<Resident 33> According to the 09/12/2024 5-Day MDS, Resident 33 had mild cognitive impairment. This MDS showed Resident 33 had diagnoses of a urinary tract infection, lung disease, and elevated white blood cell count. This MDS showed Resident 33 was taking an antibiotic medication during the assessment period. Review of Resident 33's order summary showed a 09/11/2024 order for an antibiotic to be administered three times per week for an elevated white blood cell count. This order did not include a stop date for how long Resident 33 would be taking the antibiotic. On 10/24/2024, the antibiotic order was updated showing the indication for use was for a chronic lung infection and showed no stop date on the order, indicating long term use. Review of Resident 33's 09/01/2024 comprehensive CP showed no goals or interventions related to their lung infection. There were no goals or interventions related to Resident 33 receiving antibiotics since 09/11/2024. In an interview on 10/25/2024 at 9:31 AM, Staff C (Staff Development Coordinator/Infection Control) stated Resident 33 was being followed by a lung specialist. Staff C stated the facility and the lung specialist were going back and forth to determine if the antibiotic would long term and just recently the physician determined the medication would be long term. REFERENCE: WAC 388-97-1020(1), (2)(a)(b). Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive Care Plan (CP) for 3 of 12 sampled residents (Residents 34, 7, & 33) whose comprehensive CPs were reviewed. The failure to develop comprehensive, individualized CPs with resident-specific goals and/or interventions placed residents at risk for unmet care needs and a decreased quality of life. Findings included . <Facility Policy> According to the facility's Care Plans, Comprehensive Person-Centered policy, dated 03/01/2023, the facility would develop and implement a comprehensive person-centered CP that included measurable objectives to meet the resident's physical, psychosocial, and functional needs. This policy showed the interdisciplinary team would review and update the CP for significant changes in the resident's condition, when the desired outcome was not met, upon readmission from a hospital stay, and quarterly. <Resident 7> According to a 07/19/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 7 had multiple medically complex diagnoses including dementia with severe memory impairment and required substantial assistance from staff for lower body dressing. Review of Resident 7's revised 05/25/2023 risk of skin breakdown CP showed directions to staff to apply compression stockings to both of Resident 7's lower legs in the morning and to remove in the evening. Observations on 10/23/2024 at 11:30 AM showed Resident 7 with a bandage wrapping to their left leg and no compression stockings on their right leg. In an interview on 10/25/2024 at 1:16 PM, Staff H (MDS Coordinator) stated their expectation was for staff to follow a resident's CP interventions and apply the compression stockings for Resident 7 as directed. <Resident 34> According to a 09/11/2024 Annual MDS, Resident 34 had multiple medically complex diagnoses including a stroke, with the loss of strength or muscle weakness on one side of the body, and an abnormal heartbeat which required the use of anticoagulant medications during the assessment period. Review of Resident 34's revised 04/21/2024 risk of skin breakdown CP showed directions to staff to apply compression stockings to both of Resident 34's lower legs in the morning and to remove in the evening. Observations on 10/24/2024 at 1:14 PM showed Resident 34 without compression stockings on. On 10/25/2024 at 8:00 AM, Resident 34 was wearing a compression stocking to their left leg but none on their right leg. In an interview at this time, Resident 34 stated, oh yeah, I am supposed to have on both legs, but they [staff] often cannot find the other one. Review of a 10/20/2022 COVID (a contagious respiratory illness) CP, showed Resident 34 was at risk for mood changes related to social isolation due to COVID. This CP gave directions to staff to provide Resident 34 with room activities as able and to provide alternative methods of communication with family and friends. In an interview on 10/24/2024 at 2:40 PM, Staff B (Director of Nursing) stated it was their expectation staff follow CP interventions as directed and update and revise a resident's CP with changes. Staff B stated Resident 34 did not currently have a COVID infection and should have been resolved off of the resident's CP.

Based on interview and record review, the facility failed to ensure: physician's orders were followed for 1 (Resident 34); medications were administered within ordered parameters for 1 (Resident 38); and physician orders were clarified as needed for 1 (Resident 96) of 12 sample residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Facility Policy> According to the facility's Administering Medications policy, reviewed 03/01/2023, showed staff would administer medications in accordance with prescriber orders. <Medications Given Outside of Parameters> <Resident 38> According to an 08/09/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 38 had multiple medically complex diagnoses including high Blood Pressure (BP). Review of Resident 38's August 2024 Medication Administration Records (MAR) showed the resident was receiving three different medications (Medication A, B, and C) for high BP with directions to staff to hold the dose for the following parameters: Medication A was to be held if the Systolic BP (SBP - a measure of the pressure in your arteries when your heart beats) was less than 105; Medication B was to be held if SBP was less than 140; and Medication C was to be held if the SBP was less than 105. This MAR showed staff gave Medication B outside of parameters on eight occasions. Review of Resident 38's September 2024 MAR showed staff gave Medication B outside of parameters on five occasions. Review of Resident 38's October 2024 MAR showed staff gave: Medication A outside of parameters on one occasion; Medication B outside of parameters on nine occasions; and Medication C outside of parameters on one occasion. In an interview on 10/24/2024 at 2:40 PM, Staff B (Director of Nursing) stated their expectation was for staff to follow the medication parameters as ordered by the provider. <Clarifying Orders> <Resident 96> Review of Resident 96's October 2024 MAR showed the resident had a 10/18/2024 order for a laxative suppository medication to be given as needed for constipation. A second 10/18/2024 order for the same laxative suppository was also ordered to be given as needed for constipation. In an interview on 10/25/2024 at 1:16 PM, Staff H (MDS Coordinator) stated Resident 96 should not have two of the same laxative suppository orders and the orders needed to be clarified. <Following Orders> <Resident 34> Review of Resident 34's September 2024 MAR showed a 04/04/2023 order for a liquid laxative to be given as needed for constipation if the resident had no bowel movement in two days. This MAR showed staff administered the medication at 11:12 AM on 09/06/2024. Review of Resident 34's September 2024 bowel monitoring showed staff documented the resident had two bowel movements on 09/05/2024, the day before administering the medication with directions to give if no bowel movement in two days. In an interview on 10/25/2024 at 1:16 PM, Staff H stated it was their expectation staff follow the orders and only give medications as ordered. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii). .

**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 2 (Residents 43 & 30) of 4 residents 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> According to the facility's Transfer or Discharge, Facility Initiated policy, revised 10/2022, the facility would provide a notice of transfer as soon as practicable to residents who were transferred emergently to an acute care setting. This policy showed the notice would be provided in a manner the resident could understand. The notice would include the reason, effective date, location, and an explanation of the resident's rights for transfer. <Resident 30> Review of Resident 30's 03/05/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed staff documented where and why Resident 30 was being transferred to the hospital on a 03/05/2024 Notice of Emergency Transfer form. At the bottom of this form was a statement that said to see the reverse side of the notice for information on appeal rights. The reverse side of the notice with the appeal rights was not found in Resident 30's records for the 03/05/2024 transfer to the hospital. <Resident 43> Review of Resident 43's 10/09/2024 Discharge MDS showed the resident was transferred to the hospital on [DATE], with their return anticipated. Record review showed staff documented where and why Resident 43 was being transferred to the hospital on a 10/09/2024 Notice of Emergency Transfer form. At the bottom of this form was a statement that said to see the reverse side of the notice for information on appeal rights. The reverse side of the notice with the appeal rights was not found in Resident 43's records for the 10/09/2024 transfer to the hospital. In an interview on 10/23/2024 at 2:50 PM, Staff F (Social Services Director) stated the charge nurses were responsible for filling out an emergency packet, which included the Notice of Emergency Transfer form, and provide the paperwork to the resident upon transfer to the hospital. Staff F stated the transfer form should include the appeal rights for the resident. In an interview on 10/24/2024 at 1:06 PM, Staff G (Licensed Practical Nurse) stated they were one of the charge nurses that often completed transfer paperwork when a resident was sent to the hospital. Staff G pulled a packet from a drawer at the nurse's station and stated the form was what they completed and sent with a resident upon transfer to the hospital. In an interview on 10/24/2024 at 1:12 PM, Staff F reviewed the packet provided by Staff G and confirmed it was missing the second page of the Notice of Emergency Transfer form, which included the required appeal rights. Staff F stated they would have expected the appeal rights to be included in the packet, and stated they were unable to locate them for Resident 30 or 43. REFERENCE: WAC 388-97-0140(1)(a)(b)(c)(i-iii). .

