintained in satisfactory working condition. The freezer temperature logs indicated the temperature was elevated for a month prior to the start of the survey and there was a leak in a pipe resulting in substantial ice buildup in the freezer. Although service visits were made a couple of weeks prior to the survey, the freezer continued to be out of temperature range and with significant ice buildup, without additional follow-up being implemented. This failure placed residents at risk for spoiled food. Findings included . Review of the 07/20/2023 Food and Nutrition Services Food Safety policy revealed, Food items would be stored, prepared, distributed and served in accordance with professional standards for food service safety .Frozen foods would be maintained at a temperature to keep the food frozen solid. In an initial kitchen inspection with Staff V (Dietary Manager) on 04/25/2023 at 9:12 AM, the walk-in freezer observed with an ice waterfall extending from a pipe near the ceiling down to the floor; the ice covered an area on the floor over two feet in diameter and ice was observed on nearby boxes of cauliflower, tater tots, and rolls. Staff V verified the freezer's internal thermometer read 20 degrees Fahrenheit (F) at that time. The external thermometer read 40 degrees F. Staff V stated service calls were completed by an outside vendor, but the freezer temperatures remained a problem. Staff V stated the freezer temperatures the prior day were logged at 30 degrees F and 40 degrees F. Staff V stated the freezer temperature should be zero degrees F or colder and stated they thought the freezer pipe needed to be replumbed. Staff V stated work order requests were entered into the electronic work order system to notify the maintenance staff repairs were needed. A second observation of the walk-in freezer was conducted with Staff X (Maintenance Director), and Staff V on 04/27/2023 at 2:52 PM. Staff V compared the freezer's internal thermometer with a digital thermometer: Staff V verified the internal freezer thermometer read 15 degrees F and the digital thermometer read 14.6 degrees F, indicating the internal thermometer was accurate. Some of the ice in the freezer was removed since the 04/25/2023 observation but ice continued to build up on boxes of food and on the floor. Review of temperature logs showed concerns with the walk-in freezer temperatures going back over a month. The March 2023 freezer temperature log revealed the following temperatures above zero degrees F: 03/26/2023 PM, 30 degrees F; 03/27/2023 AM, 30 degrees F; 03/27/2023 PM, 9 degrees F; 03/28/2023 AM, 5 degrees F; 03/28/2023 PM, 3 degrees F; 03/29/2023 AM, 10 degrees F; 03/29/2023 PM, 10 degrees F; 03/30/2023 AM, 7 degrees F; 03/30/2023 PM, 6 degrees F; 03/31/2023 AM, 10 degrees F. The April 2023 freezer temperatures log showed staff consistently documented freezer temperatures between 10 and 40 degrees F, twice a day from 04/05/2023 through 04/27/2023, with 36 of 45 of those temperatures documented higher than 20 degrees F. Review of a 04/16/2023 vendor invoice showed service was provided for the freezer on 03/31/2023, 04/03/2023, and 04/10/2023. The description of the problem was, Freezer not freezing. Action taken on 04/03/2023 was, Started troubleshooting. Walk in freezer, I found temperature at 0. Staff reported box spiking as high as 30. I noticed the timer motor has 4 [sic] defrost cycles set on it with 40 minute defrost lengths. I verified operation of defrost and placed the unit back into normal operation. I did not find any obvious issues. I will return next Monday morning to continue troubleshooting. All okay for now. Action taken on 04/10/2023 was, Continued troubleshooting unit. I found no signs of any leaks and again verified that the defrost operation is working properly. I noticed the staff uses the box thermometer by the door for their temperature logs. Using ice water, I found the thermometer is out of calibration by about 30 [degrees] with the box temperature at 0 it displays 30. I will let [Staff X] know and return to replace it if approved. Review of a 04/25/2023 work order revealed Staff V entered a critical work order for, Ice forming in freezer and freezer running hot. During an interview on 04/27/2023 at 1:28 PM, Staff X stated an outside repair person came to the facility on [DATE] to evaluate the walk-in freezer and would be returning today as well to adjust the freezer motor and address a hole in the pipe. Staff X stated there was a hole in one of the pipes in the freezer and the vendor had to obtain parts to make the repair, and stated the gauge was offset to a warmer temperature which the repair person reset it to a colder temperature. Staff X stated they saw the condition of the ice in the freezer and stated there was a big hole in the pipe and lots of ice resulting from the hole in the pipe. Staff X stated the freezer temperature should be maintained at zero or below. Staff X stated they were first notified of a problem with the freezer earlier in April 2023 by Staff V and it seemed to get better after the repair person came out and adjusted. Staff X stated the freezer became too warm again and was notified it still needed repair after the surveyor's initial inspection on 04/25/2023. Staff X reviewed work orders in the electronic system and the only work order they received about the walk-in freezer was from the dietary department dated 04/25/2023, after the surveyor and Staff V inspected the walk-in freezer. In an interview on 04/27/2023 at 2:36 PM, Staff A (Administrator) stated the facility was aware of the freezer issue and identified a root cause. In a telephone interview on 04/28/2023 at 3:11 PM, Staff AA (Registered Dietitian) stated part of their contract required them to complete monthly sanitation audits in the kitchen. Staff AA stated they checked the freezer logs and inspected the walk-in freezer as part of their inspection monthly. Staff AA stated they did not find any concerns with temperatures or ice buildup in the walk-in freezer in their most recent sanitation audit. Staff AA stated they did not have access to their records during the call to provide specific details. REFERENCE: WAC 388-97-2100. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately inform the resident and/or legal representative of the risks and benefits associated with prescribed psychotropic medications, and to obtain informed consent prior to implementation of the orders for 2 (Residents 46 & 39) of 6 residents reviewed for psychotropic medications. These failures detracted from residents and/or legal representatives ability to make informed decisions regarding psychotropic medication use and precluded some resident(s)/representative(s) from having the opportunity to decline the proposed treatment. Findings included . Resident 46 Resident 46 admitted to the facility on [DATE]. According to the 08/27/2021 admission Minimum Data Set, the resident was cognitively impaired, had a diagnosis of depression, and received antidepressant medication on six of seven days during the assessment period Review of Resident 46's Physician's Orders showed a 09/28/2021 order for Escitalopram (an antidepressant) daily for depression. Further record review showed no indication facility staff discussed the risks and benefits of the medication with the resident's representative, or obtained consent for its use. During an interview 10/13/2021 at 11:25 AM, when asked if there was any documentation to support the facility obtained informed consent for the Escitalopram prior to administering it Staff B, (Director of Nursing), stated, No. Resident 39 According to the 08/15/2021 Significant Change Minimum Data Set (MDS- an assessment tool) the resident received antidepressants during the assessment period. Review of the resident's medical record showed an 08/14/2021 Physicians Order for Trazodone 25 mg (milligrams) by mouth at bedtime for insomnia (difficulty sleeping). A 08/14/2021 Hypnotic/Sedative Informed Consent (IC) form showed Trazodone for insomnia. Review of the listed potential side effects (SE) showed drowsiness, confusion, dizziness as listed SE's related to sedatives/hypnotic, . Trazodone is classified as an anti-depressant with different side effects like nausea, diarrhea, anxiety, nervousness, weight gain and increased appetite In a duo interview on 10/13/2021 at 11:36 AM Staff J (Corporate Nurse Consultant) and Staff B reviewed the IC for Trazodone and stated they would expect an antidepressant IC to be used, not a hypnotic IC because Trazodone is an antidepressant, and the resident should be informed of the risks and benefits. WAC: REFERENCE 388-97-0300(3)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REFERENCE: WAC 388-97-0300(1)(e), (5), (6). Based on interview and record review, the facility failed to provide timely notice, in writing, of changes in payment status and potential charges for services not covered under Medicare/Medicaid for 2 (Residents 393 & 55) of 4 sample and one (Resident 22) supplemental residents reviewed. Failure to provide written Notice of Medicare Non-Coverage (NOMNC: a notification that Medicare benefits were ending) and Advanced Beneficiary Notices (ABN: a notification of costs when services provided may not be reimbursed by Medicare), and notify residents and their families of the results of requested appeals placed residents at risk for not having adequate information to make care and financial decisions during their continued stay. Findings included . Beneficiary Protection Notification According to Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Use of assistive devices may be used to obtain a signature. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee's medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee's liability starts on the second working day after the provider's mailing date. Findings included . Resident 393 Resident 393 admitted to the facility on [DATE] and according to the 04/17/2021 Medicare 5 Day MDS was assessed with memory problems and moderately impaired cognition with symptoms of delirium. NOMNC documents provided by the facility showed Resident 393's last covered Medicare day was 05/14/2021. According to this document, the resident's family member was given verbal notice on 05/12/2021 but no attempts for a signature were made. An ABN document provided by the facility showed issued over the phone to DPOA [Durable Power of Attorney - a legal document which delegates decision making on behalf of a resident] [sic] 05/12/21 copy sent. In an interview on 10/14/2021 at 8:52 AM Staff F indicated they were not aware a signature should be obtained stating, I will issue [notices] to the POA if the resident is unable to sign, we issue it over the phone, they don't actually sign it, I issue over the phone. In an interview on 10/14/2021 at 8:52 AM, Staff F was asked to provide the results of Resident 393's appeal or information to support the resident and/or representative were notified of these results. Staff F stated, I imagine there is a progress note that they lost their appeal. Kepro [agency which handles the appeals] notifies us within 24 or 72 hours and they contact the resident / responsible party .whoever called to file the appeal. No information was provided. Resident 55 Resident 55 admitted to the facility on [DATE]. According to census records the resident participated in Humana Advantage (a Medicare managed program). According to the 09/03/2021 Medicare 5 day MDS, Resident 55 was cognitively intact. A NOMNC signed by the resident on 10/07/2021, the resident's last day of Medicare coverage was 10/10/2021. In an interview on 10/13/2021 at 8:05 AM, Resident 55 indicated a concern about not receiving therapy stated, I haven't gotten therapy since last week. Resident 55 confirmed discussing a change in coverage but indicated he did not understand they had a right to appeal the cessation of therapy. Record review showed the resident was not issued an ABN. Resident 22 Record review showed Resident 22 originally admitted to the facility on [DATE] with a recent readmission on [DATE]. An Annual Minimum Data Set (MDS - an assessment tool) dated 08/01/2021 showed Resident 22 was able to make their own decisions and their memory was intact. A document named Notice of Medicare Non-Coverage (NOMNC) dated 10/22/2020 showed a signature of an unidentified person who signed on 10/23/2020. Record review showed no documentation to support Resident 22 was provided this form to decide about their care. In an interview 10/13/2021 at 1:52 PM, Staff F, (Social Services Director) reviewed the NOMNC and confirmed Resident 22's signature was not on the form. When asked, Staff F stated, I do not know who signed the (NOMNC). When Staff F was asked who should have signed the NOMNC form, Staff F stated, Resident 22 should be signing their own form. When Staff F was asked if Resident 22 was given the opportunity to make this decision about their care, Staff F stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the office of the State Long-Term Care Ombudsman (LTCO) received required resident transfer information for 3 (Resident's 74, 87, and 39) of 4 residents reviewed for hospitalizations, and one supplemental resident (Resident 77). Failure to ensure required notification was completed, prevented the LTCO from educating and advocating for residents regarding their rights. Findings included . According to the 11/2017 facility policy on Admission, Transfer and Discharge, Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. This policy also indicated the facility will send a copy of the notice to a representative of the Office of the State LTCO. Resident 74 According to the 09/17/2020 Admissions Minimum Data Set (MDS- an assessment tool), Resident 74 admitted to the facility originally on 09/11/2020. The 08/22/2021 Discharge MDS showed Resident 74 discharged to the hospital on [DATE], returning on 08/31/2021, according to the 09/04/2021 Significant Change MDS. Resident 74 was again discharged to the hospital on [DATE] according to a 09/12/2021 Discharge MDS and readmitted on [DATE], according to the 09/18/2021 5-Day MDS. In an interview on 10/11/2021 at 12:09 PM, Staff F (Social Service Director) was asked to provide evidence the LTCO was notified of Resident 74's transfer to the hospital. Staff F stated they do not send notification for hospitalization to the office of the State LTCO. In an interview on 10/08/2021 at 8:07 AM, Staff D (Resident Care Manager) was asked to provide information to support Resident 74 or their representative received written notification regarding the hospital transfers on 08/22/2021 and 09/12/2021. In an interview on 10/11/2021 at 12:43 PM, Staff D indicated they were unable to provide the requested information. Resident 87 Resident 87 was admitted to the facility on [DATE], according to the 08/26/2021 Admissions MDS. The 09/20/2021 Discharge MDS showed Resident 87 was hospitalized on [DATE]. Resident 87 returned to the facility on [DATE], according to the 0/28/2021 5-Day MDS. Review of the resident's record on 10/14/2021 showed no documentation that facility staff notified the LTCO of the hospitalization. Resident 39 Resident 39 was admitted to the facility on [DATE] according to the 07/06/2021 Admissions MDS. According to the 07/08/2021 Discharge MDS, Resident 39 was hospitalized on [DATE] and returned to the facility on [DATE] according to the 07/14/2021 Entry Tracking MDS. Resident 39 was hospitalized again on 08/03/2021 according to the 08/03/2021 Discharge MDS, and returned to the facility on [DATE], according to the 08/15/2021 Significant Change MDS. Review of the resident's record on 10/13/2021 showed no documentation the facility staff notified the LTCO of either hospitalization. Resident 77 Resident 77 was admitted to the facility on [DATE], according to the 07/18/2021 Admissions MDS. The 09/01/2021 Discharge MDS showed Resident 77 was sent to the hospital on [DATE] and, according to the 09/22/2021 Significant Change MDS, was not readmitted back to facility until 09/16/2021. Record review on 10/14/2021 revealed no evidence that facility staff notified the LTCO of the hospitalization. In an interview on 10/14/2021 at 8:48 AM, Staff F was unable to provide documentation that facility staff notified the LTCO and indicated it would be documented in the resident records if they had. Staff F stated they did not notify the LTCO for hospitalizations. REFERENCE: WAC 388-97-0120(2)(a-d). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately assess 5 (Residents 55, 37, 77, 6 & 22) of 23 residents whose Minimum Data Sets (MDS, an assessment tool) were reviewed. Failure to ensure accurate assessments regarding medications (Resident 37), dental status (Residents 55, 6 & 77), cognitive status (Resident 22), and non-pressure skin conditions (Residents 77), placed residents at risk for unidentified and/or unmet needs. Findings included . Resident 55 Resident 55 admitted to the facility on [DATE] and according to the 09/03/2021 admission MDS was assessed with no obvious or likely cavities or broken natural teeth. In an interview on 10/06/2021 at 8:00 AM, Resident 55 stated they had missing teeth, two broken teeth and several that were loose and had cavities, stating, I have a dentist but I am not sure if I am allowed to see him. Observation at this time showed the resident had missing teeth, two broken teeth in the left lower jaw, and multiple teeth that were discolored. In an interview on 10/08/2021 at 12:05 PM Staff H (MDS Coordinator) stated they examined Resident 55, and they identified the broken and loose teeth and would do an MDS correction. Resident 37 Resident 37 admitted to the facility on [DATE]. According to the 08/08/2021 Quarterly MDS, the resident received anticoagulant medication on seven of seven days during the assessment period. Review of the August 2021 Medication Administration Record (MAR) showed Resident 37 did not receive any anticoagulant medication during the assessment period. The resident did receive Clopidogrel (a Platelet Aggregation Inhibitor) daily. Review of the Resident Assessment Instrument manual (Manual that provides instruction on how to accurately code an MDS) showed the following instruction related coding anticoagulant medication use. Do not code antiplatelet medications such as clopidogrel here. During an interview on 10/14/2021 at 9:49 AM, Staff DD, (MDS coordinator), stated that the MDS was incorrectly coded. Resident 77 Resident 77 was admitted to facility on 09/16/2021 and according to the 09/22/2021 Significant Change MDS was assessed with no obvious or likely cavities or broken natural teeth. This assessment also indicated Resident 77 was not assessed with any ulcers or open lesions. Observations on 10/05/2021 at 9:24 AM showed Resident 77 had no upper teeth and two broken teeth at gumline to lower jaw. No dentures were observed at this time. During observations on 10/05/2021 at 12:39 PM, showed Resident 77 with an open area to left inner knee and left foot was wrapped in a white bandage. Review of 08/31/2021 wound healing provider notes showed Resident 77 with an arterial ulcer to left distal foot and an abrasion to left knee prior to admission. Review of progress note dated 09/16/2021 at 8:04 PM, indicated Resident 77 still had wounds to left foot and left knee. In an interview on 10/13/2021 at 9:05 AM, Staff D (Resident Care Manager, Licensed Practical Nurse) observed Resident 77 and verified the resident had broken lower teeth at gumline and was unable to locate any dentures in room. Staff D also verified Resident 77 had open areas to left foot and knee. Resident 6 According to the 10/22/2020 admission MDS, Resident 6 admitted to the facility on [DATE] and was assessed as having natural teeth with no dental issues. In an interview on 10/07/2021 at 12:15 PM Resident 6 stated they fell on the day they were scheduled to get new dentures and currently had no teeth and no dentures. Resident 6 expressed her preference to have dentures and stated no one was helping to get them. Three Quarterly MDS's dated 01/19/2021, 04/13/2021 and 07/07/2021 and one Annual MDS dated [DATE] all showed Resident 6 had natural teeth and no dental problems. In an interview on 10/12/2021 at 10:55 AM, Staff H reviewed all MDS assessments for Resident 6 and confirmed that no dental issues were identified. Staff H reviewed a progress note dated 07/08/2021 that showed resident (6) has natural teeth without problems. Staff H reviewed the dentist records and read that the resident is edentulous (has no teeth) and wanted dentures. When asked if the MDS assessment was correct, Staff H said, No. Resident 22 An 08/01/2021 Annual MDS showed a Brief Interview for Mental Status (BIMS- a mental status assessment) should be completed with Resident 22. The answer boxes to the interview's six questions stated not assessed and the score was blank. The facility instead completed a staff assessment which showed Resident 22's memory and decision making was intact. Another BIMS assessment was completed for Resident 22 on 07/10/2021. This BIMS noted Resident 22 was able to answer the questions for themselves, and scored 14 of 15, indicating they were cognitively intact. Skilled nursing progress notes on 07/31/2021 and 08/03/2021 both indicated Resident 22 was alert and oriented and able to make their needs known. On 10/14/2021 at 9:16 AM Staff H completed a BIMS assessment with Resident 22. Resident 22 was observed to have trouble hearing Staff H through their surgical mask but was answering the questions correctly (Resident heard Ted instead of bed and repeated it twice). Staff H calculated the total and stated Resident 22 scored a 14 of 15 which indicated Resident 22 was cognitively intact. In an interview on 10/14/2021 at 9:30 AM, Staff H (MDS Nurse) stated staff are expected to complete interviews and assessments with the resident for the MDS. When asked if the interview should have been completed with the resident on 08/01/2021 for an accurate assessment, Staff H stated, Yes. When asked if the MDS assessment was accurate without the resident interview, Staff H stated, No. REFERENCE: WAC 388-97-100(1)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluation recommendations were obtained, implemented and incorporated into the plan of care for 3 (70, 63, & 6) of 10 sampled residents reviewed for PASRR evaluations. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . Resident 70 Resident 70 was admitted to the facility on [DATE] with medically complex diagnoses, including Dissociative Identity Disorder, Major Depression and Anxiety Disorder. Resident 70 had a Level 2 PASRR Follow-Up Psychiatric Evaluation on 12/23/2020, conducted by the state contracted PASRR evaluator. The Psychiatric Evaluation Summary documented the following under Recommendations for Nursing Facility: Agree with recommendations. Their psychiatric diagnosis/diagnoses aren't at all clear. Further psychiatric history needs to be obtained. When/why did they acquire such diagnoses as dissociative identity disorder, for example, I don't have any records documenting psychotic symptoms. If these are occurring, need to be documented in detail in the progress notes. They are on a very low dose of Seroquel. What symptoms is this targeting? Refer for a thorough psychiatric evaluation. As of 10/14/2021, Resident #70's medical record documentation did not show a follow up to clarify the resident's mental health diagnoses, document targeting behavior for the medication used. Review of Behavior Health notice of determination dated 12/23/2020 showed Resident 70 has mental health diagnosis and meets the requirement to require specialized mental health services On 10/11/2021 at 11:54 AM, Staff F (Social Services (SS)) stated, It doesn't look like the recommendations were follow up and diagnosis clarified. Staff F, further confirmed that there was no target behavior documented and the resident was not receiving mental services as per 12/23/2020 behavior health notice of determination. Resident 63 According to the 09/08/2021 Quarterly MDS, Resident 63 had diagnoses including schizophrenia and depression, and was assessed to have moderate cognitive impairment and mild depression, and no behavioral concerns. Resident 63's EHR (electronic health record) included a Level II PASRR dated 8/25/2020. The Level II PASRR assessed Resident 63 to require a reassessment, stating follow up is needed. Date (usually 3 months): 11/28/2020. In an interview on 10/14/21 at 08:25 AM, Staff F stated that the facility did not, but should have ensured that Resident 63 was reevaluated. Resident 6 A 12/07/2020 PASSR Level 1 showed Resident 6 had diagnoses of schizophrenia, anxiety disorder and mood disorders and required a Level 2 PASSR assessment for a serious medical illness. An interview 10/12/2021 at 11:22 AM Staff F (Social Services Director) stated I am not sure if she had a Level 2 PASSR evaluation, we do not have a copy and it is not in the care plan. An interview 10/13/21 at 11:44 AM Staff Q (Medical Records) stated I cannot find a Level 2 PASRR in (Resident 6's) medical record. If it is not here, we do not have it. An interview on 10/13/2021 at 1:52 PM Staff F stated, The PASRR Level 2 is not in the record, I will need to call and get it. Staff F produced a copy of the Level 2 assessment later in the day. When asked if the required psychiatric services stated in the assessmetn for Resident 6 required had been implemented into their care, Staff F stated, No. REFERENCE: WAC 388-97-1915(4). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 62 According to a 09/07/2021 Quarterly MDS Resident 62 admitted to the facility on [DATE] after a stroke with deficits including left hemiplegia (mobility impairment on left side of the body). Resident 62 was assessed to be unable to speak verbally, able to sometimes make self understood and sometimes able to understand others. A 07/15/2020 nursing admission progress note showed Resident 62 had a left upper extremity contracture. A 07/31/2020 progress note defined the contracture was a left-hand contracture. No other contractures were documented in the medical record. In an observation on 10/05/2021 at 9:14 AM, Resident 62 indicated they were in pain, pointing to the right shoulder and right knee. The resident was not able to talk but could understand the question and was able to answer using hand motions. Resident 62 showed the right knee, and it was observed to be flexed. When the resident was asked to straighten their leg, they shook their head no and gestured they were not able to straighten their leg. When asked if the right knee could not straighten, Resident 62 nodded their head yes. In an observation on 10/07/2021 at 12:47 PM, Staff K (Licensed Practical Nurse) was speaking to Resident 62 in Korean and asked if they had pain. Resident 62 tapped their right shoulder and the right knee. The right knee was outside of the sheet and visibly flexed. A restorative program note dated 09/29/2021 showed, Resident continues to accept [the] nursing restorative program for passive range of motion. [Resident 62] accepted [the] passive ROM (PROM) to [the] hips, knees, and ankles 18 times in the past 30 days with 3 refusals. [Resident 62] also continues to accept upper extremity exercises. Will continue programs as outlined and review quarterly and prn as needed. Resident 62's care plan intervention dated 10/15/2020 instructed nursing staff to monitor, document and report as needed any changes including decline in function. The care plan showed a restorative program started on 04/09/2021 and included PROM to bilateral hips, ankle, and knee 3-5 times per week. An observation on 10/13/2021 at 11:01 AM showed Staff K providing ROM to Resident 62's right knee. Staff K was unable to assist Resident 62 to straighten the knee and stated the knee was contracted. In an observation and interview on 10/13/2021 at 11:07 AM, Staff Z (Lead Physical Therapist - PT) assessed ROM to Resident 62 and stated the right knee was rigid and unable to extend fully to a straight position and Resident 62 would benefit from a therapy evaluation. Review of a physician order dated 10/14/2021 showed a request for physical and occupational therapy to address upper body and lower body contractures. In an interview on 10/14/2021 at 10:22 AM Staff Z stated the prior evaluation by physical therapy on 02/10/2021 showed no contracture in the right knee and indicated nursing staff should have, but did not, report this change to therapy. Resident 38 Resident 38 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly MDS, the resident was cognitively intact, able to understand and be understood, and received no therapy or restorative services. During an interview on 10/06/2021 at 12:26 PM, Resident 38 expressed concern about getting weaker stating, I was walking [with therapy] but they took me off a couple of months ago .they gave me a new walker but I am not comfortable with it yet. I haven't walked for about a month or so [because] I need someone to walk with me, but no one comes. According to the 06/21/2021 PT Discharge Summary, a restorative walking program was established and the restorative aides were trained to walk Resident 38 in the corridor with a gait belt and one person assistance, with goals of improving balance and foot clearance. Record review revealed no restorative care plan was initiated. Review of the restorative flowsheets for June, July, August, September and October 2021, showed no indication Resident 38 received any restorative services since being discharged from therapy on 06/21/2021. In an interview on 10/14/2021 at 9:49 AM, when asked why Resident 38's restorative walking program was not initiated Staff DD, (Restorative Nurse), checked the restorative records and indicated PT's recommendation to initiate the program was not communicated. REFERENCE: WAC 388-97-1060 (3)(d),(j)(iv). Based on observation, interview, and record review the facility failed to identify or monitor change in Range of Motion (ROM) and provide treatment and services for 3 (74, 62 & 38) of 6 residents reviewed for limited ROM. The failure to identify the existence of, or worsening of contractures had the potential for harm, including pain and limited quality of life. Findings included . Resident 74 According to the 09/18/2021 Medicare 5 day Minimum Data Set (MDS - an assessment tool), staff determined Resident 74 had severe cognitive impairment and had no altered functional ROM in either the upper or lower extremities. Observations on 10/06/2021 at 12:00 PM showed Resident 74's fingers were contorted. The resident was unable to extend their fingers at this time but stated they had been like that, for a while. Record review showed no indication facility staff identified or care planned the resident's bilateral finger mobility limitations to include interventions or monitoring. During an observation of a skin assessment on 10/08/2021 at 9:15 AM showed Staff D (Resident Care Manager, Licensed Practical Nurse) confirmed the resident had limited ROM to the fingers of both the left and right hands and was unable to extend fingers and stated the fingers appeared contracted (tightened muscles or tendons causing a joint deformity). Progress notes dated 10/11/2021 showed, OT [Occupational Therapy] completed Bilateral hand assessment for potential incorporation of splints for bilateral hands. Pt [Patient] has . [finger joint] flexion contractures in bilateral hands. Pt tolerating minimal ROM for hands before reporting pain .OT to continue to follow for proper positioning, ROM and potential use of splinting to prevent further contracture impacting functional use.

Based on observation, interview, and record review, the facility failed to: ensure an environment free of accident hazards including falls and elopement for 2 (Residents 74 & 39) of 5 residents reviewed for falls. Failure to ensure only assessed fall interventions were implemented (Resident 74), fall evaluations were completed with new interventions implemented and care planned after each fall (Resident 39), and failure to identify planned elopement interventions were implemented or were non-functional (Resident 74), placed residents at risk for avoidable falls with injury and elopement. Findings included . According to the facility policy on Accident hazards/Supervision/Falls: When a resident experiences a fall, the facility will evaluate potential causal factors to aid in the development and implementation of relevant, consistent and individualized interventions to reduce the likelihood of future occurrencesand individualized interventions will be developed to reduce the potential for accidents. Resident 74 According to the 05/11/2021 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 74 was assessed with cognitive impairment and two or more falls with injury since the previous assessment. The 09/04/2021 Significant Change MDS Falls Care Area Assessments (CAA) showed the resident was at risk for falls related to weakness, impaired mobility, history of falls, potential for adverse side effects due to psychotropic and opioid analgesics, and incontinence of bladder and bowel, with the need for extensive assistance for mobility. Multiple observations of the resident, in their room, on 10/05/2021 and 10/06/2021, showed no fall mats at the bedside. In an interview on 10/06/21 at 11:44 AM, Resident 74 stated, I've had falls I think I am totally out of it. Observations on 10/07/2021 at 7:58 AM, 8:27 AM and 9:05 AM showed the resident lying or sitting at the bedside with two fall mats noted stacked next to the resident's bed. Review of Care Plan (CP) documents showed fall mats at the bedside were not listed as an intervention for falls. Observations at on 10/07/2021 at 9:36 AM showed Staff D (Resident Care Manager, Licensed Practical Nurse) remove the fall mats. In an interview on 10/07/2021 at 10:20 AM, Staff D indicated the mats were removed because they were more of a hazard because the resident was now more mobile. Wanderguard According to the 09/04/2021 Significant Change MDS, Resident 74 was identified with wandering behavior on one to three days of the assessment period. While the Behavior Symptoms CAA was triggered by wandering behavior, the assessment did not address interventions regarding wandering behaviors. The CAA for Cognitive loss/ Dementia was triggered by the resident's low cognition score and wandering behavior. This CAA did not address interventions for wandering behavior. Review of October 2021 MARs showed staff were directed to document as to the placement of a Wanderguard [a bracelet device secured to a resident which sounds an alarm when a resident attempts to leave the facility] on the right wrist each shift. Review of these documents showed of the 21 shifts from 10/01/2021 through 10/07/2021, staff failed to ensure placement of the Wanderguard on five of 21 opportunities and documented a - indicating it was not present on the remaining 16 opportunities. Review of Care Plan documents dated 09/12/2020 showed the resident was an elopement risk related to confusion and the ability to ambulate indecently, however, the use of the Wanderguard and it's monitoring was not included in the identified interventions. Observations throughout the day on 10/05/2021, 10/06/2021, and 10/07/2021 showed the resident did not have a Wanderguard bracelet to either wrist. During an observation of a skin assessment on 10/08/2021 at 9:15 AM Staff D (Resident Care Manager, Licensed Practical Nurse) confirmed the resident had no Wanderguard to either wrist. In an interview on 10/08/2021 12:22 AM Staff D indicated the resident's Wanderguard was not on the resident and not on the resident's wheelchair (on which they were sitting). In an interview at on 10/08/2021 at 12:55 PM Staff A (Administrator) suggested that when the resident had a room change on 10/06/2021, a different wheelchair was used which was why the resident did not have a Wanderguard. When asked if it was the wheelchair or the resident who was assessed as an elopement risk, Staff A replied, the resident. Resident 39 According to the 08/15/2021 Significant Change MDS Resident 39 was assessed with cognitive impairment and had four falls since the prior assessment. The 08/15/2021 Significant Change MDS Falls CAA showed the resident was assessed at risk for falls related to weakness, impaired mobility, gait and balance problems, impaired cognition, urinary incontinence, potential for adverse side effects due to cardiac medications, psychotropic and opioid use, history of falls and requiring two-person extensive assist with transfers. On 10/05/2021 at 12:45 PM and 10/14/2021 at 9:09 AM, fall mats were observed on both sides of the bed. On 10/12/2021 at 10:40 AM Resident 39 was observed sitting on their bed with the fall mats folded in half in the corner of the room. Review of the facility incident logs revealed Resident 39 had falls occurring on 07/08/2021, 07/24/2021, 07/27/2021, 07/28/2021 and 08/14/2021. Review of Resident 39's medical record showed fall evaluations occurring on 07/02/2021, 07/08/2021, 07/14/2021 and 08/14/2021. There were noo fall evaluations completed after the 07/24/2021, 07/27/2021 and 07/28/2021 falls. Review of the 07/02/2021 At risk for falls care plan showed interventions of anticipating and meeting resident needs, call light within reach with prompt response, encourage resident to use mobility aides, ensure commonly used items are within reach, and ensure the resident is wearing appropriate footwear. An additional intervention was added on 08/14/2021 which included fall mats at the bedside and on 08/16/2021 for frequent visual checks. No additional individualized interventions were implemented after the 07/08/2021, 07/24/2021, 07/27/2021 and 07/28/2021 falls. In an interview on 10/13/2021 at 10:36 AM Staff J (Corporate Nurse Consultant) and Staff B (Director of Nursing) stated they would expect a fall evaluation to be completed after each fall and new interventions implemented and care planned with each fall. Refer to F-658, Professional Standards of Practice. REFERENCE: WAC 388-97-1060(3)(g). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents admitted with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra) were assessed for catheter removal as soon as possible, catheter tubing was secured to prevent accidental tugging and pulling, and urology referrals were made when ordered for 2 (Resident 46 & 91) of 4 residents reviewed for urinary catheters. These failures placed residents at risk for urinary tract infections, decreased bladder tone, urethral erosion and unmet care needs. Findings included . Resident 46 Resident 46 admitted to the facility on [DATE]. According to the 08/27/2021 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively impaired, had a diagnosis of urinary retention, and had an indwelling urinary catheter during the assessment period. Review of Resident 46's 08/21/2021 discharge summary showed Acute recurrent urinary retention was listed under Principle Diagnoses. Under Hospital Course it stated that Resident 46 had failed at least two voiding trials while inpatient, leading to a more long term [indwelling urinary catheter], and suggest follow up outpatient with urology. Acording to the 08/21/2021 Interfacility Discharge Orders the resident had chronic urinary retention and required a Referral to Urology. The 08/30/2021 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) stated staff would provide assistance with routine catheter care and a voiding trial would be attempted as indicated. Under Is a referral to another discipline warranted staff documented Yes and indicated the resident would be referred to Occupational Therapy for activities of daily living and toileting. The CAA did not mention or address the ordered urology referral. Review of the 08/21/2021 .Has catheter related to urinary retention with failed voiding trials in hospital care plan (CP), showed the developed goal was [Resident 46] will be/remain free from catheter related trauma through review date. The CP did not include removal of the indwelling catheter as a goal. Interventions included, checking tubing for kinks, ensuring the catheter is secured and a dignity bag is in place, and to monitor for signs and symptoms of infection and catheter occlusion. There was no direction to staff to attempt a voiding trial as indicated, as stated in the CAA, or direction to refer the resident to urology and/or that a urology appointment was pending, as ordered. On 10/08/2021 at 12:03 PM, Resident 46 was observed in bed, a catheter bag was observed attached to bed frame. The resident was asked if the catheter was secured in place but was unable to provide a meaningful reply observation showed. Unable to determine if a catheter strap was in place as the resident was covered with a blanket. Record review on 10/08/2021 showed no indication facility staff assessed the resident for a potential voiding trial. Nor was there an assessment or documentation that indicated a voiding trial was contra-indicated. Additionally, there was no documentation in the record to support Resident 46 was seen by urology, or that the facility had scheduled the urology referral as ordered. Record review on 10/12/2021, showed a 10/11/2021 11:20 PM nurses' note that stated an order was obtained to discontinue Resident 46's the indwelling urinary catheter and to start voiding trials. The nurse's note indicated the residents catheter was removed at 6:30 PM. In an interview on 10/14/2021 at 8:02 AM, Staff B, (Director of Nursing) confirmed Resident 46 admitted on [DATE] with orders for a urology referral, but staff failed to schedule the appointment. When asked for documentation to support why the facility waited more than 7 weeks to attempt a voiding trial (e.g. assessed resident and determined it was contraindicated) Staff B indicated she would need time to look through the record. No further information was provided. Resident 91 According to the 01/29/19 Quarterly MDS, Resident 91 was cognitively intact, and required two-person physical assistance with activity of daily living and personal hygiene. Resident had indwelling catheter for urinary retention. Review of Resident 91's CP revised 08/12/2021 revealed, Check tubing for kinks throughout each shift, making sure secure device in place, and catheter dignity bag in place at all times. Provide Catheter care every shift. Observations on 10/05/2021 at 09:31 AM, 10/06/2021 at 09:52 AM, 10/06/2021 at 10:30 AM, and 10/12/2021 at 1:30 PM, showed Resident 91 laying in her bed, with a indwelling catheter. The catheter tubing was not secured and no privacy bag was in place. In an interview on 10/12/2021 at 11:08 PM, Staff I, (Resident Care Manager, RCM) indicated both nurses and nursing assistants were responsible to ensure a catheter leg strap was in place to avoid accidental dislodgment, kinks, and cover the collection bag with privacy bag for dignity. On 04/26/19 at 1:35 PM Staff B, indicated nursing assistants, while providing care, were expected to check a resident's catheter tubing to ensure it was secured, and that catheter drainage bags had a dignity cover. If a catheter strap or dignity cover were missing, the nursing assistants were to notify the charge nurse or RCM for replacement. REFERENCE: WAC 388-97-1060 (2)(a)(iii). .

