What is MARIANWOOD HEALTH AND REHABILITATION's CMS rating?

MARIANWOOD HEALTH AND REHABILITATION has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does MARIANWOOD HEALTH AND REHABILITATION have any serious inspection findings?

Yes, MARIANWOOD HEALTH AND REHABILITATION has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 76 total deficiencies from recent inspections.

What are the staffing levels at MARIANWOOD HEALTH AND REHABILITATION?

MARIANWOOD HEALTH AND REHABILITATION has a four-star staffing rating from CMS with 1.06 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MARIANWOOD HEALTH AND REHABILITATION located?

MARIANWOOD HEALTH AND REHABILITATION is located in ISSAQUAH, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MARIANWOOD HEALTH AND REHABILITATION have?

MARIANWOOD HEALTH AND REHABILITATION has 117 certified beds.

Who owns MARIANWOOD HEALTH AND REHABILITATION?

MARIANWOOD HEALTH AND REHABILITATION is a non profit - corporation facility and is part of the PROVIDENCE HEALTH & SERVICES chain.

Is MARIANWOOD HEALTH AND REHABILITATION safe?

MARIANWOOD HEALTH AND REHABILITATION has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at MARIANWOOD HEALTH AND REHABILITATION stick around?

MARIANWOOD HEALTH AND REHABILITATION has high staff turnover at 56%. High turnover can mean less continuity of care as staff change frequently.

Was MARIANWOOD HEALTH AND REHABILITATION ever fined?

Yes, MARIANWOOD HEALTH AND REHABILITATION has been fined $110,562 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is MARIANWOOD HEALTH AND REHABILITATION on any federal watch list?

No, MARIANWOOD HEALTH AND REHABILITATION is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at MARIANWOOD HEALTH AND REHABILITATION?

Medicare inspectors have found 76 deficiencies at MARIANWOOD HEALTH AND REHABILITATION: 1 critical, 1 serious, 74 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting MARIANWOOD HEALTH AND REHABILITATION?

Families visiting MARIANWOOD HEALTH AND REHABILITATION should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MARIANWOOD HEALTH AND REHABILITATION compare to other nursing homes?

MARIANWOOD HEALTH AND REHABILITATION has a 1-star overall rating, which is below average compared to other nursing homes in WA. Families should carefully review inspection findings and consider alternatives.

MARIANWOOD HEALTH AND REHABILITATION

3725 PROVIDENCE POINT DRIVE SOUTHEAST, ISSAQUAH, WA 98029 · (425) 391-2800

Non profit - Corporation 117 Beds PROVIDENCE HEALTH & SERVICES Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

3/100

#178 of 190 in WA

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Last Inspection: August 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Marianwood Health and Rehabilitation has received a Trust Grade of F, indicating significant concerns about the quality and safety of care provided. Ranking #178 out of 190 facilities in Washington places it in the bottom half, and #44 out of 46 in King County suggests there are only a couple of better local options available. Unfortunately, the facility is worsening, with issues increasing from 12 in 2023 to 27 in 2024. Staffing is a relative strength, rated 4 out of 5 stars, but the turnover rate is 56%, which is about average. However, the facility has been fined $110,562, which is concerning and suggests repeated compliance issues. Additionally, while the RN coverage is good, meaning there are more registered nurses than in most facilities, there have been serious incidents, including a resident not receiving necessary care for pressure ulcers and another resident being transferred without proper assistance, which increases the risk of falls. Overall, while there are some strengths, the significant number of deficiencies and ongoing issues raise alarms for families considering this facility.

Trust Score: F
In Washington: #178/190
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $110,562 in fines. Higher than 68% of Washington facilities. Some compliance issues.
Skilled Nurses: Each resident gets 63 minutes of Registered Nurse (RN) attention daily — more than 97% of Washington nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 76 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2023: 12 issues

2024: 27 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Washington average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 56%

10pts above Washington avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $110,562

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: PROVIDENCE HEALTH & SERVICES

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (56%)

8 points above Washington average of 48%

The Ugly 76 deficiencies on record

1 life-threatening 1 actual harm

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure resident responsible parties were notified when there was a change in condition or when a resident experienced a fall for 1 (Resident 1) of 3 residents reviewed. These failures violated a resident's right to have their representative involved and informed of any changes in condition. Findings included . Review of the facility policy titled, Fall Prevention and Response, revised 08/2023, showed after a resident experienced a fall the licensed nurse was required to notify the provider and the resident's representative. <Resident 1> Review of an admission Minimum Data Set (MDS, an assessment tool), dated 06/06/2024, showed Resident 1 was not able to make their own decisions, was rarely or never understood by others, and was assessed with an altered level of consciousness ( a change in the resident's awareness of the environment with reduced alertness). The MDS showed Resident 1 had impairments to one side of their body, affecting one arm and one leg. The MDS showed Resident 1 was dependent on staff for bed mobility, toileting, and transfers. The MDS showed Resident 1 was non-verbal and had diagnoses including a history of a brain bleed (stroke), high blood pressure, and diabetes. Review of Resident 1's face sheet (a summary of the residents personal and demographic information), undated showed Resident 1 had a Collateral Contact (CC) to contact for changes in condition. Review of Resident 1's fall Care Plan (CP), revised 07/23/2024, showed Resident 1 was at risk for falls related to general weakness and current medical conditions. The CP directed staff to ensure the call light was in reach, prompt the resident to call for assistance, and ensure the resident was positioned in the center of the bed. Review of a fall investigation, dated 07/25/2024, showed Resident 1 was found on the floor by their bed lying face down on their stomach. The investigation showed Resident 1 was not able to verbalize what happened and it was believed Resident 1's fall was likely caused by the resident trying to reposition themselves in bed. The investigation showed the provider and the residents representative were informed of the fall, the documentation did not show the date or time when the notifications occurred. Review of a concern form, dated 09/04/2024, showed Resident 1's CC was very concerned they did not receive notification of Resident 1's fall. The concern form showed Resident 1's CC asked several times how this happened and was told it was the facility's policy to notify the representative of a fall. During an interview on 09/11/2024 at 2:00 PM, Staff B (Director of Nursing Services) stated licensed nurse were expected to notify the resident responsible party when a resident experienced a fall. Staff B stated Resident 1's representative notification was not documented therefore it was not done. Staff B stated Resident 1's CC called the facility social worker and was upset they did not receive notification of Resident 1's fall on 07/22/2024. Staff B stated the CC found out about Resident 1's fall during a care conference on 09/04/2024. In an observation on 09/11/2024 at 2:12 PM, Resident 1 was observed sitting in a wheelchair with their eyes closed. Resident 1 did not respond to verbal stimuli or questions about the incident. During an interview on 09/30/2024 at 1:02 PM, Resident 1's CC stated they found out about Resident 1's fall a month and a half later. The CC stated they were frustrated that they did not receive notification on the date of the fall and felt bad that Resident 1 was alone and was not able to say what happened about the fall. REFERENCE: WAC 388-97-0320(1)(a) .