Based on observation, interview, and record review the facility failed to ensure 5 of 12 sample residents (Residents 33, 5, 26, 29, & 34) reviewed for care and services received the necessary care and services they required in accordance with professional standards of practice. The facility failed to monitor residents taking anticoagulant medications (Residents 33, 5, 26, &, 29) and assess, monitor, and apply compression stockings to residents with edema (Resident 34). These failures placed residents at risk for delays in treatment, potential declines in health, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's Anticoagulation Protocol policy, updated 01/2018, showed the staff and the physician would monitor for potential complications such as excessive bruising, bleeding, or bloody urine for resident's who were receiving anticoagulant medications. Review of the facility's Edema policy, reviewed 03/01/2023, showed residents with edema would be routinely assessed to determine effectiveness of current treatments and/or worsening conditions. This policy showed interventions could include compression socks, elevating the extremity, medications management, and pharmacy review. <Resident 33> According to the 09/02/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 33 had mild cognitive impairment. The MDS showed Resident 33 had diagnoses including an abnormal heart rhythm and a disease in which arteries to the heart have a build up of fatty substances. This assessment showed Resident 33 took anticoagulant medication during the assessment period. In an interview on 10/21/2024 at 12:20 PM, Resident 33 stated they had nose bleeds almost daily. Resident 33 stated they were hospitalized on ce for having a nosebleed that would not stop. Review of a 09/01/2023 hospital discharge summary showed Resident 33 was discharged to the facility with orders for an anticoagulant to be taken twice daily. Review of a 05/11/2024 progress note showed Resident 33 returned to the facility after a hospital stay with a diagnosis of gastrointestinal bleeding. Review of a 09/12/2024 progress note showed Resident 33 was readmitted to the facility after a short hospital stay due to a nosebleed. Review of Resident 33's 10/25/2024 order summary showed a 09/16/2024 order directing staff to administer an anticoagulant medication twice daily to Resident 33. This summary showed a 10/03/2024 order directing staff to monitor Resident 33 for signs and symptoms of bleeding every shift related to the use of the anticoagulant medication. The 10/03/2024 order to monitor Resident 33 for bleeding was implemented 13 months after the initial order for the anticoagulant medication. <Resident 5> According to the 08/07/2024 Quarterly MDS, Resident 5 had mild cognitive impairment. This MDS showed Resident 5 had diagnoses including an irregular heart rhythm and high cholesterol. The MDS showed Resident 5 took anticoagulant medication during the assessment period. Review of a 10/22/2024 order summary showed a 06/12/2024 order for an anticoagulant medication to be administered to Resident 5 twice daily. This order summary showed no directions to staff to monitor adverse side effects such as bleeding for the anticoagulant medication. <Resident 26> Review of the 07/22/2024 Quarterly MDS showed Resident 26 was cognitively impaired. This MDS showed Resident 26 had diagnoses of high cholesterol and an irregular heart rhythm. The MDS showed Resident 26 was taking anticoagulant medication during the assessment period. Review of Resident 26's order summary showed a 07/26/2024 order directing staff to administer an anticoagulant medication to Resident 26 twice daily. This order summary showed no instructions for staff to monitor for side effects of the anticoagulant until over two months later, when a 10/01/2024 order was written, directing staff to monitor for bleeding. In an interview on 10/24/2024 at 11:55 AM, Staff B (Director of Nursing) stated nurses should be monitoring residents for side effects to anticoagulants such as bleeding. Staff B stated they would have to check if the monitoring should be documented in the resident's record. No further information was provided. REFERENCE: WAC 388-97-1060(1). <Resident 29> According to a 09/03/2024 Annual MDS, Resident 29 had multiple medically complex diagnoses including heart failure and required the use of anticoagulant medications during the assessment period. Review of Resident 29's order summary showed a 09/18/2023 order for an anticoagulant medication to be administered to Resident 29. This order summary showed no directions to staff to document if any possible adverse side effects such as bleeding for the anticoagulant medication occurred. In an interview on 10/24/2024 at 2:40 PM, Staff B stated it was important to monitor a resident who was taking an anticoagulant medication and stated, the resident was at risk for bleeding and bruising. Staff B stated it was their expectation staff would start monitoring a resident as soon as they started taking an anticoagulant medication. <Resident 34> According to a 09/11/2024 Annual MDS, Resident 34 had multiple medically complex diagnoses including a stroke, with the loss of strength or muscle weakness on one side of the body, and an abnormal heartbeat which required the use of anticoagulant medications during the assessment period. Review of Resident 34's records showed a 07/25/2024 provider progress note indicating the resident was being assessed related to weight gain and swelling to their lower legs. Mild edema was observed by the provider with recommendations for Resident 34 to wear compression stockings on both legs during the day and off at night. This progress note showed documentation if symptoms worsen or persist, staff were to contact the provider's office. Observations on 10/24/2024 at 1:14 PM showed Resident 34 without compression stockings on. Review of an 08/23/2024 dietician progress note showed documentation that nursing staff reported no edema when compression stockings were in place, but the dietician documented they observed edema to both lower legs. Review of a 09/17/2024 quarterly progress note written by staff, showed Resident 34 utilized compression stockings secondary to edema to both lower legs. Review of a 10/03/2024 dietician progress note showed Resident 34 was experiencing some edema, correlating with weight gain. According to a 10/03/2024 History and Physical document, Resident 34 was seen by the provider related to edema to their left lower leg more than their right lower leg and ordered a low dose of a medication to promote the excretion of water from the body. This document indicated Resident 34 was assessed to have symptoms of heart failure. Review of Resident 34's comprehensive care plan showed staff did not address the resident had heart failure and was placed on a medication for edema. In a joint interview on 10/25/2024 at 1:16 PM with Staff H (MDS Coordinator) and Staff I (Resident Care Manger), Staff H stated if a resident was placed on a medication to reduce edema, they would expect staff to utilize the compression stockings and to assess and document the status of the edema. Staff I stated it was important to monitor frequently to see if the resident's edema had stabilized and how they were responding to the medications. Staff I reviewed Resident 34's records for documentation of the edema by the nursing staff on the weekly skin checks. Staff I was unable to find documentation on the weekly skin checks from staff regarding the status of Resident 34's edema.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident #26> Review of the 07/22/2024 Quarterly MDS showed Resident 26 had a diagnosis including dementia and had severely impaired cognition. The MDS showed Resident 26 had one fall with no injury and one fall with injury during the assessment period. This MDS showed Resident 26 had a bed, chair, and other alarm in place and the alarms were used daily during the assessment period. Observations on 10/21/2024 at 10:21 AM and 2:29 PM showed Resident 26's bathroom door was open and the alarm on the bathroom door was disengaged. Observation on 10/22/2024 at 8:48 AM showed Resident 26's bathroom door was open, Resident 26 entered the bathroom and the alarm on the bathroom door did not trigger. Review of Resident 26's revised 08/05/2024 Fall CP showed Resident 26 fell on [DATE], 06/02/2024, 08/08/2024, and 09/15/2024. This CP showed Resident 26 had a door chime alarm on the bathroom door to alert staff when the resident tried to use the bathroom without assistance. During an interview on 10/25/2024 at 8:49 AM, Staff E (MDS Support Nurse) stated Resident 26 had a chime alarm on the bathroom door to alert staff when the resident went into their bathroom. Staff E stated the bathroom door must remain shut for the alarm to work. REFERENCE: WAC 388-97-1060(3)(g). Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 2 (Resident 7 & 26) of 12 sample residents. The failure to ensure resident bathroom door chime alarms were activated (Residents 7 & 26), ensure a maintenance cart containing tools and chemicals was supervised in resident common areas, and ensure kitchen pantry doors and storage rooms remained closed and/or locked, placed residents at risk for accidents, injury, and other negative health outcomes. Findings included . <Maintenance Cart> Observations on 10/21/2024 between 9:36 AM and 9:47 AM showed a maintenance cart unsupervised in the hallway between resident rooms [ROOM NUMBERS]. On this cart were several accessible tools, including a drill and a bottle of a drain opening compound with a layer of powder at the bottom. In an interview on 10/25/2024 at 1:16 PM, Staff H (Minimum Data Set - MDS - Coordinator) stated unsupervised sharps and tools posed a risk for resident safety, especially with residents who had dementia. <Storage Room> Observations on 10/24/2024 at 8:07 AM showed an unlocked storage room door next to the nurse's station. Inside the room were many shelves stocked full of supplies and four bottles of a liquid medication disposal system, visible from the door. The bottles showed a warning label that the product may be harmful if swallowed and to keep out of reach of children. In an interview on 10/25/2025 at 1:16 PM, Staff H stated the storage room was supposed to be locked and kept secured so the residents could not get a hold of anything dangerous to them. <Kitchen Pantry Door> Observation on 10/21/2024 at 9:37 showed the pantry door near the nurse's station was propped open. The pantry contained an oven, prep table, dried food storage, and dishwasher. There were no staff observed in the pantry when the door was propped open. The pantry door contained a keypad lock system. In an interview on 10/22/2024 at 8:20 AM, Staff D (Registered Nurse) stated the pantry door was usually only left open during