Based on observation, interview and record review the facility failed to ensure 1 of 1 resident (Resident 62) reviewed for tube feeding (TF - nutrition or hydration delivered through a tube directly inserted into the stomach), received treatment and services to prevent complications and ensure the amount of TF formula and water was correctly calculated and infused according to the practitioner's order. This failure placed Resident 62 at risk of TF complications, malnutrition, and dehydration. Findings included . TF Formula Infusion A 06/2018 facility policy titled Tube Feeding Management/Restore Eating Skills instructed staff to collaborate with the dietician for the appropriate method of formula (liquid nutrition) infusion using gravity flow or an infusion pump (device to deliver formula). The policy instructed collaboration of the dietician and nursing staff to validate the administration of formula and water and ensure the rate and volume of infusion followed the practitioner's order. A 09/07/2021 Quarterly Minimum Data Set (an assessment tool) showed Resident 62 had a diagnosis of stroke with residual deficits including the inability to swallow. The assessment showed Resident 62 was administered all nutrition and water by tube into the stomach and the resident did not eat or drink. The 09/29/2021 practitioner's order showed the formula called Osmolite was to be infused at 60 ml (milliliters) per hour for 20 hours, turn on at 2:00 PM, turn off at 10:00 AM. The order stated the formula should provide 1200 ml total volume over 20 hours. The order does not distinguish infusion method by pump or gravity flow. Review of the September and October 2021 MAR's (Medication Administration Record) showed the 09/29/2021 order for Osmolite formula infusion should total 1200 ml over 24 hours. The MAR showed Resident 62 received 720 ml on 09/30/2021, 1400 ml on 10/01/2021, 1120 ml on 10/02/2021 and 1400 ml on 10/03/2021. An observation on 10/05/2021 at 9:14 AM showed Resident 62 in bed while Staff K, (LPN- Licensed Practical Nurse) set up a new bottle of formula and a new bag of water using a dual infusion pump (infuses both water and formula). The formula bottle had a handwritten label that showed the flow rate was 90 ml an hour. The bag of water had a handwritten label that showed the flow rate was 60 ml per hour. The flow rates were reversed with incorrect labels according to the practitioner's order and the pump was also incorrectly programmed by Staff K. In an interview on 10/5/2021 at 10:00 AM, Staff K, (LPN) stated they did not verify the infusion rates before programming the pump flow rates. Staff K stated a mistake was made and the pump rate did not match the practitioner's order. An observation on 10/12/2021 at 10:47 AM showed a bottle of formula with a written label showing the flow rate of 60 ml per hour and a start time of 7:00 AM. The pump was off and the amount remaining in the bottle was 950 ml. Only 100 ml was infused between 7:00 AM and 10:00 AM. In an interview on 10/12/2021 at 11:01 AM Staff K (LPN) stated they started the new bottle at 7:00 AM and stopped the infusion at 10:00 AM. Staff K looked at the current bottle and confirmed 950 ml remained and a full bottle is 1050 ml. Staff K confirmed Resident 62 only received 100 ml between 7:00 AM and 10:00 AM and should have received 180 ml. On 10/12/2021 at 11:05 AM Staff K stated they forgot to clear the total infused amount on the pump at the start of the shift and when starting the new bottle. When asked, Staff K was unable to determine the amount of formula infused on the day shift and stated they documented an estimate of the amount infused. In an interview on 10/12/2021 at 1:42 PM, Staff D, (RCM- Resident Care Manager), stated it is the expectation of nursing staff to calculate TF infusion correctly and ensure that TF is administered according to the practitioner's order. TF Water Infusion The 06/2018 Tube Feeding Management policy showed the facility defines the frequency and volume of water used for hydration, flushing, medication administration, and when a prescriber's order does not specify how much water to provide. The facility policy showed no instructions for volume or frequency of water administration when the prescriber's order was incomplete. The 09/21/2021 practitioner's order included . 1484 ml of water (500 ml water flush + 984 ml free water) over 20 hours of infusion. This order did not provide a flow rate for staff to administer water. The order did not specify the volume or frequency of water administration. A review of the October 2021 practitioner orders showed no instructions for providing water with crushed medications or instructions for flushing the tube with water before or after administering medications. An observation on 10/12/2021 at 11:06 AM showed Resident 62 in bed with the dual infusion pump turned off. The bag of water contained 800 ml and showed handwritten directions that the pump was infusing water at 90 ml per hour since 6:00 AM. In an interview on 10/12/2021 at 11:08 AM Staff K (LPN) looked at the TAR (Treatment Administration Record) and stated there were no directions for the pump flow rate for water and there was not a place for staff to document the amount of water to flush before and after TF administration. Staff K further stated there was not a place to document the amount of water administered with medications. In an interview on 10/12/2021 at 1:42 PM, Staff D (RCM) confirmed the MAR or TAR did not have a place for staff to document water flow rate with the pump, water flushes before and after formula or water given with medications. Staff D stated there was no calculated total for 24-hour infusion of water. Staff D stated 24-hour water calculations should have been measured and monitored. When asked if monitoring and calculations were completed daily, Staff D stated, No. Gastric Residual Volume (GRV) Monitoring The Facility's 06/2018 Tube Feeding (TF) Management policy instructed staff to verify potency and function by checking GRV or asking alert residents about symptoms that indicate a feeding is not well tolerated. A review of the October 2021 practitioner orders for Resident 62 showed no instructions to staff to verify patency of the TF by either checking for the GRV or asking the resident about symptoms. An observation on 10/05/2021 at 9:14 AM showed Staff K checked for residual volume by aspiration of the tube with a syringe. Staff K did not ask Resident 62 about symptoms. When asked if aspirating the GRV was a standard of practice when administering TF, Staff K stated, Yes. When asked where the GRV instructions and documentation for aspiration and parameters for notification of the physician was located, Staff K reviewed the MAR and TAR and could not find instructions or a place to document the GRV and stated, We do not document it. When asked at what amount would be reported to the physician, Staff K stated, I don't know. REFERENCE: WAC 388-97-1060 (3)(f). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure central venous access devices (CVAD) were assessed and monitored in accordance with professional standards of practice, and accessed maintaining aseptic technique for 2 (Residents 192 & 142) of 3 residents reviewed. The facility's failure to: consistently assess arm circumference and external length of Peripherally Inserted Central Catheters (PICC); ensure intravenous (IV) infusion orders were complete, including rate of infusion; maintain aseptic technique when accessing CVAD; and monitor a Port-a Cath (an implanted port, a type of Central Venous Catheters, CVC) site, place residents at risk for infection, unidentified complications and/or loss of venous access, and other negative outcomes. Findings included . According to the facility's CVAD dressing change policy, revised 06/01/2021, the catheter insertion site is a potential entry site for bacteria that may cause a catheter related infection. Licensed nurses caring for residents receiving infusion therapies must adhere to Aseptic Non Touch Technique [which includes maintaining asepsis for any sterile part of equipment used during an aseptic procedure, such as needle hubs, syringe tips, needles, and dressings] for all infusion-related procedures as a critical aspect of infection prevention. When a PICC dressing change is performed the documentation in the medical record includes, but is not limited to: date and time; site assessment; length of external catheter; Arm circumference; reason for dressing change; and patient response. Resident 192 Resident 192 admitted to the facility on [DATE]. According to the 10/03/2021 admission Minimum Data Set (MDS, an assessment tool) the resident was cognitively intact, had a diagnosis of osteomyelitis [bone infection], and received intravenous (IV) medication during the assessment period. Review of Resident 192's October 2021 Physician's Orders (PO) showed, 09/27/2021 orders for the following: Cefepime (an antibiotic) IV two times a day for osteomyelitis; and weekly PICC dressing changes to the left upper arm every Tuesday, with direction to measure the external length of the PICC, obtain the residents arm circumference and report changes in measurements to the doctor as soon as possible. According to the October 2021 Medication Administration Record (MAR), Resident 192's PICC dressing, external length and arm circumference were scheduled to be done on 10/05/2021. However, review of the MAR on 10/11/2021 showed the resident's PICC's external length and arm circumference were not recorded as ordered Review of the nurses notes from 10/05/201- 10/11/2021 showed no indication the resident's arm circumference or the PICC's external length was assessed. Additionally, the resident's order for Cefepime twice daily failed to include the rate of infusion or the time the medication was to be infused over (e.g. 1 hour) from which the rate could have been calculated. During an interview on 10/13/2021 at 11:21 AM , Staff J, (Corporate Nurse Consultant), explained arm circumferences should be obtained to assess for arm swelling, a potential complication with PICCs, and external length should be obtained to validate the tip of the catheter had not migrated. When asked if there was any indication that Resident 192's external length or arm circumference were assessed/obtained on 10/05/2021 as ordered Staff J stated, No. When asked if Resident 192's Cefepime order was complete Staff J stated, No and stated that it needed to include the rate of infusion or the time the medication was to be infused over. Resident 142 According to the 10/06/2021 admission MDS, Resident 142 admitted to the facility with multiple medically complex diagnoses, including infection, and required the use of Intravenous Medications and antibiotics. Observation of medication pass on 10/07/21 at 12:15 PM showed Staff U (Registered Nurse) prepare and administer medications to Resident 142, including an Intravenous antibiotic. Staff U was observed to flush the resident's PICC port (right upper arm) with 6 mls of Normal Saline (NS) without pulling back on the syringe to check for blood return. Staff U then asked the resident to hold the syringe while they obtained the tubing to connect to the IV port. According to the October 2021 MARs, staff were directed to flush the right upper arm PICC with 10 cc of normal saline solution before and after medication administration and to check for blood return prior to flush. If no blood return, notify MD. In an interview at that time, when asked why 10 cc NS was not utilized for the flush, Staff U replied, We don't flush all the way because sometimes it has drops at the end (6 cc) then we flush it again. Refer to F 880 REFERENCE: WAC 388-97-1060 (3)(j)(k)(ii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that two (45, 91) of two residents reviewed for respiratory care, were provided care consistent with professional standards of practice. Failure of the facility to maintain respiratory equipment, including Continuous Positive Airway Pressure (CPAP) and oxygen tubing, placed residents at risk of discomfort and potential negative outcomes. Findings included . According to the facility July 2018 Respiratory Care Policy, a resident with Obstructive Sleep Apnea (OSA-collapse of the upper airway during sleep) would have on-going assessments of the resident's respiratory status and response to therapy documented in the medical record. The Physician would provide orders, indication of use, equipment settings, when to use the equipment and the care plan would reflect the Physicians orders. Additionally, the facility would implement infection control measures during care, handling, cleaning, storage and disposal of respiratory equipment. Resident 45 According to the 08/26/2021 admission MDS (Minimum Data Set- an assessment tool) revealed Resident 45 was admitted on [DATE] and was assessed as cognitively intact. On 10/05/2021 at 11:00 AM a CPAP machine was observed at the resident's bedside. Review of the resident's clinical chart showed a 10/05/2021 diagnosis for Obstructive Sleep Apnea (OSA) and a 10/05/2021 Physician Orders (POs) for CPAP machine to be worn at pressure setting 14-16. Review of a 10/07/2021 CPAP CP did not address the CPAP settings, when to use equipment, and care and maintenance the equipment required. In an interview on 10/11/2021 at 11:22 AM Staff M (Registered Nurse) stated they think the resident has had the CPAP since admit on 08/24/2021. Staff M later stated on 10/12/2021 at 8:52 AM that they may have given the wrong information, as the resident moved from a different hall and had the CPAP in their bag. It wasn't until the resident took the CPAP out that Staff M knew they had a CPAP. On 10/11/21 at 12:15 PM Resident 45 stated that they brought their CPAP with them on the day of admit, use it nightly and fill the water chamber themselves with tap water. At this time the water chamber was observed to have a dried white residue caked to the inside. During an interview on 10/11/2021 at 12:39 PM Staff C (Resident Care Manager) stated they could not find anything stating why the CPAP orders were put in late. Normally CPAP orders are put in on admit and will include to clean the CPAP weekly and for night shift to fill water chamber as needed. Staff C confirmed there should be orders but did not see any. Review of the clinical record revealed no indication the facility obtained orders for the CPAP upon admission to the facility or have PO's in place to maintain and clean CPAP equipment as recommended by the manufacturer. Resident 91 Review of the clinical record showed Resident 91 re-admitted to the facility on [DATE] with several diagnoses, including chronic obstructive pulmonary disease (COPD) and required oxygen therapy. Review of a physician order, dated 06/21/2020, showed, change oxygen tubing, concentrator bottle every week (every night shift Sunday). Observation on 10/06/2021 at 08:15 AM and 10/07/2021 at 08:36 AM showed an oxygen concentrator in the resident's room dated 09/23/2021. Interview on 10/08/2021 with Staff E, Registered Nurse (RN) verified the dates and stated, this was supposed to be changed, when asked who was responsible to change, staff E said A Nurse on Sunday night shift. In an interview on 10/13/2021 at 1:05 PM, Staff D, (RCM) stated, The floor nurses are responsible to change oxygen tubing and replace concentrator water bottle every week and as needed. When asked if Resident 91's oxygen tubing was changed according to the physician orders, Staff D said No. WAC REFERENCE: 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 assess, obtain physician orders, resident/representative consent, and/ or develop care plan/ care directives for the use of bed rails (grab bars) for 1 (Resident 77) of 2 residents reviewed. This failure had the potential to place residents at risk for injury and diminished quality of life. Findings included . According to the 02/2018 facility policy on bed rails, the facility will attempt to use alternatives prior to installing a bed rail, including side rails, grab bars and other assist rails. This policy stated the facility will inform the resident and/ or representative of the risks and benefits and obtain informed consent prior to installation of bed rails. The policy also stated the use of a bed rail will be reflected in the resident's care plan (CP). Resident 77 Resident 77 was admitted to the facility on [DATE] and according to the 09/22/2021 Significant Change Minimum Data Set (MDS- an assessment tool) had medically complex conditions and was assessed as receiving hospice care. This assessment also showed Resident 77 was assessed to require extensive physical assistance for bed mobility, transfers, and personal hygiene. Observations on 10/05/2021 at 9:24 AM showed Resident 77 had upright 1/4 rail grab bars on both sides of bed. In an interview at this time Resident 77 stated they did not use the grab bars but were afraid to fall forward, without them in place. Observation on 10/06/2021 at 7:53 AM, showed Resident 77 in bed with their head elevated, turned to left side and was reaching through the grab bars to reach breakfast tray. Observation on 10/07/2021 at 8:26 AM showed Resident 77 lying on left side with their right arm resting up on grab bar. In an interview at this time Resident 77 gave a thumbs up gesture when asked if the grab bar was helping them. Review of 09/22/2021 Significant Change MDS showed Resident was not assessed to require side rails, assist rail, bed cane or other devices. Review of CP on 10/07/2021 at 2:38 PM revealed no evidence that Resident 77 had a problem identified or any interventions in place for utilizing grab bars. Review of Resident 77's records revealed no evidence that assessment, consent or physician orders were obtained for grab bars for Resident 77. In an interview on 10/13/2021 at 9:05 AM, Staff D, (Resident Care Manager, Licensed Practical Nurse) stated that staff should have completed an assessment, consent and obtained physician orders prior to utilizing grab bars. Staff D was unable to locate documentation that staff had completed those items per facility policy for Resident 77. REFERENCE: WAC 388-97-1060(3)(g), -0230. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a dementia care plan that addressed the physical, mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 (Resident 46) of 1 resident reviewed for dementia. These failures placed the resident at risk for unmet psychosocial needs, increased behaviors and decreased quality of life. Findings included . According to the facility's Treatment/Service for Dementia policy, revised 09/2018, the facility will approach dementia care with a systematic care process to meet the resident's individual needs. A Interdisciplinary team (IDT) will assess, develop, and implement care plans, using input from the resident, their family and/or representative, to the extent possible, taking into consideration the resident's symptoms and disease progression, as well as other co-existing diseases or conditions to identify and develop achievable goals. The interventions will be person centered, reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. Meaningful activities will be provided that address the resident's customary routines, interests, preferences and choices. Resident 46 Resident 46 admitted to the facility on [DATE]. According to the 08/27/2021 admission Minimum Data Set (MDS, an assessment tool), the resident had severe cognitive impairment, diagnoses of Alzheimer's disease, Non-Alzheimer's dementia, and depression, displayed signs of delirium to include continuous incoherent and disorganized thinking and fluctuating inattention, but demonstrated no behaviors or rejection of care. The 08/30/2021 Care Area Assessment (CAA) for delirium was triggered due to Resident 46's continuous disorganized thinking and inattention. According to this CAA the resident had a history of dementia and Alzheimer's disease which manifested in confusion and forgetfulness. Staff indicated the resident had a surgical repair of a fractured hip, and post anesthesia likely was contributing to the resident's altered mentation, rather than acute delirium. They concluded a delirium care plan (CP) was not indicated, and directed the reader to See CP for cognition. According to the 08/27/2021 Cognitive Loss/Dementia CAA, the resident had diagnoses of dementia and Alzheimer's disease, which affected their cognition, memory, ability to understand others, and to make self understood. The CAA indicated Resident 46 resided in a memory care facility prior to hospitalization. They determined a cognitive loss dementia CP would be developed Review of Resident 46's comprehensive CP showed the facility failed to develop and/or implement a CP, goals or interventions addressing the resident's dementia /cognitive loss. Additionally, a 08/26/2021 Activities assessment, determined the resident did not need activities to be modified to accommodate cognitive and communication deficits. Review of the 08/27/2021 activities CP, showed no indication Resident 46 had cognitive deficits. Interventions included Resident enjoys keeping up with news and current events. No direction was provided whether the resident could access news channels independently or whether staff assistance was required. During an interview on 10/13/2021 at 12:23 PM, when asked if there was any documentation to support the facility IDT developed personalized dementia plan of care, with person-centered goals and interventions based upon a systematic assessment Staff J, (Corporate Nurse Consultant), stated, I don't see one. REFERENCE:: WAC 388-97-1040 (1) (a-c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medically-related social services for 3 (Resident 15, 46, 6) of 3 residents reviewed, who demonstrated a pattern of refusals. Facility staffs' failure to identify patterned refusals and attempt to determine the reasons behind the refusals, precluded them from developing and implementing resident specific interventions to mitigate causative factors and increase acceptance of care. These failures placed the resident at risk for unmet or unidentified care needs. Additionally, the facility failed to coordinate mental health care and services for 1 supplemental resident (Resident 6) who required a community provider as part of the care team to manage mental health needs. This failure placed Resident 6 at risk for unmet emotional and psychosocial needs. Findings Included . According to the facility's Refusal of Treatment policy, dated 11/20217, staff should attempt to determine the reason for refusal of care, (such as pain) and address the concern. Resident 15 Resident 15 admitted to the facility on [DATE]. According to the 07/18/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, lost 5% body weight in the last month or 10% or more in the past six months, and was not on a prescribed weight loss regimen. A 09/24/2021 Nutrition/Dietary Note showed that Resident 15 had a 23.8 pound (9.6%) significant weight loss x 1 month. The note recommended Resident 15 receive one health shake daily. Review of the September and October 2021 Medication Administration Record (MARs) showed a 09/24/2021 order for a 118 milliliter (ml) health shake (no sugar added) every evening. Review of the intake documentation from 09/24/2021 - 10/10/2021, showed the resident refused the health shake 17 times. Record review showed no indication the facility staff identified the patterned refusals or took any action to determine why, or considered discontinuing the health shake and implementing a different nutritional intervention. In an interview on 10/14/2021 at 10:08 AM Staff F (Director of Social Services) explained Social Workers role in resident refusals was to meet with the resident to determine why the resident was refusing, and then make adjustments to the plan of care, if able, to accommodate the resident's needs and improve acceptance of care. During an interview on 10/14/2021 at 10:12 AM, Staff F was asked at what point should social work be informed of resident refusals. Staff F stated, I want to be informed after the first refusal. When asked if staff informed social work that Resident 15 refused a physician ordered health shake 17 consecutive times Staff F stated, No but indicated they should have. Resident 46 Resident 46 admitted to the facility on [DATE]. According to the 08/27/2021 admission MDS, the resident was cognitively impaired with disorganized thinking, but demonstrated no behaviors or rejection of care. Review of Resident 46's bathing flowsheet showed the resident was received a shower on 09/22/2021. On 09/30/2021 and 10/07/2021 staff offered bathing but documented the resident refused. Record review showed no indication staff identified the recurrent refusals or attempted to determine the reason for the refusals. As of 10/13/2021 Resident 46 had not been bathed for 20 consecutive days. During an interview on 10/14/2021 at 10:12 AM, Staff F indicated nursing should have notified social services of the refusals, but failed to do so. Resident 6 Resident 6 admitted to the facility on [DATE] and according to the 10/22/2020 admission MDS Resident 6 had diagnoses of Schizophrenia, Bipolar Disorder, Anxiety, Depression, and Insomnia. The resident was prescribed antipsychotic, antianxiety, antidepressant, and hypnotic medications to manage their illnesses. The 10/17/2020 hospital discharge paperwork showed Resident 6 had mental health provider and required ongoing consultation and treatment. A 10/20/2020 care plan conference form showed Resident 6 informed the facility of ongoing services they received from their mental health provider for mental illnesses and medication management. A 03/15/2021 care plan conference form showed Resident 6 was followed by a peer counselor, mental health counselor and a psychiatrist from their mental health provider on a regular basis. On 10/12/2021 Staff F reported they made a called the resident's mental health provider to obtain records and the provider asked for a release of information document signed by the resident before any information could be provided. Staff F had the resident sign the medical release on 10/12/2021 and sent to the provider. In an interview on 10/13/2021 at 1:52 PM Staff F (Social Services Director) stated there were attempts to call the psychiatrist, with progress notes that showed phone messages were left on 12/22/2020, 04/23/2021, 06/10/2021 and 05/21/2021. When asked about follow-up by the facility to connect with the psychiatrist or the office staff after the phone message was left, Staff F stated there was no follow up to the messages. Staff F said that when they called the psychiatric provider in the past to get records, the information was not provided because the provider did not have the release of information document from the resident. In an interview on 10/13/2021 at 1:52 PM Staff F stated there were no records over the past year in Resident 6's medical record to show the psychiatrist was part of the interdisciplinary team that coordinated mental health care for the resident, provided a mental illness history, documented a rationale for the ongoing use of the psychotropic medications, or participated in behavior monitoring or care planning. REFERENCE: WAC 388-97-0960(1). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 6 A 07/07/2021 Quarterly MDS assessment showed Resident 6 had a diagnosis of pain and received narcotic medication for pain. The assessment interview for pain showed Resident 6 had moderate pain, with a pain level of 7 on a scale of 1-10. A review of Resident 6's Care plan (CP) revised on 10/04/2021 showed chronic pain to the right hip, foot, and back and directed staff to monitor and record characteristics of pain routinely and as needed. The CP showed characteristics were Quality of pain (e.g., sharp, burning), severity of pain (1 to 10 scale), anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors; relieving factors. A 04/20/2021 CP included interventions that directed staff to provide non-pharmacological pain interventions such as reposition and ensure proper body alignment to decrease discomfort, deep breathe, social services to provide emotional support as needed, provide quiet environment as possible, therapy interventions, as needed. A review of the September 2021 Medication Administration Record (MAR) showed an order on 09/25/2021 for Oxycodone (narcotic medication for pain) 5 mg (milligrams) tablet by mouth every 8 hours PRN (as needed) for chronic pain scale 8-10 and monitor for sedation, hold if respiratory rate is less than 12 breaths per minute. The September 2021 MAR showed the Oxycodone was administered nine times in five days without assessment of the respiratory rate or pain characteristics. There was no data to support that non-pharmacological interventions were implemented prior to administration of Oxycodone and there was no follow up assessment of pain or sedation after medication administration. The Oxycodone was administered three times for a pain level of 6/10 which was below the physician prescribed pain level for that medication. Review of the October 2021 MAR showed administration of Oxycodone was given 10 times in six days. Oxycodone was administered five of 10 times with a pain level under eight, outside of the physician ordered parameters. All 10 administrations showed omission of an assessment before and after the administration of the narcotic as in September to determine necessity and effectiveness. Review of the September 2021 MAR showed staff was instructed to monitor Resident 6 every shift for pain and document a pain level between 1-10. Of 30 days in September, day shift did not document pain monitoring for 20 days. The evening shift did not document a pain monitoring for 5 days and night shift missed 1 day. The MAR showed evening shift documented a 0 pain level on 21 shifts but 18 of those shifts the nurse administered the PRN Oxycodone. Similar findings found that the pain monitor showed 0 pain but Oxycodone was administered on day and night shifts in September 2021 and all shifts in October 2021. During an interview on 10/14/2021 at 8:57 AM Staff L, (LPN) read the Oxycodone order out loud and stated it should only be given for a pain level of 8-10 and the respiratory rate and sedation should be monitored according to the order. When Staff L looked at the October MAR and was asked if the order was being followed and assessments documented, Staff L said, No. In an interview on 10/14/2021 at 10/42 AM, Staff J, (Corporate Nurse) stated the pain medication order must be followed and documented as ordered by the physician. When asked if the order stated give Oxycodone for a pain level of 8-10, should the medication be given for less than 8, Staff J stated, No. When asked if an assessment was expected to be completed before and after the pain medication, Staff J stated, Yes, of course. When asked if non-pharmacological interventions are expected to be tried before pain medication is administered, Staff J stated, the staff should have provided non-pharmacological interventions, and the pain scale and location should be documented. REFERENCE: WAC388-97-1060(3)(k)(i). Based on interview and record review, the facility failed to ensure two (39, 6) of five residents reviewed for unnecessary medications were free from unnecessary drugs related to the failure to adequately monitor, ensure adequate indication for use, or prevent excessive duration of use. These failures placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings included . Resident 39 According to the 08/15/2021 Significant Change Minimum Data Set (MDS-an assessment tool) the Resident admitted to the facility on [DATE] with medically complex conditions. Review of current Physician Orders (POs) showed the resident received Trazodone 25 mg (milligrams) by mouth at bedtime for insomnia (difficulty sleeping) and Melatonin 3 mg by mouth at bedtime for insomnia. An additional PO was added on 10/12/2021 for Trazodone 25 mg by mouth as needed for insomnia. In an interview on 10/13/2021 at 1:49 PM Resident 39 stated prior to admission to the facility they did not have problems with sleep and did not take anything for insomnia. Review of the record showed no indication the facility was monitoring the resident's hours of sleep to assess if the medications were effective. During an interview on 10/12/2021 at 1:48 PM Staff F (Social Services Director) stated a resident on a medication for sleep should have a sleep monitor in place. During a Duo interview on 10/13/2021 at 11:36 AM Staff B (Director of Nursing) was asked if it is common practice to be on multiple medications for insomnia, Staff B replied if the physician feels it's necessary. Staff J (Corporate Nurse Consultant) stated that Trazodone 25 mg is not a high dose and Melatonin is more of a supplement. When asked how they determined which medication was effective, Staff B replied with no sleep monitor we can't determine which medication is effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 6 Resident 6 admitted to the facility on [DATE] for a short term stay. A 10/22/2020 admission Minimum Data Set (MDS- an assessment tool) showed Resident 6 had diagnoses of Schizophrenia, Anxiety, Depression, Bipolar Disorder, and a sleep disorder. Medications prescribed were Quetiapine (antipsychotic), Diazepam (antianxiety), Bupropion (antidepressant), and Ambien (hypnotic). The assessment showed the resident was cognitively intact and could make their own decisions. Antipsychotic Medication Dose Reduction The 10/18/2020 Medication Regimen Review (MRR) document showed the Pharmacist instructed staff to confirm the current Quetiapine dose was beneficial to Resident 6. Staff were instructed to obtain a supporting diagnosis for ongoing use of Quetiapine. The Physician stated the diagnosis was Schizophrenia and instructed staff to continue the prescribed dose. The 02/08/2021 MRR showed the Pharmacist recommended a reduction in the Quetiapine dose. If the current dose was to continue, the facility interdisciplinary team (IDT) was instructed to monitor for effectiveness and potential adverse consequences. The Physician declined the recommendation and instructed the facility to obtain the Psychiatrist notes for ongoing use of Quetiapine. The 04/08/2021 MRR showed the Pharmacist again recommended reducing the Quetiapine dose. The Physician declined the recommendation and instructed the staff to follow up with the Psychiatrist for dose management and benefits of ongoing use. The signed October 2021 PO showed Resident 6 was still prescribed the same dose of Quetiapine one year after admission. A review of Resident 6's medical record showed no documentation from the Psychiatrist regarding the recommendation of dose reduction. In an interview on 10/12/2021 at 11:22 AM, Staff F (Social Services Director) stated the IDT team met monthly to discuss antipsychotic medications, dose reductions and behavior monitors. Staff F stated they did not obtain any documentation from the Psychiatrist to support the ongoing use of Quetiapine. Staff F confirmed Resident 6 was in the facility for a year and no dose adjustments were made to any psychotropic medications. Orthostatic Blood Pressure (OBP) Monitoring The 10/18/2020 MRR showed the Pharmacist recommended Resident 6 must have monthly OBP (blood pressure taken when lying, sitting, and standing to measure drop in blood pressure) monitoring. The MRR showed that administration of an antipsychotic medication could cause a drop in blood pressure upon standing and an increased risk of falls. The blood pressure log did not show that a baseline orthostatic blood pressure was obtained for October 2020. A 11/19/2020 PO directed staff to monitor Resident 6's OBP monthly. The PO instructed staff to notify the physician of a drop in blood pressure. A review of the monthly OBP measurements showed staff did not monitor the OBP in 12/2020, 02/2021, and 04/2021. The record showed staff did not monitor the standing portion of the OBP from 01/2021 through 09/2021. The record showed the blood pressure dropped in 06/2021 and 07/2021 and the staff did not notify the physician. In an interview on 10/14/2021 at 10:42 AM, Staff J (Corporate Nurse) stated the physician orders are expected to be followed. Abnormal Involuntary Movement Scale (AIMS) Assessment The 12/06/2021 MRR showed the Pharmacist instructed staff to complete an AIMS (an assessment for side effects of antipsychotic medication) assessment now and every six months. There was no baseline AIMS assessment documented in the record for 12/2021. The Pharmacist documented on the 02/06/2021 MRR, REPEATED RECOMMENDATION FROM 11/08/2020 and 12/09/2020: Nursing: Respond promptly to assure facility compliance with the Federal regulations. Recommendation: complete an AIMS assessment now and at least every six months. If Quetiapine therapy continues, the prescriber must document an assessment of risks versus benefits, indicating that (Quetiapine) continues to be a valid therapeutic intervention for this individual and the facility interdisciplinary team must ensure ongoing monitoring for effectiveness and potential adverse consequences. A review of Resident 6's record showed a 02/08/2021 AIMS assessment. There were no other AIMS assessments documented during the 12 months of residency. In an interview on 10/12/2021 at 11:22 AM, Staff F stated the IDT did not discuss the AIMS assessment or potential adverse consequences to Resident 6 according to the pharmacy recommendations. Resident Specific Behavior Monitoring The Pharmacist recommended on the 02/08/2021 MRR that target behaviors for Quetiapine must be specific to Resident 6 and non-medication interventions must be implemented. The facility noted the document on 03/09/2021, the resident specific target behaviors and non-medication interventions were not implemented. In an interview on 10/12/2021 at 11:22 AM, Staff F stated there were no records that a behavior assessment was performed to establish resident specific behaviors. The facility could not monitor specific behaviors for Resident 6 because they did not know what they were. Psychotropic Drug Use and Assessment A 01/07/2021 order from the Psychiatrist showed Diazepam 2 mg every 12 hours PRN (as needed) for anxiety/panic attacks. There was no stop date on the PRN order. A 02/08/2021 MRR showed the Pharmacist recommended the Diazepam be discontinued. If the Diazepam continued, the pharmacist instructed staff to obtain the Psychiatrist's rationale for extended use according to the required regulations. A 03/09/2021 order from the Physician extended the Diazepam PRN duration for six more months and instructed staff to obtain the rationale from the prescribing Psychiatrist. There was no rationale obtained from the Psychiatrist for the extended use per the recommendation or current regulations. An interview on 10/12/2021 at 11:22 AM, Staff F stated the Psychiatrist provided no rationale for the extended use of Diazepam. Staff F stated staff the documents were not obtained from the Psychiatrist to support the ongoing use of the PRN Diazepam. A 01/07/2021 care plan intervention showed target behaviors for Diazepam included anxiety and panic attacks. The 01/2021 through 10/2021 behavior monitoring records showed no monitoring of target behaviors of anxiety or panic attacks and no identified non-medication interventions prior to administering Diazepam. Review of 01/2021 thru 10/2021 MAR showed nearly daily administration of Diazepam, without monitoring for resident specific behaviors of anxiety or panic attacks. There were no assessments found in the MAR or nursing progress notes that showed the behaviors or symptoms were assessed prior to administration of the Diazepam. Resident 6 received Diazepam without a nursing assessment or non-medication interventions to support the use of the PRN Diazepam. In an interview on 10/14/2021 at 10:42 AM, Staff J (Corporate Nurse) stated the nurse is required to assess the resident and try non-medication interventions before a PRN medication is administered. Staff J stated the nurse must also monitor and document the effectiveness of the interventions and PRN medication. Drug-Drug Interaction A 09/13/2021 order received from the Psychiatrist renewed the Diazepam PRN for another three months. A 09/13/2021 nurse progress note showed a warning that Diazepam and Oxycodone (a narcotic) had a drug interaction causing central nervous system depression. A 09/13/2021 nurse progress note showed the drug interaction warning was acknowledged by the facility staff. There was no documentation that the Physician or the Psychiatrist was informed of the potential drug interaction or instructions received for change in administration. On 09/14/2021 at 1:40 PM and 09/28/2021 at 1:21 PM the MAR showed the Diazepam, and the Oxycodone were administered together. The drug interaction warning was not followed. Hypnotic Medication Use According to a 10/17/2020 PO, Resident 6 was prescribed Ambien 10 mg daily for insomnia. The 09/2021 sleep monitor showed Resident 6 was sleeping 7-16 hours a day and 2-7 hours of sleeping was on the day shift. Review of the sleep monitors from 10/2020 thru 08/2021 showed similar sleeping patterns. A 07/08/2021 care plan intervention showed hypnotic medication adverse effects included daytime drowsiness, dizziness, confusion, loss of appetited in the morning, increased falls, and fractures. The adverse effects showed on the October 2021 MAR included increased metabolism of medications, hypotension, and dizziness. The adverse effects symptoms did not match and thus were not monitored accurately to determine the ongoing need of Ambien. A 07/08/2021 care plan intervention showed psychotropic medication review will occur every quarter to evaluate effectiveness, side effects, and continued need for hypnotic medication. Review of progress notes and IDT notes for 07/2021, 08/2021 and 09/2021, showed no evaluation of the hypnotic medication was completed and there was no attempt at a dose reduction. In an interview on 10/12/2021 at 11:22 AM Staff F stated the Psychiatrist managed all Resident 6's psychotropic medications, including Ambien. Staff F confirmed the Ambien dose was not reduced since resident admitted to the facility a year ago. Refer to F756 Drug Regime Review REFERENCE: WAC 388-97-1060(3)(k)(i). Based on interview and record review, the facility failed to ensure 3 (Residents 74, 35 and 6) of 5 residents reviewed for unnecessary medications, were free from unnecessary psychotropic drugs related to the failure to: individualize target behaviors for psychotropic medications; provide a rationale for a dose increase; and complete orthostatic blood pressure monitoring. These failures placed residents at risk for receiving unnecessary psychotropic medications, unnecessary psychotropic medication side effects and a diminished quality of life. Findings included . Resident 74 Resident 74 admitted to the facility on [DATE]. According to September 2020 Medication Administration Records (MARs), the resident admitted to the facility with Physician Orders (POs) for Escitalopram (an antidepressant) 20 mg (milligrams) each day for depression and Seroquel (an antipsychotic) for dementia with behavioral disturbances. According to the September 2021 MARs, facility staff identified the following Target Behaviors (TBs) which required the use of psychotropic medications: Afraid/Panic, Angry, and Screaming/Yelling. In an interview on 10/08/2021 at 8:30 AM when asked if being angry, screaming or yelling was a reason to be on an antipsychotic medication, Staff D (Resident Care Manager, Licensed Practical Nurse) replied No. When asked which of the listed behaviors were those identified which required antidepressant treatment and which required antipsychotic treatment, Staff D stated, It (TBs) doesn't specify which behavior is treated with which medication or for which diagnosis but indicated it should. Progress notes on 11/12/2021 showed, .resident's depression has been stable since admission to the facility. Recommend to GDR (Gradual Dose Reductions) resident's citalopram if daughter agrees. According to November 2020 MARs, the Escitalopram was decreased to 10 mg on 11/17/2020. A progress note dated 11/17/2020 showed the resident was on alert for the GDR of Escitalopram with no changes in mood or behavior noted. Per this note the resident was noted as, Pleasant and cooperative with cares. Progress notes from 11/17/2020 through 11/26/2021 showed the resident demonstrated no signs or symptoms of depression. Census records showed the resident had a room change on 11/21/2020. A progress note dated 11/26/2020 showed, res[ident] is alert and oriented to self and able to make needs know, res is pleasant and cooperative with care and has no problems with new room or new roommate. Progress notes dated 11/27/2021 showed, Son called the facility and notify this Nurse that his mom called him stating another Resident across the hall is threatening her. Resident was anxious/agitated and reported to this nurse that Resident across the hall is threatening her .Resident reassured about her safety and was able to calm. Placed on alert. A later note on 11/27/2021 showed, Resident's daughter agreed the room change. Census records showed Resident 74 received a room change on 07/27/2021. A subsequent progress note on 11/27/2020 showed, Res is on alert for room change. Res is adjusting to new room. Res is on alert for increased behaviors r/t [related to] resident to resident altercation. Res had no noted agitation or aggression. According to November 2020 MARs, the Escitalopram was doubled to 20 mg on 11/28/2020. Record review showed staff documented the resident demonstrated no TBs during this period. Progress notes did not reflect the increase of the Escitalopram, the rationale behind it, or that the resident demonstrated depressive behaviors. In an interview on 10/08/2021 at 8:30 AM Staff D was asked to provide documentation to support why the Escitalopram was doubled to the previous dose on 11/28/2021. Upon review of the record, Staff D stated, I don't see anything [to support the dose increase]. Staff D indicated the record reflected the resident demonstrated agitation related to being threatened by another resident for which a room change was implemented. Staff D indicated that minimally, the staff should have, but did not, document the justification for the increase and place the resident on alert charting for the subsequent increase. When asked if the record reflected justification of a dose increase, Staff D replied, No. In an interview on 10/14/2021 at 8:18 AM, Staff F (Social Service Director) was asked to provide documentation to support why the Escitalopram was increased to 20 mg on 11/28/2020. No information was provided. Additionally, subsequent Pharmacy recommendations dated 12/07/2020 and 01/10/2021 showed the resident received Escitalopram 20 mg each day which exceeded the maximum recommended daily dose of 10 mg daily in those over [AGE] years of age, which placed the resident at risk for new or worsening dizziness, fatigue, slow heart rate, low blood pressure, and gait changes, which may increase fall risk, Resident 35 Target Behaviors According to the October 2021 MAR, Resident 35 had the following order to treat depression: Duloxetine HCl Capsule Delayed Release Particles Give 30 mg by mouth two times a day for Depression. The October MAR included monitoring for psychoactive medication target behaviors and identified the following target behaviors: 1 Afraid/Panic, 2 Angry, 3 Screaming/Yelling. These target behaviors for Resident 35's depression were identical to Resident 74's target behaviors for depression and psychosis. In an interview on 10/14/2021 at 08:38 AM, Staff D stated that the target behaviors were not, but should be, individualized for the resident to effectively monitor for depression. Orthostatic Hypotension Monitoring Resident 63's Psychotropic Medication CP included the goal [Resident 63] will be/remain free of psychotropic drug related complications, including . hypotension [low blood pressure] . Resident 63's MAR included orders to monitor Resident 63's blood pressure lying, sitting, and standing on the evening of 21st of each month. Review of the September 2021 MAR revealed that Resident 63's pulse had not been measured as ordered. Further review of Resident 63's EHR revealed that orthostatic blood pressure monitoring had not occurred in June, July, or August of 2021. In an interview on 10/14/2021 at 10:54 AM, Staff D stated it was important to monitor for orthostatic hypotension as it was an indicator of fall risk. Staff D further stated nursing staff should but did not monitor Resident 63 for orthostatic hypotension as ordered.