Aug 2024 25 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Facility Policy> According to the Fall Prevention and Response facility policy, revised 08/2023, the facility would redu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Facility Policy> According to the Fall Prevention and Response facility policy, revised 08/2023, the facility would reduce the risk of falls and injury resulting from falls by assessing and periodically reassessing each resident's risk for falling. The policy showed the potential risks associated with increased care needs and the environment and to implement interventions to address identified risks. <Resident 64> According to the 05/15/2024 Quarterly MDS, Resident 64 needed help with functional cognition, had visual impairment, was dependent on staff in wearing their footwear, and needed moderate assistance with dressing and transferring from bed, chair and toilet. The assessment showed Resident 64 admitted to the facility on [DATE] and had two or more falls since their admission to the facility. In an interview and observation on 07/23/24 at 1:48 PM, Resident 64 stated, I have no clothes; no shoes or socks and I only have slippers and my feet hurt when I walk. Resident 64's toenails were observed long enough to curl into bottom of foot and resident had brown suede slippers and no other shoes in the room. On 07/23/2024 at 2:05 PM, Resident 64 stated, .every time I turn around, I am falling, and the toilet commode was loose, if I lean over too much, I might fall. On 07/26/2024 at 8:39 AM, Resident 64 stated, I already got myself up, the staff don't really help me, and they come in after the fact . Observation on 07/30/2024 at 8:34 AM showed Resident 64's bed was tilted downwards to the right; the bed was unbalanced when moved and Residnt 64 stated the bed was broken. On 07/31/2024 at 11:32 AM, the bed table was propped up against bathroom door, the walker was at the foot of the bed, and resident was seated at a chair in front of bed away from walker. Record reviews of the 04/25/2024 facility fall event occurrence investigation report showed Resident 64 had a fall by the room door; the 07/1/2024 investigation report showed Resident 64 sustained a fall near their bed, and the 07/07/2024 investigation report showed another fall sustained by Resident 64 near the bathroom. The fall prevention interventions listed on the investigation reports included the application of two non-slip tape strips placed on the floor by the bedside and a signage was posted to remind resident to call for assistance before attempting to transfer. In an interview on 07/30/2024 at 8:37 AM, Staff J (Licensed Nurse) stated the bed looked broken and did not look normal. Staff J stated the care staff did not get a chance to see Resident 64 yet to notice their bed, and that the resident continually refused care so we [staff] do whatever we can. In an interview on 07/30/2024 at 8:42 AM, Staff B (Director of Nursing) stated care staff still needed to encourage residents with dementia (who refused care) and must do whatever they could to help them. Staff B stated Resident 64's bed did not look normal, and the bed looked broken. Staff B observed Resident 64's long, uncut toenails and confirmed the resident needed podiatry services. Staff B stated staff should notify them when a resident had long nails and were refusing care, as foot care was important to prevent skin injury and accidents. Refer to F677- Activities of Daily Living (ADL) Care Provided for Dependent Residents. REFERENCE: WAC 388-97-1060(3)(g). <Unit C> Observation on 07/23/2024 at 10:28 AM showed the shower room door across room [ROOM NUMBER] had a sign to keep doors locked at all times but the key combination lock was broken and the door was left unlocked; inside was unsecured chemicals including a gallon of bleach cleaning solution situated next to the toilet and a spray bottle of disinfectant solution hanging from the shower grab bar. On 07/23/2024 at 10:33 AM, Staff G (Certified Nursing Assistant - Shower Aide) came and stated they were getting the shower room ready for a resident. Staff G determined the key combination lock was broken/faulty and the door was left unlocked. Staff G stated the maintenance department should be notified to have the door lock fixed right away. Staff G stated it was important to ensure the door was kept locked at all times so confused and wandering residents could not enter the room and accidentally ingest or apply any chemicals on themselves that were left unsecured inside the shower room. In an interview on 07/23/2024 at 10:43 AM, Staff C confirmed the key combination lock to the shower room in Unit C needed to be repaired and stated the shower door must be kept locked at all times (as indicated by the posted sign on the door) for resident safety. <Unsecured Chemicals> <Unit A> Observations on 07/23/2024 at 1:38 PM showed the shower room door on Unit A was unlocked. Inside the unlocked room was a cabinet with a key in the keyhole. The key was attached to the cabinet by a chain. The cabinet door could be opened without having to turn the key. Inside the cabinet was a spray bottle of disinfectant with a label that stated, DANGER, keep out of reach of children, and identified first aid steps if the chemical was ingested. In an interview on 07/25/2024 at 9:47 AM, Staff C stated the shower room door and chemicals should be locked and secured. Observations at this time showed the door was unlocked and was easily opened when checked. Staff C stated the door should be locked not only to provide privacy for residents, but to assure chemicals are secured to reduce risks of accidents. Based on observation, interview, and record review, the facility failed to: (1) Ensure water temperatures were maintained to remain within the safe temperature of 110 (+/- 10) degrees Fahrenheit (F) as required for 13 of 13 rooms sampled for hot water temperatures (Rooms 328, 306, 330, 324, 114, 428, 202, 124, 408, 422, 102, 228, & 404); (2) ensure hazardous chemicals were kept locked and secured at all times for 2 of 4 nursing units (Unit A & C); and (3) identify potential risks associated with a resident's care needs and environment to decrease the risk of falling for 1 of 6 residents (Resident 64) reviewed for falls. The facility's failure to complete repairs identified to be necessary to the hot water system and sample hot water temperatures in resident rooms placed residents at risk for serious burn or injury caused by scalding and constituted a Immediate Jeopardy (IJ). The facility's failure to secure hazardous chemicals placed residents at risk for accidental ingestion and/or skin impairment. The facility's failure to identify risks and implement fall interventions placed residents at risk for recurrent falls and a decreased quality of life. On 07/23/2024 at 3:30 PM, the facility was notified of an IJ in F689. The facility removed the immediacy on 07/24/2024 after they immediately contacted the outside vendor to assess and/or repair the boiler, identified other high risk residents, placed temporary caution signs in resident room sinks and shower rooms to mix cold and hot water to reduce/eliminate the risk for burns/scalding, instituted audits to monitor the boiler gauge and all resident rooms- water temperature monitoring, updated the facility's rounding log, and provided education to the Facilities (Maintenance) Manager regarding the domestic water policy, and implemented a plan of correction to sustain ongoing compliance. Findings included . <Hot Water Temperature> <Facility Policy> The facility's Domestic Water Policy, revised 01/2019, showed the facility's domestic hot water would be checked monthly to ensure a hot water temperature of 105 to 115 F was maintained. <Centers for Medicare and Medicaid Service (CMS) Hot Water Guidelines> According to revised 02/03/2023 CMS guidelines: A third-degree burn would occur after five minutes of exposure to a hot water temperature of 120 F, after three minutes of exposure to a hot water temperature of 124 F, after one minute of exposure to a hot water temperature of 127 F, and after 15 seconds of exposure to a hot water temperature of 133 F. Observation on 07/23/2024 at 10:57 AM showed room [ROOM NUMBER] had two sinks, one labeled for Resident 33, and the other for Resident 68 who shared the room. When temperatures were taken, the hot water from Resident 33's sink became hot very quickly after turning on the faucet and felt uncomfortable for hand washing. The temperature measured at that time was 127 F. At the same time, Resident 68's sink's hot water measured 125 F. The following observations of hot water were made: On 07/23/2024 at 10:59 AM, the hot water temperature in room [ROOM NUMBER] was observed at 129 F. On 07/23/2024 at 11:00 AM, the hot water temperature in room [ROOM NUMBER] was observed at 124 F. On 07/23/2024 at 11:01 AM, the hot water temperature in room [ROOM NUMBER] was observed at 126 F. On 07/23/2024 at 11:05 AM, the hot water temperature in room [ROOM NUMBER] was 130 F in one sink and 131 F in the other sink. On 07/23/2024 at 11:07 AM, the hot water temperature in room [ROOM NUMBER] was observed at 127 F. On 07/23/2024 at 11:07 AM, the hot water temperature in room [ROOM NUMBER] was 127 F in one sink and 133 F in the other sink. On 07/23/2024 at 11:10 AM, the hot water temperature in room [ROOM NUMBER] was observed at 127 F. On 07/23/2024 at 11:20 AM, the hot water temperature in room [ROOM NUMBER] was observed at 132 F. On 07/23/2024 at 11:24 AM, the hot water temperature in room [ROOM NUMBER] was observed at 132 F. On 07/23/2024 at 11:45 AM, the hot water temperature in room [ROOM NUMBER] was 133 F in one sink and 134 F in the other sink. On 07/23/2024 at 11:59 AM, the hot water temperature in room [ROOM NUMBER] was observed at 134 F. On 07/23/2024 at 12:47 PM, the hot water temperature in room [ROOM NUMBER] was observed at 130 F. In total, between 10:57 AM and 12:47 PM on 07/23/2024, surveyors observed unsafe water temperatures in multiple rooms on each of the facility's four units. None of the rooms observed had hot water at a safe temperature. In an interview on 07/23/2024 at 1:40 PM, Staff C (Facilities Manager) stated they maintained a hot water temperature log. Staff C stated hot water should be no hotter than 120 F. In an interview on 07/23/2024 at 1:47 PM, Staff C stated hot water temperatures were checked and logged monthly. Staff C stated they checked a couple rooms at the end of the building near the boiler because it serve[d] the whole building. Observation on 07/23/2024 at 2:33 PM showed the facility had two boilers located in the maintenance shop. A sign on the boilers indicated they were installed on 12/31/2020. In an interview at that time, Staff C stated if they identified any problems with excessively hot water, they called a vendor for assistance to identify and repair the problem. Review of the facility's 2024 Hot Water Temperature Log provided by Staff C on 07/23/2024 showed the hot water should be 110 DEG + or - 10 degrees which was not consistent with the facility's policy for hot water to remain in the 105-115 F range. The log showed, once a month from January through June 2024, Staff C documented two temperatures. For each month, one of those temperature measurements was taken in the maintenance room, and the second was taken in either the staff break room, the facility's main dining room, or rehabilitation gymnasium (gym). No temperatures measurements were made in resident rooms. The 2024 Hot Water Temperature Log showed on 02/27/2024 the hot water was measured at 122 F in the gym, on 05/24/2024 at 121.5 F in the gym, and on 06/24/2024 at 122 F on 06/24/2024 in the maintenance room; all three temperatures were above the maximum temperature limit for hot water as required. In an interview on 07/23/2024 at 2:51 PM, Staff C stated they contacted the vendor to fix the hot water system after identifying hot temperatures exceeded safe limits. Staff C stated they would provide documentation showing when they last contacted the vendor. On 07/23/2024, Staff C provided a 04/11/2024 estimate from the vendor for repair of a failed flow switch. This invoice was signed by Staff C on 04/15/2024. The vendor's signature was left blank. There was no indication that the work was paid for or completed. Observation on 07/23/24 at 3:46 PM with Staff's C and D (Director of Rehabilitation Services) showed the hot water temperature in room [ROOM NUMBER] was at 128 F. Both staff stated the temperature reading was high. At that time, Staff C checked the readout of a digital thermometer measuring the temperature of the pipe where hot water flowed from the hot water tanks to the rest of the facility. This thermometer showed a temperature of 123.8 F. <Resident 33> According to the 04/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 33 had impaired memory and needed substantial to maximal assistance from staff for transfers and personal hygiene. The MDS showed Resident 33 had a stroke history and hemiplegia (one-sided partial paralysis) on their right side. In an interview on 07/23/2024 at 10:42 AM, Resident 33 stated sometimes they had to wait a long time for the bathroom. Resident 33 stated if staff did not come quickly enough to assist them, they got themselves up to use the bathroom even though they knew they should wait for help as they could wait no longer. Observation at that time showed Resident 33's right hand had limited range of motion. Resident 33's fingers curled in toward the palm of the hand. Observation of the sink at 07/23/2024 at 10:57 AM showed the faucet had a left lever that controlled hot water and a right lever that controlled the cold water which could impact the ability of a person with a right-hand impairment to adjust the hot water temperature with cold water. In an interview on 07/24/2024 at 11:36 AM, Staff A (Administrator) stated it was important to ensure the hot water temperature in resident rooms were maintained within the safe temperature as required to prevent adverse outcome and resident injury including burns caused by scalding. Staff A stated Staff C knew the water flow switch needed repair last April 2024 based on the facility provided project proposal but did not address the situation appropriately. In an interview on 07/24/2024 at 11:48 AM, in the presence of Staff A, Staff C confirmed they knew about the situation and stated they should have acted upon the identified water valve repair needed but did not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to obtain a consent for the use of an Antidepressant (AD) medication for 1 of 5 residents (Resident 79) reviewed for unnecessary medications. This failure placed Resident 79 at risk for receiving unwanted psychotropic medications, altered level of consciousness, and a decreased quality of life. <Facility Policy> The facility's Psychotropic Medications Policy, revised 01/2023, showed psychotropic medications should only be used after careful evaluation of potential risks and benefits. <Resident 79> According to the 07/02/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 79 had impaired memory and an acute onset change in their mental status, with fluctuating attention and consciousness. The MDS showed Resident 79 had medical diagnoses including uncontrolled muscle movements, schizophrenia (a mental disorder), and a history of cancer. The MDS showed Resident 79 received an AD medication during the assessment period. Review of Resident 79's Physician's Orders showed a 07/15/2024 order for an AD medication; to give 7.5 Milligrams at night for schizophrenia. Record review showed no evidence the facility acquired informed consent (a process where the risks and benefits of a treatment were explained so the resident could consent to the treatment with understanding, required for psychotropic medications) prior to administering the AD medication to Resident 79. In an interview on 08/01/2024 at 9:12 AM, Staff B (Director of Nursing) stated informed consent was required prior to the use of an AD medication. Staff B stated they would double check and provide any evidence informed consent was obtained for Resident 79's AD medication use. No further information was provided by the facility. REFERENCE: WAC 388-97-0260. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0569 (Tag F0569)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to notify 1 of 16 residents (Resident 10) who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries were permitted to possess without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. Findings included . <Facility Policy> Review of the facility's revised 05/2017 Resident Trust policy stated the facility would notify the resident and/or resident's guardian/durable power of attorney, facility social worker, and the local department of social and health services, in writing, when a resident, who was on Medicaid, reached an individual account balance of two hundred dollars less than the Supplemental Security Income (SSI) resource limit for one individual. The policy stated the notification would advise if the amount in the account exceed the SSI limit, the resident may lose eligibility for Medicaid or SSI. <Resident 10> Review of the facility's Fund Balances report showed Resident 10's balance was over the SSI resource limit, as of 07/23/2024. Resident 10's current balance was at $2496.53, which was $696.53 over the amount where the facility was required to notify the resident they were approaching the SSI resource limit. Resident 10's current trust balance was $496.53 over the SSI resource limit, putting the resident at risk for personal financial liability for their care. In an interview on 07/31/2024 at 11:31 AM, Staff W (Administrative Assistant) confirmed Resident 10 had a current balance over $1800 in their trust account. Staff W stated they were unaware of any Medicaid SSI resource limitations for residents and stated they did not discuss resident trust balances with the social worker. In an interview on 07/31/2024 at 11:48 AM, Staff E (Social Services Director) stated, It has been years since they were notified regarding a resident who was over their SSI resource limits. In an interview on 08/01/2024 at 2:03 PM, Staff A (Administrator) stated they reviewed the facility policy and Resident 10 should have been but was not notified as required when they reached an account balance of two hundred dollars less than the SSI resource limit. REFERENCE: WAC 388-97-0340(4). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 6> According to the 06/21/2024 admission MDS, Resident 6 was understood, had clear comprehension, and admitted t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 6> According to the 06/21/2024 admission MDS, Resident 6 was understood, had clear comprehension, and admitted to the facility on [DATE]. Review of Resident 6's medical records on 07/23/2024 at 10:25 AM did not show documentation of an AD or a declination to formulate an AD. The record showed that an AD toolkit was provided to the resident and family on 07/23/2024, with a handwritten note by the facility's social services department that a copy of an advanced directive was requested from the patient and family on 7/23/2024, two months after Resident 6's admission. In an interview on 07/29/2024 at 11:40 AM, Staff E stated it was their expectation that AD's were readily available in a resident's records. REFERENCE: WAC 388-97-0280 (3)(c)(i-ii). <Resident 31> According to a 07/12/2024 admission MDS, Resident 31 admitted to the facility on [DATE], had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 31 with no memory impairment. Observations on 07/24/2024 at 10:07 AM showed an AD packet sitting on Resident 31's bedside table. In an interview at this time, Resident 31 stated, they just brought me the packet this morning. Resident 31 stated they were not provided the AD packet prior to 07/24/2024. Review of Resident 31's records showed a scanned form from 07/24/2024 which showed the AD toolkit was provided to the resident/family, over two weeks after the resident admitted . This form included a hand-written note that said, provided to patient. <Resident 75> According to a 06/06/2024 admission MDS, Resident 75 admitted to the facility on [DATE], had no speech, was rarely/never understood, and rarely/never was able to understand others. This MDS showed staff assessed Resident 75 had severely impaired cognitive skills and never/rarely made decisions. Review of the 06/04/2024 Social Services admission assessment AD status section, showed Resident 75 did not have an AD, did not have the decisional capacity, and was unable to create an AD. This section had an option for staff to mark the AD pamphlet was provided to resident/family, this section was not marked as being completed by staff. The section for staff interview for resident preferences identified the resident prefers family or significant other involvement in care discussions. Review of Resident 75's records showed a scanned form from 07/24/2024 which showed a handwritten note that said the AD toolkit was, provided to patient, almost two months after the resident admitted . There was no indication why staff provided the packet to Resident 75, who was assessed with severe cognitive impairment, rather than the family identified in the resident's records. In an interview on 07/29/2024 at 11:40 AM, Staff E (Social Services Director) stated AD were important so staff would know what to do for a resident if they were to become unable to make their own decisions. Staff E stated it was their expectation if a resident was unable to make their own decisions, staff would reach out to the resident's family to discuss AD. <Resident 189> According to a 06/12/2024 admission MDS, Resident 189 was admitted to the facility on [DATE], had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 189 with no memory impairment. Review of the 06/12/2024 Social Services admission assessment AD status section was left blank staff and did not identify Resident 189 had a Power Of Attorney (POA). In an interview on 07/26/2024 at 8:40 AM, Resident 189 stated they had a POA for healthcare. Review of Resident 189's records showed a scanned form from 07/23/2024 which showed an AD toolkit was provided to the resident/family, and included a handwritten note underneath that said, Received. Review of Resident 189's records revealed no POA paperwork. In an interview on 07/29/2024 at 11:40 AM, Staff E stated it was their expectation that AD's were readily available in a resident's records. Based on interview and record review, the facility failed to provide timely assistance to formulate an Advanced Directive (AD - documentation explaining the resident's wishes for care if they were unable to speak for themselves) for 5 of 6 residents (Resident 68, 31, 75, 189, & 6) reviewed for ADs. This failure left residents at risk for unmet healthcare needs, unwanted care, and other negative health outcomes. Findings included . <Resident 68> According to the 06/13/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 68 admitted to the facility on [DATE]. The MDS showed Resident 68 had intact memory. Record review showed a document scanned into Resident 68's chart on 07/23/2024 at 12:34 PM (the first day of annual survey, 47 days after admission). This document had only two typed lines. The first read Advanced directive toolkit has been provided to the resident/family. Underneath this line, someone hand wrote, Received. The second line read, Advanced directive toolkit obtained from resident/family and placed in our records. This section was not annotated. The document had Resident 68's room number and no other information. The document did not indicate when the AD toolkit was provided to the resident, whether or not Resident 8 was interested in, or needed assistance to use the toolkit, or who provided the toolkit to Resident 68. In an interview on 08/01/2024 at 11:18 AM, Staff F (Social Services Assistant) stated it was important to capture residents' wishes regarding AD assistance timely. Staff F stated the AD-status document was scanned in on the 07/23/2024. Staff F stated they could not demonstrate it was provided to Resident 68 prior to that date.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to thoroughly investigate incidents for an unwitnessed fall for 1 of 9 residents (Resident 239) whose facility incident report was reviewed to rule out abuse and/or neglect. Facility failure to conduct a complete and thorough investigation as required left residents at risk for unidentified abuse and/or neglect. Findings included . <Facility Policy> The Abuse Prohibition and Prevention facility policy, revised 01/2024, showed a thorough investigation of the alleged violation would be completed and would include conducting interviews with the alleged victim and representative, accused person(s), witnesses, provider, personnel from outside agencies as appropriate. The policy showed the facility would conduct a record review for pertinent information related to the alleged violation such as progress notes and documentation sources as appropriate. The policy showed investigation results of all investigations would be reported to the administrator or designee and to other officials in accordance with State and Federal law within five working days of the incident, and if the alleged violation was substantiated, appropriate corrective action would be taken. <Resident 239> According to the 07/18/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 239 admitted to the facility on [DATE], had clear speech, their memory was intact, and had medical conditions including cancer of the bladder and the lungs extending to the liver, pressure ulcers to the buttocks, malnutrition, and was receiving end-of-life care. The MDS showed Resident 239 was assessed to be totally dependent on two staff for transfers and toileting. Review of the 07/13/2024 Fall Care Plan (CP) showed Resident 239 was at risk for falls due to generalized weakness, malnutrition, and their medical morbidities. A 07/13/2024 CP intervention showed Resident 239 would be provided assistance with their transfers and walking to reduce the risk of falls while in the facility. Observation and interview on 07/24/2024 at 12:09 PM showed Resident 239 was lying in bed, very frail and short of breath despite receiving supplemental oxygen. Resident 239's bed was in low position, and a fall mat was observed in place to the left side of the bed. Resident 239 stated they had two falls since being admitted to the facility. Resident 239 could not recall the details of their falls but stated they believed they were reaching for something while in bed and rolled out of bed. A 07/22/2024 nursing progress note showed Resident 239 sustained a fall around 9:00 AM in their room while attempting to go to the bathroom. Review of the facility investigation report of Resident 239's fall, completed on 07/25/2024, showed the resident fell while attempting to ambulate to the bathroom after breakfast. The report showed assistance with the bed pan was offered several times before breakfast but Resident 239 refused. The report showed the staff completing the investigation ruled out abuse and/or neglect. The investigation report did not contain any staff interview(s) or witness statements regarding the incident. The investigation report included conflicting information regarding the fall being witnessed or unwitnessed, and whether neurological (involving the brain) assessment was initiated and/or completed or not for the resident based on the 07/22/2024 nursing progress note that showed staff did, alongside the 07/22/2024 Fall Occurrence User Defined Assessment (UDA) which showed staff did not, it being a witnessed fall. The investigation report did not include a neurological assessment for Resident 239. Further review of the 07/22/2024 Fall Occurrence UDA showed the staff completing the assessment did not identify: (1) the nursing aide who was the last person to observe Resident 239 eating breakfast in the room, and (2) the nursing aide who claimed to have provided the last incontinent care to Resident 239 at 7:30 AM. The Fall Occurrence UDA's instruction for staff completing the assessment read, Please enter (at a minimum) first name and last initial on these line items but only wrote aid/aide on both. In an interview on 07/31/2024 at 1:42 PM, Staff B (Director of Nursing) stated Resident 239's fall was unwitnessed. When asked if there were any documented interviews/testimony from staff who were working at that time when the fall happened, Staff B stated they had conversations with staff but did not document them. Staff B stated they knew an event investigation should be completed within five days of the event occurring, including having all appropriate documentation from record review and staff/witness statements or interviews, but did not have them. The facility was not able to provide any documentation to support staff offered Resident 239 toileting assistance several times as indicated in the investigation report, where Resident 239 declined their assistance prior to the resident's unwitnessed fall. In an interview on 08/01/2024 at 10:13 AM, Staff A (Administrator) stated it was important for facility event investigations to be conducted completely and thoroughly so that resident abuse and/or neglect could be ruled out. Staff A stated they expected the designated staff responsible for facility event investigations to conduct a complete and thorough investigation and report as required. Refer to F657- Care Plan Timing and Revision. REFERENCE: WAC 388-97-0640 (6)(a)(b)(c). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 20> According to the 06/03/2024 Quarterly MDS, Resident 20 had medical conditions including a brain injury with ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 20> According to the 06/03/2024 Quarterly MDS, Resident 20 had medical conditions including a brain injury with weakness to one side of their body, malnutrition, and difficulty urinating due to organ blockage. The MDS showed Resident 20 had an indwelling Foley catheter (a flexible tube inserted into the bladder to drain urine) in place during the assessment period. On 07/25/2024 at 10:27 AM, Resident 20 stated they recall being sent to the hospital from the facility a few times due to an infection and increasing confusion. Review of the facility census showed Resident 20 was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. A 12/06/2023 nursing progress note showed Resident 20 complained of pressure and pain on their lower abdomen and had blood clots in their urine. The note showed the provider was notified and ordered to send Resident 20 to the hospital for further evaluation and treatment. Review of Resident 20's medical records showed an unsigned transfer notice acknowledging the resident and/or their representative was notified of the discharge. The transfer notice was observed incomplete and did not provide an explanation to support Resident 20's discharge to the hospital was warranted as required. In an interview on 07/31/2024 at 10:42 AM, Staff S stated they were responsible for record-keeping transfer/discharge notices and Ombudsman notification. Staff S confirmed the transfer notice had no resident or resident representative signature to acknowledge receipt and understanding of the required written notification and stated the notice should be signed. Staff S stated there was no documentation found to support the Ombudsman was notified of Resident 20's hospital transfer as required. In an interview on 07/31/2024 at 12:39 PM, Staff A (Administrator) stated it was important to provide residents and their representative written transfer/discharge notification to communicate the resident's current location and to ensure the resident and their representative were notified of the rights and regulations associated with their transfer/discharge. Staff A stated the provision of a written transfer/discharge notice went hand in hand with the required Ombudsman notification and that they expected every staff member involved (nursing and medical records) to do their part in the process. 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 provide written transfer/discharge notices and/or complete notification to the Office of the State Long-Term Care Ombudsman (LTCO) as required for 2 of 4 residents (Residents 32 & 20) reviewed for hospitalization. Failure to provide notification to the resident and/or the resident's representative of the reasons for the discharge in writing or notify the LTCO placed residents at risk for a discharge that did not meet the resident's stated goals for care and preferences, and at risk for preventing the Ombudsman from advocating for residents. Findings included . <Facility Policy> According to the facility's 01/2022 Transfer or Discharge and Ombudsman Notification policy, when a facility resident was temporarily/emergently hospitalized , a notice of transfer must be provided to the resident or their representative as soon as practical. The policy showed copies of all transfer notices were provided to the LTCO office on at least a monthly basis. <Resident 32> According to the 05/07/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 32 had severe memory impairment. The MDS showed Resident 32 had diagnoses including Alzheimer's disease (memory impairment) and Diabetes Mellitus (a condition making regulating blood glucose more difficult). According to a 06/14/2024 progress note, at 1:05 PM, Resident 32 experienced an acute change in condition including elevated blood glucose, rapid heart rate, and involuntary movements. The progress note showed Resident 32 was sent to the hospital emergently at 1:35 PM. A 06/18/2024 progress note showed Resident 32 was readmitted to the facility. Record review showed no evidence a transfer notice was completed and given to Resident 32 of their representative as required. In an interview on 07/31/2024 at 12:28 PM, Staff S (Health Information Manager) stated they were unable to find a written transfer notification for Resident 32's 06/14/2024 hospitalization. Staff S stated the facility should have notified the resident or their representative but could not demonstrate this happened. Staff S stated as the notice did not exist, it could not be sent to the LTCO office.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframe for 1 of 3 residents (Resident 67) reviewed for resident assessments and timing. The failure to ensure MDS assessments were completed timely placed residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life. Findings included . <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2023 RAI Manual showed a Quarterly MDS was a non-comprehensive assessment used to track the resident's status between comprehensive assessments that ensured residents were monitored for critical indicators of a gradual onset of significant change(s) in their status. The RAI outlined a Quarterly MDS must be completed no later than 14 days after the established Assessment Reference Date (ARD) of the assessment and no later than 92 days from the ARD of the most recent prior quarterly or comprehensive assessment (counting ARD to ARD). <Resident 67> Review of Resident 67's MDS schedule showed the comprehensive 03/15/2024 admission assessment was completed on 03/18/2024. The next scheduled 06/03/2024 Quarterly assessment was not completed until 06/17/2024 as timestamped on the MDS' assessment history report and was three days past the 92 days' regulatory completion timeframe as required. In an interview on 07/29/2024 at 11:31 AM, Staff T (MDS Coordinator) stated it was important to ensure timely completion of MDS assessments because the appropriate and safe care necessary for care planning relied on the timeliness of these assessments. Staff T confirmed Resident 67's Quarterly MDS was late. In an interview on 07/29/2024 at 1:14 PM, Staff A (Administrator) stated they expected the MDS coordinators to complete assessments accurately and timely as required. Refer to F642- Coordination/Certification of Assessments. REFERENCE: WAC 388-97-1000 (4)(a). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 3 of 21 residents (Residents 189, 28, & 68) whose Minimum Data Set (MDS - an assessment tool) were completed accurately to reflect the resident's condition at the time of assessment. This failure placed residents at risk for unidentified and/or unmet care needs. Findings included . <Resident 189> According to a 06/12/2024 admission MDS, Resident 189 admitted to the facility on [DATE]. Review of a 06/23/2024 Discharge MDS showed Resident 189 was transferred to an acute care hospital with their return to the facility anticipated. Upon Resident 189's return to the facility 12 days later, staff completed a 07/05/2024 Entry Tracking MDS and indicated the resident's type of entry was an admission, rather than a reentry as required. In a joint interview with Staff T (MDS Coordinator) and Staff X (MDS Coordinator) on 08/01/2024 at 2:25 PM, Staff X stated it was their expectation an Entry Tracking MDS be coded as a reentry if a resident was hospitalized less than 30 days. Staff X stated it was important to accurately code reentry versus an admission on an Entry Tracking MDS and stated, it is the Medicare rules. Staff X stated having accurate coding also assists with the continuity and coordination of care for a resident. Staff T reviewed Resident 189's 07/05/2024 Entry Tracking MDS and stated, I did it wrong, it should be coded as a reentry. <Resident 28> According to the 05/20/2024 Quarterly MDS, Resident 28 exhibited no delusions during the assessment period, and had a diagnosis of depression. The MDS did not identify Resident 28 with a diagnosis of psychosis. The MDS showed Resident 28 received an antipsychotic medication. Review of the Physician's Orders showed a 05/25/2023 order for an antipsychotic medication to be given twice daily for delusions. Record review showed Resident 28 had an 04/03/2023 potential for violence due to [ .] paranoia/delusions about staff Care Plan (CP), a 07/24/2020 History of delusions . CP, and a 05/31/2022 psychotropic medication CP that addressed Resident 28's use of an antipsychotic medication use. In an interview on 08/01/2024 at 9:05 AM Staff B (Director of Nursing) stated Resident 28 had a diagnosis of a psychosis. Staff B stated this should be reflected on the 05/20/2024 Quarterly MDS but was not. <Resident 68> Review of the 06/13/2024 admission MDS showed Resident 15 had intact memory. This MDS included a section for resident interviews on pain, mood, and daily and activity preferences. This activity preferences interview allowed residents to express how important a given activity was from very important to not important at all. All the activity preferences rows were marked with a 9 indicating the resident did not respond or was nonresponsive during the interview. Instead, a staff assessment was completed indicating Resident 28 was interested in keeping up with news. The row showing whether Resident 28 was interested in spending time outdoors was incomplete. In an interview on 07/31/2024 at 10:40 AM Resident 68 stated they had interest in getting outside but was not offered the opportunity. Resident 68 said they had other interests besides just watching television in their room. In an interview on 07/31/2024 at 3:43 PM Staff T stated Resident 68 was sleepy and unresponsive during the resident activity preferences interview. Staff T stated another activities interview was not attempted. When asked why Resident 68 was able to answer questions about their mood, pain, and daily preferences but not activities, Staff T stated that's a good question. Staff T stated that because the staff assessment only captured general interest in a given activity rather than the degree of interest, it provided less detailed information. REFERENCE: WAC 38-97-1000 (1)(b). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