mealtimes. Staff D stated kitchen staff usually closed the pantry door when the meal service was completed. In an interview on 10/25/2024 at 2:20 PM, Staff A (Administrator) stated the maintenance cart should not be left unsupervised when tools and sharps were accessible to residents. Staff A stated the storage room and kitchen pantry should be locked, with the door closed, if staff were not in the area and stated, you do not want confused residents to go into an unsafe space. <Fall Interventions> <Resident 7> According to a 07/19/2024 Quarterly MDS (an assessment tool) Resident 7 had multiple medically complex diagnoses including dementia with severe memory impairment and required substantial assistance from staff to transfer to the toilet. This MDS showed Resident 7 had three falls since the prior assessment, one with a major injury, and was utilizing alarms at least daily. Review of Resident 7's October 2024 Treatment Administration Records showed a 03/19/2024 order to ensure the bathroom chime alarm was in use and functioning every shift. Review of a revised 05/25/2023 fall Care Plan (CP) showed directions to staff that Resident 7 required assistance with toileting and to use a bathroom door chime alarm to alert staff when they tried to go to the bathroom. This intervention showed the bathroom door was to be kept closed at all times and staff were to check the function and presence of the bathroom door alarm every shift. Observations on 10/23/2024 at 11:27 AM showed Resident 7 lying in bed with their breakfast tray in front of them and their wheelchair at their bedside. Resident 7 stated, I need to use the bathroom. Observations at this time showed Resident 7's bathroom door was open, and the chime alarm was not activated. Similar observations of Resident 7 lying in bed with their bathroom door open and unarmed were noted on 10/24/2024 at 8:42 AM and 3:43 PM, and on 10/25/2024 at 7:52 AM. Review of Resident 7's fall incident reports from 05/09/2024, 05/18/2024, and 07/04/2024 showed staff identified the resident's falls occurred during self-transfers and staff were to continue to use a motion sensor and bathroom door chime alarm. In an interview on 10/24/2024 at 2:40 PM, Staff B (Director of Nursing) stated it was their expectation CP interventions and physician orders were followed as, that is the reason they are there. In an interview on 10/25/2024 at 1:16 PM, Staff H stated the best way to prevent falls was to follow the CP interventions staff put in place as a team. Staff H stated their expectation was for staff to keep Resident 7's bathroom door closed and have the alarm turned on to help prevent falls.

<Resident 35> According to a 04/24/2023 admission MDS Resident 35 had multiple medically complex diagnoses including a respiratory infection and lung disease. Review of Resident 35's July 2023 Treatment Administration Record (TAR) showed the resident had a PO for oxygen to be given at 3 Liters Per Minute (lpm) continuously for a respiratory infection. Observations on 07/05/2023 at 9:51 AM and on 07/07/2023 8:05 AM showed Resident 35's oxygen was set to 3.5 lpm. On 07/10/2023 at 8:41 AM, Resident 35's oxygen was observed to be set to 2.5 lpm. In an interview on 07/10/2023 at 9:00 AM, Staff H (Licensed Practical Nurse), confirmed Resident 35's order for oxygen was to be at 3 lpm. Staff H checked the oxygen flow rate and raised the level of oxygen up to 3 lpm. On 07/11/2023 at 1:45 PM, Staff C stated nursing staff should follow the POs and always check the oxygen flow rate at eye level when setting the correct oxygen dose. <Clarifying Physician Orders> <Resident 35 - Pain Medications> According to a 04/24/2023 admission MDS Resident 35 had multiple medically complex diagnoses including fractures and required the use of a narcotic pain medication during the assessment period. Review of July 2023 Medication Administration Records (MAR) showed Resident 35 had an order for a non-narcotic pain medication to be given every four hours as needed for pain. Resident 35 had additional orders for narcotic pain medications to be given every twelve hours as needed. These orders directed staff to give five milligrams (mg) of the narcotic pain medication for moderate pain, and to give 10 mg of the narcotic pain medication for severe pain. There were no directions to staff to indicate what parameters should be used when administering the non-narcotic pain medication, or what pain scale parameter to use for moderate or severe pain for the narcotic pain medications. In an interview on 07/11/2023 at 1:45 PM, Staff C stated the facility standard for pain medication parameters was for the non-narcotic pain medication to be given for mild pain and should be used for a pain level less than four. Staff C stated the narcotic pain medication parameters should be four to six for moderate pain and seven to ten for severe pain. Record review of the May 2023 MAR showed staff documented they gave Resident 35 the five mg dose of the narcotic pain medication for a pain level of 6 on 05/06/2023 and on 05/08/2023 for a pain level of 4. On 05/26/2023 staff documented they administered the non-narcotic pain medication for a pain level of 6 and indicated it was not effective in decreasing the resident's pain. Review of the June 2023 MAR showed staff documented they administered the five mg dose of the narcotic pain medication for a pain level of 7 on 06/08/2023 to Resident 35, rather than the dose for severe pain as indicated by Staff C. According to Resident 35's July 2023 MAR staff administered the non-narcotic pain medication for a pain level of 5 at 5:03 AM and the five mg dose of the narcotic pain medication for a pain level of 4 at 2:07 PM on 07/08/2023. In an interview on 07/11/2023 at 1:45 PM, Staff C stated the pain medication orders for Resident 35 should be clarified with the provider with clear directions given to staff on the pain level parameters for each medication. < Resident 35 - Probiotic Orders> According to July 2023 MAR, Resident 35 received a probiotic medication (a supplement to help balance the friendly bacteria in the digestive system when taking antibiotics) twice daily for the use of antibiotics. Review of this MAR showed no antibiotic orders were currently in place for Resident 35. Record review showed Resident 35 completed an antibiotic treatment for a respiratory infection on 06/08/2023. In an interview on 07/11/2023 at 1:45 PM, Staff C stated this order should have, but was not clarified with provider to determine if it should continue after the antibiotic order was completed. <Resident 141> According to a 06/22/2023 admission MDS, Resident 141 had multiple medically complex diagnoses including an infection of the large intestine and required the use of antibiotics during the assessment period. Review of July 2023 MAR showed Resident 141 had an order for a probiotic medication twice daily. On 07/08/2023 a second order was added by staff for the same probiotic medication twice daily. Staff were documenting they were administering both medications. In an interview on 07/11/2023 at 1:45 PM, Staff C stated Resident 141 should not receive both doses of the probiotic medication and stated, it was a duplicate order. Staff C stated the orders should have been but were not clarified with the provider. In an interview on 07/11/2023 at 2:00 PM, Staff I (Staff Development Coordinator/Infection Preventionist) stated both medications should not be given together and stated the medication nurse stated they only administered one dose. In an interview on 07/11/2023 at 2:00 PM, Staff B (Director of Nursing) stated POs should be followed, have parameters, and be clarified as needed with the providers. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i) Based on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were followed for 3 of 13 sample residents (Residents 8, 6 & 35), or clarified for 2 of 13 sample residents (Residents 35 and 141) whose care was reviewed. These failures left residents at risk for not receiving the care they were ordered, and other negative health outcomes. Findings included <Following POs> <Resident 8> According to the 04/07/20/23 Annual Minimum Data Set (MDS - an assessment tool) Resident 8 was assessed to required extensive assistance with toileting and personal hygiene. The MDS showed Resident 8 was assessed to be at risk for skin breakdown. Resident 8's POs included: a 04/06/2023 order to complete a weekly skin check scheduled for Thursday evenings; a 04/05/2023 PO for body powder to be applied to Resident 8's under arms and abdominal folds twice daily. There were no POs to treat Resident 8's groin skin. Review of the 04/02/2023 . at risk for skin breakdown . Care Plan (CP) showed staff should apply body powder to Resident 8's under arms and abdominal folds twice daily. The CP directed nursing staff to complete a skin check weekly, and as needed, and to report any concerns including areas of redness to Resident 8's nurse. In an interview on 07/05/2023 at 9:27 AM Resident 8 stated they sometimes had a rash in their groin. Resident 8 stated staff treated the rash with a powder. Resident 8 stated sometimes got a sore spot on their buttocks. According to the 07/06/2023 skin evaluation (skin check) Resident 8 had a new skin impairment of redness to their left groin area. The note stated to continue treatment as ordered. Record review showed a skin check was not completed the prior week, with the last skin check completed on 06/23/2023. In an interview on 07/11/2023 at 9:40 AM, Staff C (Resident Care Manager) stated it was important to conduct skin checks weekly, as ordered. Staff C stated a PO for skin powder was in place to treat Resident 8's groin skin. Staff C reviewed the PO and stated the skin powder did not include groin area, and the order needed to be updated. <Resident 6> According to the 05/22/2023 MDS, Resident 6 required set up assistance with eating, and had diagnoses including malnutrition. The MDS showed Resident 6 was assessed with verbal behavior directed toward others that impacted the safety and activity of Resident 6 and others. The MDS showed Resident 6's behaviors worsened since the prior MDS. Resident 6's POs included a 05/25/2023 order for a bedtime snack. The order stated staff should provide either half a sandwich or a fortified (protein-rich) pudding. The 05/23/2023 . at risk for weight loss . CP showed Resident 6 was intolerant to [ .] bananas . The CP directed staff to offer half a sandwich or a banana with pb [peanut butter] for a bedtime snack. In an interview on 07/10/2023 at 2:36 PM with Staff C and Staff D (MDS Coordinator) Staff C stated the . at risk for weight loss . CP needed to be updated so that it reflected the 05/25/2023 PO. Staff C and Staff D stated given Resident 6's behavioral issues, offering an unwelcome snack could cause an avoidable behavior.