Based on interview and record review, the facility failed to obtain timely laboratory services to meet the needs of 2 (Residents 25& 74) of six residents reviewed for infections. Failure to obtain physician ordered diagnostics for residents who were assessed to require this service, placed Residents 25 and 74 at risk for delayed treatments. Findings included . Resident 25 Record review on 10/14/2021 showed a Physician's Order (POs) dated 10/01/2021 which directed staff to obtain a URINE ANALYSIS WITH REFLEX URINE CULTURE. Record review showed no results for this ordered lab test. In an interview on 10/14/2021 at 8:37 AM, Staff I (Infection Preventionist, Licensed Practical Nurse) reviewed the record and confirmed no indication the test was performed. Staff I indicated the record should either show the test was performed or why it was not performed. Resident 74 According to POs dated 01/18/2021 a CBC (Complete Blood Count - a comprehensive blood test), CMP (Comprehensive Metabolic Panel - a comprehensive blood test) and a Vitamin D level were ordered. Record review showed no evidence these labs were drawn. In an interview on 10/13/2021 at 8:13 AM Staff D (Resident Care Manager, Licensed Practical Nurse) reviewed the resident's record and could not find these tests were performed and stated, I am going to call the lab, it's not in the record .I don't see it . According to Physician Orders dated 04/15/2021 staff were directed to draw on 4/16 CBC, BMP [Basic Metabolic Panel- a generalized blood test], TSH [Thyroid Stimulating Hormone - a test to determine thyroid function], Vitamin D level. According to the Medication Administration Record (MAR), staff were directed to sign off that this was done on 04/15/2021 through 04/30/2021. No staff signatures were present. Record review showed these labs were not drawn until 05/06/2021. In an interview on 10/13/2021 at 8:13 AM Staff D confirmed these labs should be done on the next lab day and the lab comes out five days a week. Staff D stated, It should have been done a couple of days within being ordered. REFERENCE: WAC 388-97-1620(2)(b)(i). .

Based on observation, interview and record review, the facility failed to ensure dietary orders pertaining to the consistency of foods and liquids were implemented for 2 (Residents 63 & 22) of 9 residents whose dietary intake was reviewed. This failure placed residents at risk for choking, poor nutritional intake, and weight loss. Findings included . Resident 63 According to an 08/30/2021 dietary order, Resident 63 required a Dysphagia Advanced (a diet where the texture of food is altered to facilitate ease of swallowing for residents with swallowing difficulties). According to the Alteration in Nutrition . Care Plan revised on 08/04/2021, staff should monitor/document/report PRN [as needed] any s/sx [signs and symptoms] of dysphagia [difficulty swallowing]. The care plan also noted Resident 63 appears concerned during meals. According to a 09/01/2021 progress note, Resident 63 required constant cuing to swallow. Review of Resident 63's meal ticket revealed that dietary staff prepared meals for Resident 63 with a regular consistency rather than the ordered Dysphagia Advanced diet. On 10/06/2021 at 9:39 AM, Resident 63 was observed to be in bed with their breakfast tray on the over-the-bed table. Resident 63's food was regular texture. On 10/11/2021 at 8:17 AM, Resident 63 was observed in bed with their breakfast tray untouched. Resident 63's breakfast was observed to be regular texture. In an interview on 10/12/2021 at 11:20 AM, Staff Y (Food Service Manager) stated that the meal ticket did not match Resident 63's dietary order, that there was no evidence Resident 63's order was changed or discontinued, and that Resident 63 was not, but should have been, receiving their meals as ordered. Resident 22 A 07/22/2021 dietary order showed Resident 22 required a thin liquid consistency for beverages served with meals. A 07/22/2021 diet requisition form for Resident 22, by the speech therapist and communicated to the kitchen, showed a diet change including thin liquids on meal trays. An observation on 10/08/2021 at 7:33 AM showed Resident 22 eating breakfast and had one glass of orange juice and one glass of milk both with thickened consistency on the tray. When asked if the liquids were thick, Resident 22 stated, Yes. An observation and interview on 10/11/2021 at 12:42 PM showed Resident 22's meal tray contained a meal ticket showing thickened liquids were required and contained three cups of thickened liquids. Staff L (Licensed Practical Nurse) viewed the lunch tray for Resident 22 and confirmed the tray ticket showed NTL (Nectar Thick Liquids) and verified the consistency of cranberry juice, milk and water was a thickened texture. Staff L verified Resident 22's diet order in the medical record and stated it should be thin liquids and the tray ticket was incorrect. In an interview on 10/11/2021 at 1:42 PM with Staff D (Resident Care Manager) confirmed Resident 22 had a physician order for thin liquids. Staff D viewed the lunch tray for Resident 22 on the meal cart and confirmed the tray ticket for thickened liquids and that Resident 22 was served nectar thick liquids. When asked if the Resident should be served nectar thick liquids, Staff D stated, No, they should be thin liquids. REFERENCE: WAC 388-97-1100(1), -1220. .

Based on observation, interview and record review, the facility failed to provide adaptive equipment with meals, for one (Resident 39) of one resident for who these devices were required. Failure to provide and/or set up the adaptive equipment Resident 39 was assessed to require with meals, placed the resident at risk for decreased independence, meal intake, unmet needs and a diminished quality of life. Findings included . According to the 08/15/2021 Significant Change Minimum Data Set (MDS- an assessment tool) the resident had severe cognitive impairment and required set up assistance with meals. According to a 07/16/2021 Nutrition Evaluation, under adaptive equipment needed, staff documented as none needed at this time. Similar findings for an 08/16/2021 re-admission Nutrition evaluation. On 10/07/2021 at 12:24 PM, Resident 39 was observed with their lunch tray. According to the tray card the resident was to receive a regular, small portions diet, and required the use of the following adaptive equipment: sippy cup; plate guard; and weighted utensils. Observation of the tray showed no sippy cup or plate guard was provided, but a weighted spoon and fork were present. On 10/08/2021 at 12:09 PM, Resident 39 was observed with their lunch tray. An empty sippy cup was noted on the tray next to a glass of water. Facility staff did not pour Resident 39's fluids into the sippy cup. The plate guard was also present but was lying on the tray unattached to the plate. A weighted spoon and fork were provided and in use. On 10/11/2021 at 12:05 PM Observation showed Resident 39 utilizing weighted utensils with their lunch meal. Resident 39's sippy cup was empty and not in use, and the plate guard was not attached to the plate. On 10/12/2021 at 12:23 PM, Resident 39 was observed with their lunch meal tray. Observation of the tray showed the facility failed to provide the sippy cup, plate guard and weighted utensils as directed on the tray card. Review of the 10/04/2021 Nutrition Problem care plan showed, the resident was at risk for nutritional deficits related to below normal body mass index, weight loss and history of poor appetite. The care plan did not address the resident's need for adaptive equipment for eating. During an interview on 10/14/2021 at 8:25 AM Staff V (Certified Nurses Assistant) stated Resident 39 gets adaptive equipment on their tray to include a sippy cup, plate guard and large utensils. Review of the resident's clinical record showed no direction to staff on what adaptive equipment the resident required or when and how to apply them. REFERENCE: WAC 388-97-1140(2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 39 Review of the Resident's 08/15/2021 Significant Change MDS showed Resident 39 was re-admitted from the hospital on [DATE] with hospice services. Review of an 08/14/2021 Skilled Nursing Facility Notice of Hospice indicated hospice services were started for Resident 39 on 08/14/2021. Review of the Resident 39's medical record showed no documentation of hospice visits and provisions of services. A 08/17/2021 Terminal Diagnosis CP showed the resident was on hospice. The CP did not address the name of the Hospice provider, no goals or interventions regarding coordination of care with Hospice Services, who (Hospice or Facility Staff) would provide what care to the resident, frequency of Hospice visits or what types of Services (Chaplain, Counseling, Nursing Assistant, Wound Care, Social Services, etc.) were provided by Hospice. In an interview on 10/05/2021 at 12:45 PM, Resident 39 stated, They put me on hospice, but I don't want to just lay here and die. I want to go home. I said something to the Social Worker, and they took me off hospice services. Review of the medical record revealed a PO to discontinue hospice services on 08/30/2021. On 10/12/2021 at 10:28 AM, Hospice notes for Resident 39 were requested from Staff A (Administrator) and no hospice notes were provided. Hospice Agreement On 10/05/2021 at 9:45 AM Hospice Contracts were requested from Staff A. Staff A explained that Social Services was responsible for sending over the hospice order and the Director of Nursing is the contact person for nursing related information. The facility had two hospice agreements. On 10/08/2021 at 12:37 PM the second Hospice contract was requested from Staff A. Staff A provided the contract after going back to facility management to retrieve it. Review of the 08/14/2021 Skilled Nursing Facility and Hospice Service Agreement showed the facility signed the agreement but the Hospice provider did not. In an interview on 10/14/2021 at 9:53 AM, Staff A stated that it is temporary to show that I agreed and signed. It usually takes a while for an agreement, this is their contract, they created it so I signed it. When asked if they would expect both parties to sign an agreement, Staff A responded yes. REFERENCE: WAC 388-97-1620. Based on interview and record review, the facility failed to develop and maintain a current plan of care in collaboration with hospice, which identified what services were to be provided, and which delineated hospice/facility responsibilities. Additionally, the facility did not have a system by which consistent communication between the facility and hospice staff occurred, for 1 (Resident 77) of 2 sampled residents, and one supplemental resident (Resident 39), reviewed for hospice services. The facility failed to have a signed Hospice Agreement. This failure placed the resident at risk for not receiving necessary care and services. Findings included . According to the 08/14/2021 Skilled Nursing Facility and Hospice Service Agreement hospice should provide the facility with the following information for each patient admitted to the facility: The most recent Hospice plan of care specific to each patient, Hospice election form and any advanced directives specific to each patient, Physician certification and re-certification of the terminal illness specific to each patient, Names and contact information for Hospice personnel involved in hospice care of each patient, Instructions on how to access the Hospice's 24 hour on-call system, hospice medication information specific to each patient and Hospice physician and attending physician orders specific to each resident. According to the facility's 07/2018 Hospice Policy, to provide continuity of care and collaboration of services for residents, the facility will designate a staff member to work with the hospice representative to coordinate care to the resident. This policy indicated services should include delineation of the hospice's responsibilities including but not limited to, medical direction and management of the patient; nursing, counseling, social work, medical supplies, durable medical equipment and drugs and other services necessary to care for the resident's terminal illness and related conditions. This policy indicates the facility and the hospice provider will establish a coordinated plan of care which identifies the specific services/function each provider is responsible for performing. Hospice Collaboration of Care Resident 77 Resident 77 admitted to the facility on [DATE] and according to the 09/22/2021 Significant Change Minimum Data Set (MDS - an assessment tool) was assessed with less than 6 months to live and required Hospice Services. According to the Nursing admission assessment dated [DATE], Resident 77 had multiple wounds which required treatment. Record review showed a Skilled Nursing Facility Hospice Notification indicated Resident 77's Hospice start date was 09/17/2021. Review of Care Plan (CP) documents on 10/06/2021 showed no CP indicating Resident 77 was receiving Hospice Services or identified any goals or interventions regarding coordination of care with Hospice Services. Nowhere, in the review of the Resident 77's records did the facility identify who (Hospice or Facility Staff) would provide what care to the resident, frequency of Hospice visits or what types of Services (Chaplain, Counseling, Nursing Assistant, Wound Care, Social Services, etc.) were provided by Hospice. Record review on 10/06/2021 showed no Physician Order (PO) for Hospice Services, and no documentation from Hospice to support any services were provided for over the three weeks since the start date of 09/17/2021. According to a facility progress note dated 09/27/2021 at 7:33 PM, facility staff documented Resident 77 was evaluated by a Hospice nurse and indicated the Hospice nurse will send new orders for wound care. In an interview on 10/08/2021 at 11:11 AM, Staff D (Resident Care Manager - Licensed Practical Nurse) confirmed provider notes and recommendations should be obtained and placed in the resident's record the date the services were provided in order to provide continuity of care. In an interview on 10/08/2021 at 12:58 PM, Staff D identified a PO for hospice services was obtained on 10/07/2021. Staff D indicated staff should have, but did not, obtain the Hospice order on 09/17/2021. Staff D also identified a Hospice CP was initiated on 10/07/2021. Staff D indicated the CP should have been initiated on 09/17/2021 Staff D was also unable to locate any Hospice notes or assessments in Resident 77's medical record. In an interview on 10/11/2021 at 11:55 AM, Staff Q (Health Information Coordinator) confirmed they just received all the Hospice provider notes and stated, They (Hospice documents) were in my box this morning. Staff Q indicated it was this facility's first time working with this Hospice provider and, We are ironing out some kinks. In an interview on 10/12/2021 at 9:04 AM, Staff B (Director of Nursing) reported their Wound provider company last provided wound services for Resident 77 on 08/31/2021. When asked to provide information regarding who monitored, tracked, and objectively assesed Resident 77's wounds after they were enrolled in Hospice, Staff B could provide no documentation. Staff B stated that residents on Hospice should have CPs that delineate who is responsible for the services provided to that resident. Staff B also indicated that Hospice usually initiates a CP when they come. Staff B confirmed neither facility or Hospice staff initiated a timely Hospice CP which provided goals or directed coordination of care for Resident 77.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to maintain infection control prevention measures during medication pass for 2 (91 & 192) of 11 residents observed for medication administration. Additionally, the facility failed to implement isolation precautions timely to potentially prevent the spread of infection for 1 (45) of 2 residents reviewed for Transmission Based Precautions and failed to ensure risk assessments (used to assess COVID 19 risk for residents) were completed for residents going to the community for medical appointments for 1 (51) of 1 supplemental residents. These failures placed residents at risk for the development and transmission of disease and infection, including COVID-19. Findings included . According to the 03/2021 Infection Prevention and Control Policy the facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. According to the 04/2021 Facility Covid-19 general Protocols, all residents will be screened on admission, everyday in the community, and upon re-entry when they leave and return to the facility. Medication Pass Resident 91 Observation during medication pass showed Staff N (Licensed Practical Nurse) administer medications, including an inhaler with an attachable aerochamber (a device which enhances inhaled medications) to Resident 91. After administration of the inhaler, Staff N was observed to place the inhaler and aerochamber in their pocket during handwashing. After handwashing, Staff N removed the inhaler and aerohamber from their pocket and placed them in the medication cart. In an interview on 10/14/2021 at 11:02 AM, Staff J (Corporate Nurse Consultant) stated nursing staff shouldn't put inhalers in their pockets. Placing resident specific used inhalers in staff pockets is considered to be unsanitary. Resident 192 On 10/13/2021 at 08:43 AM, Staff R, (Licensed Practical Nurse), was observed preparing to administer Resident 192's Cefepime IV (Intravenous, medication given through the vein). Staff R entered the room and performed hand hygiene, donned gloves, removed the empty bag of Cefepime that was connected to the IV tubing in an IV pump at the bedside. Staff R then spiked (inserting the spiked end of the IV tubing into the port on the IV medication bag) the new bag of Cefepime with the same tubing and attempted to prime the tubing. After cleansing and flushing the luer lock (a connector piece between the end of the IV and where medication can be given) on the resident's PICC (Peripherally Inserted Central Catheter), Staff R removed the cap from the IV tubing but realized there were copious air bubbles in the tubing. While holding the uncapped IV tubing in the left hand Staff R spent the next 8 minutes opening the pump removing the tubing and re-threading the tubing several times. On multiple occasions the uncapped tip of the IV tubing came into direct contact with Staff R's gloves and the IV pump. Once Staff R effectively primed (made sure bubbles were removed from the IV line) the IV tubing, Staff R cleansed the luer lock on the PICC and attempted to attach the uncapped IV tubing to the PICC before surveyor intervened to prevent the contaminated tubing from being attached to the resident's IV. In an interview on 10/13/2021 at 9:02 AM, Staff I, (Infection Preventionist), who was present in the room for part of the observation, acknowledged Staff R's failure to protect the end of the exposed tubing from contacting unclean surfaces. Staff I then accompanied Staff R in removing the contaminated tubing. Isolation Precautions Resident 45 According to the 08/26/2021 admission Minimum Data Set (MDS- an assessment tool) the resident admitted on [DATE] and was assessed to be cognitively intact. On 10/05/2021 at 11:00 AM a Continuous Positive Airway Pressure (CPAP) machine was observed on the resident's bedside. On 10/06/2021 at 10:15 AM Resident 45 was observed with an isolation cart outside of the room and a sign posted that showed, Stop, Aerosol Contact Precautions. At this time Staff A (Administrator) stated they were on precautions because they have a CPAP, and it is an aerosol generating procedure. Isolation signs will be up at bedtime and taken down three hours after the resident wakes up and removes the CPAP. In an interview on 10/11/2021 at 12:15 PM Resident 45 stated they brought their CPAP from home on [DATE] when they admitted . Review of the resident's medical record showed Physician Orders (POs) were placed on 10/05/2021 for CPAP to be worn at pressure settings 14-16 and Aerosol Isolation when CPAP is in use. The orders instructed staff to remove CPAP at 7 AM and keep door closed for 3 hours after removing CPAP. In an interview on 10/12/2021 at 12:39 PM Staff C (Resident Care Manager) was asked why CPAP orders were put in on 10/05/2021 if the resident admitted on [DATE]. Staff C reviewed the medical record and stated they could not find anything that would explain why the orders would be put in late. During an interview on 10/14/2021 at 9:53 AM Staff A (Administrator) stated they put the resident on isolation and physicians orders in the medical record on 10/06/2021 because 10/06/2021 is when the staff identified it and there was no PO and so POs were put in for them to use it. Risk Assessments Resident 51 On 10/07/2021 at 10:58 AM Resident 51 stated they had an appointment for follow up x-rays on 10/08/2021. On 10/08/2021 at 12:15 PM Resident 51 was getting ready to leave for their appointment at 1:00 PM. Review of the resident's medical record on 10/11/2021 revealed no risk assessment (used to assess Covid 19 risk for residents) was completed before leaving or upon return to the facility for Resident 51's medical appointment outside of the facility. During a duo interview on 10/13/2021 at 10:36 AM Staff J (Corporate Nurse Consultant) reviewed Resident 51's record and was unable to locate the Risk Assessment from the resident's 10/08/2021 medical appointment. Staff A (Administrator) stated that they just spoke with the resident, and they believe they had no contact with a COVID positive person during their appointment. Maybe the resident has the packet or gave it to the nurse. In an interview on 10/13/2021 at 11:01 AM Staff A (Administrator) when asked where to find Risk Assessments for medical appointments, Staff A stated the process is that the assessment form is given to the driver or transportation, and they will help fill it out upon return to the facility. It also depends on if the resident is fully vaccinated, we will ask questions and interview the resident. Staff A further stated the Risk Assessment would be in the chart, if it is not there then Medical Records would have it to scan into the electronic record. In an interview on 10/13/2021 at 11:28 PM Staff Q (Health Information Coordinator) stated they are all caught up on scanning and do not have the risk assessment. REFERENCE: WAC 388-97-1320(1)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to allow 8 (Residents 74, 142, 58, 192, 91, 13, 28 & 91) of 12 sample and 1 (Resident 6) supplemental residents reviewed for choices, the right to make choices regarding important daily routines and health care, including accommodating preferences for the frequency and/or type of bathing. The facility's failure to accommodate resident choice placed these residents at risk for a diminished quality of life. Findings included . Resident 74 Resident 74 originally admitted to the facility on [DATE] and according to the 09/04/2021 Significant Change Minimum Data Set (MDS, an assessment tool) was assessed with clear speech and able to understand and be understood in conversation. In an interview on 10/06/2021, Resident 74 was noted with unbrushed hair and indicated they wanted, but did not receive, showers frequently. The resident was unable to state when they last received a shower. According to Care Plan (CP) documents dated 09/13/2021, Resident 74 had daily routine preferences which included, Resident prefers 2 showers a week. During record review on 10/08/2021 at 10:35 AM, Staff D (Resident Care Manager, Licensed Practical Nurse) confirmed, according to bathing records, Resident 74 did not receive two showers a week per stated preference. Resident 142 Resident 142 admitted to the facility on [DATE] and according to the Medicare 5 day MDS, was assessed as cognitively intact with clear speech, able to understand and be understood in conversation. In an interview on 10/05/2021 at 1:29 PM, Resident 142 indicated no bathing was provided since admission, stating, [Before admission] we took a bath every day and almost daily since I moved [to this state], I don't know why I haven't gotten a shower. The resident elaborated they used a towel to, wash up in the sink but really wanted a shower. According to the [NAME] (written instructions to staff on resident care needs) Resident 142 was scheduled for bathing on Wednesday and Saturday. Record review showed that as of 10/12/2021 at 2:00 PM, Resident 142 did not receive any bathing. Resident 58 Resident 58 was admitted to the facility on [DATE] and according to the admission MDS dated [DATE] was assessed as able to understand and be understood in conversation. In an interview on 10/05/2021 at 1:46 PM, Resident 58 reported they were only showered twice since admission. During an interview on 10/08/2021 at 12:15 PM, Resident 58 stated they preferred a, shower most definitely! Resident 58 reported they preferred showers a couple times a week, and indicated facility staff did not asked about their preferences. According to the facility shower schedule dated 08/06/2021, Resident 58 was scheduled for a bed bath on Tuesdays and showers on Fridays. Record review showed that as of 10/11/2021 at 1:15 PM, facility staff documented Resident 58 received only two showers since admission. In an interview on 10/12/2021 at 1:15 PM, Staff C (Resident Care Manager, Registered Nurse) stated that it did not appear facility staff provided bathing twice weekly as Resident 58 preferred and indicated they would expect preferences to be updated on the CP, as well as progress notes and follow up to be done regarding any bathing not completed. Resident 192 Resident 192 admitted to the facility on [DATE]. According to the 10/03/2021 admission MDS, the resident was cognitively intact, able to understand and be understood, and required one person physical assistance with bathing. In an interview on 10/06/2021 at 12:44 PM, Resident 192 stated, I have only had one shower since I've been here. The resident indicated no one explained when or how often showers were provided stating, They just showed up one day and said they were taking me for a shower. In an interview on 10/11/2021 at 10:17 AM, Resident 192 was still concerned about the frequency of bathing and stated, I have had only two showers [in 14 days] since I admitted . I have been using the wash pads from the hospital, they're like thick baby wipes, to clean myself at the sink but I just ran out of them. According to Resident 192's undated [NAME], the resident was scheduled for showers twice a week on Tuesdays and Fridays. Review of the September and October 2021 bathing flowsheets showed Resident 192 was showered on 09/29/2021 and 10/07/2021 (once per week). During an interview on 10/14/2021 at 11:24 AM, Staff B (Director of Nursing) confirmed Resident 192 was scheduled to be bathed twice a week and did not receive bathing as scheduled. Resident 91 Review of the clinical record showed Resident 91 re-admitted to the facility on [DATE] with multiple medically complex diagnoses, including a stroke with left side weakness, and was assessed as able to understand and be understood in conversation. Review of Resident 91's CP dated 12/06/2020 showed Bathing/Showering: Resident 91 is totally dependent on one staff to provide bath/showers and as necessary. Resident prefers two showers a week. In an interview on 10/05/2021 at 8:46 AM, Resident 91 reported they were only showered once a week and sometimes a bed bath. When asked if they have a preference between showers and bed baths and the resident stated, I prefer showers. Review of Resident 91's Bath flow sheet 30 days look back between 09/09/2021 and 10/10/2021 showed resident received two showers and two bed baths instead of eight showers per the care planned. In an interview on 10/12/2021 at 1:15 PM, Staff D confirmed that there was no specification when the showers were offered and stated, It appears that facility staff did not provide bathing per Residents 13, 28 and 91 preferred schedules and routine. All residents are supposed to be given showers per preferences and any refusal notified to the RCM and follow up done regarding any bathing missed. Resident 13 Resident 13 admitted to the facility on [DATE] and according to the 10/06/2021 Quarterly MDS was assessed as able to understand and be understood in conversation. In an interview on 10/06/2021 at 10:46 AM, Resident 13 reported they were only showered once a week. When asked if they have a preference between showers and bed baths and the resident stated, I prefer showers and more than one a week and indicated facility staff had not asked about their preferences. Review of Resident 13's Bathing records between 09/14/2021 and 10/14/2021 showed the resident received only four showers in a month. Resident 28 Resident 28 admitted to the facility on [DATE] and according to the 08/08/2021 Quarterly MDS was assessed as able to understand and be understood in conversation. In an interview on 10/05/2021 at 9:46 AM, Resident 28 reported they were only showered once a week. When asked if they have a preference between showers and bed baths and the resident indicated a preference for showers twice a week and indicated facility staff did not ask about their preferences. Review of Resident 28's Bath flow sheet 30 days look back between 09/10/2021 and 10/10/2021 showed Resident 28 received only four showers. Resident 6 Resident 6 admitted to the facility on [DATE] and according to the 07/07/2021 Quarterly MDS was assessed with no cognitive impairment and indicated it was very important to choose between a shower, bed bath or tub bath. In an interview on 10/11/2021 at 1:22 PM, Resident 6 stated, I told them I prefer showers twice a week on Tuesday and Friday. They come and tell me what days I can shower. There were some weeks when I did not get even one shower. I can do my own bed baths with the wipes. According to the facility shower schedule dated 08/06/2021, Resident 6 was scheduled on Mondays for a shower and Thursdays for a bed bath. Resident 6's CP dated 9/13/2021, showed Resident 6 preferred showers on Tuesday and Friday. A review of the shower documentation log from 09/07/2021 to 10/11/2021 showed Resident 6 received five of 11 showers scheduled. There were no showers provided to Resident 6 for the week of 9/26/2021 to 10/02/2021. REFERENCE: WAC 388-97-0900(1)(3). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 22 Record review showed Resident 22 originally admitted to the facility on [DATE] and was readmitted on [DATE]. An Annual MDS assessment dated [DATE] showed Resident 22 was able to make decisions regarding tasks of daily life and memory was intact. According to the record (profile) Resident 22 was listed as the responsible party and #1 emergency contact. Resident 22 had a friend and daughter both listed as additional #2 emergency contacts. According to the September 2021 physician orders, the resident is capable of managing own finances, participating in own plan of care and capable of understanding and exercising rights. In an interview on 10/07/2021 at 9:29 AM, Resident 22 was asked if they had an advanced directive and stated No. Resident 22 was asked if the facility had offered to help create an advanced directive. Resident 22 stated, No. admission documents dated 08/22/2019 were signed by Resident 22 and reviewed with Resident 22 on 07/10/2021 at readmission but did not include options to formulate or decline to formulate an advanced directive. Resident 22's care plan dated 03/04/2020 showed, Facility staff provided me with the information related to my right to have an Advanced Directive and what an Advanced Directive is. In an interview on 10/13/2021 at 11:44 AM, Staff Q (Medical Records) reviewed Resident 22's medical record and stated there was no records on file for an advanced directive decision. In an interview on 10/13/2021 at 1:52 PM, Staff F (Social Services Director) was asked if Resident 22 was given the opportunity to formulate or decline to make and Advanced Directive, Staff F stated, No. Resident 38 Resident 38 admitted to the facility on [DATE]. According to the 05/14/2021 admission MDS, the resident was cognitively intact, able to understand and be understood. On a 05/10/2021 Resident Rights-Advanced Directives document, Resident 38 marked the box that stated I DO have an advanced directive. Review of the resident's record revealed no AD was present, nor was there any indication facility staff had made attempts to obtain it. On 10/14/2021 at 10:51 AM, Staff A (Administrator) indicated staff were unable to locate an AD for Resident 38. Staff A then stated the resident's care plan did not indicate Resident 38 had an advanced directive. Staff A was asked for documentation to support how the facility determined Resident 38 did not have an AD, given the resident signed the 05/10/2021 Resident Rights-Advanced Directives form, which stated they did. During an interview with Staff A on 10/13/2021 at 11:21 AM, a copy of Resident 38's AD was requested or documentation to support the facility had made attempts to obtain it. No information was provided. REFERENCE: WAC 388-97-0280 (3)(a)(c)(i-ii), -0300 (1)(b). Based on interview and record review, the facility failed to address required documentation for advanced directives, including incorporation into the care planning process, for 5 (Residents 5, 55, 74, 22 & 38) of 10 residents reviewed for Advanced Directives (ADs). These failures placed the residents at risk of losing their right to have their stated preferences/decisions regarding end-of-life care followed. Findings included . According to the facility policy on Resident Rights dated 11/2017, the facility will communicate the resident's wishes to the resident direct care staff and physician. Resident 5 According to the 04/13/2021 admission Minimum Data Set (MDS, an assessment tool), Resident 5 was assessed with severe cognitive impairment. A 04/10/2021 document from the admission packet showed Resident 5 had an advanced directive. According to Care Plan (CP) documents dated 04/15/2021, Resident's grandson is (their) POA (Power of Attorney- a legal document which designates a decision maker) for care and financial. According to the contacts section of the resident's record, the resident's son was listed as Responsible Party, Emergency Contact #1 POA. Record review showed a 12/23/2021 POA which indicated the resident's son was financial POA. There was no POA documents for healthcare. In an interview on 10/11/2021 at 8:33 AM when asked to provide evidence of an AD for healthcare as indicated in the care plan, Staff C (Resident Care Manager, Registered Nurse) stated according to the resident's POLST (Physician Order for Life Sustaining Treatment, a document that is not an Advanced Directive), was for a full code. Staff C was asked to provide the POA for healthcare or documentation to support the resident did not have a POA for healthcare. No information was provided. Resident 55 According to the admission MDS dated [DATE], Resident 55 was assessed as cognitively intact and able to understand and be understood in conversation. In an interview on 10/06/2021 at 7:46 AM Resident 55 indicated he did not recall being offered information about formulating an advanced directive. A admission packet document dated 08/30/2021 showed Resident 55 did not have an an Advanced directive. Staff did not discern if the resident wanted or received information and education on advanced directives. In an interview on 10/11/2021 at 8:33 AM, Staff C indicated they would attempt to find information to support the resident was offered information about ADs. No information was provided. Resident 74 Record review showed Resident 74 originally admitted to the facility on [DATE] with a 09/18/2021 readmission Medicare 5 Day Assessment which showed the resident had severe cognitive impairment. According to the record (profile) the resident was listed as responsible party with a daughter and son listed as first and second emergency contacts. According to physician orders, the resident is incapable of participating in own plan of care but is capable of understanding and exercising rights admission documents dated 09/01/2021, updated on 09/14/2021, indicated the resident had an advanced directive. This document, reviewed by Resident 74's daughter, indicated education about ADs was not requested. Care Plan documents dated 01/21/2021 showed, Resident does not have an advanced directive . In an interview on 10/08/2021 at 8:55 AM when asked about the discrepancy between the CP, which indicated the resident did not have an advanced directive, and the 09/01/2021 admission documents which indicated the resident did have an AD, Staff D stated, I will look into it. When asked staff should obtain ADs if the family or resident documents there is one, Staff D replied, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure resident rooms were cleaned, swept, and trash cans were emptied, and resident wheelchairs were cleaned regularly. Additionally, the facility failed to ensure hallway handrails were well maintained on 2 of 3 units reviewed (West and East Units). These failures resulted in some residents being exposed to an unclean environment and placed residents at risk for feelings of frustration and a diminished quality of life. Findings included . Resident 192 Resident 192 admitted to the facility on [DATE]. According to the 10/03/2021 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact with clear comprehension. During an interview on 10/07/2021 at 10:22 AM, Resident 192 expressed concern about the cleanliness of the room and stated, I have only seen the housekeeper one time since I got here. The resident then shared: the trash can in the bathroom needed to be emptied; there were no gloves in the bathroom, so every time staff were assisting, they had to leave in the middle of it to go get gloves; the electric dispenser for paper towels was completely empty and needed to be filled; and the floor in the room around the bed was dirty and hadn't been swept. Resident 192 then pointed to a green piece of candy in the corner to the right of the bed, and stated that was there when they got here. Each of the resident's reported concerns were validated. Additionally, four approximately 2.5-foot-long non-slip adhesive strips had been placed on the floor on each side of the bed. Observation of the edges of the non-slip strips showed they were off white/ light tan in color initially. The middle foot of each strip was now black and heavily soiled. Resident 192 indicated that they had not reported their concerns to facility staff yet, but would after (writer) left. Upon entering resident 192's room on 10/11/2021 at 10:31 AM, Resident 192 shared that a housekeeper had come in, and just ran a dust broom over the main path by the sink to the second bed. Then wiped the sink down and emptied the trash. (Resident 192 clarified this was the sink and the trash from the trash can in the room, not the bathroom.) According to Resident 192 the electric paper towel dispenser in the bathroom remained empty, there still were no gloves, and although the trash had been emptied since (10/07/2021), it did not occur daily and was almost full. Observation of the bathroom showed the trash can was 3/4 full, an empty box of gloves remained on a handrail, and the electric paper towel dispenser was empty. Upon exiting the bathroom Resident 192 smiled and pointed to the green piece of candy which was still present in the corner. In an observation/interview on 10/11/2021 at 10:45 AM, Staff GG (Housekeeping Supervisor) stated that each resident room is cleaned daily with a five-step process that included sweeping, wiping down sinks, toilets, and handrails, emptying trash cans, dusting and restocking items, such as toilet paper and paper towels. Staff GG then assessed Resident 192's room and confirmed the electric paper towel dispenser was empty, indicating it should be filled. When asked about the lack of gloves Staff GG indicated nursing restocked the gloves. When asked to describe the non-slip adhesive strips on the floor next to the resident's bed Staff GG stated, A buildup of black .we just talked about this about a week and a half ago, we need to scrape it up. Staff GG then observed the green candy in the corner (peanut M&M) and indicated if the room was being cleaned thoroughly, the peanut M&M would not have been repeatedly missed. Handrails Observations of the South Unit made on 10/08/2021 at 08:11 AM revealed the plastic-like trim on the handrail between rooms [ROOM NUMBERS] was brittle and pieces were breaking off, exposing the screws that attached the trim to the rail. In the hallway outside the Activities/Assisted Dining Room on 10/08/2021 at 08:25 AM, the clear plastic-like trim on the handrail was observed to be brittle and broke off with no effort, leaving sharp edges that could tear resident skin. The handrail also had extensive scratching of the dark brown finish, exposing the much lighter wood in scrapes throughout its length, making it difficult to clean. On 10/11/2021 at 01:19 PM, handrails on the East Unit near the shower room, and outside the Nurses Station and care managers' office were observed with multiple scratches and missing pieces of trim. Further observation on 10/14/2021 at 08:05 AM on the [NAME] Unit showed more missing and/or fragmented trim on the handrail between room [ROOM NUMBER] and the laundry room. Chunks were broken off around 3 screws, with the remaining trim brittle and loose. 