<Resident 31> According to a 07/12/2024 admission MDS, Resident 31 had multiple medically complex diagnoses including cancer, had clear speech, was understood, and able to understand others. Thi...

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<Resident 31> According to a 07/12/2024 admission MDS, Resident 31 had multiple medically complex diagnoses including cancer, had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 31 with no memory impairment. In an interview on 07/25/2024 at 9:16 AM, Resident 31 stated they were certain they lost some weight due to their cancer diagnosis. According to the 07/12/2024 nutritional Care Area Assessment Resident 31's nutritional concerns would be addressed in the residents CP. Review of Resident 31's comprehensive CP showed no CP addressing nutrition was developed or implemented. In an interview on 07/30/24 at 10:31 AM, Staff B stated it was important for CPs to be complete to ensure the interventions residents required where in place. Staff B stated they expected CPs to be developed and implemented. <Resident 66> According to the 06/28/2024 admission MDS, Resident 66 had mild memory impairment, and one unhealed pressure ulcer. There MDS showed Resident 66 had diagnoses including heart disease, high blood pressure, unstable blood sugar level in the body, and malnutrition. Review of Resident 66's comprehensive CP showed a 06/28/2024 severe protein calorie malnutrition CP was initiated, but staff failed to develop any resident goals or interventions. <Resident 75> According to a 06/06/2024 admission MDS, Resident 75 had medical conditions including the loss of the ability to use one side of their body and required the use of a feeding tube to provide at least half of the resident's nutritional intake. Review of Resident 75's comprehensive CP showed a 06/07/2024 altered nutrition CP was initiated, but staff failed to develop any resident goals or interventions. <Resident 189> According to a 06/12/2024 admission MDS, Resident 189 had multiple medically complex diagnoses and required the use of a feeding tube to provide at least half of their nutritional intake. Review of Resident 189's comprehensive CP showed a 06/12/2024 altered nutrition CP was initiated, but staff failed to develop any resident goals or interventions. In an interview on 07/30/24 at 10:31 AM, Staff B stated it was important for CPs to be complete to ensure the interventions residents required where in place. Staff B stated they expected CPs to be developed and implemented. REFERENCE: WAC 38-97-1020(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 5 of 21 sampled residents (Residents 68, 31, 66, 75, & 189) 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 03/2012 Resident Care Plan policy, within 21 days after admission, the facility would develop and implement a comprehensive CP to address all the resident's care needs. The policy showed the CP should include measurable, resident-specific goals. <Resident 68> According to the 06/13/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 68 had intact memory and diagnoses including a wound infection, malnutrition, and depression. The MDS showed Resident 68 was on a physician-prescribed weight loss program. Observation on 07/24/2024 at 1:44 PM showed Resident 68 was very thin. At that time, Resident 68 stated they lost weight they wished to gain back. Review of Resident 68's comprehensive CP showed a 06/14/2024 Severe calorie protein malnutrition related to physiological cause [as exhibited by] physical exam indicates muscle and fat loss CP. This CP did not have any associated goals or interventions. In an interview on 08/01/24 at 9:13 AM, Staff B (Director of Nursing) stated the malnutrition CP should have associated goals and interventions, but did not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were followed for 1 (Resident 13) and POs were clarified as needed for 1 (Resident 189) of 21 sampled residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes. Findings included . <Following Orders> <Resident 13> During observations of medication pass on 07/29/2024 at 8:56 AM, Staff E was observed to prepare a pain medication gel for Resident 13 by squeezing the tube into a 30-milliliter medication cup until 3/4 of the bottom of the cup was filled with the gel. Staff E did not use a dose measuring card to prepare the dose. Review of Resident 13's July 2024 Medication Administration Records (MAR) showed a 04/04/2024 order to apply four grams of the pain medication gel to the resident's right knee twice daily for pain. In an interview on 08/01/2024 at 11:36 AM, Staff L (Manager Long Term Care, Registered Nurse) stated there was no way for staff to determine how much four grams of the gel was if they used a medication cup to dispense. In an interview on 08/01/2024 at 1:03 PM, Staff B (Director of Nursing) stated in order to measure the correct dose of the pain medication gel, staff would need to use the dosing card provided with the medication. Staff B stated their expectation was for staff to squeeze an even line of the medication from the tube onto the dosing cared, using the marks on the card to measure the prescribed dose. <Clarifying Orders> <Resident 189> According to a 06/12/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 189 had multiple medically complex diagnoses and required the use of a feeding tube to provide at least half of their nutritional intake. Review of a 07/21/2024 PO showed diet orders for Resident 189 to have no food or fluids by mouth, and to take medications through a PEG Tube (Percutaneous Endoscopic Gastrostomy tube; a surgically placed tube allowing artificial nutritional to flow straight into the stomach). Review of Resident 189's July 2024 MAR showed a 07/22/2024 order to administer a blood thinning medication daily by mouth, rather than via the PEG Tube as identified in the 07/21/2024 order to have nothing by mouth. In an interview on 08/01/2024 at 1:03 PM, Staff B stated their expectation was for staff not to give the medication by mouth and stated the order for Resident 189 needed to be clarified. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

<Resident 64> According to the 05/15/2024 Quarterly MDS, Resident 64 needed some help with functional cognition, had visual impairment, was dependent on staff for footwear, and needed moderate a...