<Resident 29> Review of a 03/29/2023 Quarterly MDS showed Resident 29 had a diagnosis of unspecified swelling and did not reject care. Review of Resident 29's 07/05/2023 PO summary showed the resident had a 06/29/2023 PO to receive a medication to treat their swelling daily. This order summary showed a 07/05/2023 PO that instructed staff to apply knee high compression stockings to Resident 29's legs in the morning and remove the compression stockings before bedtime in the evening. In an interview and observation on 07/07/2023 at 10:05 AM, Resident 29 was being assisted to their room from the dining room. Resident 29 was not wearing compression stockings. Resident 29's lower legs were red with notable swelling around their ankles. Staff D stated Resident 29 was not wearing the compression stockings because they refused to have them put on. Staff D stated they documented in the record when a resident refused their compression stockings. Record review on 07/10/2023 at 12:33 PM, showed no documentation of Resident 29 refusing their compression stockings. In an observation and interview on 07/10/2023 at 11:23 AM, Staff E (CNA) and Staff F (CNA) were assisting Resident 29 to get dressed after a shower. Staff E stated they did not put compression stockings on Resident 29 and there was nothing in their computer system showing staff to put compression stockings on Resident 29. Staff F verified there was nowhere for the CNAs to document putting on or taking off Resident 29's compression stockings. In an interview on 07/10/2023 at 12:33 PM, Staff B (Director of Nursing) stated it was their expectation staff followed orders to put compression stockings on Resident 29. Staff B acknowledged the PO as written did not allow staff to document completion or resident refusal of the task. Staff B stated refusals should be documented in Resident 29's records. REFERENCE: WAC 388-97-1060(1). <Resident 35> According to a 04/24/2023 admission MDS Resident 35 had multiple complex diagnoses including heart failure and required the use of diuretic medication during the assessment period. This MDS identified Resident 35 had no rejection of care. Review of Resident 35's Physician Orders (POs) showed the resident was assessed to require knee high compression stockings to be put on in the morning and removed at bedtime for swelling to their feet/ankles. According to the July 2023 Medication Administration Records (MAR) Resident 35 was taking a medication once daily to treat the swelling to both feet. Observations on 07/05/2023 at 9:38 AM, 07/07/2023 at 8:05 AM, and on 07/10/2023 at 2:12 PM showed Resident 35 only wearing yellow nonskid socks. Resident 35 was not wearing the compression stockings. In an interview on 07/11/0223 at 11:00 AM, Staff D (Certified Nurse's Aide - CNA) stated they worked with the residents on the unit for a long time and indicated they knew who wore compression stockings. Staff D listed residents that required compression stockings but did not identify Resident 35 to require compression stockings. In an interview on 07/11/2023 at 11:05 AM, Staff J (Registered Nurse) stated they oversaw the care provided by the CNAs and when refusals occurred a progress note was made, staff followed up as needed. Staff J stated if a resident had an order for compression stockings, staff would be expected to assist the resident with putting them on. Staff D stated they were not aware of any refusals for compression stockings for Resident 35. Based on observation, interview, and record review the facility failed to ensure new skin issues were identified, assessed, or treated for 1 of 3 residents (Resident 11) reviewed for non-pressure skin and failed to ensure treatments were provided as ordered for 2 of 2 residents (Residents 35 & 29) reviewed for edema (fluid retention that causes swelling). These failures placed residents at risk for discomfort, untreated skin impairments, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's revised 07/10/2023 Skin Management- Non Pressure Related and Skin Tears policy, upon discovery of a new skin impairment such as a skin tear, abrasion, or bruise, staff must complete an Event/Skin Report. The policy directed staff to report any new impairment to the resident's responsible family member and physician. <Resident 11> According to the 04/24/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 11 had no speech and rarely understood others in conversation. The MDS showed Resident 11's memory was assessed to be severely impaired and required extensive assistance with most care. The MDS showed Resident 11 had diagnoses including non-traumatic brain injury and dementia and had no skin impairment. According to the 05/05/2023 . at risk for skin breakdown . Care Plan (CP) staff were to evaluate Resident 11's skin on a daily and weekly basis. Observation on 07/05/2023 at 1:33 PM showed a small skin abrasion on the right side of Resident 11's nose. There was no dressing on the skin abrasion. Observation on 07/07/2023 at 10:07 AM showed the skin abrasion was still present on Resident 11's nose. Record review showed no nurses or aides documented the skin abrasion in Resident 11's record. There was no documentation demonstrating nursing staff completed an Event/Skin Report, or notified Resident 11's responsible family member or physician. In an interview and observation on 07/10/2023 at 10:00 AM, Staff C (Resident Care Manager) observed Resident 11's abrasion on the right side of their nose and stated no staff informed them of the impairment to the resident's skin but should have so the appropriate notifications and processes could be completed. Review of the 07/10/2023 weekly skin evaluation, time stamped at 11:07 AM showed no skin impairment for Resident 11.

**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 the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information for 3 (Residents 35, 36, & 141) of 3 residents reviewed for hospitalization. Failure to ensure required notification was completed, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . According to a March 2023 facility Transfer or Discharge Notice policy, the facility would notify the resident and/or representative in writing regarding the resident's transfer or discharge and a copy of the notice would be sent to the LTCO. <Resident 35> According to a 05/26/2023 Discharge Minimum Data Set (MDS - an assessment tool), Resident 35 was discharged emergently to an acute care hospital on [DATE] with return anticipated. Record review showed no documentation indicating the LTCO was notified of the 05/26/2023 transfer as required. <Resident 141> According to a 06/09/2023 Discharge MDS, Resident 141 was discharged emergently to an acute care hospital on [DATE] with return anticipated. According to a 06/23/2023 Discharge MDS Resident 141 had a second discharge to an acute care hospital on [DATE] with return anticipated. Record review showed no documentation indicating the LTCO was notified of the transfer as required for either the 06/09/2023 or 06/23/2023 transfers. <Resident 36> According to the 07/01/2023 Discharge MDS, Resident 36 was discharged emergently to an acute hospital on with return anticipated. Record review showed no documentation indicating the LTCO was notified of the 07/01/2023 transfer as required. In an interview on 07/10/2023 at 2:02 PM, Staff B (Director of Nursing) stated the facility's social worker did the LTCO notifications but no longer worked at the facility. Staff B was unable to locate any documentation of notification to the LTCO for Resident 35, 141, or 36 as required. REFERENCE: WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii) .