1 screw was observed to be fully exposed. In an interview and observation rounds on 10/14/2021 at 09:28 AM, Staff X, Maintenance Director, stated they were unsure of the purpose of the trim and that they would remove it. On 10/14/2021 at 10:14 AM, Staff X was observed removing trim from the handrail outside the laundry room near room [ROOM NUMBER]. On 10/14/2021 at 11:26 AM, a screw was observed to remain attached to the handrail next to laundry room, sticking out 5/8 inch from the rail. Wheelchair Cleaning On 10/06/2021 at 10:48 AM, the frame of the wheelchair belonging to Resident 65 was observed to have a deep layer of debris coating its metal frame. The buildup of a white-ish substance was sufficient that the black paint on the frame appeared white. The cushion of the wheelchair was dusted with small white flakes. The fabric covering the right handle's padding had frayed and was covered in a white tape. On 10/12/2021 at 9:33 AM, Resident 65's wheelchair was observed to remain uncleaned. In an interview on 10/14/2021 at 9:22 AM, Staff K (licensed Practical Nurse) stated that maintenance used to be responsible for cleaning resident wheelchairs and that there had recently been a change in the Maintenance Director position. In an interview on 10/14/2021 at 9:28 AM, Staff X, (Maintenance Director) stated that the cleaning of resident wheelchairs was the responsibility of the housekeeping department, that they would inform the housekeeping department of the need to clean Resident 65's chair, and that they would repair the taped handle. REFERENCE: WAC 388-97-0880 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions and/or a PASRR was completed for each resident for 3 (Resident 46, 74 & 65) of 6 residents reviewed. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . Resident 46 Resident 46 admitted to the facility on [DATE]. According to the 08/27/2021 admission Minimum Data Set (MDS, an assessment tool), the resident had severe cognitive impairment, a diagnosis of depression, and received antipsychotic and antidepressant medications during the assessment period. Record review revealed no PASRR was present in the resident's record. On 10/14//2021 at 10:08 AM, when asked if they could locate the resident's PASRR Staff F, (Social Service Director), Stated, No, I don't see one [PASRR,] but indicated it could be in medical records and just was not scanned into the Electronic Health Record yet. During an interview on 10/14/2021 at 10:19 AM, Staff Q, (Health Information Coordinator), stated that they had already looked through Resident 46's medical record, and acknowledged there was no PASRR. Resident 74 Record review showed Resident 74 originally admitted to the facility on [DATE]. And according to the 09/17/2020 admission MDS, the resident had multiple medically complex diagnoses including non-Alzheimer dementia and depression, but did not have anxiety or psychotic disorders. This MDS showed the resident received antipsychotic and antidepressant medications on six days of the assessment period but did not receive antianxiety medication. According to the 09/11/2020 PASRR, the resident had no serious mental illness indicators. A second PASRR, completed by facility staff on 12/23/2020, three months after the resident was admitted , showed the resident had both mood and anxiety disorders. Under the additional comments section staff documented updated to reflect depression dx [diagnosis]. In an interview on 10/11/2021 at 11:19 AM, Staff D (Resident Care Manager) confirmed the resident did not have an anxiety disorder and stated the diagnoses on the PASRR, would have to be clarified. In an interview on 10/14/2021 at 8:18 AM, Staff F was asked why the 12/23/2020 PASRR reflected an anxiety disorder when the MDS did not reflect that diagnosis and the resident wasn't actively treated for anxiety disorder. After reviewing the record, Staff F indicated the hospital discharge records indicated a history of anxiety disorder from 2015. According to PASRR instructions, staff should mark only those mental illnesses for which the individual has shown indicators within the last two years of the mental disorder. Staff F was asked to provide information to support the anxiety disorder diagnosis for the PASRR. No information was provided. Additionally, review of Resident 74's Physician Orders (POs) showed a 07/26/2021 order for an antipsychotic medication for dementia with psychosis. In an interview on 10/14/2021 8:18 AM, when asked if the PASRR should be updated to reflect a psychotic disorder, Staff F stated yes. Resident 65 According to the 12/23/2020 admission MDS, Resident 65 admitted to the facility on [DATE] with a diagnosis non-Alzheimer's Dementia, and no mental health diagnoses. According to the 06/15/2021 Quarterly MDS, Resident 65 was assessed with an anxiety disorder. According to an undated Level I PASRR, Resident 65 was assessed to have an Anxiety Disorder, prior to admitting to the facility. According to the Level I PASRR, Resident 65 was not assessed to have functional limitations due to serious mental illness, and did not require a Level II PASRR screening. According to a 07/20/2021 progress note, Resident 65 readmitted to the facility on [DATE] after being hospitalized with a skin infection. According to the 07/26/2021 5-Day MDS, Resident 65 was identified with new mental health diagnoses of schizophrenia and personality disorder. In an interview on 10/12/2021 at 08:50 AM, Staff F stated that residents who have a significant change in their mental health, including new mental illness diagnoses, should be reevaluated through the PASRR process. Staff F stated that the new diagnoses of schizophrenia and personality disorder should have, but did not, prompt a reevaluation for Resident 65 for PASRR services. WAC REFERENCE: 388-97-1980(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 39 Review of Resident 39's record showed no signed baseline care plan or documentation that the resident or resident representative received a written copy, signed a copy, or agreed with the plan of care. Resident 51 Review of Resident 51's record showed no signed baseline care plan or documentation that the resident or resident representative received a written copy, signed a copy, or agreed with the plan of care. Resident 73 Review of Resident 73's record showed no signed baseline care plan or documentation that the resident or resident representative received a written copy, signed a copy, or agreed with the plan of care. In an interview on 10/13/2021 at 11:01 AM Staff J (Corporate Nurse Consultant) stated that resident baseline care plans are initiated from the admission assessment. When asked where I can find a signed copy from the resident or the resident's representative, Staff J stated Staff F (Social Service Director) was not aware that the resident and/or resident's representative should receive a written copy, sign, agree with plan of care and that is should be documented in the resident's record. REFERENCE: WAC 388-97-1020(3) Resident 192 Resident 192 admitted to the facility on [DATE]. According to the 10/03/2021 admission MDS, the resident was cognitively intact, and was able to understand and be understood. In an interview on 10/06/2021 at 12:44 PM, Resident 192 stated that she did not get to participate in her plan of care stating, I have only had one shower since I've been here. The resident indicated no one explained when or how often showers were provided. The resident then shared that other than therapists, no one had come and discussed anything with her, and denied being provided a copy of the baseline care plan. Record review showed a 09/28/2021 IDT Care Plan Conference/Welcome Meeting form, completed by Staff F, that indicated Resident 192 was present at the conference when the plan of care, therapy goals and discharge plan were discussed. In an interview on 10/08/2021 at 11:53 AM, when asked if there was a meeting with Staff F, Resident 192 stated, yes but indicated the discussion was about whether insurance would pay for intravenous infusion on a out patient basis, not about care at the facility. In an interview on 10/14/2021 at 10:11 AM, Staff F indicated the IDT Care Plan Conference was what the facility used to discuss the baseline plan of care with new residents. Staff F indicated Resident 192 attended and was involved, but acknowledged a copy of the baseline plan of care was not provided as required. Resident 93 Similar findings were noted for Resident 93 who admitted to the facility on [DATE]. Record review showed the IDT Care Plan Conference did not take place until 08/16/2021, four days after admission. Additionally, record review showed no documentation or indication the resident or resident representative was provided a copy of the baseline plan of care as required. Based on interview and record review the facility failed for 6 (142,192, 93, 39, 51,73) of 6 residents reviewed, to develop a baseline care plans, to ensure continuity of care and/or to provide residents and their representative with a summary of their baseline care plan (CP). This failure resulted in residents not being informed of their initial plan for delivery of care and services and placed residents at risk for unmet needs and possible complications. Findings included . Resident 142 Record review showed the resident admitted to the facility on [DATE]. According to the 10/06/2021 Medicare 5 day Minimum Data Set (MDS - an assessment tool), the resident was assessed as cognitively intact ,with clear speech, able to understand and be understood in conversation was cognitively intact. Observations on 10/05/21 at 1:42 PM showed the resident lying in bed watching television. In an interview at this time, the resident stated they did not participate in an interdisciplinary team (IDT) meeting to discuss care needs and no copy of any Baseline Care Plan (CP) was provided since admission. Record review showed a IDT Care Plan Conference form which showed the resident received an invite notice on 10/01/2021. This documentation showed that Staff F (Social Service Director) and the resident were present and discussed discharge information but there was no indication the resident was provided with a copy of the initial CP. In an interview on 10/11/21 at 11:39 AM Staff F indicated that the care conference took place, but that a copy of the initial CP was not provided. Additionally, according to Preference CP documents dated 10/01/2021 showed an intervention of, Resident is satisfied with current facility bathing routine and will notify staff of preference change. A 09/30/2021 gastric disease CP showed interventions of Provide small frequent meals rather than 3 large ones and encourage resident to avoid alcohol, smoking coffee .encourage a bland diet. Record review showed the resident did not have orders for small frequent meals or a bland diet. In an interview on 10/13/2021 at 8:45 AM, Staff D stated it appeared someone auto populated interventions without ensuring they were accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were accurately reviewed and revised to reflect current resident needs, for 17 of 24 residents (Residents 38, 46, 192, 93, 15, 63, 5, 55, 74, 39, 6, 22, 62, 77, and 58) whose CPs were reviewed. This failure left residents at risk for unmet care needs. Findings included . Resident 38 Resident 38 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly MDS, the resident was cognitively intact, had diagnoses of Post Traumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD), diabetes and depression, and required supervision with bed mobility, walking in room and dressing. Review of Resident 38's comprehensive CP showed the facility failed to develop a diabetic CP. During an interview on 10/13/2021 at 11:21 AM, Staff J, (Corporate Nurse Consultant), stated a Diabetic CP should have been developed, but was not. In an interview on 10/12/2021 at 12:43 PM, Resident 38 expressed a desire to discharge and stated, I transfer myself, dress myself, toilet myself, do my own morning care, feed myself, and make my make my own bed. I could get a little stronger with walking because I haven't been doing that. In a joint interview on 10/12/2021 at 12:50 PM, Staff V and Staff BB, (Certified Nursing Assistants, who work with Resident 38), both confirmed Resident 38 was independent with activities of daily living (ADL), indicating they only setup the resident's meal tray. According to the 05/10/2021 ADL CP, Resident 38 required extensive assist with dressing, and two person extensive assist with bed mobility, transfers and toileting. During an interview on 10/13/2021 at 11:21 AM, Staff J, stated the CP needed to be updated. According to a 05/10/2021 limited physical mobility CP, Resident 38 was Non-Weight Bearing The CP did not indicate what part of the body it was referring to. Review of the 06/21/2021 Physical Therapy discharge summary, showed the resident had met their goals and recommended the resident transition to a restorative walking program. During an interview on 10/13/2021 at 11:21 AM, Staff J, stated the CP needed to be updated. According to the 05/10/2021 Elopement CP, the resident was an elopement risk d/t forgetfulness and being independently mobile. Staff were directed to use diversion and redirection if the resident was exit seeking. According to the 08/09/2021 Quarterly MDS, Resident 38 was cognitively intact, able to understand and make self understood. Review of the Physician's orders showed the resident was her own decision maker and was assessed to be capable of exercising her rights and and managing her own finances. During an interview on 10/13/2021 at 11:21 AM, Staff J, stated the CP needed to be updated. A 05/10/2021 Nutritional problem CP, directed staff to assist with obtaining special equipment as needed, provide, and serve diet as ordered, and provide and serve supplements as ordered. The CP failed to identify what if any special equipment the resident required, what diet the resident had ordered, or what supplements, if any the resident was to receive. During an interview on 10/13/2021 at 11:21 AM, when asked if CP interventions should be resident specific and personalized, Staff J stated, Yes and acknowledged Resident 38's were not. Resident 46 According to the 08/27/2021 admission MDS the resident had severe cognitive impairment, and diagnoses of Alzheimer's disease, Non-Alzheimer's dementia. Review of the 08/27/2021 Cognitive loss/Dementia Care Area Assessment (CAA) showed facility staff stated a Dementia CP would be developed. Review of Resident 46's comprehensive CP, showed no Dementia CP had been initiated. During an interview on 10/13/2021 at 12:23 PM, when asked if there was Dementia CP, Staff J stated, I don't see one. A 10/07/2021 Resident is at risk for elopement due to wandering CP, list one intervention Resident has wanderguard in place. The CP does not indicate where the wanderguard is located or direct staff to monitor its placement or check its function. Nor was there any instruction about how staff should respond if the resident was actively exit seeking. During an interview on 10/14/2021 at 8:08 AM, Staff B, (Director of Nursing ), indicated the CP needed to be completed and personalized. Resident 192 A 09/27/2021 CP identified a problem of .The resident is on IV [intravenous] medications to administer IV antibiotics. The goal was for the resident to have no complications related to IV therapy. Interventions included instructions to Monitor, document, report signs and symptoms of leaking at the IV site and observe dressing every shift, change dressing and record observations of the site. The CP did not identify the type or location of Resident 15's venous access device. During an interview on 10/14/2021 at 8:08 AM, Staff B, acknowledged that the problem did not make sense, and that the CP should identify the site and type of venous access, but did not. Resident 93 Resident 93 admitted to the facility on [DATE]. According to the 08/18/2021 admission MDS, the resident was cognitively intact, had a diagnosis of end stage kidney disease and received dialysis during the assessment period. Record review showed a 08/20/2021 provider note, that stated Resident 93 had chosen to stop dialysis and was placed on comfort care. According to the 08/20/2021 9:04 PM nurses note, the resident was aware that stopping dialysis would lead to a rapid deterioration in condition. According to the note the nurse practitioner, social worker, resident care manager, Director of Nursing and Resident 93's family were all notified of the decision. All oral medications were discontinued, other than comfort medications. Review of the Resident 93's comprehensive CP showed a 08/12/2021 Dialysis CP which indicated the resident continued to be dialyzed on Mondays, Wednesdays and Fridays. Further review also showed no comfort CP, or psychosocial/grieving CP were developed. No direction was provided to staff on how best to support Resident 93 through the dying process. In an interview on 10/14/2021 at 8:03 AM, Staff B stated that Resident 93's CPs should have been updated to reflect the decision to cease dialysis, and that comfort and psychosocial support CPs should have, but were not developed. Resident 15 According to the 08/01/2021 At risk for infection due to a history of urinary tract infections CP, staff were directed to Give Hiprex [urinary bacteriostatic - a medicine that fights off bacteria] as ordered. Monitor/document for side effects. According to Resident 15's Physician's Orders (POs), the order for Hiprex was discontinued on 07/30/2020. During an interview on 10/14/2021 at 8:08 AM, Staff B indicated the CP needed to be updated. Resident 63 According to the 09/08/2021 Quarterly MDS, Resident 63 had diagnoses including Parkinson's Disease and generalized weakness and required extensive assistance with eating. According to the resident's ADL self-care performance deficit r/t (related to) weakness with impaired mobility CP, Resident 63 required set up assistance only for eating. According to the resident's [NAME] (resident-specific care instructions provided to aides) reviewed on 10/15/2021, Resident 63 required set up assistance for eating. In an interview on 10/14/2021 at 07:41 AM, Staff L, CNA, stated that Resident 63 required set up assistance and monitoring for eating. On 10/14/2021 at 07:55 AM, Resident 63's dinner tray from the previous evening (10/13/2021) was observed to be left on the sink. In an interview at that time, Staff K, LPN, explained that the tray remained in the room overnight because Resident 63 ate slowly and complained when staff remove the tray. In an interview on 10/14/2021 at 10:48 AM, Staff D, RCM, reviewed Resident 63's CP and stated that it needed to be updated, adding I have observed her requiring more assistance in the dining room. Resident 5 According to the 10/01/2021 Quarterly MDS, Resident 5 was assessed with moderate cognitive impairment and able to understand and be understood in conversation. According to the resident's 04/14/2021 Activities of Daily Living self care performance CP, the resident's goal was to, improve current level of function through the review date. In an interview on 10/13/2021 at 8:47 AM Staff D stated this goal was not measurable and needed clarification. According to a 04/14/2021 physical mobility CP, goals included, resident will demonstrate the appropriate use of adaptive equipment. In an interview on 10/13/2021 at 8:47 AM, Staff D was unable to describe what adaptive equipment the CP referenced. A 04/12/2021 CP showed the resident had a Urinary Tract Infection (UTI). This CP was reviewed on 09/28/2021 with a target date of 12/04/2021. In an interview on 10/13/2021 at 8:47 AM, Staff D indicated the resident did not have a current UTI and the CP should be revised. A 04/14/2021 CP showed the resident had bladder incontinence related to impaired mobility with a goal of the resident will decrease frequency of urinary incontinence times per week. In an interview on 10/13/2021 at 8:47 AM Staff D stated this goal was not objective or measurable and needed to be clarified. Resident 55 Resident 55 admitted to the facility on [DATE] and according to the admission MDS dated [DATE] was assessed as cognitively intact and able to understand and be understood in conversation. In an interview on 10/06/21 at 7:54 AM Resident 55 stated they had a surgically implanted port in their upper right chest, and they received medication through this port every three weeks from the hospital. Review of CP documents showed no indications the resident had an implanted port. In an interview on 10/13/2021 at 8:34 AM, Staff D confirmed this should be care planned with goals and interventions. According to CPs dated 09/02/2021 the resident had a psychosocial wellbeing problem related to a lack of motivation. In an interview on 10/13/2021 at 7:54 AM Staff D was asked to describe how the identified lack of motivation impacted the resident's psychosocial wellbeing. Staff D stated the CP was not clear. Interventions for the 09/02/2021 the psychosocial wellbeing CP included an intervention of encourage participation from resident who depends on others to make own decisions. In an interview on 10/13/2021 at 7:54 AM Staff D confirmed Resident 55 made his own decisions, and the CP should be revised. Resident 74 Resident 74 originally admitted to the facility on [DATE] and according to the 09/04/2021 Significant Change Minimum Data Set (MDS, an assessment tool) was assessed with clear speech and able to understand and be understood in conversation. According to the 09/18/2021 Medicare 5-day assessment, the resident had severe cognitive impairment. According to the Special Instructions heading on the resident's CP, reviewed on 10/07/2021, the resident should have Nectar Thick liquids. Observations of breakfast and lunch on 10/06/2021 and 10/07/2021 showed the resident received thin liquids and had no water pitcher at bedside. In an interview on 10/08/2021 at 11:26 AM, Staff D (Resident Care Manager, Licensed Practical Nurse) stated the resident should have a water pitcher and the resident's diet changed on 10/01/2021 to thin liquids. Staff D stated the CP should be updated at the time the orders changed. Review of computerized records showed the resident was their own responsible party. Physician orders dated 08/31/2021 showed the resident is incapable of administering own medications and incapable of participating in own plan of care. Further record review showed the resident's daughter signed multiple consents. Review of CP documents showed no indication of who was responsible for giving informed consent for treatment. In an interview on 10/13/2021 at 8:13 AM, Staff D stated the CP should reflect who was responsible for providing informed consent for treatment of Resident 74. According to an Activities of Daily Living self care performance CP dated 09/08/2021, staff documented a goal of resident will improve current level of function through the review date. When asked in an interview on 10/13/2021 at 8:13 AM what level of function needed to improve, Staff D stated, That's not really clear, it needs to be clarified. Observations on 10/06/2021 at 11:52 AM showed Resident 74 had limitation in mobility of their fingers, which were noted to be bent abnormally. Progress notes dated 10/11/2021 showed the resident was seen by Occupational Therapy and assessed with contractures in bilateral hands. In an interview on 10/13/2021 at 8:13 AM Staff D stated the CP should, but did not, reflect the resident's contractures. According to CPs dated 09/08/2021 the resident had a psychosocial well being problem related to a lack of motivation. In an interview on 10/13/2021 at 8:13 AM Staff D was asked to describe how the identified lack of motivation impacted the resident's psychosocial well being. Staff D stated the CP was not clear. According to a psychosocial wellbeing CP dated 09/08/2021, interventions included a consult with Pastoral care. In an interview on 10/13/2021 at 8:13 AM Staff D stated no evidence of a Pastoral Care Consult was found, and the CP needed to be clarified. Resident 39 Review of the resident's record showed Resident 39 was receiving Hospice Services from 08/14/2021 to 08/30/2021 when hospice services were discontinued. Review of Resident 39's CP on 10/06/2021 showed a 07/02/2021 Psychotropic CP that stated the resident used psychotropic medications as an appetite stimulant. Review of the October 2021 Physicians orders (POs) showed Remeron as an appetite stimulant was discontinued on 08/10/2021. Review of Resident 39's CP on 10/06/2021 showed a 08/14/2021 Anti-anxiety CP that stated the resident used anti-anxiety medications related to hospice and end of life status. Review of the October 2021 PO's showed Lorazepam for anxiety was discontinued on 08/28/2021. Review of the resident's CP on 10/06/2021 showed a 07/02/2021 Activities of Daily Living self-care deficit CP related to weakness, pain, recent abdominal and vascular surgeries and recent seizure activity. On 08/14/2021 an additional problem was added as the resident was now a hospice client with declining condition. Similar findings for a 07/02/2021 Limited physical mobility CP that addressed Resident 39 being a current hospice client with an expected decline in condition and a Resident Goal CP that stated the resident's goal is to remain long term care in the facility. Review of October 2021 PO's showed Hospice was discontinued on 08/30/2021. During an interview on 10/13/2021 at 11:36 AM Staff J (Corporate Nurse Consultant) stated they would expect CPs to be personalized, individualized, and updated as needed to reflect the residents current plan of care. Resident 6 A 07/07/2021 Quarterly MDS assessment showed Resident 6 required one-person physical assistance for bathing, supervision with personal hygiene, one-person assistance for bed mobility, and one-person extensive assistance with toilet use. The assessment showed Resident 6 had diagnoses of asthma, hypothyroidism, and gastric reflux. The CP dated 10/20/2020 showed Resident 6 required extensive assistance of two people for bathing and limited assistance of one person for personal hygiene. The CP revised on 11/23/2020 showed Resident 6 was independent for bed mobility and toilet use. The CP did not address the resident care needs for asthma, hypothyroidism, or gastric reflux. The CP for Resident 6 did not match the assessment. The CP dated 01/21/2021 stated Resident 6 had a durable power of attorney (DPOA) and a copy would be placed in the medical record. In an interview on 10/07/2021 at 12:15 PM, Resident 6 stated they did not have a DPOA and did not recall the staff helping to obtain a power of attorney. Resident 6 stated they did not have anyone to help them. In an interview on 10/12/2021 at 10:55 AM, Staff H (MDS Nurse) stated they were not able to locate the DPOA document. When asked if the CP was correct regarding the DPOA if there was not a confirming document in the medical record. Staff H stated, No. Resident 22 A 08/01/2021 Annual MDS assessment showed Resident 22 had a diagnosis of end-stage renal disease and received hemodialysis (a procedure to clean blood of toxins). A re-admission nursing assessment dated [DATE] after hospitalization showed the fistula (the site used for hemodialysis) was located on the upper right arm. During an observation and interview on 10/07/2021 at 9:29 AM, Resident 22 was asked where his fistula was located, and they moved shirt sleeve and showed the right upper arm. The CP dated 10/10/2019 identified the fistula was located on the left upper arm and not to draw blood or take blood pressure in left arm. The CP showed to monitor and report any signs or symptoms of infection, redness, swelling, warmth, or drainage of the left fistula. The CP incorrectly identified on which arm the fistula was located. Resident 62 A 09/07/2021 Quarterly MDS assessment stated Resident 62 had highly impaired vision and did not wear glasses. Resident 62 was assessed to require extensive assistance from two staff for bed mobility, toileting, and bathing. During an interview on 10/12/2021 at 1:06 PM, Resident 62 was observed to be in bed, not wearing glasses. When asked if they wore glasses, Resident 62 shook their head no. Staff K was in the room and when asked if Resident 62 wore glasses, Staff K stated, no. Staff K searched the room and did not find any glasses belonging to Resident 62. When Staff K was asked how many staff provided care for bed mobility, toileting and bathing Staff K stated one. The CP dated 09/03/2020 for Resident 62 stated Resident 62 had impaired visual function and used glasses. The CP dated 10/14/2020 showed Resident 62 was totally dependent on one person for bed mobility, transfers, and bathing. The CP did not match the assessment, observation, or interviews. In an interview on 10/12/2021 at 10:55 AM, Staff H stated the assessment and CP were expected to match. Staff H confirmed the assessment and CP did not match for Resident 6, 22 and 62. Resident 77 Resident 77 was re-admitted to the facility on [DATE] and according to the 09/22/2021 Significant Change MDS was assessed with severe cognitive impairment, required extensive physical assistance for bed mobility, transfers, and personal hygiene and required end of life services. According to the 09/16/2021 Nursing admission assessment Resident 77 was identified with multiple wounds. Observations on 10/06/2021 at 7:53 AM showed Resident 77 with an open wound to their inner left knee and had a white bandage wrapped around their left foot. Review of CP documents on 10/06/2021 revealed facility staff did not update or revise the CP to include Resident 77's wounds. Resident 77's CP gave no direction to staff regarding goals, treatment, or interventions regarding the residents impaired skin. Record review showed a Skilled Nursing Facility Hospice Notification which indicated Resident 77's Hospice start date was 09/17/2021. Review of CP documents on 10/06/2021 revealed no indication that facility staff revised Resident 77's CP to reflect receiving Hospice services or identified any goals or interventions regarding care to provide to the resident. In an interview on 10/08/2021 at 12:45 PM, Staff D stated they would expect wounds to be on the CP and confirmed Resident 77 did not have CP updated to reflect current wound status. Staff D indicated the CP should have been initiated regarding Hospice on 09/17/2021 when services started. Resident 58 Similar findings were found for Resident 58. Physician orders dated 09/04/2021 directed staff to off-load heels for mushy/blanchable redness to bilateral heels and to apply cream to lower back twice daily for blanchable redness. Review of the CAA dated 09/09/2021 identified Resident 58 with soft heels and redness to their lower back area on admission. Review of CP documents on 10/06/2021 showed no indication facility staff added identified skin areas, goals, and interventions to prevent skin breakdown to Resident 58's CP. REFERENCE: WAC 388-97-1020(2)(c)(d) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 22 According to a 08/01/2021 MDS, Resident 57 was admitted to the facility on [DATE] with a diagnosis of end-stage kidney disease on hemodialysis (procedure for cleaning toxins from blood) and was on an oral restriction of fluids. A 12/11/2020 physician orders showed Resident 22 was on a fluid restriction and could not have more than 2000 milliliters (ml) of fluids to drink in a 24-hour period. The order showed the allowed fluids were divided into Dietary = 1000 ml, Nursing = 1000 ml further divided into Day shift= 400 ml, Evening shift= 400 ml, and Night shift= 200 ml. The nurse was to request the resident's actual meal fluid intake from the aides and document the total each shift. In an interview on 10/07/2021 at 9:29 AM, Resident 22 stated they (resident) did not keep track of how much they drink in a day. When asked if the nurses or aides ask how much water they drink, Resident 22 said, No. Review of the October 2021 MAR showed the following documentation for day shift intake: 10/2= 200 ml, 10/3= 240 ml, 10/4= 250 ml, 10/5= 600 ml. Evening shift showed 10/2= 200 ml, 10/3= 240 ml, 10/4= 250 ml, 10/5= 400 ml. These amounts do not follow the physician's order and do not account for dietary totals from the aides. Review of January 2021 thru October 2021 MAR's (10 months) did not show a daily accounting of the resident's fluid intake or a 24-hour recap summary that the fluid restriction was maintained according to the physician orders. In an interview on 10/11/20201 at 1:42 PM, Staff D (RCM) stated there was not a 24-hour calculation or review of fluid restriction completed daily for Resident 22. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i). Resident 77 Resident 77 was re-admitted to the facility on [DATE] and according to the 09/22/2021 Significant Change MDS was assessed with medically complex conditions including gangrene (a serious medical condition where a loss of blood supply causes body tissue to die.) According to the September 2021 Treatment Administration Record (TARs) staff were directed to do head to toe skin checks every week and document results on Weekly Skin Observation Assessment (WSOA). Staff documented this as completed on 09/23/2021 and 09/29/2021. Record review revealed no subsequent evidence that weekly WSOA's were completed by staff as directed by physician. According to the October 2021 TARs staff were directed to provide wound care to inner left knee daily and cover with foam dressing. Observation on 10/05/2021 at 12:39 PM showed Resident 77 had an open area without a dressing to left inner knee. Similar findings were noted on 10/06/2021 at 8:30 AM. In an interview at this time, Staff BB (Certified Nursing Assistant) stated, I had [Resident 77] since yesterday and it [the knee wound] has been open like this since then. Observation on 10/07/2021 at 8:05 AM showed Resident 77 had foam dressing to left inner knee dated 10/06/2021. Observations of Resident 77 on 10/08/2021 at 12:30 PM, showed the same foam dressing to left inner knee still dated 10/06/2021. Review of October 2021 TARs showed staff documented wound care and foam dressings were completed to inner left knee daily. In an interview on 10/12/2021 at 1:17 PM, Staff C stated nursing staff should not sign for tasks that were not performed.Resident 35 According to the 08/15/2021 Quarterly MDS, Resident 35 had diagnoses including medically complex conditions and arthritis, and experienced frequent pain. Review of Resident 35's October MAR revealed the following orders: Acetaminophen - Give 650 mg by mouth every 6 hours as needed for [ .] pain level 1-3 NTE [not to exceed] 3000 mg/24 hours -Start Date- 08/26/2021; Norco -10-325 MG (HYDROcodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for [ .] Pain level 5-10 -Start Date- 08/26/2021. Resident 35 was administered Norco outside of ordered parameters for a pain of 3 on 10/3/2021. Resident was administered Acetaminophen outside of ordered parameters for a pain of 4 on 10/06/2021, for a pain of 5 on 10/03/2021, and for a pain of 7 on 10/7/2021. According to the September 2021 MAR, Resident 35 received Norco outside of ordered parameters eight times in the month of September. Resident 35 received Acetaminophen outside of ordered parameters twelve times in the month of September. In an interview on 10/14/2021 at 08:38 AM, Staff D, RCM, stated that nurses should not give pain medications outside of the parameters of the order. Staff D also stated that Resident 35's pain management orders were unclear, and should have been, but were not clarified. Resident 63 According to the 09/08/2021 Quarterly MDS, Resident 3 received diuretic medications on all 7 days of the look back period. Review of Resident 63's October MAR revealed the following order: Lasix Tablet 20 MG (Furosemide) Give 20 mg by mouth one time a day for BLE [bilateral lower extremities - legs] edema -Start Date- 08/07/2021. Resident 63's altered cardiovascular status r/t [related to] heart failure, HTN [hypertension] CP, included a 06/24/2020 intervention for nurses to Monitor/document/report PRN [as needed] any changes in . edema . Resident 63's unplanned/unexpected weight gain CP included a 05/05/2021 intervention to Notify MD if: . escalating edema . According to a 08/06/2021 progress note, Resident 63 was Noted bilateral lower extremities with plus 2 edema. ARNP was notified with order to start res Lasix first dose. 9/5/2021 On 8/4/21 resident weight was 245.2 lbs., resident current weight on 9/4 is 228.4 lbs. A 09/05/2021 progress note stated weight fluctuation is expected r/t lasix 20 mg daily started on 8/6/21 r/t b/l [bilateral - both sides] leg Edema. In an interview on 10/14/2021 at 10:45 AM, Staff D, RCM, stated that it is important to monitor lower extremities for edema in order to assess the effectiveness of Lasix, and could provide no evidence of edema monitoring for Resident 63. Staff D provided no answer when asked how without monitoring for edema, the weight fluctuation identified in the 09/05/2021 progress note was determined to be related to Lasix and edema.Resident 13 According to the Quarterly MDS dated [DATE], Resident 13 was assessed as cognitively intact and able to make needs known. Review of Resident 13's active orders dated 09/11/2020 reflected knee high [NAME] hose (compression stocking) on in AM and Off at hours of sleep (HS). Notify Nurse Practitioner of any refusal. Observations on 10/06/2021 at 11:16 AM showed Resident 34 sitting up in a wheelchair in her room and was noted with bilateral (both right and left) edema. At this time the resident stated, they are swollen sometimes, they don't put on my socks. Similar observations were noted on 10/11/2021 at 12:41 PM, 10/12/2021 at 10:09 AM, and at 12:03 PM, when the resident was noted sitting in a wheelchair with feet dependent and not wearing [NAME] hose. Review of the treatment administration record (TAR) dated 09/01/2021 through 09/31/2021 morning treatment showed Resident 13's Knee -High [NAME] hose was not put on applied for eighteen days and signed as removed at bedtime. Review of TAR dated 10/01/2021 through 10/11/2021 bedtime treatment showed, Resident 13's Knee -High [NAME] hose was signed to be off at bedtime hours when they were not put on in morning hours. In an interview on 09/14/2021 at 11:30 AM, Staff N LPN confirmed that Resident 13.'s ted-hose were not put on to the resident. Staff N stated that the nursing assistant are responsible to put on the knee-high [NAME] hose. When asked about how the ted-hose were signed off as removed when they were not put on, Staff FF stated that if the ted hose were not put on in the morning the nurse will not document removed. In an interview on 09/15/2021 at 10:30 AM, Staff D RCM confirmed that Resident 13's ted-hose were not put on, and the expectation was ted-hose to be put on in the morning and removed in the evening. Staff D confirmed that the nurses signed off as removed ted hose when they are not put on. If the resident declined multiple times, the physician should be notified to review the treatment. When asked if evening nurses should document ted hose off, Staff D said No, they were not put on. Resident 38 Review of the resident's current POs showed a 07/26/2021 order for Propranolol 10 mg, administer 1/2-1 tab nightly, as needed (PRN) for anxiety or panic attacks. Hold for a Systolic blood pressure (SBP) less than 110 mm/hz (millimeters mercury) and/or a pulse less than 55. The order did not include instruction or an objective method to assess the resident's anxiety, to determine if 1/2 tab or 1 tab should be administered. During an interview on 10/13/2021 at 11:21 AM, when asked how nurses determined what dose of Propranolol to administer Staff J stated that the order needed to be clarified. Review of the September 2021 MAR showed nurses were provided a place to document the resident's SBP, pulse and their initials, but not a place to document the dose that was administered. According to the September 2021 MAR, Resident 38 received 20 PRN doses of Propranolol, but the dose administered was not identified. During an interview on 10/13/2021 at 11:21 AM, when asked what dose Resident 38 received for each of the 20 doses administered in September 2021 Staff J acknowledged the facility nurses failed to document the dose administered. According to the September 2021 MAR, on 09/16/2021 Resident 38 received a dose of Propranolol at 8:47 AM, and again at 10:13 PM. Similar findings were noted for 09/22/2021, when nursing administered Propranolol at 3:36 PM, and again at 11:18 PM. During an interview on 10/13/2021 at 11:21 AM, Staff J acknowledged the nurses failed to follow the PO, which stated Propranolol could be administered nightly as needed. According to the September 2021 MAR, on 09/27/2021 at 5:01 AM Resident 38's pulse was N/A (not applicable), yet the nurse administered the Propranolol. It was unclear how the nurse determined the Resident's pulse was not less than 55, and it was safe to administer the medication. During an interview on 10/13/2021 at 11:21 AM, Staff J acknowledged the nurse failed to follow the Physician's order. Review of the September 2021 MAR, showed a 07/24/2021 order for Ditiazem (a cardiac medication) to be administered four times daily. On 09/01/2021 at 10:00 AM and 09/08/2021 at 10:00 AM, the nurse documented 9. According to the MAR Legend a 9 means other/ See progress notes. Review of Resident 38's record showed there were no progress notes made on 09/01/2021 or 09/08/2021. Thus, it was unclear if the resident received the medication or if it was held for some reason. During an interview on 10/13/2021 at 11:21 AM, Staff J indicated it was unclear if the medication was administered or why the nurse documented to see the progress notes, because the nurse failed to write one. Resident 192 Review of Resident 192's POs showed the resident had a 10/11/2021 order for Neurontin (an anticonvulsant, often used to treat neuropathy) three times a day. On 10/13/2021 at 9:31 AM, Staff R, (Licensed Practical Nurse) was observed for medication pass. While administering medications to Resident 192, the resident stated, I don't want my new pill, it made me feel off, I haven't taken it since the first day, I only took it once, then told them I don't want it, but they keep offering it to me and I say no, I would rather have the neuropathy. Staff R confirmed Resident 192 refused the Neurontin. Review of the September 2021 MAR showed Staff R documented the resident refused the Neurontin, but Staff JJ documented the evening dose was administered 10/12/2021. In an interview on 10/14/2021 at 8:46 AM, Staff JJ confirmed Resident 192's evening dose of Neurontin was administered on 10/12/2021. When Staff JJ was informed Resident 192 stated the dose wasn't administered, Staff JJ acknowledged Resident 192 refused the medication. On 10/11/2021 at 11:45 AM, Resident 192 indicated the dressing change to their left toe finally was done on 10/10/2021. The resident shared that upon returning from a podiatrist appointment (on 10/05/2021) they informed the nurse that the cast was removed and the podiatrist wanted a dressing changes performed on the toe, but the nurse just said that there was not an order for dressing changes. The Resident then explained their son and daughter in law found the order on 10/08/2021 but didn't have a fax machine, so were not able to fax it to the facility until Friday: 10/09/2021. Record review showed the 10/05/2021 podiatry consult was not present in the record. In an interview on 10/11/2021 at 11:53 AM, when asked what a nurse should do if a resident returned from a podiatry appointment, stated the podiatrist wanted a new treatment to be performed, but no consultation report or orders were sent back with the resident Staff J stated, Call the podiatrist for orders or clarification. When asked if there was any indication that occurred Staff J stated, No. Resident 15 Review of Resident 15's current POs showed 08/26/2021 orders for Oxycodone 10 mg every six hours PRN for pain 1-5 on a scale to 10; and Oxycodone 15 mg every six hours PRN for pain 6-10 on a scale to 10. Review of the October 2021 MAR showed on 10/06/2021 at 12:00 PM, Resident 15 reported a pain level of 7/10, and was medicated with Oxycodone 10 mg, instead of 15 mg as ordered. Similar findings were noted for 10/10/201 at 11:16 AM, when the resident reported a pain level of 6/10, and was again medicated with 10 mg of Oxycodone instead of 15 mg as ordered. In an interview on 10/11/2021 at 12:38 PM, Staff J confirmed facility nurses failed to administer the Oxycodone as ordered by the physician.Based on interview and record review, the facility failed to ensure services provided, met professional standards of practice for 14 (Residents 39, 73, 55, 74, 142, 61, 38, 192, 15, 13, 35, 63, 77 & 22) of 23 residents reviewed. Nursing staffs' failure to obtain, follow, clarify and timely implement physicians's orders (POs), and to only sign for tasks that were completed, placed residents at risk for delays in treatment, unmet care needs, and potential negative outcomes. Findings included . Resident 39 Medication/Treatments According to the 10/12/2021 Significant Change MDS Resident 39 was assessed to be cognitively intact ,able to understand and be understood in conversation. Review of Resident 39's facesheet showed an allergy to Tylenol. During an interview on 10/12/2021 at 10:40 AM Resident 39 stated if they took Tylenol they would start itching and swell up. Review of the Physician Order's (POs) showed a 09/07/2021 order for Tylenol 1000 mg (milligrams) by mouth three times a day for right foot pain. Review of the September 2021 Medication Administration Record (MAR) showed the resident received Tylenol 14 times and refused Tylenol three times. In an interview on 10/12/2021 at 10:40 AM Resident 39 stated they were not aware the physician ordered Tylenol. It wasn't until one of the nurses stated I have your Tylenol the resident knew they were given Tylenol. Resident 39 stated that I told them I couldn't take it because I had an allergy. Review of the PO's showed an 08/16/2021 Treatment order to cleanse abdominal incision with normal saline and cover with a dressing. On 10/12/2021 at 10:40 AM Resident 39's abdomen was observed with a healed surgical incision and no dressing present. During a combined interview and observation on 10/14/2021 at 8:29 AM Staff M (Registered Nurse) confirmed Resident 39 had an active order for abdominal incision dressing change. Staff M confirmed the surgical incision was healed and did not require a dressing. Wanderguard According to the 10/13/2021 Significant Change MDS Resident 39 was assessed to be cognitively intact and did not have wandering behaviors. On 10/05/2021 at 12:45 PM Resident 39 was observed with a Wanderguard [a bracelet device secured to a resident which sounds an alarm when a resident attempts to leave the facility] to the left wrist. When asked what it was the resident responded I was bad and tried going out the front door once, so they put it on me. Observations of Resident 39 on 10/05/2021 at 12:45 PM, 10/07/2021 at 8:33 AM, 10:57 AM and 12:24 PM, 10/08/2021 at 8:31 AM and 12:09 PM, 10/11/2021 at 11:20 AM and 12:05 PM, 10/12/2021 at 9:01 AM, 10:40 AM and 12:23 PM, 10/13/2021 at 1:49 PM and 10/14/2021 at 9:09 AM showed no wandering or exit seeking behaviors. Review of the resident's evaluations showed a 08/15/2021 Wander Evaluation that assessed the resident at low risk for wandering or elopement. Additional Wander Evaluations were done on 07/05/2021 and 07/14/2021, indicating the resident was a low risk for wandering or elopement. Review of the resident's medical record showed no PO, no device evaluation, no wander guard monitoring, no consent, or care plan for the wander guard. During a duo interview on 10/14/2021 at 10:11 AM Staff B (Director of Nursing) and Staff J (Corporate Nurse Consultant) were asked why Resident 39 had a Wanderguard. Staff B stated because they wander. When asked if they would expect there to be an order, consent, evaluation, monitoring and care plan for the device, Staff B and Staff J verified there wasn't but should be. Follow Up Appointment Review of the residen'ts clinical record showed a 07/14/2021 Hospital Discharge Summery that showed Resident 39 was to follow up with neurology appointment in 1-2 weeks. During an interview on 10/11/2021 at 12:05 PM Resident 39 stated they had a seizure over the weekend and was sent to the hospital. Resident 39 stated I don't understand why am I having seizures if I am on medication for it. In an interview on 10/12/2021 at 10:40 AM Resident 39 stated they have not seen a neurologist since admitting to the facility. During an interview on 10/13/2021 at 10:36 AM Staff J (Corporate Nurse Consultant) stated they would expect an appointment to be made and a consult to be completed. Staff J reviewed the residents clinical record and confirmed there was no Neurologist consult appointment and no notes or documentation addressing the appointment. Pain Assessment Review of the resident's clinical record showed PO's for Oxycodone 5 mg (milligram) by mouth as needed every 8 hours for moderate to severe pain and Oxycodone 5 mg by mouth as needed every 8 hours for pain for 30 days. In an interview on 10/13/2021 at 11:36 AM with Staff J (Corporate Nurse Consultant) stated we [the facility] would need to clarify the order when asked which one would the nurse give. Review of the resident's 07/14/2021 re-admission Pain Assessment showed questions on the assessment was blank that addressed the location of pain, pain level, what makes pain better or worse, and medications used to manage pain. During an interview on 10/13/2021 at 11:45 AM Staff J (Corporate Nurse Consultant) agreed the pain assessment was not thorough. Resident 73 According to the 09/17/2021 admission MDS Resident 73 had diagnoses of Heart failure and hypertension and admitted to the facility on [DATE]. Review of PO's showed a 09/14/2021 order for Fluid Restriction of 1500 ml (milliliters) daily. The amount was divided and the dietary department had 750 ml and the Nursing department had 750 ml. These amounts were split between the day shift with 300 ml, evening shift with 300 ml and night shift 150 ml. Review of the October 2021 Medication Administration Record (MAR) showed on 10/02/2021 the resident consumed 300 ml of fluids on day shift, 259 ml on evening shift and 300 ml on night shift for a total of 859 ml for the day. On 10/07/2021 the resident consumed 500 ml's for day shift, 200 ml on evening shift and 120 ml on night shift, for a daily total of 820 ml. In an interview on 10/12/2021 at 12:39 PM with Staff C (Resident Care Manager) stated the resident's fluid restriction was to regulate the amount of fluids related to the diagnoses of chronic kidney disease, acute kidney failure and pleural effusion (excess fluid of the lung). Staff C reviewed the October 2021 MAR and agreed the resident went over the fluid restriction and that the physician was not notified. Resident 55 Resident 55 admitted to the facility on [DATE] and according to the admission MDS dated [DATE] was assessed as cognitively intact and able to understand and be understood in conversation. In an interview on 10/06/2021 at 7:54 AM Resident 55 stated they had a surgically implanted port in their upper right chest and they received medication through this port once every three weeks from the hospital. The resident stated at this time that facility staff did not access or look at the device stating, I don't know if they even know I have it. Record review showed POs dated 08/31/2021 which directed nursing staff to monitor right upper chest portal for infusion daily. Nursing staff documented each shift this was done. In an interview on 10/15/2021 at 9:05 AM, Staff D observed the resident's chest, confirming the placement of the port. When asked by Staff D if facility staff checked their chest daily, the resident replied, No. In an interview at this time, Staff D confirmed nursing staff should have clarified the order as the resident did not receive daily infusions through the port. Resident 74 According to the 09/18/2021 Medicare 5 day MDS, Resident 74 was assessed with severely impaired cognition and no wandering behavior. According to the 08/31/2021 At risk for Wandering/Elopement assessment, the resident was determined to be at risk for wandering/elopement. This assessment showed Resident 74 experienced pain and received regularly scheduled and as needed pain medications. According to September 2021 MARs, Staff were instructed to provide Oxycodone (a narcotic pain medication) as needed for pain levels of 5-10. Of the four doses received, staff provided the medication outside of stated parameters on 09/07/2021 for a pain level of 2. Similarly, an order dated 09/14/2021 directed staff to provide 2.5 mg of Oxycodone for pain levels of 6-10. On four of the 18 times the resident received this as needed medication in September 2021, staff administered it out of parameters (09/15/2021 2; 09/19/2021 4; 09/20/2021 0 and 09/28/2021 5). Similarly, review of August 2021 MARs showed staff were directed to administer Hydrocodone with Acetaminophen for pain of 1 to 5, but administered the medication for pain levels of 6 and 8 on 08/17/2021 and 08/19/2021 respectively . In an interview on 10/13/2021 at 8:55 AM, Staff D indicated nursing staff should, but did not, follow physician orders regarding narcotic pain administration. Review of September 2021 MARs showed direction to staff Wanderguard to right wrist, monitor placement every shift. According to this document, staff documented the Wanderguard was present until 09/25/2021 when staff documented NA on 09/25/2021 dayshift, but + (positive) on evening and night shift for 09/25/2021. Starting on 09/26/2021 through evening shift on 09/28/2021, staff documented NA, 0, or X indicating it was not present. However on evening shift on 09/28/2021, staff documented + indicating it was present. For each of the following six shifts in September 2021, Staff documented 0, x or failed to document at all. Review of October 2021 MARs showed staff were directed to document the placement of the Wanderguard on the right wrist. Review of these documents showed of the 21 shifts from 10/01/2021 through 10/07/2021, staff failed to ensure placement of the Wanderguard on five of 21 opportunities and documented a - indicating it was not present on the remaining 16 opportunities. Periodic observations throughout the day on 10/05/2021, 10/06/2021, and 10/07/2021 showed Resident 74 did not have a Wanderguard bracelet on either wrist. In an interview on 10/08/2021 at 11:49 AM, Staff D conformed the resident did not have a Wanderguard and that nursing staff should have, but did not, document the rationale behind the NA, 0 and X's and implement the physician's order as directed. Resident 142 Resident 142 admitted to the facility on [DATE]. According to the Medicare 5 day MDS, the resident was assessed as cognitively intact, had clear speech, and was able to understand and be understood in conversation. During observation of medication pass on 10/07/2021 at 12:15 PM, a medicine cup containing two and one half tablets of calcium carbonate were noted at the resident's bedside. Observations on 10/08/2021 at 8:27 AM showed the resident was sleeping in bed, a medicine cup with two and a half tablets of Calcium Carbonate were noted at the bedside. Similar observations on 10/08/2021 at 10:26 AM 10/08/2021 10:48 AM in an interview at this time, Resident 142 stated this was not the same medication from the previous day, this was from this morning when, The nurse gave it to me and I didn't need it. Similar observations of medications at bedside were noted on 10/11/2021 at 8:49 AM. This observation was confirmed by Staff C (Resident Care Manager, Registered Nurse) who stated, They (nurses) shouldn't leave medications at bedside. According to Skilled Nursing Notes dated 10/07/2021, nursing staff assessed the resident with, bowel sounds active x4 Quadrants. Denies abdominal pain or discomfort. Review of MARs showed the resident received Lomotil (a medication for diarrhea) on 10/07/2021 at 12:10 PM. In an interview on 10/07/2021 at 12:35 PM, Resident 142 stated she had just received medication for stomach cramping. Similar findings were noted on 10/08/2021 and 10/09/2021 when nursing staff documented no gastrointestinal issues but administered Lomotil on 10/08/2021 at 12:32 PM, and on 10/09 at 7:37 AM and 3:15 PM. In an interview on 10/13/2021 at 9:05 AM, Staff D indicated the Skilled Nursing Notes should reflect the resident's general condition, not just the shift in which the note is made. Resident 61 According to the 09/07/2021 admission MDS, the resident admitted on [DATE] and was assessed as cognitively intact, had clear speech and was able to understand and be understood. On 10/05/2021 at 10:48 AM a medication cup with a white powdered substance was observed sitting on the bedside table. The medication cup was unlabeled. No staff was present. On 10/05/2021 at 10:50 AM Staff M (Registered Nurse) stated they did not bring in or leave medication for Resident 61 and was not sure what the white powdered substance was. Staff M stated that we don't leave medication at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure personal hygiene, and incontinence care were provided to 6 (Residents 55, 74, 5, 58, 87, and 77) of 12 sample residents and 4 (Residents 46, 70, 63 and 51) supplemental residents reviewed for Activities of Daily Living (ADLs) who were dependent on staff for care. Facility staff's failure to consistently provide assistance with ADLs placed residents at risk for poor hygiene, diminished self-image, embarrassment, and decreased quality of life. Findings included . According to the 11/2017 facility policy on ADLs, A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. The facility's 08/2018 Quality of Care Foot Care policy indicated staff would, provide the resident with foot care, including treatment to prevent complications from diabetes, peripheral vascular disease or immobility that is consistent with professional standards of practice. Resident 55 Resident 55 admitted to the facility on [DATE] and according to the 09/03/2021 admission Minimum Data Set (MDS - an assessment tool) was assessed as cognitively intact and required extensive two person assistance with bed mobility, transfers, and toilet use and one person extensive assistance for personal hygiene. Nail Care In an interview on 10/06/2021 at 7:54 AM Resident 55 stated they did not receive the assistance required for trimming of toenails, and added I can get my fingers myself, but I can't really get to my feet. Observations on 10/11/2021 at 8:30 AM, confirmed by Staff C (Resident Care Manager, Registered Nurse), showed Resident 55's right third and fourth toes had nails which curled over the ends of the toes and the first toenail was long and jagged. The fifth toe of the left foot had a toenail which curved around the tip of the toe. In an interview at this time, Staff C stated the resident's toenails were long and need trimming. Toileting In an interview on 10/06/2021 at 7:54 AM, Resident 55 stated they did not receive the assistance they required for toileting. Resident 55 stated I can tell when I need to go, but I need help to get on the toilet. I can get off the bed onto a bedside commode, but I have to wear a diaper. The therapist is trying to get me out of the diaper but none of the aides will assist me to the bathroom or a bedside commode. I have to defecate in my diaper because I don't get assistance. At this time Resident 55 pointed out that staff assisted with transfers to the wheelchair multiple times a day. According to the 09/03/2021 admission MDS, Resident 55 was assessed as always incontinent of bowel. According to the Care Area Assessment (CAA) associated with the admission MDS, staff documented that Resident 55 used a urinal at the bedside or the bedpan, that they were incontinent of bowel, and that they may wear a brief for dignity and security if desired. The CAA stated that incontinence care was provided and that the residemt worked with OT (Occupational Therapy) for ADLs including toileting, hygiene and clothing management. The CAA further stated Will proceed to care plan with focus on reducing incontinence and avoiding incontinence-related skin injury. This CAA identified that pain and mobility impacted the resident's incontinence. While an 08/30/2021 Bowel and Bladder Screen indicated Resident 55 was a good candidate for retraining, record review showed staff did not assess which type of bowel incontinence interventions, such as a toileting program, might increase continence of bowel. In an interview on 10/13/2021 at 8:42 AM, Staff D (Resident Care Manager-RCM, Licensed Practical Nurse-LPN) indicated there was no reason staff could not assist with toileting, and that if mobility and pain were the listed barriers for continence, staff should identify interventions to prevent incontinence. Resident 74 According to the 09/18/2021 Medicare 5-Day MDS assessment, staff determined Resident 74 had severe cognitive impairment and required one person extensive assistance with personal hygiene. Observation on 10/06/2021 at 9:53 AM showed Resident 74's hair was unbrushed and white debris was noted in the resident's gumline. When asked, Resident 74 was unsure if staff provided assistance with brushing their teeth. Observation on 10/07/2021 at 7:25 AM showed Resident 74 seated in a wheelchair in their room, waiting for breakfast. The resident's teeth appeared unbrushed with white debris along the gumline. At this time a clean toothbrush was noted behind a yellow kidney basin in the top drawer of a bedside stand. No toothpaste was noted. Similar observations of the toothbrush were noted at 10/07/2021 at 10:04 AM. During an observation on 10/08/2021 at 9:12 AM Staff D confirmed the resident's teeth and gums had moderate amounts of white debris and indicated it did not appear the resident had received oral care recently. Staff D confirmed the presence of the toothbrush behind the yellow kidney basin in the bedside stand. Resident 5 According to the 10/01/2021 Quarterly MDS, Resident 5 was cognitively intact and required extensive one person physical assistance for bed mobility, transfers, dressing and personal hygiene. Observations on 10/06/2021 at 8:43 AM showed Resident 5 had long fingernails which extended well past the tips of the fingers on the first and fifth fingers of the right hand and the fifth finger on the left hand. In an interview at this time, the resident stated staff did not consistently trim nails and they would like their nails trimmed so they are all the same length. Similar observations of untrimmed fingernails were noted on 10/07/21 at 7:55 AM, 10/08/2021 at 7:20 AM and 10/11/2021 at 7:45 AM. Observation on 10/12/2021 at 1:18 PM with Staff C showed Resident 5's fingernails were trimmed. When asked about their fingernails the resident stated, Look they trimmed my nails when I got a shower yesterday! See? They're all the same size. Resident 46 Resident 46 admitted to the facility on [DATE]. According to the 08/27/2021 admission MDS, the resident was cognitively impaired, required extensive assistance for transfers, hygiene, physical assistance for bathing, and identified choices related to bathing as very important. According to Resident 46's bathing flowsheet, showers were to be provided every Monday and Thursday. Review of the Resident 46's September and October 2021 bathing flowsheets showed for the 20-day period between 09/23/2021 -10/13/2021, Resident 46 had six scheduled shower days. On 09/23/2021, 09/27/2021, 10/04/2021 and 10/11/2021, facility staff failed to offer/provide a shower as scheduled. On 09/30/2021 and 10/07/2021 staff documented that the resident refused. Record review showed no indication facility staff re-approached the resident or offered a shower at a later time. Facility staffs' failure to offer/provide a shower on four of six scheduled shower days, and failure to re-approach and/or re-offer a shower after the two documented refusals, resulted in Resident 46 going 20 consecutive days without being bathed. During an interview on 10/13/2021 at 11:21 AM, Staff J, (Corporate Nurse Consultant), reviewed Resident 46's bathing record and acknowledged there was no indication Resident 46 had been bathed for 20 consecutive days. Resident 70 Resident 70 was admitted to the facility on [DATE]. According to the 09/12/2021 Quarterly MDS the resident was diagnosed with medically complex diagnoses, including diabetes, muscle weakness and difficulty with walking. According to this assessment Resident 70 required extensive assistance with transfers and mobility as well as ADLs, including hygiene, grooming and dressing. According to the revised CP dated 06/22/2021, Resident 70 had an ADL self-care deficit related to generalized weakness and history of upper extremity tremors. Interventions included extensive assist of one staff with personal hygiene and oral care. Resident 70 had limited mobility related to generalized weakness. Intervention includes resident uses manual wheelchair for locomotion, with total dependence of staff for transfers and locomotion. Multiple observations though the survey period 10/05/2021 through 10/14/2021, Resident 70 was observed laying in their bed. When asked about their mobility, the resident indicated, they have a wheelchair and they need help to be dressed and to sit in the wheelchair. Resident 70 indicated it has not happened for some time. Resident 70's teeth were observed unbrushed with white yellowish debris around their gumline and to have carious (decayed) teeth. In an interview with 10/07/2021 at 11:30 AM Staff N (LPN), confirmed that Resident 70 was not dressed and assisted to their wheelchair per the care plan. Staff N, further indicated, Resident 70 refuses care but they reapproach. When asked about cleaning the resident's teeth, Staff N stated nursing assistants are responsible to help with cleaning resident's teeth. In an interview on 10/12/2021 at 12:30 PM, Staff D revealed the expectation is to offer the resident to get dressed and get up to wheelchair, when asked if that was happening with Resident 70, Staff D said No. When asked about the resident's grooming and oral care, Staff D stated the resident spends most times in bed, and the nursing assistants are expected to offer grooming and oral care, and any refusal should be reported to the RCM. When asked if there were any refusals of care reported to them, staff D stated, No. Resident 63 According to the 09/08/2021 Quarterly MDS, Resident 63 had diagnoses including Parkinson's Disease and generalized muscle weakness. Resident 63 was assessed to require extensive assistance from one person for eating. According to the ADL self-care performance deficit . CP revised 02/03/2021, Resident 63 required set up assist of (1) staff for eating. According the [NAME] (care instructions for nursing aides) reviewed on 10/15/2021, Resident 63 required set up assist of (1) staff for eating. According to a 09/05/2021 progress note, Resident 63 sleeps every after bite if not assisted. On 10/07/21 at 9:29 AM, Resident 63 was observed to be in bed, watching television, with their breakfast tray untouched on the over-the-bed table. On 10/11/2021 at 8:17 AM and at 8:56 AM, Resident 63 was observed to be seated in bed, with their breakfast tray on the over-the-bed table. Resident 63's food was cut into bite sized portions and no assistance was observed to be provided. In an interview on 10/14/2021 at 10:48 AM, Staff D, confirmed that Resident 63 required extensive assistance with eating, and the CP needed to be updated, adding I have observed [them] requiring more assistance in the dining room. Resident 58 Resident 58 admitted to the facility on [DATE] and according to the admission MDS dated [DATE] was assessed to require extensive two-person physical assistance with bed mobility, transfers, and personal hygiene as well as total dependence on two-person physical assistance for bathing. Nail Care In an interview on 10/05/2021 at 9:56 AM, Resident 58 stated their nails were only trimmed once since admission and reported it had been a few weeks. Resident 58 reported they felt their nails were getting too long and needed to be trimmed. Observations at this time revealed Resident 58's fingernails were longer than preferred with debris under all nails on both hands. Observation on 10/08/2021 at 12:15 PM, showed Resident 58's fingernails were trimmed and the resident smiled and stated, They came in and clipped them! In an interview on 10/12/2021 at 1:17 PM, Staff C stated that nail care should be done by staff weekly. Bathing In an interview on 10/05/2021 at 1:46 PM, Resident 58 reported they were only showered twice since being admitted . Resident 58 stated they preferred showers a couple times a week. According to the facility shower schedule dated 08/06/2021, Resident 58 was scheduled for bathing twice weekly. Record review showed that as of 10/11/2021 at 1:15 PM, facility staff only documented Resident 58 received two showers since admission on [DATE] and 09/17/2021. In an interview on 10/12/2021 at 1:15 PM, Staff C stated they would expect progress notes and follow up to be done regarding any bathing not completed. Staff C indicated it did not appear Resident 58 received showers as scheduled. Resident 87 Resident 87 was admitted to the facility on [DATE] and according to the 08/26/2021 admission MDS was assessed to require extensive physical assistance with bed mobility, transfers, and personal hygiene. This assessment also assessed Resident 87 to require total dependence with two-person physical assist for bathing. Nail care Observations on 10/07/2021 at 10:15 AM with Staff C showed Resident 87's fingernails were long with debris under nails on both hands and Staff C requested nursing staff to come trim nails. Staff U (Registered Nurse), entered room at 10:35 AM to do nail care and stated, Oh my, they are dirty! In an interview on 10/12/2021 at 1:17 PM, Staff C stated Resident 87 should have had orders for weekly nailcare by licensed nurses related to diabetes. Staff C stated staff should have, but did not, trim fingernails weekly. Bathing Record review of Resident 87's Documentation Survey Report for September and October 2021 showed Resident 87 had only one documented shower since admission. In an interview on 10/12/2021 at 10:27 AM, Staff C confirmed there was no documentation that Resident 87 received bathing in past 30 days and stated staff should have, but was not providing bathing twice weekly per facility schedules. Resident 77 Resident 77 was admitted to the facility on [DATE] and according to the 09/22/2021 Significant Change MDS was assessed to require extensive physical assistance for bed mobility, transfers, and personal hygiene. In an interview on 10/05/2021 at 9:24 AM, Resident 77 stated their fingernails are filthy and indicated the length of them are big enough to build my own planet. Observations at this time showed Resident 77 had untrimmed fingernails with debris under nails to both hands. Similar observations of untrimmed fingernails were noted on 10/07/2021 at 11:51 AM and 10/11/2021 at 12:22 PM. In an interview on 10/11/2021 at 12:22 PM, Staff D confirmed with Resident 77 that their fingernails were longer than preferred and were not trimmed by staff recently. Resident 51 According to the 08/30/2021 admission MDS, the resident admitted to the facility on [DATE] and was assessed to require two-person extensive physical assistance with bed mobility, transfers, dressing and bathing. In an interview on 10/05/2021 at 12:20 PM, Resident 51 stated that when they first came to the facility, they were given bed baths but told staff they preferred showers. Review of Resident 51's 08/25/2021 CP showed Bed bath/sponge bath/tub/shower per resident preference on day scheduled [Tuesday and Friday].and PRN (as needed). Review of September 2021 Bathing documentation, showed Resident 51 received a shower on Monday 09/13/2021 and on Monday 09/27/2021. According to the resident's preference and care plan of twice weekly bathing, the resident only received bathing once a week, not twice a week as preferred. In an interview on 10/11/2021 at 12:00 PM, Resident 51 stated they were scheduled for a shower on Friday 10/08/2021 but had an appointment that day. The shower aide told the resident if you get back in time we can do it, if not we will do the shower on Saturday. Resident 51 stated that no one came to shower me on Saturday. In an interview on 10/14/2021 at 9:01 AM, Resident 51 stated they did get a shower on Tuesday 10/12/2021 but was really hoping they could have had a shower before their appointment on 10/08/2021. In an interview on 10/13/2021 at 11:36 AM, Staff B (Director of Nursing) was asked if a resident refuses or misses a shower when do you re-offer, Staff B replied residents are scheduled for bathing twice a week and was not sure how the staff knew which residents missed showers but will get back to me. No additional information was provided. REFERENCE: WAC 388-97-1060(2)(C).