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<Resident 64> According to the 05/15/2024 Quarterly MDS, Resident 64 needed some help with functional cognition, had visual impairment, was dependent on staff for footwear, and needed moderate assistance with their upper and lower body dressing. Review of the revised 05/20/2024 CP showed staff were to meet the Resident 64's ADL needs daily. On 07/23/2024 at 01:48 PM, Resident 64 stated, I have no clothes, no shoes, only slippers. I don't have socks and I do all my own dressing. I have to wait for staff and then it gets to be too late .at night I freeze because I don't have nothing to keep me warm. On 07/23/2024 at 1:48 PM, observed Resident 64's fingernails were long and extended ¼ inch past nail bed; their nail polish was mostly chipped off and their toenails were long enough to curl back into the toes. Resident 64 did not have socks on during observation. On 07/26/2024 at 8:39 AM, Resident 64 stated they had the same clothing on from yesterday and they wore the same clothes when they go to bed. On 07/29/2024 at 8:26 AM, Resident 64 stated, I helped myself get dressed this morning, I rarely have help, I would love to sometimes get some help. On 07/30/2024 at 8:37 AM, Resident 64 stated their hair was not combed from the shower the other day and stated, they [staff] do not help me with my hair. On 07/31/2024 at 11:32 AM, observed Resident 64's hair was not combed and was standing straight up on their head. On 08/01/2024 at 8:28 AM, Resident 64 stated, another patient said they would do my hair for me, I like to keep my hair up and I am trying to get it braided. In an interview on 07/30/2024 at 8:42 AM, Staff B stated they still encourage residents who refuse care and staff were to do whatever they can to help. Staff B observed Resident 64's toenails were not cut and stated they should be cut/trimmed. Staff B stated staff should tell us when there were residents with long nails and refusals for care, but did not. REFERENCE: WAC 388-97-1060(2)(c). Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) for 2 of 3 residents (Residents 32 & 64) reviewed who were dependent on staff for daily cares. The failure to provide required bathing and grooming assistance placed residents at risk for poor hygiene, diminished feeling of self-worth, and a decreased quality of life. Findings included . <Resident 32> According to the 05/07/2024 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 32 sometimes understood conversation, difficulty focusing, and disorganized thinking. The MDS showed Resident 32 was dependent on staff assistance for bathing and required and substantial to maximal assistance for personal hygiene. The MDS showed Resident 32 had a diagnosis of Alzheimer's disease (a memory impairment). The 06/15/2022 preferences Care Plan (CP) showed Resident 32 preferred showers. This CP showed Resident 32's preferences would be honored. The 06/15/2022 risk for deterioration in ADL function .' CP showed Resident 32 may require assistance and encouragement with ADLs. On 07/24/2024 at 12:39 PM, Resident 32 was observed to have several days of beard growth. On 07/26/2024 at 12:22 PM, Resident 32 was observed to still be unshaven. Resident 32's beard was longer than observed on 07/24/2024. On 07/29/2024 at 2:10 PM, Resident 32 still was unshaven with their beard thicker than previously observed. On 07/31/2024 01:43 PM, Resident 32 was observed to be shaved. In an interview on 07/31/2024 at 3:21 PM, Staff B (Director of Nursing) stated they knew Resident 32 for a long time. Staff B stated Resident 32's Alzheimer's disease progressed to where the resident was less able to express their preferences for grooming than previously. Staff B stated they knew appearance was important to Resident 32. Staff B stated they expected nursing staff to assist Resident 32 to shave as part of their ADL care. Staff B stated Resident 32 should be clean shaven.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 1 of 3 residents (Resident 64) reviewed for activities. Failure to provide residents with meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Resident 64> According to a 05/15/2024 Quarterly admission Minimum Data Set (MDS - an assessment tool) showed Resident 64 preferred to have books, newspapers, listen to music, and choose daily activity preferences. The assessment showed Resident 64 had unspecified dementia and behavioral disturbances. Review of a revised 04/16/2/2024 Resident Care Plan (CP) the Problems/Strengths focused area showed Resident 64 needed encouragement to participate in daily scheduled activities. The CP showed that Resident 64 was dependent on staff for locomotion and needed supervision for ambulation and transfers. The CP showed Resident 64 would obtain assistance in choosing and identifying enjoyable activities. Record Review of Physician Orders dated 02/25/2024, showed Resident 64 could participate in therapeutic recreation activities without restrictions unless directed otherwise. Review on 07/26/2024 at 9:26 AM of the [NAME] (worksheet used by care staff to inform them of key patient information and instructions based on the CP) did not show any activities listed for Resident 64. On 07/23/2024 at 1:52 PM, Resident 64 stated if I could, I would participate in activities, I don't see how I could if I don't have anything to do. On 07/26/2024 at 8:39 AM, Resident was crying that she could not go anywhere and stated I can't even go outside, they won't let me. Resident was observed sitting in their room with no activities available. On 07/29/2024 at 11:42 AM, Resident 64 stated they were happy to have someone to talk to. In an interview on 07/30/2024 at 1:37 PM, Staff U (Activities Supervisor) stated we don't do group activities if we have units sectioned off. Due to COVID we shut down all group activities. Staff U stated they did pass out newsletters in the mornings. Staff U stated for residents with cognitive impairments, the facility provided activities that stimulated memory and social check-ins. Staff U stated that every person had a CP with specific goals. Staff U stated they did not receive any activity complaints during this current COVID outbreak. Staff U stated on August 6th activities would open up again. In an interview with Staff Q (Infection Preventionist) on 07/30/2024 at 11:36 AM, Staff Q stated that activities should have continued during the current COVID outbreak, although group gathering activities were stopped. Staff Q stated the activities department should still have gone room to room with crossword puzzles, small puzzles, reading and providing one on one discussions. If a resident had active COVID, chaplain visits and activities were still to occur. In an interview with (Director of Nursing) on 08/01/2024 at 10:15 AM, Staff B stated staff did not sit with Resident 64. If the resident moved to another unit, it would be more social for the resident. Staff B stated there were limited interactions in the unit because of the outbreak. Staff B stated staff were encouraged to engage with residents. Staff B stated the activities department should be involved in all activities for Resident 64. Staff B stated their expectation was that one-on-one activities be provided, and for the activity team to touch base with the resident regarding activity preferences. Staff B stated activities were one of the most important interventions for Resident 64 because of their cognitive and behaviors. Staff B stated for residents with dementia, the CP should be individualized for the residents needs. Staff B could not find an activity assessment for Resident 64 and stated, I don't see an activity assessment was done for the resident. Staff B stated more specific activities guidance should be added to the CP for Resident 64. Staff B stated activity assessments were important because they showed the resident's likes and dislikes are which helped with redirection and helped calm residents. <Resident Council> In an interview with Resident Council members on 07/29/2024 at 1:17 PM, council members stated during the current COVID outbreak, no activities were provided. Resident (27) stated there was nothing to do. Resident 27 stated on the daily activity newsletter, there was a puzzle on the back, but Resident 27 stated they found them boring, so they were limited to only phone calls or watching television for recreation. REFERENCE: WAC 388-97-0940 (1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 12) reviewed for pain management received the necessary treatment, services, and follow-up care to manage their pain. This failure placed residents at risk for avoidable pain and a diminished quality of life. Findings included . <Facility Policy> According to the 08/2024 Pain Management Policy, its purpose was to establish how residents would be assessed, care planned, and treated in accordance with professional standards of practice. The policy showed resident choices would be honored related to pain management. The policy showed a resident who had a major change in pain status should be placed on alert charting and their pain should be assessed every shift while on alert. <Resident 12> According to the 05/29/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 12 had clear speech, intact memory, and with medical conditions including chronic pain and discomfort due to osteoarthritis (joint pain and stiffness). The MDS showed Resident 12 had limited range of motion. According to the 05/31/2024 At risk for pain and discomfort due to arthritis Care Plan (CP), Resident 12's goals were for their joint pain to be relieved within one hour of intervention and for staff to administer medications as ordered. The CP included directions for staff to report unrelieved pain, joint stiffness, swelling, and new contractures (irreversible joint stiffening) to the Medical Director with follow-up as indicated. Record review of Resident 12's July 2023 Medication Administration Record (MAR) showed a 03/11/2024 order for a narcotic pain medication 5 milligrams for pain that should be offered as needed. The MAR showed non-pharmaceutical pain interventions should be offered including repositioning, warm packs, one on one visits, and to offer food and drinks. On 07/29/2024 at 11:26 AM, Resident 12 stated, I am in pain every day. In an interview on 07/30/2024 at 12:40 PM, Resident 12 stated they had sharp pain on their left lower leg in the calf area and it hurt to stand on it. Resident 12 stated, nobody is doing anything to help me with my pain. I told the nurses about the constant pain, and I told my doctor and the staff have not followed up with me. If I tell one nurse, I expect them to tell the next nurse and follow through on this. If there is one thing I don't like about this place, it 's that they don't follow-up with me. I haven't heard anything from the doctor or nurse about my calf pain, nobody tells me anything. In an interview on 07/31/2024 at 11:39 AM, Resident 12 stated their left leg really hurt at that time and rated their pain at 8.5 out of 10. Resident 12 stated heat packs, movement, and pain medications helped, so they tried to do their own pain management such as lifting their leg up. Resident 12 stated, nobody comes here and talks to me, and I've been through physical therapy for a long time, but it does not seem to work, I try to live with it when it gets too bad, then I take medicine. Record review of Resident 12's progress notes on 07/30/2024 and 07/31/2024 at 1:00 PM did not reflect documentation of the resident's pain in their left leg. Interviews on 07/30/2024 at 12:30 PM and 12:51 PM, Staff V (Licensed Practical Nurse) stated they were not aware of Resident 12's calf pain. Staff V stated residents must tell the nurses when something was wrong daily so the nurses would take care of it. Staff V stated they did not see pain monitoring on Resident 12's CP or in the progress notes, and not every shift would have known about the resident's concerns. Staff V stated nurses did not document at shift change but verbally report off to the next nurse. Staff V stated Resident 12's pain was not mentioned at shift change. Staff V stated it was up to each resident to tell nurses daily about their pain issues so nurses could put a resident on alert if needed. In an interview on 07/31/2024 at 12:26 PM, Staff B (Director of Nursing) stated they expected nursing staff to document notes of residents' pain, both to the doctor and from nurse to nurse in the progress notes because it alerted the nursing team to review the problem and obtain orders when documentation were captured and seen by the care team. Staff B stated alert charting and progress notes should have, but were not completed for Resident 12. Staff B stated documentation was important so residents' pain could be identified and treated as fast as possible. REFERENCE: WAC 388-97-1060 (1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

<Unlocked Medication Cart> Observations of Unit C Medication Cart on 07/30/2024 at 12:28 PM showed an unlocked medication cart in the hallway with a resident sitting nearby. Staff were passing o...