Based on interview and record review, the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use for 4 (Resident 19, 243, 38 & 141) of 12 residents reviewed for unnecessary antibiotics and 3 (May 2023, June 2023, & July 2023) of 3 months of infection control documents reviewed. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of antibiotics. Findings included . According to the facility's revised 11/2016 Surveillance for Infections policy, the Infection Preventionist (IP) would conduct ongoing surveillance of infections that had a substantial impact on potential resident outcomes and could require transmission-based precautions and other preventative measures. The policy stated the purpose of the surveillance of infections was to identify both individual cases and trends of infections to guide appropriate interventions, and to prevent future infections. For residents with infections that met the criteria for surveillance, staff should collect the following data as appropriate: .admission date; infection site; pathogens [infectious agent that causes disease]; .treatment measures and precautions. The policy directed staff to summarize monthly data for each nursing unit by site and by pathogen and to compare monthly/quarterly incidence of current infections to previous data to identify trends and patterns. <May Infection Surveillance Log (ISL)> Review of the facility provided ISL for May 2023 showed on 05/04/2023 Resident 19 was placed on an antibiotic for seven days for a suspected skin infection. According to the log staff identified Resident 19 had redness, pain, and heat to their skin. The log did not identify where the symptoms were located, if the infection was facility acquired, or if the resident admitted with the infection. The facility surveillance monitoring map provided for the month of May 2023 was blank and no summary of monthly data was completed by staff to identify trends or patterns. <June 2023 ISL> Review of the facility provided ISL for June 2023 showed staff only documented for one of six residents whether their infection was facility acquired or if the resident admitted with the infection. Resident 243 was identified on the log with a urinary tract infection. Staff did not document on the log what the infectious organism was identified or include the urine test results in the ISL binder for surveillance monitoring. The facility's surveillance monitoring map provided for the month of June 2023 was blank and no summary of monthly data was completed by staff to identify trends or patterns. <July 2023 ISL> Review of the facility provided July 2023 ISL showed two residents identified on the log. Resident 38 was identified on the log with having a urinary tract infection. Staff did not indicate if the infection was facility acquired or if resident admitted with the infection. Resident 141 was documented on the log for a contagious infection of the large intestine with an onset date for symptoms of 07/08/2023. The section of the log ACTION- Other than Standard Precautions for Resident 141 was left blank by staff and did not identify if the resident should be on contact precautions. Observations on 07/05/2023 at 9:02 AM showed a Contact Precaution sign was hung on the resident's door. Record review showed a 07/05/2023 progress note by staff identifying Resident 141 had loose stools and was placed on contact precautions. In an interview on 07/07/2023 at 2:04 PM, Staff I (Staff Development Coordinator/IP) confirmed Resident 141's onset date of symptoms was 07/05/2023, not the 07/08/2023 date identified on the log. Staff I stated the log should be complete and accurate to evaluate the surveillance of infections. In an interview on 07/11/2023 at 12:07 PM, Staff I stated they utilized the McGeer Criteria for infections (a set of criteria used to determine whether to treat an infection with antibiotics). Staff I reviewed the documented symptoms listed on the ISL for Resident 19 and the McGeer Criteria for skin infections and stated, Resident 19 did not meet the required criteria. Staff I stated staff should have but did not follow up with the provider to review the use of the antibiotic medication. Staff I stated they did not complete any monthly summaries, map location of infections to identify trends or patterns, or attend the facility's Quality Assurance and Performance Improvement meetings since March 2023 due to other obligations. REFERENCE: WAC 388-97-1320 (1)(a). .

Based on observations and interview, the facility failed to ensure the Chlorine bleach test strips and QUAT test strips (Quaternary test used to verify the concentration level of sanitizers) were current (not expired) in the main kitchen and Health Center kitchen. This failure prevented kitchen staff from accurately monitoring cleaning solutions used to maintain kitchen counter and equipment sanitized. Findings included . Observation of the facility's main kitchen on 07/05/2023 at 9:05 AM showed Staff M (dishwasher) doing dishes using the dishwashing machine. The documentation for dishwasher daily sanitization and temperature log was requested. Staff M stated they did not see the log and approached Staff K (Executive Chef) for this information. On 07/05/2023 at 9:05 AM Staff K stated they did not keep a log for dishwasher sanitization and red bucket. Observation on 07/05/2023 at 9:10 AM showed Staff K obtain test strips and demonstrate how the sanitization solution was tested. The bottle of Chlorine test strips showed an expiration date of May 2019. QUAT check test strips showed an expiration date of May 2023. Observation and interview on 07/05/2023 at 9:39 AM in the second-floor health center kitchen showed staff removing dirty dishes from the dishwashing machine. Staff N (Assistant Director of Food and Beverage) stated the facility was out of sanitizer test strips and staff planned to wash the dishes in main kitchen. Staff N stated staff were to test dishwasher sanitization after every meal and QUAT test every two hours. Staff N stated the test strips were expired. In an interview on 07/10/2023 at 10:08 AM, Staff L (Director of Food and Beverage) stated they did not know about the expired test strips. Staff N stated they should have checked the test strips for the expiration date but they did not. REFERENCE: WAC 388-97-2980 (6).

Based on observation, interview, and record review the facility failed to initiate and investigate an injury for 1 (Resident 14) of 15 residents reviewed. The facility failed to identify the cause of the injury. The failure to implement preventative measures placed the resident at risk for further potential injury. Findings included . According to the 04/01/2019 Investigating Falls, Incidents and Injuries facility policy, the nurse on duty or the nurse supervisor will promptly initiate and document investigation of a resident related fall, accident, or incident. Any descriptions in the medical record shall be objective and sufficiently detailed (such as dimensions and location of bruises). Resident 14 According to the 01/12/2022 Quarterly Minimum Data Set (MDS an assessment tool), the resident was assessed with severe cognitive impairment, was able to understand and be understood, had diagnoses of medically complex conditions, and had skin conditions of a skin tear. A 01/12/2021 at risk for skin breakdown care plan directed staff to report anything concerning about the resident's skin, like redness or open areas, and to monitor skin bruises or any skin alterations for infections and healing, until the skin alteration was healed. In an interview on 03/21/2022 at 9:54 AM Resident 14 stated they bumped their left leg but couldn't remember when it happened but stated their leg was getting better. Observations of the resident's left lower leg showed minimal redness to the upper shin area. Review of a 12/23/2021 progress notes showed a skin check was performed on Resident 14 and a purple/blue bruise was found on the resident's left lower extremity. The resident informed staff they hit their leg when using the bathroom. Review of subsequent notes showed no indication the facility monitored the bruise. Review of a 12/25/2021 progress note showed facility staff changed the dressing to the resident's left leg skin tear. There was no mention of a bruise in the 12/25/2021 progress note. Review of December 2021 Physicians Orders (PO) showed a 12/25/2022 PO to cleanse wound, apply gauze, and secure dry dressing daily until resolved. This PO was discontinued two days after on 01/27/2022. Review of the December 2021 Incident Log showed no entry including the bruise. No documentation was found that the facility investigated the cause of the bruise to Resident 14's left lower leg. During an interview on 03/25/22 at 10:12 AM Staff B (Director of Nursing) stated when a resident is observed with a bruise, regardless of their cognitive status, Staff B expected nursing staff to fill out an incident report, start the investigation by obtaining statements from staff caring for the resident, collect data, determine root cause, and rule out abuse or neglect. Staff B acknowledged an incident report was not done, and the bruise was not investigated but stated an investigation should have been done to protect the resident and rule out environmental factors that could have caused the bruise. REFERENCE: WAC 388-97-0640 (6)(a)(b). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medical supplies, wound care supplies and COVID-19 tests were discarded when expired in 1 of 3 medical storage areas reviewed. These failures placed residents at risk for compromised supplies being used during care and possible false results of COVID-19 testing. Findings included . Review of the [DATE] facility policy titled, Storage of Medications, showed all outdated drugs or biologicals would be returned to the pharmacy or destroyed. An observation on [DATE] at 3:26 PM of the facility treatment cart showed the following items were expired: * Basic spill clean-up kit, expired date [DATE] * Box of single use packets of bacitracin (antibiotic) ointment, expired date 05/2020 * Hemorrhoidal ointment, expired date 08/2020 * Medical Honey (used for wound care) 1.5-ounce tube, expired date [DATE] * Four individual use packets of lubricating jelly, expired date [DATE] * Three COVID-19 test kits with expiration dates of [DATE], [DATE] and [DATE] * Sterile foam tipped measuring stick expired [DATE] * Collagen sheet (used for wound care), expired 08/2021 * Calcium alginate package (used for wound care), expired 01/2022 In an interview on [DATE] at 3:26 PM, Staff F stated they did not know how often the treatment cart was checked for expired items and the identified items would be removed from the cart. In an interview on [DATE] at 11:17 AM, Staff K (Unit Coordinator) stated they were responsible for checking the expiration dates in the medication room and central supply area, but they did not check the supplies in the treatment cart. In an interview on [DATE] at 1:35 PM, Staff D (Resident Care Manager) stated they checked the medication carts monthly but did not check the treatment cart. In an interview on [DATE] at 10:00 AM, Staff B (Director of Nursing) stated that the treatment cart was to be checked by the night nurse weekly, and that expired items should have been removed. REFERENCE: WAC 388-97-1300 (2). .