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 91 According to the [DATE] Quarterly MDS, Resident 91 was cognitively intact, and required two-person physical assistance with activity of daily living, transfers and personal hygiene. Resident used motorized wheelchair for mobility. In an interview on [DATE] at 08:50 AM, Resident 91 revealed that the motorized wheelchair was broken and not been able to get out of bed for few weeks. Resident would like to be up on the wheelchair and move about the room. When asked if the facility offered alternative wheelchair, Resident 91 said no. Review of Care Plan dated [DATE] showed Resident 91 has decreased mobility related to weakness, obesity and muscles spasms. Intervention: The resident uses motorized wheelchair for all independent mobility. resident prefers to tilt back for comfort at times. Review of Progress note dated [DATE] showed Resident is verbalizing desire to start getting up in her wheelchair once again and has asked for physical therapy to evaluate. Order obtained and therapy a ware. In an interview on [DATE] with staff Physical Therapist (PT) confirmed that Resident 91 was broken, and the resident has not been able to use the wheelchair for weeks. When asked if the resident was evaluated for another alternative wheelchair, staff stated No. Interview [DATE] at 12:30 PM Staff D RCM verified Resident 91's had broken wheelchair and PT had not assessed the resident for another alternative wheelchair. Staff confirmed that the resident remained in bed since the wheelchair was broken. Resident 28 Resident 28 admitted to the facility on [DATE] and according to the Quarterly Minimum Data Set (MDS, an assessment tool) dated [DATE], was assessed to require two-person physical assistance with activity of daily living, transfers and personal hygiene. Resident used manual wheelchair for mobility. In an interview on [DATE] at 11:50 AM, Resident 28 Stated Am stuck in this bed, I lost my wheelchair and I have to stay in bed, when asked when how long the wheelchair been missing, Resident 28 said months and the staff are aware Review of Care plan dated [DATE] showed the resident has limited physical mobility related to generalized weakness. Interventions include resident uses manual wheelchair for locomotion, resident require extensive assist of one for locomotion, and Tilt wheelchair for positioning and comfort. Review of social service (SS) progress note dated [DATE] showed SS assistant spoke to the resident regarding her missing bariatric wheelchair. SSA filed a grievance on behalf of the resident. In an interview on [DATE], at 11:10 AM Staff SS confirmed that the resident's wheelchair was missing and filed a grievance on behalf of the resident. When asked about the process of getting alternative wheelchair, Staff said we have not follow-up In an interview [DATE] at 12:30 PM Staff D RCM verified Resident 28's wheelchair was missing, and the expectation was the resident to get a facility wheelchair to use while the grievance is being followed. When asked the resident was provided with another alternative wheelchair, staff D said No In an interview on [DATE] at 1:05 PM, Staff B, Director of Nursing (DON) stated, we are responsible to ensure the residents mobility devices are functional and available for the residents to use. When asked about Resident 91 and Resident 28's wheelchairs, Staff B stated they need to be followed up and provide alternative wheelchairs for mobility Failure to provide alternative wheelchair mobility for Resident 91 and 28 placed both residents remain in bed for weeks without mobility devices and at risk of diminished quality of life. REFERENCE: WAC 388-97-1060 (1). Non-pressure skin Resident 15 On [DATE] at 10:01 AM, Resident 15 was observed lying in bed with both feet exposed (blankets pulled up to shins and no socks in place). A 1 centimeter (cm) by 1 cm area of dry black devitalized tissue was noted to the tip of Resident 15's 3 rd toe on the right foot. On [DATE] at 11:24 AM, Resident 15 was again observed lying in bed with bilateral feet exposed. The 1 cm by 1 cm area of dry, black, devitalized tissue was still present and clearly visible. Resident 15 indicated the podiatrist accidentally nicked the toe on the last visit (08/192021). The resident stated facility nurses were aware of the wound. Similar observations was made on [DATE] at 1:30 PM. Record review showed no indication the facility was treating or monitoring the wound. Review of the [DATE] Treatment Administration Record (TAR) showed facility staff failed to identify the black devitalized area on the [DATE] skin check, despite its presence on [DATE]. On [DATE] at 1:36 PM, Staff R (Licensed Practical Nurse) assessed Resident 15 has a 1 cm by 1 cm dark scab that remained flush with the surrounding skin. When asked if the area was previously identified Staff R stated, I don't think so. When asked if the black area to the tip of 3rd digit , Right foot, was eschar (devitalized tissue) Staff R stated, No. On [DATE] Resident 15 was assessed by the facility nurse practitioner. According to the provider note, the resident was assessed with small areas of eschar to the tip of the right 1st and 3rd toes. Resident 5 According to the [DATE] Quarterly Minimum Data Set (MDS - and assessment tool), Resident 5 was assessed with moderate cognitive impairment and required extensive one person physical assistance for bed mobility, transfers, dressing and was at risk for pressure ulcers. According to a provider note dated, [DATE], the resident was identified with a 3 x 3 cm [centimeter], 2 x 2 cm approx, felt a rounded, cyst-like/encapsulated. Record review showed no further assessment of this growth. Care plan documents showed no indication of this skin issue and no directions to staff to monitor for any changes. Observations on [DATE] at 8:58 AM showed Resident 5 had a red irregularly shaped growth on the left side of their nose, which was approximately the size of two to three peas. The resident stated it was there for a while and has gotten a little bigger. The resident stated, My son wanted to get it looked at, but he died. During an observation on [DATE] at 1:18 PM Staff C (Resident Care Manager, Registered Nurse) confirmed the presence of the nose growth a dark spot with the appearance of a blood blister noted on the right fourth toe. Staff C stated, That looks like dried blood. At this time when Staff C asked about the nose growth, the resident replied, My son wanted to get it taken care of, but he died. In an interview on [DATE] at 1:25 PM, Staff C confirmed direct care staff should have identified the issue on the right forth toe during dressing and reported it. Staff C reviewed the record and confirmed there was no assessment or evaluation of the growth on the resident's nose. Resident 77 Resident 77 was re-admitted to the facility on [DATE] and according to the [DATE] Significant Change MDS was assessed with severe cognitive impairment, required extensive physical assistance for bed mobility, transfers, and personal hygiene and required end of life services. Review of Care Area Assessment (CAA) dated [DATE] indicated Resident 77 had wounds to their left toes and foot and an open area on left knee. The CAA assessed Resident 77 was at risk for further skin breakdown. According to the Care Plan (CP) dated [DATE], Resident 77 was at risk for impaired skin integrity related to fragile skin but did not reflect the resident's identified open areas or what interventions should be implemented to prevent further skin breakdown. According to physician orders dated [DATE], Resident 77 had orders for wound care daily to inner left knee and left toes and foot. Failure to Provide Wound Care Observation on [DATE] at 12:39 PM showed Resident 77 had an open area without dressing to left inner knee and a white bandage wrapped around his left foot. Similar findings were noted on [DATE] at 8:30 AM. In an interview at this time, Staff BB (Certified Nursing Assistant) stated, I had [Resident 77] since yesterday and it [the knee wound] has been open like this since then. Observation on [DATE] at 8:05 AM showed Resident 77 had foam dressing to left inner knee with date of [DATE] documented on dressing. Observation on [DATE] at 12:30 PM, showed Resident 77 had the same foam dressing to left inner knee dated from [DATE]. In an interview on [DATE] at 12:30 PM, Staff AA (admission Nurse- Licensed Practical Nurse) confirmed the dressing was dated [DATE] and nursing staff should have, but did not, follow the physician ordered dressing change on [DATE]. Failure to Ensure Wound Monitoring Record review showed a wound provider note dated [DATE] which objectively assessed and measured Resident 77's wounds. A progress note dated [DATE] reflected a nursing assessment with wound measurements. Further record review showed no subsequent objective measurable assessment of the resident's wounds. According to the [DATE] Treatment Administration Record (TARs) staff were directed to do head to toe skin checks every week and document results on Weekly Skin Observation Assessment. Record review revealed facility staff failed to document any skin check results or wound monitoring on these forms as ordered by physician for weekly skin assessments. In an interview on [DATE] at 12:45 AM, Staff D (Resident Care Manager- Licensed Practical Nurse) stated nursing staff should, but did not, perform weekly wound assessments, including size, appearance, drainage, etc. Staff D stated they would expect wounds to be on the CP and confirmed Resident 77 did not have CP updated to reflect current wound status. Failure to objectively assess and monitor wounds detracted from staff's ability to determine improvement or decline of wounds. Resident 74 According to the [DATE] Medicare 5 day MDS assessment, staff determined Resident 74 had severe cognitive impairment and required extensive two person assistance assistance with bed mobility and transfers and was at risk for pressure ulcers. Review of Treatment Administration Records (TARs) showed nursing staff signed for a head to toe skin assessment on evening shift on [DATE]. Record review on [DATE] showed nursing staff did not perform a skin assessment. Additionally, according to the TARs, staff were directed to monitor bruising to the forehead, bruises to the left first second and third toes and to D/C [discontinue] when resolved. Nursing staff signed off on each of these on [DATE] but did not discontinue any of the orders as being resolved Observation of a skin assessment on [DATE] at 9:15 AM showed Staff D (Resident Care Manager, Licensed Practical Nurse) identified dark scabs on the left third and fifth toes and a scab to the left lateral foot, proximal to the base of the fifth toe. No bruising was noted to the resident's forehead. Staff D indicated at this time direct care staff should have identified and reported the scabs noted on the foot. Progress notes dated [DATE] showed, New scabs found on pt's (patient's) feet. scabs are not bleeding . s/s (signs / symptoms) of infection. Denies pain on area. Closely monitored for safety. There was no objective measurable description of the location, size, or possible origin of the scabs. In an interview on [DATE] at 11:20 AM Staff D confirmed the weekly skin assessment should be, but was not, completed as directed and nursing staff should have discontinued the monitor for the bruising to the forehead and toes as they resolved. Positioning Resident 58 Resident 58 admitted to the facility on [DATE]. According to the admission MDS dated [DATE] Resident 58 was assessed to require extensive two-person physical assistance with bed mobility, transfers, and personal hygiene and was at risk of developing pressure ulcers. According to the CAA dated [DATE] Resident 58 admitted to facility with soft heels and redness to their lower back area. Review of CP dated [DATE] identified Resident 58 at risk for potential impairment of skin integrity and included interventions to educate resident and caregivers measures to prevent skin injury and to identify the cause and resolve where possible. In an interview on [DATE] at 9:05 AM, Resident 58 stated they had a little spot on their tailbone and left heel. Observations at this time showed Resident 58's heels resting directly on mattress. There were two purple heel protectors sitting on the chair in room. Similar observations were made on [DATE] at 9:46 AM and [DATE] at 11:44 AM. In an interview on [DATE] at 8:15 AM, Staff CC (Certified Nursing Assistant) stated they were not aware of any skin concerns for Resident 58. Review of Resident 58's physician orders dated [DATE] directed staff to off-load heels for mushy/ blanchable redness to bilateral heels and to apply cream to lower back twice daily for blanchable redness. Observations on [DATE] at 8:08 AM, showed Resident 58 was wearing the purple heel protectors on both feet. In an interview at this time, Resident 58 stated, Look what they gave me, I'm not sure where they came from. In an interview on [DATE] at 1:35 PM, Staff C (Resident Care Manager, Registered Nurse) stated staff should have, but were not off-loading Resident 58's heels per physician orders to prevent skin breakdown. Resident 62 A [DATE] Annual MDS assessment showed Resident 62 had a diagnosis of a stroke with left hemiparesis (immobility of left side of body), diabetes and malnutrition and required extensive assistance supported by two people for bed mobility and bowel/ bladder incontinence care. Resident 62 was assessed to be at risk of pressure injuries (wounds on the skin from laying in one position for a long period of time). Review of the [DATE] care area assessment (CAA) for pressure ulcers showed Resident 62 was at risk for skin injury related to weakness, impaired mobility, risk for malnutrition, bowel/bladder incontinence and needed extensive assistance for position changes with pressure relief and for toileting with adequate hygiene. The CAA worksheet identified Resident 62 required extensive assistance with bed mobility and repositioning to prevent pressure to the skin. A review of a [DATE] care plan intervention, not revised after the annual MDS, showed Resident 62 is totally dependent on one staff for repositioning and turning in bed. The care plan does not instruct staff on the frequency or schedule to reposition Resident 62 in bed. Observations were made of Resident 62 lying in bed on their left side without any pillows for positioning or adjusting pressure to the skin. Observations of left side laying included [DATE] 8:45 AM, 9:14 AM, 11:30 AM, 12:15 PM, on [DATE] at 8:40 AM, 10:50 AM, 1:06 PM, on [DATE] at 9:05 AM, 9:45 AM, 10:10 AM, 11:07 AM, 12:17 PM, 12:49 PM, and on [DATE] at 7:44 AM, 8:37 AM, 9:19 AM. Every observation on [DATE] to [DATE] showed Resident 62 laying on their left side. In an interview on [DATE] at 11:01 AM, Staff K (LPN) stated Resident 62 can move their feet in bed and does not like pillows under the heels. When asked if Resident 62 can move themselves in bed and reposition themselves without help, Staff K stated, No, (Resident 62) needs help to move in bed. When asked how often Resident 62 was assisted to reposition in bed, Staff K stated there was no schedule for repositioning. Based on observation, interview, and record review, the facility failed to ensure 10 (Residents 74, 15, 46, 91, 28, 38, 5, 77, 58, 62 ) of 23 residents reviewed, received the necessary care and services in accordance with professional standards of practice, and the comprehensive person-centered care plan. The facility failed to provide services for 2 (Residents 46 & 38) of 6 residents reviewed bowel management, 4 (Residents 15, 5, 77 & 74) of 7 residents reviewed for non pressure skin, 2 (Resident 58 & 62) of 2 resident reviewed for positioning and 2 ( Residents 91 & 28) supplemental residents. These failures placed residents at for decline in medical status, unmet care needs and decreased quality of life. Findings included . Facility Policy The Facility's 08/2018 Quality of Care policy directed nursing staff to: ensure care plans included resident care needs and described the services and care required; ensure residents with non-pressure-related skin ulcers/wounds were assessed by a clinician, including documentation of underlying conditions contributing to ulceration, characteristics of the wound edge and wound bed, location, shape and condition of surrounding tissues; ensure treatment of such conditions were in accordance with physician orders and incorporated appropriate preventive measures. Bowel Management Resident 46 Review of Resident 46's Physician's Orders (PO) showed the following [DATE] as needed (PRN) bowel care orders: Milk of Magnesia (MOM) 30 ml, if no bowel movement (BM) in 3 days, administer on day 4, Day shift; and Dulcolax suppository 10 mg rectally PRN, on day 4 evening shift, if no BM after MOM. Review of Resident 46's September and [DATE] bowel flowsheets showed the resident went more than three days without a BM on the following occasions: [DATE] - [DATE] (6 days); and [DATE] - [DATE] (4 days). Review of the [DATE] MAR showed facility nurses failed to administer MOM to Resident 46 on 09/14//2021 as ordered. MOM was not provided until [DATE] (day 7, without a BM). Similarly, facility nurses failed to administer MOM on [DATE] (the 4th day without a BM) as ordered by the Physician. In an interview on [DATE] at 12:41 PM, Staff J, confirmed facility nurses should have administered MOM on [DATE] and 0 [DATE] day shift (4th day without a BM), but failed to do so. Resident 38 In an interview on [DATE] at 12:24 PM, Resident 38 stated, I am having some trouble with my bowels .constipation, because I don't get the same bowel medications I was taking at home. the resident reported she sometimes goes four days without a bowel movement (BM). Review of Resident 38's September and [DATE] bowel flowsheet showed the resident went more than three days without a BM on the following occasions: [DATE] at 12:24 PM to [DATE] at 7:09 PM (more than 4 days.); [DATE] at 3:52 PM to [DATE] at 7:53 PM (more than 5 days). Review of Resident 38's showed no as needed (PRN) bowel medications were ordered. In an interview on [DATE] at 12:41 PM, Staff J, stated orders for PRN bowel medications should've been obtained upon admit but were not. Per Staff J nursing should have identified the issue when the resident went 4 days with no BM and obtained the orders at that time, but acknowledged that did not occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide goods and services to maintain hearing and vision for 4 (Resident 5, 74, 91 and 6) of 8 residents reviewed for hearing and vision services. Failure to ensure residents received assistance in hearing/vision services placed residents at risk for unmet needs and decline in Activities of Daily Living (ADLs). Findings included . Resident 5 According to the 04/10/2021 admission Minimum Data Set (MDS - an assessment tool) Resident 5 was assessed with highly impaired hearing with no hearing aide. The Care Area Assessment of the same date stated This [resident] admitted to the facility following an ER visit due to a fall and diagnosed with a UTI. During interview with the resident [they] report[ed their] hearing is horrible and when [they] speak [they] speak loudly. This writer was able to communicate with [them] by speaking clearly and in a loud tone. It is reported [they] hear better out of [their] left ear. [They are] able to speak clearly and respond appropriately to questions asked. Resident denies a need for a white board or written communication. Care plan will proceed with information to staff to ensure [they] hear what is being said. During an interview on 10/06/2021 at 9:00 AM, Resident 5 shook their head and stated, I am deaf in my right ear .you gotta talk real loud in this one and proceeded to point at their left ear. The Resident gestured to a white board (an erasable board used for written communication) with a marker on the bedside stand and stated, they just gave me this yesterday, go ahead and write on it. A 04/14/2021 CP showed the resident was identified with a communication problem, hard of hearing, hears better in the left ear. Interventions included: anticipate and meet needs, be conscious of resident position when in groups, activities, dining room to promote proper communication with others, allow adequate time to respond, repeat as necessary, request clarification from the resident to ensure understanding, and face when speaking. Observations on 10/07/2021 at 8:35 AM showed Resident 5 watching TV wearing a set of blue tooth headphones. The resident stated the headphones allowed her to hear the television, which she said was helpful. Observation of the Resident Counsel Meeting on 10/12/2021 at 1:01 PM showed Staff W (Activity Assistant) provide Resident 5 a pocket talker (a machine that amplifies sound). In an interview on 10/12/2021 at 10:50 AM, Staff W stated she provided Resident 5 with a pocket talker during activities because, she is hard of hearing. Frequent observations on each day of the survey showed no pocket talker was provided to the resident to communicate with staff. Record review showed no indication facility staff provided consistent adaptive equipment to facilitate communication, or assessed Resident 5 to determine if hearing aids or a pocket talker would enhance Resident 5's capacity to communicate. In an interview on 10/12/2021 at 1:02 PM, Staff C (Resident Care Manager, Registered Nurse) indicated the Resident 5's blue tooth headphones were not, but should be, care planned. Staff C was unable to state who provided the headphones or when they were provided. Asked when the white board was implemented, Staff C stated, I would say I don't know because there is no documentation. When asked why staff determined the resident would benefit from a pocket talker during activities but not during regular day to day communication with staff, Staff C indicated she was not sure why a pocket talker was not provided but would look into it. According to physician orders dated 04/10/2021 Resident 5 May have dental, vision and eye health, hearing and podiatry consults as needed. In an interview on 10/12/2021 at 1:02 PM, when asked if Resident 5 needed hearing aids or an evaluation for hearing aids, Staff C stated, We don't have a consult. Resident 74 According to 09/17/2020 admission MDS, Resident 74 was assessed with severe cognitive impairment, adequate vision and no corrective lenses. Observations on 10/06/2021 at 12:00 PM showed Resident 74 up in a chair, waiting for lunch. The resident stated they wore glasses but was unsure if they had them here but was sure they needed their glasses. Care Plan documents dated 09/11/2020 showed Resident 74 had impaired visual function with interventions including, ensure appropriate visual aids are available to support resident's participation in activities and remind resident to wear glasses when up. Ensure resident is wearing glasses which are clean free from scratches and in good repair. Report any damage to nurse/family. According to an undated [NAME] (instructions to direct care staff regarding care), Resident Care included, glasses - reading. A separate CP dated 09/08/2021 showed the resident enjoys magazines, romance books . Observations on 10/06/2021, 10/07/2021, 10/08/2021 showed no evidence of glasses either with the resident or in the resident's room. During an observation on 10/08/2021 at 9:12 AM, Staff D (Resident Care Manager, Licensed Practical Nurse) was unable to locate any glasses for Resident 74. In an interview on 10/11/2021 at 11:16 AM Staff D indicated they spoke with the resident's daughter who reported the glasses were missing. When asked how long, Staff D was unable to answer stating, Staff should have reported that they couldn't find the glasses as they were directed to ensure she had them. Resident 91 Review of the clinical record showed Resident 91 re-admitted to the facility on [DATE] with several diagnoses, including chronic obstructive pulmonary disease (COPD) and stroke to the left side weakness. The 09/26/2021 Quarterly MDS reflected the resident had adequate vision and no corrective lenses. According to the 04/26/2020 CP, Resident 91 had impaired visual function with interventions of, Arrange consultation with eye care practitioner as required, ensure appropriate visual aides are available to support resident's participation in activities. Remind resident to wear glasses when up. Ensure resident is wearing glasses which are clean free from scratches and in good repair. Glasses for reading. Report any damage to nurse/family. Observation on 10/06/2021 at 8:50 AM, revealed Resident 91 lying in bed. The resident indicated at this time they had impaired vision to the left eye. The resident indicated that they had reading glasses previously, but no longer had glasses. In an interview on 10/13/2021 12:55 PM, Staff D, Resident Care Manager - RCM, stated, I don't know if she has reading glasses, but I will make sure she gets scheduled to be seen by the eye doctor, Staff D further confirmed that Resident 91 did not have reading glasses and indicated nurses are responsible to make referrals on any vision issues with the resident. In an interview on 10/13/2021 at 1:05 PM, Staff B, Director of Nursing (DON) stated, The floor nurses are responsible to make referrals to the physician for evaluation and treatment. When asked if Resident 91's care plan was followed, Staff B said No. Resident 6 According to a 10/18/2020 admission nursing assessment, Resident 6 had eyeglasses and could see with glasses and adequate lighting. Observations on 10/05/2021 or 10/06/2021 showed no evidence of glasses either with Resident 6 or in the resident's room. In an interview on 10/07/2021 at 12:15 PM, Resident 6 was lying down and reading in bed, holding a tablet about 12 inches from the face. Resident 6 stated they used to have glasses, but the glasses went missing about 4-5 months ago and thought they went into the trash can. Resident 6 stated they reported the missing glasses to Staff AA and was told to fill out a grievance form. Resident 6 stated the form was completed and returned, and they never heard any response and was still without glasses. In an interview on 10/12/2021 at 1:04 PM, Staff AA (Admissions Nurse) stated they did not recall the name of the resident or a report of missing glasses. Review of the facility 2021 grievance log showed no entry for lost glasses for Resident 6. In an interview on 10/12/2021 at 11:21 AM, Staff F (Social Services Director) stated anyone in the community can file a grievance and give it to the Administrator. Staff F stated if a grievance was a matter for which social services is responsible, it would be directed to Staff F. Staff F confirmed that missing property is designated to social services. Staff F stated they were not aware of missing glasses for Resident 6. On 10/13/2021 at 1:52 PM, Staff F stated Resident 6's room was searched and no glasses were found, and that Resident 6 was added to the optometrist list for 10/19/2021. REFERENCE: WAC 388-97-1060(3)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a system by which resident weights (wts) were obtained, evaluated, meal intake assessed, significant wt loss identified, and interventions were developed and implemented for 8 (Residents 5, 74, 15, 46, 28, 77, 6 & 51) of 10 residents reviewed for wt loss/nutrition. Facility staffs' failure to: obtain and evaluate wts and meal intake; offer replacement meals to residents who required them; conduct weekly nutrition at risk interdisciplinary meetings (IDT), precluded staff from identifying and implementing interventions to provide additional nutritional support to residents experiencing unplanned wt loss/gain. Findings included . Facility Policy According to the skin and Nutrition Meeting Guidelines dated 10/2019, Monthly wts are to be completed by the first full weekend of the month. Weekly wts should be done on the same day of the week, at least one day prior to the meeting for consistency. Residents whose wt is plus or minus 3 pounds from their previous wt will be re-weighed to verify accuracy of current wt. According to the Skin and Nutrition Outline, dated 10/2019, significant wt loss or gain was defined as: 3% in one week; 5% in one month; 7.5% in three months; or 10% in six months. When a significant wt change was identified, the resident would be reviewed in the weekly Skin and Nutrition meeting, where a interdisciplianry team would assess to determine causative factors and develop interventions to meet the resident'd nutritional needs. In the meeting staff would identify the root cause of the loss/gain by assessing: labs; edema; special diet; wounds; and change of condition. Resident 5 Resident 5 admitted to the facility on [DATE] and according to the 04/13/2021 admission Minimum Data Set (MDS, an assessment tool) weighed 160 pounds (lbs). According to the 07/06/2021 Quarterly MDS Resident 5 weighed 164 lbs. In an interview on 10/06/2021 at 8:54 AM, Resident 5 stated they had experienced a change in wt. Review of wt records showed staff weighed Resident 5 on admission for three consecutive days. Subsequent wts were obtained on 04/20/2021 and 04/27/2021 when the resident was assessed to wt 164 lbs. No further wts were obtained until over five months later on 10/04/2021, when staff assessed the resident to weigh 170 lbs. A nutrition note dated 08/13/2021 showed, Resident reported feelings of hunger post dinner meal. Resident agreed to pudding with dinner meal .Will continue to monitor. Facility staff failed to identify no wts were obtained in over three months. In an interview on 10/11/2021 at 8:28 AM Staff C (Resident Care Manager, Registered Nurse) was asked why there were no wts listed between April and October 2021 and how staff monitored the resident's nutritional status in the absence of wts. Staff C confirmed that facility staff did not, but should have, obtained and monitored Resident 5's wts at least monthly. Resident 74 Resident 74 admitted to the facility on [DATE] and according to the admission MDS dated [DATE] weighed 100 lbs and required a mechanically altered diet. The 09/04/2021 Significant change MDS showed the resident weighed 106 lbs. The resident discharged from the facility on 09/12/2021 and readmitted on [DATE]. The 09/18/2021 5 day medicare MDS showed the resident weighed 90 lbs. In an interview on 10/06/2021 at 11:53 AM Resident 74 indicated they thought maybe they had a wt loss. Wt records showed the resident was assessed to wt 106 lbs on 08/31/2021 and 84 lbs on 09/05/2021, a loss of 24 lbs. Record review showed there was no assessment to determine accuracy of this wt. A 09/10/2021 dietary note showed, -10.0% change [ 22.4% , 24.2 ] RD [Registered Dietician] present for significant wt change. Per nursing documentation, noted a 22.1 lb (20%) significant wt loss x <1 week. BMI: 14 (underweight). Recorded PO 60% of meals and 50-100% of Med Pass 2.0 120 ml BID. Re-weigh requested to verify wt loss. Will continue to monitor and follow up as indicated. The resident was not weighed again until 09/16/2021 and was assessed to weigh 90.2 lbs. There was no assessment based on a wt change of more than three pounds, per facility policy and a six day delay from the RD's recommendation for a reweigh. Wt records showed the resident was assessed on 09/20/2021 to weigh 77.2 lbs, a wt loss of 13 lbs. There was no reweigh to establish accuracy of this weight. The resident was next weighed on 10/04/2021 and determined to weigh 99 lbs, a gain of 22 lbs. There was no reweigh to determine accuracy of this weight, and no assessment of the weight change. Additionally record review showed that, according to Medication Administration Records (MARs) on 09/14/2021 and 09/15/2021 staff were directed to obtain wts (Order read weight every evening shift for 3 days starting 09/14/2021). Staff did document a wt of 90.2 lbs on 09/16/2021, but failed to document the other weights as directed. According to MARs for September 2021, staff were directed to provided MED Pass 2.0 [a nutritional supplement] three times a day for Med Pass 2.0 related to inadequate (oral) intake. Please document mls consumed. Staff documented intake of 60 to 120 mils but there was no direction as to how much to offer/provide. In an interview on 10/12/2021 at 1:57 PM, Staff B (Director of Nursing) confirmed staff should, but did not, reweigh the resident after the weights deviated three pounds from previous weights. Staff J (Nurse Consultant) confirmed the system for obtaining accurate weights was identified as an issue. Resident 15 Resident 15 admitted to the facility on [DATE]. According to the 07/18/2021 Quarterly MDS, the resident was cognitively intact, had lost 5% of body weight in the past month or lost 10% or more in six months, and was not on a physician prescribed weight-loss regimen. Review of Resident 15's weight flowsheet showed the resident's weights were as follows:; 07/27/2021- 247.2 lbs; 08/12/2021- 223 lbs (-9.63 % , no reweigh was obtained as directed in the facility's policy); and on 08/26/2021- 223.4 lbs, validating the Resient 192's significant weight loss. Record review showed no indication facility staff identified Resident 15's significant weight loss of 9.63 % in less than 30 days. No Nutritional Screen was performed and the resident was not assessed in the weekly Skin and Nutrition meeting until 09/24/2021, 43 days after the significant weight loss occurred. The 09/24/2021 Nutrition/ Dietary Note stated, Registered Dietician (RD) present to address significant weight loss. Per nursing documentation, noted a 23.8 lb (9.6%) significant weight loss x 1 month. Weight loss deemed positive related to elevated BMI [Body Mass Index, a weight-to-height ratio used as an indicator of obesity and underweight] however, time frame in which weight loss occurred is not recommended. Additional food preferences obtained. Resident requested pudding in place of fruit when served as dessert. RD will honor request. The RD then recommended Resident 15 receive fortified potatoes twice a week and No Sugar Added (NSA) Health Shakes daily. Record review showed no indication Resident 15 was reviewed in the next weekly Skin and Nutrition meeting, to assess the effectiveness of the nutritional interventions implemented on 09/24/2021. Review of the September and October 2021 MARs showed a 09/24/2021 order for a 118 milliliter (ml) NSA Health Shake every evening. Review of the intake documentation from 09/24/2021 - 10/10/2021, showed the Resident 15 refused the Health Shake all 17 times it was offered. Review of the nurses' notes showed facility staff failed to identify the resident's patterned refusals of the Health Shake. During an interview on 10/13/2021 at 12:43 PM, Staff J (Corporate Nurse Consultant) acknowledged that facility staff failed to timely identify Resient 15's significant weight loss resulting in a delay in implementation of nutritional interventions. Additionally, once interventions were implemented, facility staff failed to assess the effectiveness of the interventions, resulting in a delayed identification that Resident 15 did not receive the NSA Health shake for 17 consecutive days since it was ordered. Inspite of these failures, Resident 15 was able to maintain weight at 223 lbs. Resident 46 Resident 46 admitted to the facility on [DATE]. According to the 08/27/2021 admission MDS, the resident was cognitively impaired, and had diagnoses of Alzheimer's disease, Non-Alzheimer's dementia and malnutrition. According to the 08/21/2021 Resident has nutritional problem due to malnutrition . care plan, the goal was for the resident to maintain weight through the next review. Staff were directed to monitor, record, and report to the MD signs and symptoms of malnutrition, such as unintentional weight loss, muscle wasting or significant weight loss of: 3 lbs in one week; weight loss of greater than 5% in one month; greater than 7.5 % in three month; or greater than 10% in 6 months. Review of Resident 46's weight flowsheet showed the resident weighed the following: 08/23/2021- 138.8 lbs; 08/24/2021- 138 lbs; 08/25/2021- 121 lbs (-17.8 lbs or 12.83%); and a re-weigh on 08/26/2021- 121 lbs. Review Resident 46's 08/25/2021 Nutrition Evaluation, showed the Registered Dietician used the 08/23/2021 weight of 138.8 lbs and the 08/24/2021- 138 lbs for the assessment. the assessment concluded that the resident would likely have some weight shift s secondary to edema and diuretic use, but had adequate intake to meet nutritional need. The goal was No significant changes in weight. Record review showed no indication facility staff identified the 17.8 lbs weight loss/ variance between the 08/23/2021 weight of 138.8 and the 08/25/2021 weight of 121 lbs. Further review of Resident 46's weight flowsheet showed the following: 09/17/201-125.4 lbs; 09/24/2021- 119.2 lbs(- .2 lbs lbs or 4.9 %); and 10/11/2021- 116 lbs (-9.4 lbs and 7.5% , in less than 30 days) demonstrating a significant weight loss. Record review again showed facility staff failed: to identify the significant weight loss; review the resident in the weekly skin and nutrition meeting, identify causes and to implement interventions. During an interview on 10/13/2021 at 12:43 PM, when asked if there was any documentation to support facility staff identified the 08/25/2021 significant weight loss or the 10/11/2021 significant wt loss Staff J indicated the 08/25/2021 weight loss was due to inaccurate admission weights, but acknowledged there was no indication anyone assessed the resident determine that. Staff J then acknowledged that the 10/11/2021 significant weight loss of 7.5% in 30 days, had not yet been addressed. Resident 28 Resident 28 admitted to the facility on [DATE] and according to the 08/08/2021 Quarterly MDS, was assessed as able to understand and be understood in conversation. Review of Resident 28's weights showed his weight was documented as 264 pounds on 09/12/2020 using a mechanical lift, and on 10/12/2021 the weight increased to 295.2 per mechanical lift (a change of 31 pounds (lbs.), (11%) significant weight in one month). Review of the progress notes for that date showed no evaluation of the weight difference. According to his Nutrition/dietary note dated 08/04/2021, Weight Warning: Noted a 27 lbs. (10%) significant weight gain in 180 days. Resident weight 02/22/2021 was 244 lbs and weight on 07/29/2021 was 271. No edema noted, resident is wheelchair bound. Portion of weight gain likely related to physical inactivity. In an interview on 10/12/2021 at 12:20 PM, Staff D, RCM was asked about who was responsible to follow up when there was a substantial weight gain or loss. Staff D stated the nurses and RCM's were responsible. When asked about the follow up for Resident 28's weight changes, Staff D stated I will follow up now. In an interview on 10/13/2021 Staff FF Dietician confirmed Resident 28's significant weight gain in one month and indicated that the resident's weight was not addressed. Staff FF further stated the expectation of any weight more than 3 lbs. need to be addressed. Resident 28 Resident 28 admitted to the facility on [DATE] and according to the 08/08/2021 Quarterly MDS, was assessed as able to understand and be understood in conversation. Review of Resident 28's weights showed his weight was documented as 264 pounds on 09/12/2020 using a mechanical lift, and on 10/12/2021 the weight increased to 295.2 per mechanical lift (a change of 31 pounds (lbs.), (11%) significant weight in one month). Review of the progress notes for that date showed no evaluation of the weight difference. According to his Nutrition/dietary note dated 08/04/2021, Weight Warning: Noted a 27 lbs. (10%) significant weight gain in 180 days. Resident weight 02/22/2021 was 244 lbs and weight on 07/29/2021 was 271. No edema noted, resident is wheelchair bound. Portion of weight gain likely related to physical inactivity. In an interview on 10/12/2021 at 12:20 PM, Staff D, RCM was asked about who was responsible to follow up when there was a substantial weight gain or loss. Staff D stated the nurses and RCM's were responsible. When asked about the follow up for Resident 28's weight changes, Staff D stated I will follow up now. In an interview on 10/13/2021 Staff FF Dietician confirmed Resident 28's significant weight gain in one month and indicated that the resident's weight was not addressed. Staff FF further stated the expectation of any weight more than 3 lbs. need to be addressed. Resident 77 Resident 77 was re-admitted to the facility on [DATE] and according to the 09/22/2021 Significant Change MDS was assessed with medically complex conditions including malnutrition and weighed 178 lbs. Review of Care Plan (CP) revised on 09/24/2021 indicated Resident 77 was at risk for a potential nutritional problem related to decreased intake, acute disease process, fair appetite and wounds. This CP indicated goals for Resident 77 were to have no significant weight loss of 5% in 30 days or 10% in 180 days and Resident 77 would maintain adequate nutritional status as evidenced by maintaining weight. In an interview on 10/06/2021 at 8:23 AM, Resident 77 stated they were shocked when they dropped weight. Review of physician orders dated 09/16/2021 directed staff to obtain weight every day for three days and then every week for four weeks. Record review showed staff documented Resident 77's weight on 09/28/2021 at 179.2 lbs with a subsequent weight obtained by staff on 10/05/2021 of 155.4 lbs. This showed a significant weight loss for Resident 77 of 13.28% in only seven days. No documentation was found in chart that staff did a follow up weight to verify accuracy as directed in facility policy. In an interview on 10/08/2021 at 11:46 AM, Staff U (Registered Nurse) stated if a resident has a weight change, the resident should be re-weighed, the doctor notified, and referred to dietician with changes. When asked when the re-weigh should be done, Staff U stated the expectation is the weight should be retaken the next day. Resident 6 A 07/07/2021 Quarterly MDS assessment showed Resident 6 had a diagnosis for malnutrition. A weight was not obtained for Resident 6 at the time of assessment and weight loss/gain 5% in the past month was not identified in the assessment. Review of Resident 62's weight log showed a last recorded weight of 151.0 on 04/27/2021 and no recorded monthly weights for May 2021 or June 2021. On 07/26/2021 a recorded weight of 173.4 pounds indicated a weight gain of 22.4 pounds (+14.8%). A nutrition note dated 07/26/2021 showed the weight was 151.0 pounds on 04/27/2021. The note showed monthly weights were not being obtained and nursing and requested Resident 6 to be weighed and start obtaining monthly weights. The weight gain of 22.4 pounds on 07/26/2021 was not identified by the dietician or nursing. There were no further nutrition or nursing notes found in the medical record that identified, assessed or addressed the weight gain of Resident 6. In an interview on 10/11/2021 at 1:42 PM, Staff D, (RCM, LPN) stated if the nurse enters a weight into the record, they should let the manager know about a change. Staff D stated weight changes are discussed weekly with the dietician, the dietician keeps notes and would enter a progress note based on the discussion. Staff D stated this system is dysfunctional. Resident 51 According to the 08/30/2021 admission MDS the resident admitted to the facility on [DATE] for aftercare following a fracture and weighed 229 pounds (lbs.). Review of the residents Weights showed a 08/26/2021 weight of 233.4 lbs. and a 09/20/2021 weight of 221.0 lbs., a total of 5.31% weight loss in less than 30 days. Review of a 08/30/2021 Nutrition CP showed a goal that resident will not have significant weight loss of 5% in 30 days or 10% in 180 days. Review of the resident's record showed no indication the RD or Physician was notified of a significant weight loss. In an interview on 10/13/2021 at 11:45 AM Staff J (Corporate Nurse Consultant) stated they would expect the Registered Dietician (RD) and and physician to evaluate the resident. Staff J reviewed the record and confirmed there was no follow up from the RD or physician after the weight loss. REFERENCE: WAC 388-97-1060 (3)(h)(i). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were added to resident records andthat recommendation were reviewed and incorporated for 8 of 9 residents (Residents 5, 74, 46, 35, 39, 73, 6 and 22) whose medication regimens were reviewed. This failure placed residents at risk for delays in necessary medication changes, at risk for adverse side effects and at risk of receiving medications without required pharmacist oversight. Findings included . Resident 5 Record review showed a pharmacy review dated 08/06/2021 which indicated, See report for any noted irregularities and/or recommendations. In an interview on 10/14/2021 at 8:11 AM, Staff D (Resident Care Manager, Licensed Practical Nurse) reviewed the resident's record, conferred with Medical Records staff and reported they were unable to find the referenced Pharmacy report or the physicians response to the report. Any additional information was requested, none was provided. Resident 74 According to Pharmacy Recommendations dated 01/10/2021 pharmacy staff documented, REPEATED RECOMMENDATION FROM 12/7/2020 Please respond promptly to assure compliance with Federal regulations. She receives Escitalopram 20 mg qd which exceeds the maximum recommended daily dose of 10 mg daily in those over [AGE] years of age. The elderly are at an increased risk for significant adverse effects with doses greater than 10 mg daily including dizziness. with Recommendations of Please reduce Escitalopram to 10 mg qd. Rationale for Recommendations included Medications that cause increased risk for falls, and consequently fractures to to adverse effects should be avoided in the elderly. If this therapy is to continue , it is recommended that a) the prescriber document an assessment of the risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences (e.g. new or worsening dizziness, fatigue, traycard, hypotension, gait changes) which may increase fall risk. The provider indicated, I decline the recommendations above and do not wish to implement any changes to the reasons below: will need to discuss w/ daughter first. Further record review showed a 08/06/2021 Pharmacy Medication Regimen Review which indicated, see report for any noted irregularities and / or recommendations. Record review showed no such referenced report. Record review revealed no documentation to support the provider or any facility staff discussed the 01/10/2021 pharmacy recommendations with the resident's daughter. Record review showed no evidence of the pharmacy recommendations that were made on 12/07/2020 or 08/06/2021. In an interview on 10/08/2021 at 8:30 AM, Staff D was asked to provide contact information for the Consulting Pharmacist. In an interview on 10/11/2021 at 9:55 AM, Staff D indicated the Pharmacist declined to provide contact information. In an interview on 10/12/2021 at 8:55 AM Staff B (Director of Nursing) reviewed Resident 74's record and confirmed that the results of the 01/10/2021 were not, but should be in the record. Staff B was unable to find the 12/07/2020 or 08/06/2021 Pharmacy recommendations. Resident 46 Record review showed a 08/22/2021 pharmacy recommendation to change Amitriptyline (an antidepressant) 50 milligrams (mg) to Escitalopram (an antidepressant) 10 mg to decrease the risk for falls. Under Physician's response, the practitioner checked I accept the recommendations and signed the form on 08/23/2021. However, the recommendation was not noted by a facility nurse until 09/28/2021 (36 days later.) Review of Resident 46 Physician's orders (PO) showed the order to discontinue the Amitriptyline and start Escitalopram was not carried out until 09/28/2021. During an interview on 10/13/2021 at 11:28 AM, Staff J, indicated the order should have been carried out the day the practitioner approved the recommendation, and acknowledged that it was not. Record review showed a 09/09/2021 pharmacy recommendation to change Metoprolol Succinate 25 mg extended release (ER) two times a day to Metoprolol Succinate 50 mg ER daily. The practitioner checked I accept the recommendation above and signed on 09/11/2021. Review of Resident 46's POs showed the order was not carried out until 09/28/201 (17 days later). During an interview on 10/13/2021 at 11:28 AM, Staff J, indicated the order should have been carried out the day the practitioner approved the recommendation, and acknowledged that it was not. Resident 35 Review of the EHR (Electronic Health Record) revealed MRRs for Resident 35 for February 2021, May 2021 and August 2021 that each stated, see report for any noted irregularities. No associated reports were found in the record. In an interview on 10/14/2021 at 08:48 AM, Staff D, RCM, was asked where any associated reports would be found, and stated they would look for them and produce them if located. Staff D was unable to provide any documents that the MMR reports were included in Resident 35's medical record, and that any identified irregularities and recommendations were acted upon. Resident 39 According to the 08/15/2021 Significant Change Minimum Data Set (MDS-an assessment) Resident 39 admitted on [DATE] with medically complex conditions including Gastroesophageal Reflux Disease (GERD). Review of the resident's medical record showed Consult Pharmacist Medication Regimen Reviews was completed and recommendations were made on 10/07/2021. No Pharmacist Recommendations were found in the resident's medical record. On 10/14/2021 at 10:11 AM Staff B (Director of Nursing) provided copies of the Pharmacist recommendations from 10/07/2021 that showed, please consider discontinuing Pantoprazole (used to treat GERD) and please consider changing Trazodone (sleep medication) to 25 mg (milligrams) every night as needed for insomnia for 14 days. Both recommendations were not signed by the physician. Review of Resident 39's Physicians Orders (POs) showed Pantoprazole was discontinued on 10/12/2021 and an order was added for Trazodone 25 mg by mouth every night as needed for insomnia for 14 days. In an interview on 10/14/2021 at 10:28 AM Staff B (Director of Nursing) was asked where the physician had signed off on the recommendations. Staff B stated they didn't have signed ones and they had a problem with the process, Staff B called and spoke with the physician about the recommendations, that is how the orders changed. Review of the resident's clinical record showed no documentation of a conversation with the physician or with the resident or their POA (power of attorney) regarding the medication changes. Resident 73 According to the 09/17/2021 admission MDS Resident 73 admitted to the facility on [DATE] with hypertension (high blood pressure) and atrial fibrillation (A-fib-an irregular heart rate). Review of the resident medical record showed Consult Pharmacist Medication Regimen Review were completed and recommendations were made on 09/15/2021 and 10/08/2021. During an interview on 10/12/2021 at 10:28 AM Staff A (Administrator) was asked to supply the pharmacy recommendations. On 10/14/2021 at 10:11 AM Staff B (Director of Nursing) provided copies of the Pharmacist recommendations from 09/15/2021 that showed, please administer Xarelto (a medication for A-fib) once daily with the evening meal to increase absorption when given with food, please ensure the administration time of Torsemide (a diuretic) for the last dose of the day is at least 6 hours prior to resident's bedtime to decrease the risk for functional incontinence and falls and lastly please consider administering Metoprolol (for hypertension) once a day to reduce med pass labor. All three recommendations were not signed by the physician. No documents were provided for the 10/08/2021 Pharmacist Recommendations. In an interview on 10/14/2021 at 10:28 AM Staff B (Director of Nursing) was asked where the physician had signed off on the recommendations. Staff B stated they didn't have signed ones and they had a problem with the process. Review of the resident's medical record showed no indication the 09/14/2021 Pharmacist recommendations were reviewed by the Physician, or the medications were changed as recommended. Resident 6 Resident 6 admitted to the facility on [DATE] for a short term stay for rehab. A 10/22/2020 admission MDS showed diagnoses for Schizophrenia, Bipolar Disorder, Depression, Anxiety Disorder and Sleep Disorder. Record review showed pharmacy medication reviews dated 09/09/2021 and 10/07/2021 which indicated, See report for any noted irregularities and/or recommendations. The MMR reports were not located in Resident 6's medical record. In an interview on 10/14/2021 at 8:11 AM, Staff D (Resident Care Manager) stated the reports are scanned into the medical record when completed. In an interview on 10/13/2021 at 11:44 AM, Staff Q (Medical Records) stated the signed MMR reports for 09/09/2021 and 10/07/2021 were not in the medical record for Resident 6. Refer to F689 Accidents Refer to F758 Free from Unnecessary Psychotropic Meds/PRN REFERENCE: WAC 388-97-1300(1)(c)(iii) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REFERENCE: WAC 388-97-1300(2). Unlocked Treatment and Medication Carts During observation on 10/05/2021 at 9:01 AM the South Treatment cart was noted to be unlocked and accessible by unauthorized personnel. The cart was full of treatment supplies, including lidocaine ointment (medication applied to skin to decrease pain), povidine iodine (used for skin disinfection), and steroid anti-inflammatory ointment (medication used to treat redness, swelling or itching to skin). During observation on 10/06/2021 at 12:13 PM the medication cart parked next to the South Nurse's Station was noted to be unlocked and accessible by unauthorized personnel. There was no licensed nursing staff in line of sight of the medication cart until 12:35 PM, at which time the licensed nurse came back to unit and locked the cart. In an interview on 10/12/2021 at 1:17 PM, Staff C stated medication and treatment carts should not be left unlocked and confirmed it was facility policy to keep carts locked for safety and to prevent accidental ingestion. West 1 Medication Cart Observation of the [NAME] 1 Medication Cart with Staff E on 10/05/2021 at 11:35 AM, showed medication for discharged residents in the cart, a bottle of nitroglycerin tablets, 2 estradiol patchs (a hormone medication) 0.05mg, ketoconazole (antifungal) cream, iodasorb gel and clobetasol gel (cream for itching skin condition). When asked what happens to the medication when a resident discharges, Staff N (Licensed Practical Nurse) stated medication should be removed from the cart and destroyed or returned to pharmacy. Further observation showed expired medications; Aspirin 325mg expired 09/02/2021, Mucus relief guaifenesin expired 06/2021, Levothyroxine 137 mcg expired 01/01/01/202, Ondansetron 4mg expired 07/16/2021, Midodrine 10 mg expired 09/30/2021, two cards of Carvedilol 6.25 mg expired 07/31/2021, glipizide 5mg expired 08/31/21, metoprolol 25 mg expired 09/30/21, and two cards of famotidine 20mg expired 08/31/202. Staff N verified the medications were expired and indicated the expectation was that all expired medication were to be removed from the cart and destroyed. The following medications were observed without open dates, Ketoconazole cream, a bottle of liquid docusate 100mg, hydrocortisone cream, clotrimazole cream, clobetasol cream, and three bottles of nystatin powder. Staff N confirmed the medications were undated and stated all liquid, creams and powders should be dated when opened. The cart was observed with 115 unidentified tablets, 5 broken pieces of tablets on the base of second drawer, lots of powder on the base edges of second drawer and 3 tablets on the base of the bottom drawer. When asked what medications were on the base of the drawers, Staff N stated, I don't know. East Medication Room Observation of the East Medication Room on 10/05/2021 at 10:28 AM, with Staff C revealed the following: A multi-dose vial of Tuberculin purified protein derivative (PPD) opened 08/31/2021; and an opened, undated Humulin R insulin pen for Resident 395, who discharged from the facility 08/30/2021, Return not anticipated. In an interview on 10/05/2021 at 10:34 AM, when asked how long an opened vial of PPD was good for Staff C stated 28 days and acknowledged the vial of PPD was expired. When asked about Resident 395's Insulin pen Staff C stated that the pen should have been dated when opened and needed to be discarded. East 2 Medication Cart Observation of the East 2 Medication Cart on 10/05/2021 at 10:46 AM, with Staff R, (Licensed Practical Nurse), revealed an opened, undated, Novolog insulin pen for Resident 4. In an interview on 10/05/21 at 10:55 AM, Staff R confirmed the insulin pen was opened, and undated, an indicated the insulin pen needed to be discarded. East 1 Medication Cart Observation of the East 1 Medication Cart on 10/05/2021 at 10:06 AM, with Staff M (Registered Nurse) showed multiple over the counter medications were expired. These medications included Aspirin 325 mg that expired in 09/2021, Gentle Laxative that expired in 05/2021, Selenium 200 mcg (micrograms) that expired in 06/2021, Niacinamide that expired in 06/2021, Bisacodyl that expired in 08/2021 and Cetirizine 10 mg that expired in 05/2021. Further observations included a Lantus Insulin pen belonging to Resident 36 that was opened, used and not dated. In an interview on 10/05/2021 at 10:15 AM Staff M stated that expired medications should not be in the cart and when a medication is put in the cart or opened it should be dated. Based on observation, interview, and record review, the facility failed to ensure medications and/or biologicals were properly secured for 1 of 1 treatment carts reviewed, and 1 of 5 medication carts reviewed, which placed residents at risk for accidental ingestion. Observations of 4 of 5 medication carts and 2 of 3 medication rooms revealed staff failed to ensure expired medications and biologicals were disposed of timely, and that medications were not dated when opened which detracted from staff's ability to determine if these medications were expired. Findings included . According to the November 2017 facility policy titled, Labeling and Storage of Drugs and Biologicals, the facility stores drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. This policy stated, for medications designed for multiple administrations, the label identifies the specific resident for whom the medication was prescribed. The policy also indicated that if a mulit-dose vial was been opened or accessed, the vial should be dated and discarded wtihin 28 days unless the manufacturer specifies a different date for that opened vial. South Medication Cart Observation of the South Medication Cart with Staff E (Registered Nurse) on 10/05/2021 at 10:00 AM, showed a clear glass bottle containing white tablets. A piece of tape strapped across the bottle was handwritten, Sodium Bicarb [an antacid medication]. There was no other identifying information on the bottle. When asked the dose of pills or for whom they were intended, Staff E (Registered Nurse) replied, It's not labeled, it should be labeled. Observed in the second drawer of the medication cart, amongst oral medications were noted two oranges and a banana. In an interview at this time, Staff E stated, Maybe that's for a snack for residents. When asked if food should be stored with medications, Staff E stated, I should take those out. South Medication Room Observation of the South Medication Room on 10/05/2021 at 10:08 AM, Staff C (Resident Care Manager- Registered Nurse) showed a plastic bag with multiple IV (Intravenous- a method by which medications are administered directly into a vein through a hollow tube) Heparin (a medication that prevents blood clots) flushes for Resident 143. Record review showed Resident 143 discharged from the facility on 06/14/2021. In an interview at this time, Staff C indicated medications and treatments should be removed from medication carts and medication rooms when residents are discharged . A bag of IV normal saline was observed with a label, expires [DATE]. In an interview at this time, Staff C confirmed the IV solution was expired, and stated, We should contact the pharmacy and ask them what they want us to do. Also identified was a bag of IV fluids (5 % dextrose and 0.45% sodium) for Resident 144, who discharged from the facility on 06/09/2021. Observation of over-the-counter medication storage showed a bottle of Niacinomide (a dietary supplement) which Staff C confirmed was expired in June of 2021 and a bottle of Cetirizine (an allergy medication) which Staff C confirmed expired 04/10/2021. Also noted was a house supply of Benadryl (an allergy medication) 25 milligrams (mg) tablets which Staff C confirmed expired in August 2021. In the medication room was a drawer containing bags of multiple personal home medications for multiple residents. In an interview at this time, Staff C stated any medications brought into the facility from an outside pharmacy was kept in the medication room and returned to the resident at the time of discharge. A bag of resident's home medications, including but not limited to: Vitamin D2, Glipizide (an oral diabetic medication), Lisinopril (antihypertensive medication) x 2 and Lasix (a diuretic) was noted for Resident 145. When asked if the resident remained in the facility, Staff C stated, [They were] a patient here. Record review showed Resident 145 was discharged on 09/27/2021. Observations showed multiple medications including inhalers and Levetiracetam (a seizure medication) and multiple other oral medications for Resident 146, who was discharged on 07/13/2021. A plastic bag of multiple medications (inhalers, nasal sprays, cardiac medications and others) of outside medications were noted for Resident 147 who discharged three months previously on 07/05/2021. Review of the Refrigerator in the South Medication Room Review of the medication room refrigerator showed multiple bags of IV antibiotics for Resident 148 who discharged from the facility on 09/17/2021. Multiple multi-dose syringes of insulins were noted in the bottom drawer of the refrigerator for Resident 149. Record review showed Resident 149 discharged on 04/13/2021. Multiple multi-dose syringes of insulin were noted for Resident 150, who discharged from the facility three months previously on 07/02/2021. Levemir insulin was identified for Resident 151, who discharged from the facility on 04/21/2021. Insulin was identified for Resident 152, who discharged from the facility on 06/24/2021. Humulin insulin, dated as dispensed from the pharmacy on 04/03/21, was identified for Resident 154 who discharged from the facility on 06/22/2021. Also identified was insulin for Resident 153, who discharged from the facility on 05/07/2021. In an interview on 10/05/21 at 10:31 AM, when asked, who was responsible to review the medication room for expired medications or medications for discharged residents, Staff C replied, Central supply for the over-the-counter medications and nurses for the fridge. When asked which nurse and what shift was responsible, Staff C replied, The medication nurse. I am not sure what shift. Staff C confirmed it did not appear staff ensured medications were removed at the time of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure prompt dental services were provided for five (Residents 5, 74, 28, 65, and 77) of six residents reviewed for dental services. These failures placed the residents at risk for unmet dental needs, and a diminished quality of life. Findings included . According to the November 2017 facility policy titled, Dental Services the facility provides supplies for and assistance with dental/ oral care. This policy indicated the facility assisted with referrals promptly within three business days of receiving information of residents with lost or damaged dentures for denture services. The policy also stated if the facility was unable to make a referral within three business days, Social Services provides documentation of what was done to support the resident to eat and drink adequately while awaiting dental services. Resident 5 Resident 5 admitted to the facility on [DATE] and according to the 04/13/2021 admission Minimum Data Set (MDS - an assessment tool), was assessed with no teeth. According to the Care Area Assessment associated with this MDS, staff documented, Resident has a full set of upper and lower dentures. She denies any issues with her teeth or gums and reports her teeth fit well. Care plan [CP] will proceed with approaches for ensuring her oral hygiene and denture care is completed. According to a CP dated 04/14/2021, the resident was identified with oral/ dental health problem related to having no teeth. The CP showed interventions of has upper and lower dentures assist with cleaning and placement as needed. Observations on 10/06/2021 at 8:48 AM showed the resident was wearing only upper dentures. At this time the resident stated, One night I put the bottoms in a glass they threw them away .they were gonna get me new dentures on the bottom, but they haven't. That's why I have a hard time eating. Observations on 10/08/21 at 12:18 PM showed Resident 5 did not eat the medallion carrots that were served for lunch stating, They're too hard, I can't chew 'em. In an interview on 10/08/2021 at 12:45 PM, Staff T (Appointment Scheduler) indicated Resident 5 was not on the current list for dentures. In an interview on 10/08/2021 at 12:25 PM, Staff C (Resident Care Manager, Registered Nurse) stated Nursing was unaware the resident's lower dentures were missing. Observations on 10/11/2021 at 12:07 PM showed the resident did not eat the carrots that were served with the lunch meal. In an interview at this time, the resident indicated they didn't eat them because they couldn't chew them. In an interview on 10/11/2021 at 8:54 AM Staff F (Social Service Director) stated, Yes, I knew they [lower dentures] were missing, I know there was a grievance. I think what may have happened with this is [they] told us [their] dentures were missing and we spoke with [them] and [their] family, we said we could replace them. [The Resident] was referred to the dentist. Staff F was unable to state when the dentures went missing or if there was a plan for a dental appointment. Review of the facility grievance log showed no grievance for Resident 5's missing dentures. Record review showed no indication the resident had missing dentures or any plan to have them replaced. When asked, in an interview on 10/11/2021 at 8:54 AM, if staff should evaluate the resident's ability to chew upon identification the dentures were missing, Staff F replied, Yes. Record review showed this did not occur. In an interview on 10/12/2021 at 8:27 AM, Staff T provided the dental exam list for 8/25/2021 for which Resident 5 was to receive an Exam - check white deposits . According to the Smile Seattle Dentures form from 08/25/2021 showed the resident had upper dentures and lower edentulous with a recommendation of new dentures upper and lower. In an interview at that time, when asked why the reason for the dental referral list didn't mention dentures, Staff T stated, I forgot to add about that. Resident 74 Resident 74 admitted to the facility on [DATE] and according to the 09/17/2020 admission MDS, was assessed with no dental problems. According to the admission Nursing Evaluation dated 09/11/2020, the resident was assessed with upper and lower partial dentures. CP documents dated 09/13/2020 and revised on 03/15/2021 showed the resident had upper and lower partial dentures. According to the undated [NAME], direct care staff were advised the resident had Partials - upper/lower. In an interview on 10/06/21 at 9:59 AM, Resident 74's teeth appeared carious with white debris in the gumline. The resident stated, I've had lots of problems with my teeth, I've had them quite a while. The resident was noted at this time without any dentures or partials. According to the Smile Seattle Dentures consult form dated 12/16/2020, Resident74 was identified with decayed teeth, missing teeth, and a broken tooth (number 23). The doctor identified at this time no dentures or partials used at this time. During an observation on 10/08/2021 at 9:12 AM, Staff D (Resident Care Manager, Licensed Practical Nurse) confirmed the resident did not have either upper or lower partials in their mouth or anywhere in the resident's room. Staff D interviewed an aide at that time who stated they were not aware Resident 74 ever had any partials. In an interview on 10/11/2021 at 11:15 AM, Staff D indicated nursing staff did not know the partials were missing stating, It should be on the CP. Staff D indicated staff were unaware of how long they were missing, but direct care staff should have reported they were missing as the CP informed them of the need for the upper and lower partials. In an interview on 10/11/21 at 1:16 PM when asked if it would it be important to find out if a resident was missing dentures or partial, Staff Y (Food Service Manager) stated, Yes, I would get speech involved to see if they had difficulty chewing; see if they want to do a temporary down grade 'til they get their dentures back . Record review revealed no such assessment took place for Resident 74. Telephone orders dated 10/11/2021 Referral to denturist, for missing partials upper and lower, referral to dentist for teeth cleaning evaluation. Resident 28 Resident 28 admitted to the facility on [DATE] and according to the Quarterly MDS dated [DATE], was identified with broken or loosely fitting partial dentures. In an interview on 10/06/2021 at 9:40 AM, Resident 28 stated, I have upper dentures, but they don't fit, they hurt when using them to chew. Observations at this time showed Resident 28's lower natural teeth were observed to have dark/ yellowish debris around their gumline and to have decayed teeth. Review of Smile Seattle Dentures consult dated 12/16/2020 revealed, Resident 28 notified the dentist [they] had difficulty wearing dentures and would like new dentures. Resident 28's partial dentures were loose or not fitting and recommendation of new upper dentures. In an interview on 10/11/2021 at 1:17 PM, Staff T, confirmed Resident 28 was not scheduled for dental appointment and the referral was not followed. Record review revealed no indication that staff ever attempted to set up a dental appointment for Resident 28 as recommended on 12/16/2020. In an interview on 10/12/2021 at 12:06 PM. when asked for any indication the facility attempted to set up a dental appointment for Resident 28 to have new dentures, Staff C stated, I don't see anything on the resident's file. Resident 65 According to the 09/10/2021 Quarterly MDS, Resident was assessed to have obvious or likely cavity or broken natural teeth. In an interview on 10/06/21 at 10:43 AM, Resident 65 stated they had a raging toothache and that they needed dental care. Resident 65 was observed at that time to have extensive tooth decay in their upper front teeth. Review of the electronic health record revealed scanned paperwork from an 08/25/2021 dental appointment that identified Resident 65 had six decaying teeth, four missing teeth and one broken tooth. The paperwork referred Resident 65 for x-rays and evaluation. In an in interview on 10/14/21 at 10:58 AM, Staff D stated that the paperwork for the 08/25/2021 appointment had not been uploaded until 09/25/2021, and they were unsure if an appointment to follow up for x-rays and evaluation was made I'll have to see and get back to you. Staff D provided no further information. Resident 77 Resident 77 was re-admitted to the facility on [DATE] and according to the 09/22/2021 Significant Change MDS was assessed with medically complex conditions, including malnutrition, and required extensive physical assistance for personal hygiene. According to a CP dated 07/16/2021, Resident 77 was identified with an alteration in oral hygiene related to upper dentures with a goal to maintain dentures in good repair. This CP directed staff to refer to dentist for evaluation as needed and to place dentures in resident's mouth before meals. Review of Resident 77's Inventory of Personal items dated 07/13/2021 showed Resident 77 admitted with upper and lower dentures. Resident was subsequently hospitalized and readmitted to facility on 09/16/2021. Review of Resident 77's Inventory of Personal items dated 09/16/2021 was blank and was not completed by staff. Review of the 09/16/2021 Nursing admission Evaluation form indicated Resident 77 had full upper dentures on re-admission. In an interview on 10/05/2021 at 9:24 AM, Resident 77 stated they did not have dentures and did not believe they owned any. Observations at this time showed Resident 77 with no upper teeth and two broken teeth at gumline to lower jaw. Similar findings were observed on 10/08/2021 at 8:59 AM. Observation on 10/08/2021 at 9:00 AM showed Resident 77 with tray in front of them and was finishing breakfast. In an interview at this time, Staff EE (Certified Nursing Assistant) stated they were not aware if Resident 77 had any dentures and indicated they have not seen the resident wearing any. Review of 10/08/2021 Dietary Profile for Resident 77 showed Staff Y documented Resident is missing teeth. No further documentation by staff regarding Resident 77 missing dentures or referrals made for dentist. Observation on 10/11/2021 at 12:22 PM with Staff D showed Resident 77 without dentures in their mouth and Staff D was unable to locate dentures in the resident's room. Staff D stated it should have been reported to nursing staff if Resident 77's dentures were missing. In an interview at this time, Resident 77 stated they did not have dentures and were unsure where they went. In an interview on 10/14/2021 at 8:48 AM, Staff F stated they were unaware of any missing dentures or referrals to dental for Resident 77. REFERENCE: WAC 388-97-1060 (3)(j)(vii). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 6 Resident 6 was admitted to the facility 10/17/2020 and according to the 10/22/2020 admission MDS was assessed as cognitively intact, able to make their own decisions and could make their needs known. In an interview on 10/05/2021 at 11:05 AM, Resident 6 stated the food is yuck, it is cold most of the time, same thing over and over. They know what I do not like, it still shows up on my tray; yesterday was pancakes on the menu, my tray ticket showed I do not like them, I was served pancakes anyway and I did not eat breakfast. They do have alternates; they do not publish a menu anymore. When I asked if I could have a menu, they said yes, but never gave me one. I must call the day before to see what is being served for lunch and dinner. They will not cook something different unless ordered by 11:00 AM the day before. An observation on 10/06/2021 at 12:20 PM showed a stack of menus at the nurse's station. Resident 6 looked at the menu and stated, they used to send this weekly, I have not received one in a long time. Resident 6 stated, the menu did not show the alternate meal. The resident called earlier in the day and found out the alternate was a turkey sandwich if you did not like the egg salad sandwich. Resident 6 stated they must call the kitchen or would not know what the alternative was for lunch. In an interview on 10/06/2021 at 12:23 PM Staff L (LPN) stated there is usually two entrees at lunch and dinner, looked at menu and stated, the alternate was not listed on the menu but could call the kitchen to request. Staff L stated there is no alternate for breakfast. Staff L stated the menu used to go to the residents weekly on the Saturday or Sunday meal tray. Staff L stated they had not seen menus provided to the residents in a long time, but if the resident asked they could get one from the kitchen. An observation on 10/08/2021 at 8:34 AM (tray service started at 8:15 AM) showed Resident 6 awake, lying on the bed with the lights off using a tablet. A tray of breakfast was on the overbed table pushed to the side untouched. Resident 6 stated I'm not eating this, lifted the lid and stated the eggs were cold, they did not like hot cereal, and it was cold anyway and stated they might eat the coffee cake later. The tray was observed later inside the kitchen cart with only the coffee cake missing. The tray ticket showed the resident did not like hot cereal, pancake group or French toast. An observation and interview on 10/11/20201 at 1:22 PM, Resident 6's meal tray was on the bedside table untouched. When asked how was lunch, Resident 6 uncovered the plate and stated look at all that ketchup covering the meatloaf, there is hardly any meat there, those carrots are brown, would you serve that to your family? I sure would not. Resident 6 stated, I am not going to eat that which means, I am not getting lunch today. Resident 6 stated they would not be asking for something else to eat because they would have had to order it yesterday. Resident 25 An observation on 10/11/2021 at 11:38 AM showed Resident 25 yelling from bed to hallway stated Help me, help me- I am hungry. Help please- I'm having Help, Help. Is anyone getting food, can anyone get water? Can I take some food? Can I please, can I get something, I can't find it. At 11:44 AM Resident 25 was still yelling out, help me. Is there anyone out there to get me (garbled)? Help me help me. Please help, please help, help can I talk, can I eat? When entered the room, the curtain was closed, Resident 25 was in bed with left leg off side of bed, was laying sideways, the blanket and sheet was wrapped in ball on top of the resident. When asked, Resident 25 was not able to reach the call button located at the head of the bed, clipped to the sheet out of the resident's reach. Resident 25 stated they were calling out for something to eat. An interview at 12:10 PM Staff HH (CNA) assigned to Resident 25 was told about the calling out and stated, it is almost lunch time, and I will bring them a tray. An observation and interview at 12:37 PM, Resident 25 was again yelling Help, help, please help. Resident 25 stated they did not receive lunch yet and was hungry. At 12:44 PM (lunch tray service started at 12:15 PM) Resident 25's meal tray was still on the kitchen cart; it was the last tray on cart. Staff HH walked out of room next door to Resident 25 with bag of trash and walked down the hall. At 12:50 PM Staff HH delivered a tray to Resident 25 and did not reheat the food. Staff HH removed the plate warmer and cover from the plate and took them out in the hall to the kitchen cart. Then Staff HH went to get help to reposition the resident in bed. Staff L (LPN) entered room with Staff HH at 12:55 PM. In an observation and interview with Staff L (40 minutes after tray service started), found the meal tray contained meatloaf, mashed potatoes, and cooked carrots. Resident 25 was eating the carrots quickly with their fingers and stated the food was cold, but they were so hungry. Staff L stated the food could be re-heated. Resident 25 said, no they did not want to wait. Resident 18 An assisted dining room observation and interview on 10/06/2021 at 12:10 PM, Resident 18 was observed to have difficulty with fine motor skills and needed some assistance with eating. There was a large scoop of egg salad, untouched on the plate and an uneaten whole orange in the peel. Resident 18 was asked how lunch was today and replied they did not like egg salad and pointed to the tray ticket which showed egg salad on the dislike list, and it was circled. Resident 18 stated they got a banana or orange every day and only wanted one occasionally. Resident 18 stated they needed help to peel the fruit and must ask for help every day, it did not come to them peeled or set up by staff ready to eat. The tray ticket did not show the fruit needed to be peeled and ready to eat. Staff II (Administrator in Training) stated they already identified, circled, and resolved the issue of egg salad and would notify the kitchen. Staff II gave Resident 18 pudding as a replacement to the egg salad instead of the turkey sandwich alternate. An observation and interview on 10/11/21 at 12:15 PM in the assisted dining room, Resident 18 stated they wanted gravy on potatoes, they asked and did not receive gravy because it was not available in the dining room, only the kitchen. In an interview 10/11/2021 at 1:42 PM Staff D (RCM) stated the caregivers are expected to check the tray ticket before delivering the tray to the resident. Staff D stated the resident preferences should be followed, and if a resident did not like pancakes and it was on the tray ticket, then pancakes should not be served to that resident. Staff D stated when the tray is picked up and the resident has not eaten, it would be expected that an alternate food of same nutritional value would be offered or if the resident ate less than half of the meal, a supplement drink would be provided. REFERENCE: WAC 388-97-1120(2)(a), -1100(1), -1140 (6). Resident 39 According to the 08/15/2021 Significant Change MDS the resident admitted on [DATE]. On 07/08/2021 the resident was discharged to the hospital and returned to the facility on [DATE]. Review of the resident's clinical record showed a 10/06/2021 Facility Dietary Profile that included the resident's preferences, likes and dislikes. Resident 39 preferred 2% milk, orange juice and cold cereal for breakfast. For lunch the resident preferred other please specify, no others specified in the Dietary Profile. For dinner the resident preferred 2% milk. The resident likes were listed as corn, veggies and mashed potatoes and dislikes were scrambled eggs. During an interview on 10/05/2021 at 12:35 PM Resident 39 stated that they like vegetables but their tray card stated they do not like vegetables. On 10/07/2021 at 12:24 PM Resident 39 was observed with their lunch tray, that consisted of shredded beef, green beans, mashed potatoes, white dinner roll and spiced peaches for dessert. Resident stated they prefer wheat bread but are served white bread. On 10/08/2021 at 12:09 PM Resident 39 was observed with their lunch tray, that consisted of shrimp, mashed potatoes, asparagus, garlic bread, a glass of water and berry crisp for dessert. Resident 39 stated they prefer apple juice, but it never comes on their meal trays. On 10/12/2021 at 12:23 PM Resident 39 was observed with their lunch tray that consisted of a chicken taco, black beans, zucchini squash, a glass of milk and pudding for dessert. During an interview on 10/13/2021 at 11:36 Staff B (Director of Nursing) provided a 08/17/2021 paper copy of a food preference interview that was not part of the resident's record. Review of Resident 39's food preference interview showed the resident preferred apple juice for breakfast, lunch and dinner. They preferred wheat bread and most vegetables except zucchini and squash. The food preference interview was completed a month after the resident admitted to the facility. Staff B stated the Dietary Manager collects resident preferences and it is expected to be done within eight days after admitting to the facility. Staff B agreed the dietary profile was completed late on 10/06/2021 when resident admitted on [DATE] and the preferences were not followed. Resident 51 According to the 08/30/2021 admission MDS the resident admitted on [DATE]. On 10/07/2021 at 12:29 PM Resident 51 was observed with their lunch tray that consisted of shredded beef, baked beans, green beans, corn bread, 5 ounces (oz) glass of milk and a fruit cup for dessert. On 10/07/2021 at 12:29 PM Resident 51 stated that they told an aide they needed 8 oz of milk for the extra protein instead of 5 oz, but they couldn't remember who they told. Resident 51 stated the staff member told them to talk to the dietary manger, but they had been there for over 6 weeks and no one from the dietary department had come to see them. Review of Resident 51's tray card showed a regular diet, regular texture with a special request of 8 oz of 2% milk. Review of Resident 51's record revealed a 10/11/2021 Dietary Profile that included the resident's preferences, likes and dislikes. The resident preferred 2% milk and apple juice for breakfast, for lunch the resident preferred other please specify, no others specified in the dietary profile. For dinner the resident preferred 2% milk. The resident's likes were listed as real butter and extra sauce and dislikes were listed as beans. On 10/12/201 at 12:00 PM Resident 51 stated that someone from the dietary department came to talk with them about preferences, likes and dislikes. In an interview on 10/14/2021 at 9:01 AM Resident 51 stated they have asked for real butter because they prefer it, but margarine is served on their tray. During an interview of 10/14/2021 at 11:36 AM Staff B (Director of Nursing) agreed that the preferences were obtained late and not within 8 days after admitting. Resident 73 According to the 09/17/2021 admission MDS, the resident admitted on [DATE]. In an interview on 10/06/2021 at 12:54 PM Resident 73 stated that they get a whole turkey sandwich and cottage cheese every day for lunch. It is one of those things, you don't know who to talk to. I have told them I prefer only half a sandwich, but they send me a whole sandwich and don't cut it in half for me. On 10/07/2021 at 12:22 PM Resident 73 was observed with their lunch tray which consisted of a whole turkey sandwich, cottage cheese, fruit, a side of peanut butter, a glass of milk and coffee. On 10/08/2021 at 12:22 PM Resident 73 was observed with their lunch tray that consisted of shrimp with lemon butter, mashed potatoes with gravy, asparagus, cottage cheese, a side of peanut butter and a glass of water. When asked why they weren't sent their usual lunch of a turkey sandwich, Resident 73 replied a young lady came in here and went over my preferences, likes and dislikes. Review of the resident's clinical record showed a 10/8/2021 Facility Dietary Profile that included the resident's preferences, likes and dislikes. The resident preferred 2% milk and orange juice for breakfast, for lunch the resident preferred other please specify, no others specified in the dietary profile. For dinner the resident preferred 2% milk. The resident's likes were listed as pudding, yogurt and cottage cheese and dislikes were fish and scrambled eggs. During an interview of 10/14/2021 at 11:36 AM Staff B (Director of Nursing) agreed that the preferences were obtained late and not within 8 days after admitting. Based on observation, interview and record review the facility failed to ensure 5 (55, 142, 39, 51, & 73) of 11 residents reviewed for preferences, including 3 supplemental residents (6, 25 & 18) received food that accommodated the resident's preferences and intolerances, served timely at an appropriate temperature, and was palatable and visually appealing. This failure placed the residents at risk for dissatisfaction with food and weight loss. Findings included . Resident 55 Resident 55 admitted to the facility on [DATE] and according to the 09/03/2021 admission Minimum Data Set (MDS- an assessment tool) was assessed as cognitively intact, able to understand and be understood in conversation. In an interview on 10/05/2021 at 1:10 PM Resident 55 stated they continued to get oatmeal instead of cornflakes, despite repeated requests for cornflakes. An observation on 10/06/2021 at 8:15 AM showed the resident was served oatmeal despite the tray card that clearly stated, Cornflakes in place of oatmeal. In an interview on 10/06/21 at 8:04 AM, Resident 55 stated, They serve the same breakfast food, just slight variances of eggs, toast is cold, breakfast is cold. The resident also stated he received the same evening snack daily of peanut butter and jelly sandwiches. Review of Physician Orders dated 09/01/2021 showed nursing staff were directed to serve an evening snack four nights a week of a peanut butter and jelly sandwich. Observation of the South hall snack refrigerator on 10/07/2021 at 8:24 AM showed the only type of sandwich was peanut butter and jelly. Observations of the lunch meal on 10/06/2021 showed resident 55 received a scoop of egg salad. In an interview on 10/06/2021 at 12:20 PM, Resident 55 stated, You missed it, we got a big flaky croissant, and we're supposed to put the egg on it. The resident gestured to the scoop of egg and stated, This is an egg salad sandwich, they make us do the work but my buddy over there (roommate) only has one good arm and can't make a sandwich of it. According to the menu the resident was supposed to be served an egg salad sandwich on a croissant with lettuce and tomato. The resident received a scoop of egg salad, the croissant, but no lettuce or tomato. In an interview on 10/06/2021 at 12:33 PM, Staff Y (Food Service Manager) confirmed that if the menu said an egg salad sandwich, It should be a sandwich. In an interview on 10/07/2021 at 8:04 AM the resident expressed concern that they received, No meat, I don't get meat at breakfast that's what we'd (roommate) like, another protein with the eggs, because it seems like scrambled eggs is all we get. Sometimes eggs with potatoes but no other meat, no bacon or sausage or turkey links or turkey bacon. Review of Resident 55's record showed they received a Controlled Carbohydrate 2 Gram (Gm) Sodium (NA) diet. Review of the menus showed that on the day Biscuits and Gravy was served, the residents on a 2 Gram Sodium diet received scrambled eggs. On the day pancakes and bacon were served, residents on the 2 Gm NA diet received scrambled eggs and no bacon. When the menu called for a baked cheese omelet, the 2 Gm NA diet received scrambled eggs. When the menu called for french toast and sausage patty (10/11/2021), 2 GM NA diet received scrambled eggs and no sausage patty. Review of the menu from 10/03/2021 through 10/09/2021 showed, based on diet, Resident 55 received scrambled eggs on five of seven days and no bacon or sausage. Menus reviewed did not meat alternatives available for breakfast as residents preferred. Observation of the lunch meal on 10/07/21 at 12:23 PM showed Resident 55 was served a slice of pork, rice, and green beans. The resident stated, This is the bland rice I was telling you about. Also, I always get water with lunch, I'd like something else to drink, they gotta have some sort of sugar free Kool-Aid drink. The resident stated, after sampling the pork, that it was dry. Observations on 10/08/2021 at 12:15 PM showed Resident 55 was served Shrimp [NAME] and an unidentifiable green vegetable which the resident stated was okra. According to the menu, steamed asparagus cuts were served with lunch. In an interview at this time, the resident stated he was served only water with his lunch meals. Observations of the lunch meals on 10/06/2021, 10/07/2021, and 10/08/2021 supported this statement. Resident 142 Resident 142 admitted to the facility on [DATE]. According to the Medicare 5-day MDS, the resident was assessed as cognitively intact, clear speech, able to understand and be understood in conversation and had no dental issues. In an interview on 10/05/2021 at 1:35 PM, Resident 142 stated the food, gets cold fast and staff did not inquire about their ethnic preferences stating, Nobody has ever asked me if I want a snack, I've had snacks from the vending machine, but I have to walk down there to get them. The resident elaborated that the food lacked seasoning and they serve mainland food, meat and potatoes, meat and a roll, nothing like any food that I would like to have from home. My daughter will bring food in, they'll buy some fried rice, I don't like this haole (a disparaging word to describe non-Polynesian inhabitants of Hawaii) food. In an interview on 10/05/2021 at 1:38 PM, Resident 142 stated they were lactose intolerant, They give me ice cream I don't eat it; they give me sherbet, I eat that. Nonfat milk, skim I can drink. Observation of the breakfast meal on 10/07/21 at 8:10 AM showed Resident 142 sitting at the bedside with their breakfast tray stating, I normally use sugar or brown sugar on oatmeal, this is wall paste. When asked why the resident wasn't eating the yogurt that was served, the resident replied, I don't know why they gave it to me, I only ate a little bit because it didn't say dairy free. The resident indicated they were lactose intolerant and could only drink low fat milk. The resident elaborated that despite being lactose intolerant, they are still served dairy products. Observation of the lunch meal on 12/07/2021 at 12:05 PM showed the resident was served a slice of pork, rice and green beans. The resident stated, This is part of the pork we got days ago, I can hardly chew it, why doesn't it have gravy? The chicken we had the other day was dry too. How am I supposed to chew this? Staff U (Registered Nurse) who was present offered to cut the meat stating, Yes I can see it's dry and offered the resident a peanut butter and jelly sandwich. At this time, the resident questioned why there were no choices for meals. In an interview on 10/11/2021 at 8:21 AM Resident 142 indicated they were still mad about the dry pork stating, Even if you put it in water, it wouldn't soak it up it's just too bad the meat is always hard and hard to eat . System for alternate meals In an interview on 10/12/2021 at 11:52 AM, Staff Y was asked how staff knew what the resident preferences were for meals, for instance, on 10/12/2021 the meal was chicken tacos with an alternate of meatballs. Staff Y indicated staff went off the resident's dislikes, so if the resident disliked chicken they would get the beef meatballs, the dislikes are printed on tray card, if both things were on the dislikes, I would go to talk to them. Staff Y explained the residents had a choice from the menu located at the nurse's station. Staff Y stated, They just have to ask their caregiver for it then they can fill it out. When Staff Y was informed by the residents, at the resident council meeting, many didn't know about the menu being available, Staff Y stated, Activities used to pass it out and get it filled out and back to us. Staff Y explained these menus went to the nurses every Saturday but was unable to explain how staff distributed the menus to residents so they could make choices between the main meal and the alternate. When asked how many alternate meals were requested for today (10/12/2021) Staff Y said, One, but it was for a hamburger which is on the always option menu. When asked how many alternates were requested for the previous day, she indicated no alternate meals were requested from the alternate menu, only from the list of foods that were always available (hamburger, chef salad, hotdogs, fruit plate). When asked how residents were informed of the food choices, Staff Y stated, You may have something there.

Based on interview and record review, the facility failed to develop a thorough facility-wide assessment to determine the resources needed to care for residents. Failure to accurately complete all components resulted in an assessment that lacked: a thorough profile of the resident population; a comprehensive staffing plan; staff training/education and competencies; policies and procedures for provision of care; an assessment of health information technology, and evaluation of the infection control program. This failure placed all residents of the facility at risk for unmet care needs. Findings included . Review of the 09/30/2021 Facility Assessment showed the facility used the Centers for Medicare and Medicaid Services facility assessment template and had not fully assessed the areas identified below. Resident Profile (Section 1.4) The facility assessment failed to identify which residents smoked and if the facility accepted residents who currently smoked. Ethnic, Cultural and Religious Factors (Section 1.6) The facility assessment listed Ethnical, Cultural, or Religious factors as variances in languages and dietary considerations. According to the facility assessment there were multiple residents with English as a second language and had cultural food preferences. The assessment did not identify which languages besides English residents listed as their primary language, or what specific dietary considerations were prevalent for the facility's population. Staff Type (Section 3.1) The facility assessment did not address lab service providers, wound care service providers, hospice providers, or diagnostic service providers. Staffing Plan (Sections 3.2 and 3.3) The facility assessment's Staffing Plan did not address how the facility determined and reviewed individual staff assignments for coordination and continuity of care. The assessment failed to address the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet each residents needs. The facility failed to complete the second part (Section 3.3) of the staffing plan that included how the facility determined and reviewed individual staff assignments for coordination and continuity of care for residents within and across the staff assignments. The facility failed to identify how many staff were needed for an average daily census, how many residents would be assigned to each staff member, or, when there were fluctuations in census, how staffing would be determined. Staff Training/Education and Competencies (Section 3.4) Review of the Competencies section showed the facility did not address which staff required which competencies in order to provide the level and types of support and care needed for the facility's resident population. The assessment failed to address staff education requirements including on-boarding/new hire education, and annual education requirements. Policies and Procedures for Provisions of Care (Section 3.5) The Policies and Procedures for Provision of Care section of the facility assessment should indicate how the facility evaluated which policies and procedures were required for the provision of care, and how the facility would ensure their policies and procedures met current professional standards of practice. The facility assessment stated they worked with medical practitioners to ensure: staff have the capabilities required to care for resident's clinical needs; community and societal considerations (i.e. natural disasters, pandemic, community events and changes to current resident population); adoption of new clinical skills and services through acquired skills, certification and training; changes to the admission inventory, Dear Administrator letters and changes to the requirements of participation for Medicare and Medicaid. The facility failed to address how they evaluated policies and procedures, how often policies and procedures were reviewed and revised, or who is responsible for revising policies and procedures. Section 3.6 of Policies and Procedures for Provisions of Care addressed the process by which management, staff and direct care nursing staff should familiarize themselves with the standards of care and competencies required by the resident population, as assessed by medical practitioners/other healthcare professionals. The facility documented they provided policies and procedures to medical professionals operating in the facility. The medical professionals were invited to a monthly corporate call to review changes in policies or procedures. The facility failed to address how the management staff and direct care nursing staff would familiarize themselves with expectations of medical practitioners following their review. Health Information Technology (Section 3.10) The facility assessment failed to identify how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility. Additionally, the facility assessment did not address when and how to implement the procedure for downtime and how the facility ensured that residents and their representatives could access their medical records upon request and obtain copies within required timeframes. Infection Control (Section 3.11) Review of the Evaluation of the Infection Control Program showed the facility failed to identify how their Infection Control Program would be evaluated for effectiveness. The facility assessment did not identify specific prevalent organisms identified in the resident population, the prevalence of Multi-drug resistant organisms (MDRO) in the facility population, and how the data collected was used to evaluate whether changes needed to be made to the Infection Control Program. In an interview on 10/14/2021 at 10:11 AM Staff A (Administrator) stated that the facility normally utilized 5 nurses and 10 certified nurses assistants based on the average daily census and that they were unsure if that was reflected on the facility assessment. Staff A stated the facility assessment did not address the following: equipment needs for an average daily census and during an emergency; transportation needs and options in an emergency; how many residents required oxygen/a Continuous Positive Airway Pressure (CPAP) machine/tube feeding equipment/ an IV (Intravenous) pump. Staff A stated that those topics would be addressed in the facility's emergency preparedness and risk assessment. Staff A stated they didn't feel these topics should be included in the facility assessment as they pertained to emergency preparedness. REFERENCE: WAC 388-97-1620(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for 8 (Residents 142, 5, 55, 65, 77, 39, 74, 63 & 38) of 24 residents whose records were reviewed. The Facility failed to ensure: staff completed and maintained resident inventories; documents were entered into resident records timely. Failure to ensure clinical records were complete and accurate placed residents at risk for unmet care needs and lost property. Findings included . Personal Inventories Resident 142 Record review on 10/10/2021 showed Resident 142's personal inventory was blank. In an interview on 10/11/2021 at 8:50 AM Staff C (Resident Care Manager, Registered Nurse) confirmed the inventory was blank. Staff C explained blank inventories are provided to residents on the morning of discharge for them to fill out. Staff C stated the purpose was to establish at that time if anything was missing so that the social worker could be informed. Staff C confirmed personal inventories should be completed at the time of admission and updated when new items were brought into the facility. Resident 5 Resident 5 admitted to the facility on [DATE] and according to the 04/13/2021 admission Minimum Data Set (MDS - an assessment tool), was assessed with no teeth. According to the Care Area Assessment associated with this MDS, staff documented, Resident has a full set of upper and lower dentures. She denies any issues with her teeth or gums and reports her teeth fit well. Care plan will proceed with approaches for ensuring her oral hygiene and denture care is completed. A Computerized Inventory of Personal Items dated 04/10/2021 was blank and reflected that clothing items were not marked and did not reflect the presence of any belongings, including dentures. In an interview on 10/08/2021 at 8:20 AM, Staff D (Resident Care Manager, Licensed Practical Nurse) indicated it was important to complete personal inventories in order for staff to confirm or refute any issues with missing items. Resident 55 Resident 55 admitted to the facility on [DATE] and, according to the 09/03/2021 admission MDS, was cognitively intact and understood and able to understand conversation. Record review showed a personal inventory which was blank. A separate inventory scanned in on 09/01/2021 was incomplete and did not include all the resident's current clothing items. Resident 65 In an interview on 10/06/2021 at 11:14 AM, Resident 65 stated that they were missing their purse. Resident 65 shared their concerns regarding a missing purse with facility staff on 02/10/2021, 04/13/2021 and 09/14/2021, according to corresponding progress notes on those dates. In an interview on 10/14/2021, Staff F (Social Services Director) stated Resident 65 complained about a missing purse upon admission, and further stated Resident 65's guardian confirmed Resident 65 had a purse. Staff F stated that it was important for staff to complete inventories upon admission, and that in the absence of an inventory in a resident's record, it was not possible to verify whether a given item is missing. Staff F stated they were unsure if there was a completed inventory for Resident 65, and they would provide a copy, if located. No copy was provided. Resident 77 Record review on 10/07/2021 showed Resident 77's personal inventory was blank upon re-admission to facility on 09/16/2021. In an interview on 10/11/2021, Staff D confirmed Resident 77's personal inventory form was blank and stated a new inventory should be completed on re-admission to find out if anything was missing or changed. Staff D stated not having a complete inventory with each admission detracts from the staff's ability to determine at what point Resident 77's dentures went missing. Resident 39 In an interview on 10/12/2021 at 12:23 PM Resident 39 stated they were missing a dark blue blanket. Review of the record showed no inventory list in the resident's medical record. Late Entries Resident 74 Record review showed multiple posted dated provider notes including: a note created on 06/10/2021 from an encounter date of 05/04/2021; a note created on 09/02/21 for an encounter on 08/31/2021; a note created on 08/05/2021 for an encounter on 07/26/2021; a note created on 08/05/2021 for an encounter date of 07/06/2021, and a note created 06/10/21 for an encounter on 05/13/2021. Inaccurate Assessments/Records Resident 63 Review of Resident 63's electronic health record revealed a 09/24/2021 Psychotropic Medication Assessment that identified Resident 63 as taking Aripiprazole, as well as other psychotropic medications. Further record review showed that Resident 63's order for Aripiprazole was discontinued after a successful gradual dose reduction started in June 2021, with a last dose administered on 07/08/2021. In an interview on 10/13/2021 at 12:31 PM, Staff D, RCM, stated that due to the inclusion of Arpiprazole, the psychotropic medication assessment could not be accurate. Resident 38 Review of the September 2021 Medication Administration Record (MAR) showed a 05/10/2021 order to obtain vital signs every shift. Review of the vital signs showed on 09/06/2021 day shift nursing documented Resident 38 had a pulse of 6. During an interview on 10/13/2021 at 11:21 AM, when asked what action was taken to address Resident 38's pulse of 6 Staff J, (Corporate Nurse Consultant), stated that the pulse was inaccurate. Review of the September 2021 MAR showed a 07/26/2021 order for Propranolol with direction to hold if pulse is less than 55. Review showed on 09/22/2021 the nurse documented a pulse of 18 and still administered the medication. During an interview on 10/13/2021 at 11:21 AM, Staff J indicated 18 was erroneously recorded and the pulse should have been 81, which was consistent with the resident's usual pulse of high 70's. Review of the September 2021 MAR showed a 05/27/2021 order for Lispro insulin sliding scale coverage. The order had three areas for the nurse to document as follows: Units; blood sugar, and the time (e.g., 0730, 1100 etc.). Review of the documentation showed for the 7:30 AM sliding scale coverage staff only documented the units administered 7 times in 31 days. On the other occasions staff documented and X or N/A despite sliding scale being required 19 of the 31 days. It turned out some nurses documented the units of insulin administered in the box along with their initials. Due to this it was difficult to determine how many units the nurse had administered, as some staff initials are followed by a number 1 or 2, and because legend numbers are also recorded in this box (e.g. if staff documented a 2, according to the legend, 2 indicated drug refused. During an interview on 10/13/2021 at 11:21 AM, Staff J stated that nurses should be documenting the units administered in the units box, but acknowledged that did not consistently occur. Similar findings were noted for the 11:30 AM sliding scale. Incomplete Records Resident 77 Resident 77 was admitted to the facility on [DATE] and was subsequently started on Hospice services on 09/17/2021. Record review on 10/07/2021 revealed no evidence of Hospice assessments or Hospice progress notes since Resident 77 was started on Hospice In an interview on 10/08/2021 at 11:11 AM, Staff D confirmed provider notes and recommendations should be obtained by staff and placed in the resident's record the date the services were provided in order to provide continuity of care. In an interview on 10/11/2021 at 11:55 AM Staff Q (Health Information Coordinator) confirmed they just received all the Hospice Provider notes and stated, They (Hospice documents) were in my box this morning. Staff Q indicated it was this facility's first time working with this Hospice Provider and, We are ironing out some kinks. Resident 39 Record review showed no Level I Pre-admission Screening and Resident Review (PASRR) in Resident 39's medical record. In an interview on 10/12/2021 at 1:48 PM Staff F stated Level I PASRRs should be completed prior to admit. Staff F stated they could not locate a Level I PASRR in Resident 39's record and added that one may be located elsewhere. On 10/13/2021 at 2:00 PM Staff F presented Resident 39's 07/02/2021 Level I PASRR and acknowledged it was not scanned in the resident's medical record, but it would be. Review of the Resident 39's medical record showed the 07/02/2021 PASRR scanned in on 10/13/2021. Refer to F849 REFERENCE: WAC 388-97-1720(1)(a)(i-iv)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to employ an effective Quality Assurance and Performance Improvement (QAPI) Program that self-identified deficiencies, investigated causes, developed, and implemented effective action plans, which were closely monitored, to ensure they delivered a desired and sustainable result. Failure to monitor action plans to ensure improvement was sustained, and failure to recognize deficiencies in care and services that were identified during survey and/or previously cited, placed residents at risk for ongoing unmet care needs and diminished quality of life. Findings included . An interview regarding the facility's QAA process was conducted on 10/14/2021 at 10:15 AM with Staff A (Administrator) and Staff J (Corporate Nurse Consultant). Staff A explained the facility's continuous improvement process was based off their plan of correction format: How to correct the issue for identified residents; How to protect residents in sililar situations; measures to take to prevent reoccurrence; plan to monitor performance to ensure the solution is maintained; and the date(s) the corrective action should be completed by. Self-Determination / Provision Bathing 1) The facility was cited on the 02/09/2020 annual survey for failing to honor resident choices related to frequency of bathing. 2) On 04/09/2021 the facility was cited for failure to provide showers to residents who were dependent on staff to meet their bathing needs. 3) On 07/16 2021 the facility was again cited for failure to provide showers to residents who were dependent on staff to meet their bathing needs. 4) On 08/26/2021 the facility was cited for failure [NAME] honor resident choices/ preferences related to frequency of bathing. 5) On 10/14/2021 the facility was cited for both failure to honor resident choices/ preferences related to desired frequency of bathing, and failure to provide showers to residents who were dependent on staff to meet their bathing needs. This was cited only 30 days after the facility had been put back in compliance for the same citation. Professional Standards 1) The facility was cited on the 02/09/2020 annual survey for failure to ensure services provided met professional standards of practice related to following physician's orders and only documenting for tasks that were completed. 2) The facility was cited on the 07/31/2020 complaint investigation for failure to ensure services provided met professional standards of practice related to following physician's orders and only documenting for tasks that were completed. 3) The facility was cited on 04/19/2021 complaint investigation for failure to ensure services provided met professional standards of practice related to following physician's orders and only documenting for tasks that were completed. 4) The facility was cited on 10/14/2021 annual survey for failure to ensure services provided met professional standards of practice related to following physician's orders and only documenting for tasks that were completed. Quality of Care 1) The facility was cited on 2/9/2020 annual survey for failure to ensure non-pressure skin areas and edema were assessed and monitored. 2) The facility was cited on 7/31/2020 complaint investigation for failure to ensure non-pressure skin areas and edema were assessed and monitored. 3) The facility was cited on 10/14/2021 annual survey for failure to ensure non-pressure skin areas and edema were assessed and monitored. Nutrition and Hydration 1) The facility was cited on 02/09/2020 annual survey for failure to identify significant weight changes, assess underlying causes and develop interventions to meet resident specific nutrition and hydration needs. 2) The facility was cited on 07/31/2020 complaint investigation for failure to identify significant weight changes, assess underlying causes and develop interventions to meet resident specific nutrition and hydration needs. 3) The facility was cited on 10/14/2021 annual survey for failure to identify significant weight changes, assess underlying causes and develop interventions to meet resident specific nutrition and hydration needs. Staff A and Staff J were informed the pattern of repeated citations demonstrates thier current system/ methodology was ineffective for monitoring if desired outcomes were attained and sustained. Refer to F561, F658, F684 and F692 REFERENCE: WAC 388-97-1760(1)(2) .

Based on interview and record review, the facility failed to ensure COVID-19, an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death, testing was documented as completed and/or the results of testing was documented in the residents' record for nine (39, 73, 45, 51, 22, 62 ,74, 87 and 91) of nine residents reviewed for documentation of COVID testing. Failure to add COVID testing results to individual health records left residents at risk for inaccurate health records. Findings Included . According to the 09/2021 Facility Infection Prevention and Control Program Testing for Covid 19 Policy, test results for residents would be recorded in the resident's medical record and testing documentation would include the date and time of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions taken by the facility based on the results. Review of a 09/28/2021 E-mail from the Local Health Jurisdiction (LHJ) showed that following identification of a positive individual who was in the building while infectious, the LHJ recommend testing all residents and all staff every 3-7 days until 14 days passed with no new positive Covid 19 cases. Resident 39 Review of the resident's Physician Orders (POs) showed an 08/14/2021 order to Test for Covid 19, using Point of Care (Rapid) Testing or Laboratory PCR (Polymerase Chain Reaction) testing as needed. Review of Resident 39's October 2021 Lab Administration Record showed no documentation that testing was performed. Review of the Lab results showed no documentation of Covid Testing. Review of Resident 39's Progress Notes showed no documentation of Covid testing including the time and date of the test, what type of test was performed, and the results of the test. Resident 73 Review of Resident 73 's POs showed an 09/14/2021 PO to Test for Covid 19. Review of Resident 73's October 2021 Lab Administration Record showed no documentation that testing was performed. Review of the Lab results showed no documentation of Covid Testing. Review of the resident's Progress Notes showed no documentation of Covid testing, when tested, what type of test performed, and test results. Resident 45 Similar findings for Resident 45. Resident 51 Similar findings for Resident 51. Resident 22 Similar findings for Resident 22. Resident 62 Similar findings for Resident 62. Resident 74 Similar findings for Resident 74. Resident 87 Similar findings for Resident 87. Resident 91 Similar findings for Resident 91. In an interview on 10/12/2021 at 11:53 AM Staff B (Director of Nursing) stated that Covid test results from testing on 09/29/2021 and 10/05/2021 were kept in a binder for all residents. When asked why they weren't part of the resident's medical record, Staff B stated that they could understand the requirement if the results were positive, and that the facility had conducted these tests for outbreak testing. When asked if, regardless of the reason for testing, the results should be part of the record, Staff B stated they should, and Staff J (Corporate Nurse Consultant) stated yes, they should be part of the resident's medical record. REFERENCE: WAC 388-97-1780(1)(2)(c)(d) .