Based on observation and interview, the facility failed to prepare foods in a manner that maintained proper consistency, flavor, and/or nutritive value of the food. This failure placed 2 (Residents 24 and 6) of 2 residents who required pureed food at risk for improper texture and a lack of palatability. Findings included . Observation during the lunch meal preparation on 03/24/2022 showed Staff J (Kitchen Assistant) preparing meals for residents in the facility's 3rd floor kitchen. At 10:29 AM Staff J was observed to blend soup for residents who required an altered texture diet. Staff J poured soup into the blender and added thickener, pulsed the mixture in the blender and checked the consistency of the now-blended soup. Staff J stated they did not follow a recipe to puree meals for residents who required a pureed texture, that they knew the consistency preferred by the residents who required pureed food and that they knew pureed food was properly prepared when it had a yogurt consistency. At 10:33 AM, Staff J was observed to put a rice casserole in a blender using a measuring scoop, then poured without measuring hot broth directly from a pot on the burner into the blender. Staff J added pumps of thickening fluid and blended the casserole mixture. Staff J then looked at the blender, determined the correct consistency had not yet been achieved, and added more thickener. At 10:44 AM, Staff J pureed boiled peas and carrots in a blender without measuring the broth or thickener added. In an interview on 03/24/2022 at 3:16 PM, Staff H (Dietary Manager) stated that the facility had recipes that included specific ratios of fluids and thickeners to ensure that altered-texture diets maintained nutritive value for the residents who required them. Staff H stated following the recipe was important in order to ensure pureed meals reached the appropriate texture, and maintained their nutritive value and palatability. Staff H stated Staff J should have but did not follow the recipe. In an interview on 03/22/2022 at 9:23 AM, Resident 6 stated the food tasted terrible and added, it's mushy and doesn't taste good. I need someone to care what it tastes like. REFERENCE: WAC 388-97-1100 (1), (2). .

Resident 30 According to the 03/10/2022 Quarterly MDS, Resident 30 had multiple medically complex diagnoses including a fracture and a surgical wound infection. This MDS assessed Resident 30 with moderate cognitive impairment, no behaviors or rejection of care. Resident 30 was assessed to require extensive physical assistance from staff for bed mobility, transferring and bathing. Review of a 03/17/2022 PO showed Resident 30 had an IV (Intravenous-fluid delivered into a vein) antibiotic medication for a bone infection. Resident 30 had a 03/07/2022 PO for non-weight bearing (NWB) on left lower extremity (LLE). Review of Resident 30's CP on 3/21/2022 revealed no CP or interventions were initiated for the care of the IV antibiotic or the NWB on LLE. A review of the 06/17/2022 CP for risk of skin breakdown, showed interventions to Use pillows, pads, or wedges to reduce the pressure on heels and pressure points, and Reposition every 2 hours and as needed. Observations on 03/21/2022 at 8:30 AM and 03/22/2022 at 8:00 AM, showed Resident 30 was in bed, lying on their back, with no pillows or wedge noted under them, and Resident 30 was repositioning themselves. In an interview on 03/24/2022 at 11:26 AM, Staff B stated Resident could reposition themselves in bed without any assistance. Staff B stated the CP needed to be updated to reflect the current status. REFERENCE: WAC 388-97-1020(2)(c)(d), (5)(b). Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were consistently reviewed and revised to meet residents' current needs for 5 (Residents 15, 6, 39, 34, & 30) of 15 sample residents reviewed for care plans. The failure to revise care plans and define changes in resident care, placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 15 The 01/13/2022 Minimum Data Set (MDS- an assessment tool) showed Resident 15 had diagnoses of heart failure and presence of an internal pacemaker (a device to regulate heart function). The current (undated) care plan (CP) for Resident 15 showed a goal to keep the heart rate above 60 beats per minute and an intervention showed I want you to check my apical (pulse site over heart) pulse weekly. Notify the cardiologist if the rate is below 60 beats per minute. The 10/25/2019 Physician Order (PO) showed a pacemaker check: check apical rate on the first of each month. There were no parameters on when or who to notify if the pulse was abnormal. A review of the vital signs report for 02/2022 and 03/2022 pulse monitoring showed no apical pulse recorded weekly for Resident 15. The report showed no monthly apical pulse recorded for 02/01/2022 or 03/01/2022. In an interview on 03/23/2022 at 12:49 PM, Staff B (Director of Nursing) confirmed that the CP and the PO did not match and the apical pulse was not checked weekly or on the first of each month. Staff B stated the CP, and the PO should match so the apical pulse is checked timely. Resident 34 According to the 02/07/2022 Quarterly MDS Resident 34 was assessed with moderately impaired cognition and was able to understand and be understood. Resident 34 had diagnoses including dementia (memory loss) and age-related osteoporosis (weak, brittle bones) with a current pathological fracture (a break in bone caused by an underlying disease). A review of the 11/19/2021 fall risk care plan showed on 12/31/2021 interventions were added after the resident sustained a fall. The interventions included, keep the resident's walker and wheelchair in the bathroom and the resident needed staff assistance with transfers. On 03/22/2022 at 9:40 AM, Resident 34 was observed sleeping in bed with the wheelchair next to the resident's bed. Similar observations were made on 03/23/2022 at 8:58 AM and 2:04 PM and 03/24/2022 at 8:28 AM. During an interview on 03/25/2022 at 11:14 AM, Staff B stated Resident 34 could self toilet and the CP needed to be updated. Resident 6 Glasses According to a 03/09/2022 Quarterly MDS, Resident 6 had severe cognitive impairment and was assessed to require extensive physical assistance from staff for transfers, dressing, and personal hygiene. This MDS assessed Resident 6 with impaired vision that required the use of corrective lenses. According to a 09/09/2020 vision CP, interventions included to assist Resident 6 to clean and put on their glasses each morning and to provide a magnifying glass as needed. An observation on 03/23/2022 at 8:53 AM, showed Resident 6 was at the medication cart, not wearing glasses. Similar observations were noted on 03/23/2022 at 12:11 PM and 6:05 PM of Resident 6 in the dining room for meals, not wearing glasses. An observation on 03/24/2022 at 8:17 AM, showed Resident 6 in their wheelchair in the dining room, not wearing glasses. In an interview on 03/24/2022 at 9:08 AM, Staff T (Certified Nursing Assistant- CNA) stated Resident 6 only had reading glasses and did not require the use of them when up during the day. Functional Maintenance Program (FMP- an exercise program) According to a 09/09/2020 impaired physical mobility CP, interventions included that Resident 6 was on a FMP three times a week to maintain functional ability. A review of the March 2022 FMP documentation showed Resident 6 received the FMP twice weekly. In an interview on 03/24/2022 at 2:00 PM, Staff V (Restorative Aide) stated Resident 6 received the FMP twice weekly, on Wednesday and Friday. Dentures and Weight Monitoring According to a Resident Summary (directions to staff regarding how to provide care) printed on 03/23/2022, Resident 6 had interventions to wear partial dentures- upper and lower and to weigh resident weekly. A review of Resident 6's March 2022 POs showed Resident 6 had orders to be weighed monthly. An observation on 03/22/2022 at 9:36 AM showed Resident 6 was not wearing partial dentures. In an interview at that time, Staff W (CNA) indicated Resident 6 was no longer using the partial dentures. In an interview on 03/25/2022 at 9:31 AM, Staff B confirmed the CP and Resident Summary should have been, but were not, revised and updated to reflect Resident 6's current condition. Staff B indicated it was important that staff review and update CPs with changes so staff get an accurate picture of the resident's care needs. Resident 39 Glasses According to a 02/15/2022 Quarterly MDS, Resident 39 had severe cognitive impairment and was assessed to require extensive physical assistance from staff for transfers, dressing, and personal hygiene. The MDS assessed Resident 39 with impaired vision and required the use of corrective lenses. According to a Resident Summary printed on 03/24/2022, interventions indicated Resident 39 required glasses. Observations on 03/21/2022 at 9:08 AM, showed Resident 39 was in the dining room and was not wearing glasses. Similar observations on 03/22/2022 at 9:07 AM, 03/23/2022 at 9:39 AM and 03/24/2022 at 8:57 AM showed Resident 39 was not wearing glasses. In an interview on 03/24/2022 at 10:38 AM, Staff U (CNA), stated Resident 39 only had reading glasses and the family only wants [them] to wear them when reading. FMP According to the 11/07/2017 impaired physical mobility CP, interventions showed Resident 39 was on an FMP three times a week to help them remain at their current level of function. Review of March 2022 FMP documentation showed Resident 39 received the FMP twice weekly. In an interview on 03/24/2022 at 2:00 PM, Staff V stated Resident 39 received the FMP twice weekly, on Tuesday and Thursday. Weight Monitoring According to a 11/05/2022 risk of weight gain/loss CP, Resident 39's interventions included weight twice monthly. Review of Resident 39's current (undated) Resident Summary showed instructions for weight weekly. In an interview on 03/25/2022 at 9:31 AM, Staff B confirmed staff should have updated and revised the CP and Resident Summary to reflect Resident 39's current care needs.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent (%). Failure to properly administer 2 of 25 medications during the medication pass observation, resulted in a medication error rate of 8%. The failure to follow professional standards while administering insulin by pen placed the residents at risk for adverse side effects and/or reduced medication effectiveness due to improper administration. Findings included . Review of the facility procedure titled Insulin Injection Know-How Copyright date 2020, instructed staff to prime the insulin pen prior to injection. The needle was to remain in the skin for 10 seconds after the injection was administered. In an observation on 03/23/2022 at 4:54 PM, Staff G (Licensed Practical Nurse) prepared a Lispro insulin (rapid acting insulin) pen and a glargine insulin (long-acting insulin) pen for administration to Resident 11. Staff G attached the needles to the pens and set the prescribed dose but did not prime the needle. Staff G started and was stopped from administering the insulin injection and asked if the needle was primed before administering. Staff G stated they did not prime the needles and were not aware of the requirement to prime the needle when using an insulin pen. Observation on 03/23/2022 at 4:54 PM showed Staff G injected the lispro insulin via the pen into the left upper side of the resident's abdomen and left the needle in place for three seconds and removed the needle. Staff G then injected the glargine insulin via the pen into the resident's right upper abdomen and left the needle in place for four seconds and removed the needle. In an interview on 03/23/2022 at 5:23 PM, Staff G stated they did not monitor how long the needle remained in contact with the skin and was not aware there was a set timeframe of administration to assure the complete dose was administered. In an interview on 03/24/2022 at 2:49 PM, Staff E (Staff Development Coordinator) stated the Insulin Injection Know-How document was the procedure for the nurses to use when administering insulin pens and the facility did not have any package inserts that came with the insulin pens. Staff E stated that the facility insulin competency did not include insulin pen use. Staff G was not evaluated for competency and accurate administration of an insulin pen. REFERENCE: WAC 388-97-388-97-1060 (3)(k)(ii). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases, including Covid-19 and other infections The facility failed to perform Covid-19 testing for a symptomatic resident and implement transmission based precautions timely to potentially prevent the spread of infection for 1 (Resident 495) of 5 residents reviewed for Infection Control and 1 (Resident 29) supplemental resident; failed to ensure staff appropriately used Personal Protective Equipment (PPE) in resident care areas; and failed to ensure staff performed appropriate hand hygiene during meal services. These failures placed residents at risk for the development and transmission of disease and infection, including COVID-19. Findings included . According to the 07/2020 Resident Screening and Surveillance for Covid-19 facility policy, resident's with signs or symptoms of Covid-19 must be identified and isolated to help control the spread of infection to other residents, staff and visitors. The policy directed staff to monitor residents daily for signs of respiratory infection and/or symptoms of Covid-19, including: fever or chills, cough, shortness of breath (SOB) difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. Residents with fever, or signs or subjective symptoms of Covid-19 should be tested, per current CDC (Centers for Disease Control) and LHJ (Local Health Jurisdiction) guidance. While results are pending, symptomatic residents should be placed on transmission based precautions. Covid-19 Testing/Transmission Based Precautions (TBP) Resident 495 According to the 03/07/2022 admission Minimum Data Set (MDS an assessment tool) the resident admitted on [DATE], had severely impaired cognition, was not able to make decisions, and usually was understood and understands others in conversation. Resident 495 had diagnoses including pneumonia, dysphagia (difficulty swallowing), and diabetes. Review of the 03/01/2022 Risk for potential exposure to Covid-19 virus care plan (CP) directed staff to observe the resident for the following signs/symptoms: fever or chills, cough, SOB or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. If any signs or symptoms present initiate transmission based precautions and notify the Physician and the Infection Preventionist (IP). Review of a 03/01/2022 Physician order (PO) showed staff must monitor the resident every shift and observe for the following signs/symptoms: fever or chills, cough, SOB or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. If any signs or symptoms were noted nurses should initiate transmission based precautions and notify the Physician and the IP. A 03/11/2022 Nursing progress note showed the resident was more congested and bi-lateral (both sides) breath sounds (sounds of air moving through the lungs) were diminished. According to the note, the Physician's Assistant was notified and new orders were received to include a chest x-ray (CXR) and lab testing. There was no indication the facility isolated or tested Resident 495 for Covid-19 for symptoms of congestion. A second progress note on 03/11/2022 showed the resident was up in the wheelchair for dinner. A 03/12/2022 nursing progress note showed the resident continued on alert charting for congestion and was up in the wheelchair for all meals. A 03/13/2022 and 03/14/2022 nursing progress note showed the resident continued to experience congestion. Review of 03/13/2022 CXR results showed no acute disease. During an interview on 03/24/2022 at 2:05 PM Staff D (Resident Care Manager) stated Resident 495 was tested every two days for 7 days after admitting on 03/01/2022. Staff D was not sure if the resident was tested for Covid-19 on 03/11/2022 when the resident displayed symptoms of congestion. Review of March 2022 Treatment Administration Record (TAR) showed the resident was tested on [DATE] and 03/06/2022. In an interview on 03/24/2022 at 2:31 PM Staff E (Infection Preventionist/Staff Development Coordinator) stated the resident was being treated for pneumonia at the time so they were not tested for Covid-19. Staff E reviewed McGeer's criteria (surveillance definitions of infections in long term care facilities) and acknowledged congestion is not a symptom of pneumonia. Staff E stated they would expect staff to test a symptomatic resident for Covid-19 and isolate the resident in transmission based precautions. Resident 29 According to the 01/28/2022 Quarterly MDS the resident was cognitively intact, able to understand and be understood in conversation, and had diagnoses including obstructive sleep apnea and utilized a a Continuous Positive Airway Pressure (CPAP) machine. On 03/21/2022 at 9:11 AM a CPAP machine was observed at the resident's bedside. Resident 29 stated they used the CPAP nightly and turned it on and took it off by themselves. There was no signage observed in or outside the room indicating Aerosol Generating Procedures (AGP- a procedure that creates uncontrolled respiratory secretions) were in place during and after the resident utilized the CPAP machine. During an interview on 03/25/2022 at 8:51 AM Staff E stated Resident 29 rarely used the CPAP from their understanding and the resident may put it on by themselves but they always kept their door shut. Staff E stated if the CPAP is in use staff were expected to wear full PPE (Personal Protective Equipment) before entering the resident's room. There was no indication the facility posted AGP signage outside of the resident's room informing staff the CPAP was in use or was used and removed, and how long staff must wear an approved N95 in the room after the AGP was completed. Personal Protective Equipment (PPE) According to the 02/28/2022 Washington State Department of Health Interim Guidance for Covid 19 Source Control in Healthcare Settings, source control refers to the use of well-fitting facemasks to cover a person's mouth and nose to prevent the spread of potentially infectious respiratory secretions when breathing, talking, sneezing, or coughing. Because of the potential for asymptomatic (no symptoms present) and pre-symptomatic (before symptoms occur) transmission, source control measures are for everyone in the healthcare facility, even if they do not have symptoms of Covid-19. Review of the 02/02/22 CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic showed healthcare personnel should wear source control when they are in areas of the healthcare facility where they could encounter patients, for example common halls or corridors. On 03/24/2022 at 07:11 AM, Staff Q (Housekeeping) was observed cleaning the bathroom at the end of the 100 Hall. Staff Q was not wearing a surgical mask as required. When Staff Q noticed a surveyor, they removed a mask from their pocket and put it on. When asked why they were working without the required Personal Protection Equipment (PPE), Staff Q stated It get's hot. I get sweaty. When asked if being hot and sweaty was sufficient reason to not follow PPE requirements, Staff Q stated Don't worry about it. On 3/23/2022 at 11:52 AM Staff X (Certified Nurses Assistant) was observed wearing a surgical mask and sitting at a dining table assisting Resident 27 with their lunch meal. At 11:58 AM Staff X got up from the table and returned wearing a face shield. In an interview on 03/24/2022 at 11:20 AM Staff E stated staff are expected to wear a surgical mask and face shield when within 6 feet of residents. Staff E stated the face shield needs to be worn when staff are assisting to feed a resident. Hand Hygiene According to the 11/2016 Hand Hygiene facility policy, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Staff should use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: after contact with a resident's intact skin and before and after eating or handling food. During an interview on 03/24/2022 at 11:20 AM Staff E stated they did not expect staff to wear gloves when handling soiled dishes or utensils during meal services, unless there was a special circumstance. Staff E did expect staff to perform hand hygiene between serving food and picking up soiled dishes. When asked about the kitchen pantry where meals were served from and staff entering and exiting through both available doors to bring out food and bring in soiled dishes, Staff E stated the staff get confused sometimes between the clean and dirty side, we really need to put a sign on the door indicating the clean and dirty side. Refer to F812 Food Procurement, Store/Prepare/Serve-Sanitary REFERENCE: WAC 388-97-1320(1)(a) .

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in accordance with food service safety standards. Facility failure to maintain a clear division between the handling of clean and soiled dishes, safely store dry and cold foods, and maintain a kitchen free of cross-contamination sources left residents at risk for consuming contaminated or spoiled foods. Findings included . Sanitary Workflow Observartions of lunch food service on 03/23/2022 from 12:00 PM to 12:45 PM revealed the following: staff served the residents in the dining room from an adjacent Pantry. This Pantry had a door opening directly to the dining room. This door had a handle on the dining room side and opened out from the Pantry to the dining room. The Pantry had a second door that opened into hallway. Throughout lunch service dietary staff and CNAs (Certified Nursing Assistant) were observed to handle both dirty dishes and clean dishes without performing hand hygiene between and/or wearing gloves during these tasks. Staff used the exterior handle of the dining room-side door to enter the Pantry also without performing hand hygiene, wearing gloves, or sanitizing the door handle. Examples included: At 12:00 PM, an unidentified CNA entered the Pantry through the dirty side, opening the door using the handle and without performing hand hygiene (HH), returned with a coffee for a resident; at 12:07 PM Staff R (Dietary Lead) enetered the Pantry on the dirty side, using the handle to open the door bare handed, and returned immediately with a resident's lunch tray without performing HH; at 12:10 PM and at 12:31 PM Staff R was observed to readjust their facemask while serving residents lunch without performing HH; at 12:13 PM, an unidentified CNA was observed to enter the dirty side of the Pantry with a used coffee cup, after comforting a resident by holding their hand, Staff S (Unit Coordinator) was observed to enter the Pantry on the dirty side using the handle; at 12:15 PM, after a touching a male resident on the arm, Staff I was observed to enter the Pantry using the dirty door handle without performing HH, and immediately exited the same door where they served a bowl of soup from a pot while still not having performed HH; at 12:34 Staff R entered the dirty side of the Pantry using the handle without performing HH; at 12:37 PM Staff R was observed to wipe down a table and return dirty dishes to the Pantry using the dirty door handle and return to the Dining Room without performing HH; at 12:48 PM Staff I was observed to enter the pantry on the carrying soiled dishes, using the dirty door handle and not performing HH. On 03/24/2022 at 10:38 AM in the Third Floor Kitchen, Staff O was observed preparing resident meals while wearing gloves Staff O stopped preparing trays and took a blender from the left side of the dishwasher which had just completed a washing cycle. Staff O rinsed the blender in the sink to the left of the dishwasher. The sink was observed to be soiled with food waste. Staff O then took the blender, while still wearing the same gloves and began preparing to blend a pureed meal. In an interview on 03/24/2022 at 10:47 AM, Staff H stated the left side of the dishwasher was the dirty side and the right side was the clean side. Staff I stated Staff O should have taken the blender from the clean side rather than the dirty side. In an interview with Staff H and Staff I on 03/24/22 03:16 PM, Staff H stated Staff O should not have taken the blender out of the dishwasher in the dirty side and did not need to rinse it before use as it was already clean. Staff I described the workflow in the Pantry between clean and dirty dishes should be as follows: The door between the Pantry and the 100 Hall with no handle on the outside was the dirty side and staff should take all dirty dishes through that door and that the door between the Pantry and the Dining Room was the clean side. Dry Storage On 03/21/2022 at 9:06 AM, during an initial tour of the facility's kitchen, a bag of pasta was observed to be opened and wrapped in plastic wrap with no date noted when the pasta was opened was not recorded. Staff L (Kitchen Assistant) confirmed the lack of date and stated that all opened food packet should be dated to ensure the contents were used timely. On 03/21/2022 at 9:30 AM, in the facility's 3rd floor pantry area, a bag of rice and a bag of orzo pasta were observed opened, resealed with plastic wrap and not dated. On 03/24/2022 at 9:52 AM, in the facility's main first floor kitchen, a bottle of wok sauce was observed to be undated and opened. Staff M (Executive Chef) confirmed the bottle was not but should have been dated when opened. Cold Storage On 03/21/2022 at 12:50 PM, a bottle of lemon flavored, thickened water (water with thickener ordered for residents with swallowing difficulties) was observed to be opened and not dated in the Pantry by the dining room from which resident meals are served. Staff I, (Assistant Dietary Manager) stated the thickened lemon flavored water was open and should have been, but was not dated. Dirty Fans On 03/21/2022 at 9:07 AM, two fans were noted in the third floor kitchen, a large black standing fan and a small white fan with a small water cannister with corresponding nozzles that allowed the fan to generate a mist. The black standing fan had a build up of cobwebs and dust on the fan blades and wire housing. The black fan was positioned so the flow of air from the fan would blow directly towards the food when resident meals are being plated. The small white fan had observable dust and cobwebs on the blades and was also positioned where the flow of air from the fan would carry to the food during plating. In an interview on 03/24/2022 at 3:16 PM, Staff H stated the facility did not have a fan cleaning schedule or policy. Staff H stated the fans were brought to the third floor kitchen by other staff without approval and that they removed the black fan on 03/22/2022 but had not removed the white fan. Staff H stated that the white fan with the water cannister was not suitable for the kitchen; it should be removed. It could spray over the food. Hair Nets On 03/21/2022 at 09:00 AM, when surveyors sought to enter the third floor kitchen, Staff L (Kitchen Assistant) stated there were no hair nets available for use. On 03/24/2022 at 9:33 AM, Staff M was observed in the first floor main kitchen not wearing a hairnet. When asked why the were not wearing a hair net at that time, Staff M, who was standing in the kitchen at that time, stated they generally worked from their office (located within the main kictchen) were they did not require a hair restraint. During lunch preparation on 03/24/2022 at 09:35 AM, two unidentified service staff were observed repairing equipment in the main kitchen and were not wearing hairnets, and Staff N (First Floor Kitchen Staff) was observed sanitizing counter tops without a hair restraint. Staff N left after a conversation with Staff M and returned immediately after with a hairnet. In an interview on 03/24/2022 at 09:39 AM Staff N stated Staff M directed them to put on a hairnet. Staff N stated that they normally don't use a hairnet; I am cleaning - normally it's just the food preparation staff that wear them. On 03/24/2022 at 11:12 AM, Staff H was observed in the kitchen without a hair restraint. Staff H expressed surprise and stated they had put on a hair net earlier that day. On 03/24/2022 at 10:42 AM, Staff O (cook) was observed wearing a baseball cap and no other hair restraint while preparing residenty lunches. Staff O's baseball cap did not cover the lowest part of Staff O's head and did not prevent hair from falling into food. Refer to F880 Infection Prevention and Control REFERENCE: WAC 388-97-1100 (3), 2980. .