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<Unlocked Medication Cart> Observations of Unit C Medication Cart on 07/30/2024 at 12:28 PM showed an unlocked medication cart in the hallway with a resident sitting nearby. Staff were passing out lunch trays. Staff EE (RN) came out of a room across from the medication cart. In an interview at this time, Staff EE stated it was their expectation the medication cart be locked at all times when they are not present. In an interview on 08/01/2024 at 9:59 AM, Staff A (Administrator) stated it was important to keep the medications safe and away from residents who could easily access it. Staff A stated they expected all nurses to ensure medication carts were kept locked and secured at all times for resident safety. <Medications Unsecured at Bedside> <Resident 240> Observations on 07/25/2024 at 11:17 AM showed Resident 240 with an inhaler and a medication cup filled with nine pills at their bedside. A second inhaler was sitting on Resident 240's window ledge. In an interview at this time, Resident 240 stated the nurse had brought in the medications but left them when the resident had requested to take a medication for nausea first. In an interview on 07/25/2024 at 11:28 AM, Staff KK (LPN) confirmed the medications were left at Resident 240's bedside and was unsure if the resident had an assessment for self-medications. Staff KK stated it was important not to leave medications unsecured for resident safety and to also ensure the resident took the medications. In an interview on 07/25/2024 at 11:31 AM, Staff B validated Resident 240 did not have a self-medication assessment to have medications at bedside. Staff B stated Resident 240 did have an order to keep the inhaler at bedside but indicated staff should have done an assessment and assured it was care planned. Staff B stated it was their expectation staff would not leave medications unsecured at bedside without an order or being assessed for safety first. REFERENCE: WAC 388-97-1300 (2). Based on observation and interview, the facility failed to ensure medications were stored, labeled, and dated when opened and/or discarded when expired for 3 of 4 medication carts (Unit A, Unit B, & Unit D) and 2 of 2 medication rooms (Unit A & Unit B) observed. The failure to ensure unneeded medications were returned to the pharmacy, medications carts were secured when not in use by a nurse, and medications were not left at the resident's (Resident 240) bedside placed the residents at risk for receiving unauthorized, compromised, and/or ineffective medications. Findings included . <Facility Policy> Review of a 07/2024 facility Medication Storage and Disposal policy showed all drugs and biological will be stored in locked compartments and access granted to authorized personnel only. This policy stated outdated medications were to be removed from medication carts and disposed of according to procedures for medication disposal. The policy stated all medications were to be properly labeled and stored, separated from other residents medications, and separate from food or toxic chemicals. <Unit A Medication Cart> Observations of Unit A Medication Cart on 07/24/2024 at 10:22 AM showed an open vial of a blood thinning injection medication with no date or resident label indicating who it was for and an unopened vial of insulin for a resident with a label that said to keep refrigerated. In an interview on 07/24/2024 at 10:38 AM, Staff HH (Regional Director of Nursing Services) stated it was their expectation that medications have resident labels and are dated when opened. Staff HH stated the insulin injection medication should have, but was not refrigerated until opened by staff. <Unit B Medication Cart> Observations of Unit B Medication Cart on 07/24/2024 at 10:52 AM showed the following: an eye drop medication used to treat glaucoma (a condition of increased pressure in the eye) with an open date of 05/29/2024; and multiple tubes of creams, ointments, and gels being stored together in one container. There was antifungal cream, pain medication gel, and vaginal creams observed. In an interview at this time, Staff M (Staff Registered Nurse - RN) looked at the list of medication expiration dates on the medication cart, and stated the eye drop medication expired 42 days after it was opened. Staff M stated the medication expired the week before and stated, I missed it, I will discard this. Staff M confirmed the tubes of medications were not separated and were being stored together inside one bin. <Unit D Medication Cart> Observations of Unit D Medication Cart on 07/31/2024 at 2:52 PM showed a package of individual unit doses of a cough medication and a bottle of an acid solution used for bladder irrigation being stored up against a container of germicidal alcohol wipes container. In an interview at this time, Staff CC (Licensed Practical Nurse - LPN) confirmed the medications were being stored next to the disinfectant container. <Unit A Medication Room> Observations of Unit A Medication Room on 07/24/2024 at 10:40 AM showed a bin of 5-milliliter syringes that expired on 12/31/2023, over six months earlier and a bin of culture swabs that expired on 05/01/2024, almost two months earlier. In an interview at this time, Staff II (LPN) confirmed the expired supplies and stated they needed to be removed from the medication room. <Unit B Medication Room> Observations of Unit B Medication Room on 07/24/2024 at 11:02 AM showed two bins over full of medication bingo cards and bottles. There were medications in the bin for residents who discharged : on 04/15/2024, over three months earlier; on 06/03/2024, over one month earlier; on 06/13/2024, over one month earlier; and on 07/08/2024, over two weeks earlier. In an interview at this time, Staff M stated the medications needed to go back to the pharmacy. In an interview on 08/01/2024 at 1:03 PM, Staff B (Director of Nursing) stated it was their expectation staff label and date medications, separate medications, refrigerate medications as required, and remove expired medications and/or supplies. Staff B stated medications should be returned to the pharmacy within 30 days of a resident discharging.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 55> According to the 06/17/2024 Annual MDS, Resident 55 had a long-term indwelling urinary catheter (tubing to d...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 55> According to the 06/17/2024 Annual MDS, Resident 55 had a long-term indwelling urinary catheter (tubing to drain urine from the bladder for people with certain urinary problems). Observation on 07/30/2024 at 8:40 AM, showed Resident 55 lying in bed with their catheter drainage bag lying on the floor. In an interview on 07/30/2024 at 10:50 AM, Staff V (Licensed Practical Nurse) stated the catheter drainage bag should not have touched the floor because of infection control concerns. REFERENCE: WAC 388-97-1320 (1)(a). <Wound Care> <Facility Policy> Review of the Hand Hygiene [HH] facility policy, revised 09/2019, showed HH would be performed after removing Personal Protective Equipment (PPE), after contact with patient surroundings, after patient contact, and upon exiting the patient room. The policy showed compliance with the proper HH procedure before and after patient contact was an expectation of all healthcare disciplines. <Resident 68> According to the 06/04/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 68 had medical conditions including a wound infection. The MDS showed Resident 68 admitted with a Stage IV (full thickness) Pressure Ulcer (PU) and was provided PU treatment during the assessment period. On 07/25/2024 at 9:06 AM, the wound care team, together with Staff B (Director of Nursing), was observed providing Resident 68 PU care and treatment to Resident 68's buttocks. When the procedure was completed, Staff Y (Certified Nursing Assistant) removed all their personal protective equipment and left Resident 68's room to retrieve a garbage bag from the clean wound cart without washing their hands. In an interview on 07/25/2024 at 9:23 AM, Staff B stated HH was important in infection control to prevent cross-contamination of bacteria (germs). Staff B stated they expected all staff to wash their hands and/or apply an alcohol-based hand sanitizer after touching dirty surfaces and prior to touching clean areas. 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 sharps containers were emptied before they reached an unsafe volume for 3 of 16 resident rooms reviewed (room [ROOM NUMBER], 104, & 416); maintain an environment free of uncleanable surfaces for 1 of 16 resident rooms reviewed (room [ROOM NUMBER]); failed to maintain a Water Management Program (WMP) for 1 of 1 buildings; failed to provide wound care within professional standards of infection control for 1 of 5 residents (Resident 68) reviewed for pressure ulcers; failed to ensure urinary catheter placement did not create an infection control risk for 1 supplementary resident (Resident 55) reviewed for catheter care. The failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <Sharps Containers> Observations on 07/23/2024 at 9:26 AM showed room [ROOM NUMBER] with a sharps container full beyond the maximum fill line. Observations on 07/26/2024 at 8:44 AM and 07/31/2024 at 9:05 AM showed room [ROOM NUMBER] with a sharps container full beyond the maximum fill line. Observations on 07/30/2024 at 10:15 AM showed room [ROOM NUMBER] with a sharps container full beyond the maximum fill line. In an interview on 07/30/2024 at 10:49 AM, Staff Q (Infection Preventionist) stated the facility used sharps containers to promote safe injection practices in the facility. In an interview and observation on 08/01/2024 at 10:46 AM, Staff Q confirmed the sharps containers in the identified resident rooms were filled beyond the maximum fill line. Staff Q stated having the sharps containers overfull increased the risk for staff and/or residents to get accidental needle sticks and risk transmission of diseases. <Uncleanable Surfaces> <Resident 26> Observations on 07/26/2024 at 9:19 AM showed floor mats on each side of Resident 26's bed. Both floor mats had corners that were torn and peeling, exposing the foam underneath the vinyl cover. In an interview and observation on 08/01/2024 at 10:46 AM, Staff Q confirmed the floor mats for Resident 26 were uncleanable and increased the risk for infections. <Water Management Program> Review of a revised 08/2023 facility, .Water Management Program policy showed the purpose of the policy was to establish a standard for identifying points of risk for Legionella growth; prevention control measures; surveillance; and documentation and communication. This policy directed to, See attached facility-specific diagrams. In an interview on 07/30/2024 at 3:34 PM, Staff C (Facilities Manager) stated they did not have a diagram of the facility with identified areas of risk for Legionella (bacteria that can cause severe types of respiratory infections). Staff C reported the only thing they were instructed to do was complete a log and test for chlorine each month. In an interview on 07/30/2024 at 3:50 PM, Staff A (Administrator) provided additional documents of the facility's risk assessment forms, and stated, it appeared staff started the risk assessment, but did not complete it. When asked if the WMP be complete and up to date, Staff A stated yes.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure resident beds did not have gaps that could pose as an entrapment risk or assess the mattress used and/or obtained/purchased separately from the bed frame to ensure they were well-fitting for 1 of 21 residents (Resident 45) whose beds were observed for accident hazards. This failure placed residents at risk for injury, entrapment, or death. Findings included . <Facility Policy> The Medical Devices and Equipment facility policy, revised 07/2024, showed the facility would establish guidelines for the assessment, use, and maintenance of medical devices and equipment, including beds and mattresses, to ensure the safety and well-being of residents. The policy showed the facility would conduct regular inspections and preventative maintenance of medical devices/equipment. <Food and Drug Administration (FDA) Document> The 03/10/2006 FDA document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, identified seven potential zones of entrapment: Zone 1- Within the Rail, Zone 2- Under the Rail, Between the Rail Supports or Next to a Single Rail Support, Zone 3- Between the Rail and the Mattress, Zone 4- Under the Rail at the Ends of the Rail, Zone 5- Between Split Bed Rails, Zone 6- Between the End of the Rail and the Side Edge of the Head or Foot Board, and Zone 7- Between the Head or Foot Board and the End of the Mattress. The document showed facilities should determine the proper dimensions and distances apart of various parts of the bed such as the distance between bed frames and mattresses to prevent entrapment by users of the bed. The document suggested facilities determine the level of risk for entrapment and take steps to mitigate and reduce potential life-threatening entrapments associated with the use of hospital bed systems. <Resident 45> According to the 06/17/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 had clear speech and intact memory, with multiple medical diagnoses including a condition characterized by elevated levels of blood sugar in the body, heart and kidney failure, and generalized weakness with decreased muscular function on the left side of the body. The MDS showed Resident 45 had functional limitations with their range of motion, and was assessed to require substantial/maximum assistance with most of their activities of daily living including bed mobility. The 04/04/2024 Air Mattress (a type of mattress filled with air used for pressure relief)/Bilateral Side Rails Care Plan (CP) showed the risk and benefits were discussed with Resident 45 and a consent was obtained regarding the use of these high-risk devices. The CP intervention instructed staff to minimize gaps between the mattress and bed frame. In an observation and interview on 07/25/2024 at 9:47 AM, Resident 45 was observed to have a bolster air mattress(a type of air mattress with a defined perimeter on the sides to prevent falls) in place and bilateral side rails were installed. Resident 45's bed mattress was observed to be smaller than the bed frame. There was a loose pillow wedged in between the mattress and the foot board. The gap from the bed mattress to the head of the bed measured six inches. Resident 45 stated they did not have any skin issue and did not use the side rails for independent bed mobility. Observation on 07/26/2024 at 9:35 AM with Staff K (Licensed Practical Nurse) showed Resident 45 was angled downward on the bed. Staff K attempted to flatten Resident 45's bed and observed the button that adjusted the food part of the bed on hand-held bed controller was not working. There was no pillow wedged between the bed mattress and the foot board at this time, exposing a gap that measured 10 inches. In an interview on 07/26/2024 at 10:16 AM, Staff C (Facilities Manager) confirmed the gap measurements and stated it was an entrapment risk for Resident 45. Staff C stated it was important to ensure the air mattress was well-fitting on the bed frame to avoid injury and entrapment. Staff C stated the Rehabilitation Department would usually put wedges on both ends of the bed if there was a significant gap but obviously did not see any in place. In an interview on 07/26/2024 at 10:47 AM, Staff D (Director of Rehabilitation) ensuring resident beds were free of significant gaps that could pose as an entrapment risk was a collaborative effort between the interdisciplinary team including the Maintenance Department. Staff D saw the actual gap in Resident 45's bed and stated they were surprised the Rehab Department did not catch it since they see the resident more often than Staff C. Staff D stated, .definitely a miss on our part for this one. REFERENCE: WAC 388-97-2100. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 6> Review of the 06/21/2024 admission MDS showed Resident 6 was understood and had clear comprehension. Review ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 6> Review of the 06/21/2024 admission MDS showed Resident 6 was understood and had clear comprehension. Review of care plan dated 05/07/2024 showed the resident was at risk for deterioration in ADL function and medical stability due to paraplegia (loss of function in both legs) and other medical issues, and staff were to respect the resident's preferences. On 07/25/2024 at 9:58 AM, Resident 6 stated the maintenance man took away their Air Conditioner (AC), but they needed it for their legs. Resident 6 stated it should be in their care plan that they needed an AC as their legs do not sufficiently sweat and they needed it to keep their legs cool. On 07/26/2024 at 8:55 AM, Resident 6 stated repeatedly they needed their AC, .I couldn't sleep all night. Resident 6 stated they had an AC unit in their room before the State [surveyors] got there and the facility took away the AC. Resident 6 stated they had verbalized their concern to the nursing staff. In an interview on 07/26/2024 at 10:17 AM, Staff M (Registered Nurse) stated the night shift nurse told them that the resident asked for their AC in their room last night, but it was not reported to the manager yet. However, Staff M did ask maintenance to re-install the AC, but they were waiting. Staff M stated they knew that Resident 6 needed the AC for their legs. On 07/29/2024 at 12:19 PM, Resident 6 stated, I didn't file a grievance report yet, but I asked 2 care aids and a nurse and they didn't know how to file a grievance report. In an interview on 07/29/2024 at 12:40 PM, Staff E stated they were notified by the facility's pastor on 7/25/2024 of Resident 6's concern. In an interview on 07/29/2024 at 11:37 AM, Staff L (Manger Long Term Care Registered Nurse), stated, the usual process for when a resident has an issue is, the nursing staff are notified, and we will address the issue and look further into it. In an interview on 07/30/2024 at 8:46 AM, Staff B stated the staff were to provide the resident with a grievance report if there was an issue, our social workers are then in charge of grievances and in keeping the logs. Staff B stated the nursing staff should report grievances to their nursing managers and interview the resident. REFERENCE: WAC 388-97-0460. <Resident 31> According to a 07/12/2024 admission MDS, Resident 31 admitted to the facility on [DATE], had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 31 with no memory impairment. In an interview on 07/25/2024 at 9:14 AM, Resident 31 stated they were frustrated about missing clothes from a week ago. Resident 31 stated the clothes went to laundry, last Friday. Resident 31 stated they kept asking staff, but nobody was able to find them. Resident 31 stated they had company coming to the facility on [DATE] and they wanted their clothes back for the visit. In an interview on 07/26/2024 at 8:37 AM, Resident 31 stated their clothes were still missing, but staff had helped them find something else to wear for when their visitors arrive. Review of the grievance log on 07/26/2024 showed no grievance reports were logged for Resident 31 regarding their missing clothes. In an interview on 07/29/2024 at 11:40 AM, Staff E stated grievances were important so staff can address any issues a resident may have. Staff E stated it was their expectation staff would come let them know of any concerns/grievances, at times the issue can be resolved on the spot, and if not, Staff E stated they tell staff to fill out a grievance form. Staff E stated once they receive a grievance, their expectation was for staff to resolve and address the concern back with the resident within 10 days. Staff E stated they do not log missing items, but instead they send an email out to staff to be on the lookout for the missing items. When asked how staff track and trend missing items, Staff E stated, we just put it in emails. Review of Staff E's emails showed the email system was set to delete the emails after two years. When asked if there were currently any missing items for residents, Staff E stated, there was a missing pair of dentures, missing nightgown, and a green dress. Staff E did not have information regarding Resident 31's missing clothes. In an interview on 07/29/2024 at 12:10 PM, Resident 31 stated they finally got their clothes back a couple days ago and stated they were frustrated it took so long. <Resident 30> In an interview on 07/29/2024 at 11:40 AM, Staff E showed an email from 07/15/2024 regarding Resident 30 having a missing bag with about $100 worth of stuff inside. When asked what the outcome of that reported missing item from 14 days ago, Staff E stated, they went home, and they have not reached out to me. Review of a 07/17/2024 Discharge MDS showed Resident 30 discharged from the facility with their return not anticipated. In an interview on 07/31/2024 at 12:28 PM, Resident 30 stated they had not heard from the facility regarding the missing items until just two days prior on 07/29/2024. Resident 30 stated they found the missing bag at home, but stated they were still missing some clothes. Resident 30 stated they told the facility they did not need to replace it. In an interview on 08/01/2024 at 1:03 PM, Staff B (Director of Nursing) stated their expectation was for staff to start an investigation if a resident had a concern or missing item, by first looking for the items, and if unable to locate or resolve within 48 hours, would expect staff to address it as a grievance. Staff B stated there were, some gaps in the grievance process. Based on observation, interview, and record review, the facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved timely for 4 of 4 residents (Residents 28, 31, 30, 6) reviewed for personal property and living environment. Facility failure to ensure missing personal items were found or replaced and resident environmental concerns were addressed placed residents at risk for missing property, an uncomfortable or less-than-homelike environment, and a decreased quality of life. Findings included . <Facility Policy> According to the 07/2024 Complaint and Grievance Policy, the facility would attempt to resolve all grievances as promptly as possible, but no longer than 10 days. The policy showed the facility would maintain grievance records for no less than three years. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had impaired memory and was dependent on staff for self-care and grooming. The MDS showed Resident 28 had medical conditions including partial weakness to one side of the body and memory impairment. In an interview on 07/24/2024 at 2:39 PM, Resident 28 stated they had lost items [they] didn't get back. Resident 28 identified they were missing an electric razor, nail clippers, and a $350 watch. Resident 28 stated they were told it was facility practice when a resident was missing property for the resident to replace the item and then get reimbursed by the facility. Resident 28 asked, What do you do if you don't have the money up front? I could not cover it. I never got it back. Resident 28 stated the watch went missing about a year ago. Resident 28 was not wearing a watch at the time of the interview. Review of the facility's Grievance Log did not include any grievances related to missing items for Resident 28. In an interview on 07/29/2024 at 12:29 PM, Staff E (Social Services Director) stated they recalled Resident 28 reporting a missing watch a couple years ago during the pandemic. Staff E stated Resident 28 provided them with a picture of the watch at that time. Documentation of the missing watch and picture was requested, but staff was unable to provide the requested information. Staff E stated the facility policy was that the resident was required to come up with the money in order to do the reimbursement. Staff E stated the process was that once a resident provided the receipt, the facility would then reimburse for the missing item. When asked what the plan was for the missing watch, Staff E stated, I do not know. In an interview on 08/01/2024 at 11:07 AM, Staff E stated when a resident had a concern with a missing item, they sent out an email to the appropriate staff to be on the look out for the item. Staff E stated that until survey began on 07/23/2024, they did not add missing items concerns to the Grievance Log. Staff E stated after they sent out an email, either the item was located or the resident replaced the item and was reimbursed. Staff E stated they did not recall a situation where a resident was unable to temporarily cover the cost of an item. In an interview at 08/01/24 11:48 AM, Staff E stated they just (since the prior interview) asked Resident 28 if they told anyone they did not have the means to cover the cost of the missing watch. Staff E stated they could not find evidence the watch was replaced or addressed in their emails. In an interview on 08/01/2024 at 2:03 PM, Staff A (Administrator) stated the grievance process was important so residents receive help with the concerns they had and gave the facility the opportunity to correct things. Staff A stated they considered a grievance or concern something they were unable to fix in a reasonable time, for example less than 24 hours, or on a Monday if occurred over the weekend. Staff A stated they considered a missing item a grievance and would expect staff to notify the social worker and complete a grievance form if the item was not found. Staff A stated the facility would reimburse the resident once they were able to determine an estimate, get guidance from the resident, or a receipt and expected documentation to show the outcome of the missing item.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0642 (Tag F0642)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of resident assessments was knowledgeable of the Minimum Data Set (MDS - an assessment tool) process for 3 of 3 residents (Residents 67, 20, & 45) whose Quarterly MDS assessments were reviewed for accuracy and timeliness. The facility's failure to report accurate MDS data placed residents at risk for violations of the Social Security Act. Findings included . <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2023 RAI Manual showed signatures of persons completing the assessment would certify that the accompanying information accurately reflected resident assessment information. The RAI manual showed, by attesting and signing the MDS, the RN coordinator and its signatories understood these information were used as a basis for ensuring residents receive appropriate and quality care, a basis for payment from federal funds, and that payment of such federal funds and continued participation in the government-funded health care programs was conditioned on the accuracy and truthfulness of the MDS information provided. The RAI manual showed MDS signatories could be personally subjected to or may subject the organization to substantial criminal, civil, and/or administrative penalties for submitting false information. <Resident 67> Review of Resident 67's 06/03/2024 Quarterly MDS showed a completion date of 06/14/2024 in the resident's medical records but the assessment history report showed the RN coordinator completed the assessment on 06/17/2024. <Resident 20> Review of Resident 20's 06/03/2024 Quarterly MDS showed a completion date of 06/07/2024 in the resident's medical records but the assessment history report showed the RN coordinator completed the assessment on 06/11/2024. <Resident 45> Review of Resident 45's 04/01/2024 Quarterly MDS showed a completion date of 04/05/2024 in the resident's medical records but the assessment history report showed the RN coordinator completed the assessment on 04/09/2024. In an interview on 07/29/2024 at 12:42 PM, Staff T (MDS Coordinator) confirmed they refer to the RAI manual for assessment coding and guidance. Staff T stated MDS assessments should be completed accurately and items identified that were coded inaccurately needed to be clarified and corrected. Staff T stated MDS completion dates should not be backdated because it was unethical. Staff T confirmed the completion dates reflected in Residents 67, 20, and 45's Quarterly MDS assessments in the medical records were backdated and not the actual dates of completion and stated they needed MDS education. In an interview on 07/29/2024 at 1:14 PM, Staff A (Administrator) stated backdating MDS completion dates was an unacceptable practice and that Staff T should be educated. Staff A stated they expected the MDS coordinators to attest and document the actual MDS completion date in the resident's medical records. Refer to F638- Quarterly Assessment At Least Every 3 Months. REFERENCE: WAC 388-97-1000 (5)(a). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Level 1 Preadmission Screening and Resident Reviews (PASRR - a Serious Mental Illness (SMI)/Intellectual Disability (ID) screening for the need for further assessment for outside resources while in a nursing home environment) were accurate upon admission and updated as needed after a significant change as required for 3 of 5 residents (Residents 28, 45, & 32) reviewed for unnecessary medication. This failure left residents at risk for unassessed mental health needs, and other negative health outcomes. <Facility Policy> According to the PASRR facility policy, revised 01/2023, all residents would undergo a Level 1 PASRR screening prior to admission. The policy showed current residents must undergo a Level 1 PASRR if a significant change in their physical or mental condition was identified. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had impaired memory and medical diagnoses including dementia (a memory impairment), anxiety, and depression. The MDS showed Resident 28 received Antipsychotic (AP), Antidepressant (AD), and Antianxiety (AA) medications. Review of the 04/26/2023 Level 1 PASRR showed this PASRR did not include Resident 28's dementia diagnosis. This PASRR included a handwritten note showing reviewed but no dx (diagnosis) of dementia. In an interview on 07/31/2024 at 10:24 AM, Staff E (Social Services Director) stated it was important for PASRRs to be available in the chart and accurately reflect the resident's current condition. In an interview on 08/01/2024 at 11:55 AM Staff E stated it was important for PASRRs to be accurate and updated with changes. <Resident 45> According to the 06/17/2024 Quarterly MDS, Resident 45 admitted to the facility on [DATE] and had medical conditions including depression and anxiety. Review of Resident 45's Physician Orders (POs) showed a 01/12/2024 order for daily administration of AD and AA medications since the resident's facility admission. A 04/11/2024 social services progress note showed staff reviewed and updated Resident 45's Level 1 PASRR and referred the resident to the PASRR office for a Level 2 evaluation due to the presence of SMI. Review of Resident 45's medical records did not show the resident's Level 1 PASRR form was accessible to staff. In an interview on 07/31/2024 at 10:24 AM, Staff E indicated they found Resident 45's updated Level 1 PASRR inside a folder in their office and stated PASRRs should be accessible to staff, but Resident 45's was not. <Resident 32> According to the 05/07/2024 Significant Change MDS, Resident 32 had a severe memory impairment, difficulty focusing, and disorganized thinking. The MDS showed Resident 32 had diagnoses including Alzheimer's disease (a memory impairment) and depression. The MDS showed Resident 32 received AP and AD medications. Review of the (POs) showed a 05/15/2024 order for an AP medication prescribed for dementia, unspecified severity, with behavioral disturbance. Record review showed the facility completed a Significant Change MDS for Resident 32 on 03/07/2024 related to the resident's decision to be placed on hospice services. A second Significant Change MDS for Resident 32's health improvement was completed on 05/07/2024 following their dis-enrollment from hospice services. Record review showed the most current Level 1 PASRR in Resident 32's chart was dated 01/19/2021. This PASRR did not include Resident 32's dementia diagnosis. No Level 1 PASRR screening was completed in relation to Resident 32's 03/07/2024 and 05/07/2024 Significant Change MDSs. In an interview on 08/01/2024 at 11:55 AM, Staff E demonstrated they had a newer Level 1 PASRR dated 04/11/2024 in a file in their office that was more current. Staff E stated they did not know a Level 1 screening was required for a significant change and so did not complete a Level 1 screening after the 05/07/20234 Significant Change MDS as required. REFERENCE: WAC 388-97-1915 (1)(2)(a-c). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 64> According to the 03/03/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 64 admitted to t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 64> According to the 03/03/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 64 admitted to the facility on [DATE]. The MDS showed Resident 64 had dementia and for several days would feel down or depressed and often felt lonely or isolated. Resident also had vision impairment and may reject care for 1 to 3 days. Review of Resident 64's CP showed goals for behavior of No injuries related to dementia during facility stay and for rejection of care the goal showed the Resident would not harm self. Interventions shown in the CP were to encourage the resident to participate in daily scheduled activities, spiritual visits, provide one on one listening and to assist resident in identifying enjoyable activities. Review of [NAME] (work sheet used by care staff to inform them of key patient information and instructions based on CP) on 7/26/2024 at 9:25 AM, showed no instructions provided to care staff in the following areas on the [NAME], What makes life meaningful to resident, What resident likes to do, Hearing/Vision/Dental and no specific instructions on what to do if the Resident rejected care. Observation on 07/23/2024 at 11:07 AM Resident 64 stated the staff are not doing anything for me, they treat me like I am not even here, they ignore me. Observation on 07/26/2024 at 08:39 AM, Resident 64 started crying and stated I am so lonesome. In an interview on 07/30/2024 at 08:37 AM Staff J stated Resident 64's toenails were long and not of normal length and stated for residents who refuse care, it should have been documented and put in progress notes that the resident refused care. In interviews on 07/30/2024 at 8:42 AM and 08/01/2024, Staff B (Director of Nursing) stated staff still need to encourage residents who continually refuse care, because Resident 64 has dementia, staff still need to do whatever they can. Staff B also said that don't have the time to sit with Resident 64. In an interview on 07/30/2024 at 10:31 AM, Staff B (DNS) stated the CP must be complete, accurate and updated accordingly so proper interventions would be in place to prevent injury and is used for staff to follow in providing resident care. REFERENCE: WAC 388-97-1020(2)(c)(d). <Resident 239> According to the 07/18/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 239 had clear speech, intact memory, and had diagnoses including end stage cancer and malnutrition. The MDS showed Resident 239 did not walk and was assessed to be totally dependent on two staff for transfers and toileting. Observation and interview on 07/24/2024 at 12:09 PM showed Resident 239 was lying in bed; the bed was in low position and a fall mat was placed on the left side. Resident 239 stated they had two falls since they admitted to the facility on [DATE]. The same observations of the bed and the fall mat were noted on 07/25/2024 at 2:35 PM and on 07/26/2024 at 9:41 AM. Review of a 07/22/2025 nursing progress note showed Resident 239 had a fall in their room after attempting to go to the bathroom during breakfast. Review of a late entry progress note dated 07/24/2024 showed a Physical Therapy (PT) staff assessed Resident 239's functional mobility post-fall and implemented fall and injury prevention interventions including lowering the bed height and the use of fall mats. Review of Resident 239's Care Plan (CP) showed a 07/13/2024 Fall CP indicating the resident was at risk for falls due to generalized weakness, malnutrition, and their medical diagnoses. The CP did not show the use of a fall mat observed in place. In an interview on 07/30/2024 at 10:31 AM, Staff B (Director of Nursing) stated the CP should be complete, accurate, and revised/updated accordingly to ensure proper interventions were in place, and for Resident 239's case, to prevent recurrent falls and/or injuries. Staff B stated they expected fall interventions identified by the interdisciplinary team to be reflected in Resident 239's CP. Staff B reviewed Resident 239's CP and stated the current use of a fall mat should be listed as an intervention, but was not. <Resident 66> According to the 06/28/2024 admission MDS, Resident 66 had recent surgery and required the use of Intravenous (IV - a tube placed inside a vein to deliver medications) antibiotic medications. Review of Resident 66's 06/24/2024 comprehensive CP showed staff developed a CP related to Resident 66 requiring IV antibiotic medications. This CP gave directions to staff to monitor the residents IV site for redness and swelling and to change the IV dressing as ordered. Review of Resident 66's July 2024 Medication Administration Records (MAR) showed the resident's IV antibiotics were discontinued on 07/11/2024, two weeks earlier. In an interview on 08/01/2024 at 1:03 PM, Staff B stated it was their expectation Resident 66's CP be updated and revised when the IV medication was discontinued. <Resident 189> According to a 06/12/2024 admission MDS, Resident 189 had multiple medically complex diagnoses and required the use of a feeding tube to provide at least half of their nutritional intake. Review of a 07/21/2024 physician order showed diet orders for Resident 189 to have no food or fluids by mouth. Review of Resident 189's comprehensive CP showed the following: a 06/07/2024 constipation CP which showed directions to staff to encourage fluids; and a 06/07/2024 dehydration CP which showed directions to staff to encourage fluids. In an interview on 08/01/2024 at 1:03 PM, Staff B stated Resident 189's CP should have been updated and revised as staff should not be encouraging fluids to Resident 189. Based on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were revised and updated to reflect residents' current care needs for 6 of 21 sampled residents (Residents 28, 32, 66, 239, 64, & 189) whose CP were reviewed. This failure left residents at risk for unmet care needs, unsafe provision of care, and a decreased quality of life. Findings included . <Facility Policy> Review of the Resident Care Plan policy, revised 03/2012, showed the Resident's CP should be a communication tool for staff to provide consistency and continuity in resident care based on resident needs, values and preferences. The policy showed CPs would describe a specific plan that reflected resident preferences and care needs with measurable, specific, realistic, and achievable goals so the resident could attain or maintain their highest practicable physical, mental, and psychosocial well-being. The policy showed CPs should be revised quarterly and as needed. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had medical conditions including heart failure and a chronic inflammatory lung disease. The MDS showed Resident 28 experienced Shortness of Breath (SOB) with exertion, at rest, and when lying flat, and received supplemental oxygen for these conditions. According to the 05/23/2022 SOB CP, Resident 28 had a goal for clear lung sounds. This CP included an intervention for nurses to administer a nebulizer treatment (a treatment that aerosolizes an inhaled respiratory medication). Observations on 07/24/2024 at 2:51 PM and 07/30/2024 at 8:08 AM showed no nebulizer machine in Resident 28's room. In an interview on 08/01/2024 at 9:05 AM, Staff B (Director of Nursing) verified Resident 28's Physician's Orders (POs) and stated Resident 28 no longer received as needed nebulizer treatments. Staff B stated the SOB CP needed to be revised. <Resident 32> According to the 05/07/2024 Significant Change MDS, Resident 32 had a severe memory impairment and required staff assistance for mobility. The MDS showed Resident 32 had cardiorespiratory (heart/lung) diagnoses including an irregular heart rate, high blood pressure, and weakness. Review of the 06/08/2023 .on continuous oxygen therapy . CP showed Resident 32 received oxygen per the PO. The CP directed staff to monitor for SOB and changes in skin tone. Observations on 07/26/2024 at 8:50 AM, 07/26/2024 at 12:22 PM, and on 07/29/2024 at 8:35 AM and 2:10 PM showed Resident 32 breathing without supplemental oxygen. There was no oxygen therapy equipment seen in Resident 32's room. In an interview on 08/01/2024 at 8:56 AM Staff B stated Resident 32 no longer required continuous oxygen therapy. Staff B stated the CP needed to be updated to reflect Resident 32's current condition.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure 4 of 7 residents (Residents 45, 20, 58, & 239) reviewed for limited Range of Motion (ROM) were evaluated or provided care and services they were assessed to require, including Restorative Nursing Program (RNP). This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> The RNP facility policy, revised 01/2022, showed the facility would provide restorative nursing services to promote a resident's ability to function at their highest level and live as independently and safely as possible. The policy showed residents who would benefit from RNPs included those who were at risk for functional decline, and residents with identified deficit(s) and had an established need. The Rigid Splint Application facility policy, revised 02/19/2024, showed splints applied incorrectly could cause unnecessary injuries such as skin or soft-tissue complications including pressure injuries and contact dermatitis beneath the splint. The policy showed prompt identification of impaired nerve or circulatory function was critical in preventing patient harm. The policy showed staff were expected to document splint care, skin assessment, and monitoring for complications. <Resident 45> According to the 06/17/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 had clear speech, intact memory, and with medical conditions including heart and kidney failure and a brain injury with resulting weakness on the left side of the body. The MDS showed Resident 45 was assessed to have functional limitations in their ROM. Review of Resident 45's 01/16/2024 Restorative Care Plan (CP) showed the resident was at risk for decreased upper and lower extremity mobility and had Active ROM (AROM) exercises in place. A 04/12/2024 CP intervention instructed staff to continue the application of a right ankle splint. Review of the 07/01/2024 Rehabilitation to Restorative Nursing - Nursing Recommendation Form showed Resident 45 was assessed for AROM RNP up to six days a week. The form showed rehabilitation department recommended right ankle splint application for up to 4.5 hours/day and assessed Resident 45 for splinting RNP up to six days a week. Observation and interview on 07/25/2024 at 9:49 AM showed Resident 45 was lying in bed in the room; their left foot was rotated outwards and their left arm/hand was bent inwards toward their body and was lying on top of their chest with minimal function/movement. There was no splint observed in place. Resident 45 stated they were only able to lift their left arm and leg a little bit off the pillow. When asked if they were provided exercises to help improve and/or maintain mobility and function on the left side of their body, Resident 45 stated, .once a week. Review of Resident 45's AROM RNP documentation 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided once on 07/05/2024 and was declined by the resident twice on 07/01/2024 and 07/03/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided once on 07/08/2024 and was declined on 07/11/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided once on 07/15/2024 and was declined on 07/16/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was not provided and was declined by the resident on 07/22/2024 and 07/23/2024. The facility was not able to provide any documentation to support the AROM RNP was offered to Resident 45 by staff up to six days a week as assessed and planned. Review of Resident 45's Splint Training RNP documentation from 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided three times on 07/01/2024, 07/03/2024, and 07/05/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided three times on 07/08/2024, 07/09/2024, and 07/11/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided two times on 07/15/2024 and 07/16/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was provided once on 07/23/2024 and was not provided on 07/25/2024 because Resident 45 was sleeping. The facility was not able to provide any documentation to support the Splint Training RNP was offered to Resident 45 by staff up to six days a week as assessed and planned. Review of Resident 45's Physician Orders (PO) showed a 04/12/2024 order for staff to conduct skin checks pre- and post-splint applications and to report any skin issues to the licensed nurse. Review of the July 2024 Treatment Administration Record (TAR) on 07/30/2024 did not show staff were conducting skin checks on Resident 45 before and after the application of their right ankle splint as ordered. There was no orders instructing staff to check Resident 45 for neurovascular (nerve and blood flow) compromise associated with splint application. In an interview on 07/26/2024 at 10:35 AM, Staff K (Licensed Practical Nurse) stated the RNP aide was responsible in applying the right ankle splint for Resident 45. In an interview on 07/26/2024 at 10:56 AM, Staff D (Director of Rehabilitation Services) stated resident RNPs was a shared responsibility between themselves, the MDS Coordinator, and the RNP aide. Staff D stated they were not providing RNP up to six days per the RNP assessment plan because their understanding was, as long as residents were provided at least 1-2 days of RNP and the residents were not declining, it was ok. Staff D stated RNPs were not offered six days in a week by the RNP aide. In an interview on 07/30/2024 at 11:53 AM, Staff B (Director of Nursing) stated skin checks should be performed on residents with splint(s) for early identification of device-related pressure injuries. Staff B stated they expected all staff involved with the facility RNPs to conduct skin checks as ordered. Staff B reviewed Resident 45's POs and stated no skin checks were being documented in Resident 45's TAR in line with the resident's current splint use. <Resident 20> According to the 06/03/2024 Quarterly MDS, Resident 20 had clear speech, intact memory, and medical conditions including a brain injury with resulting weakness on the left side of the body. The MDS showed Resident 20 was assessed to have functional limitations in their ROM. Review of Resident 20's 11/21/2023 Restorative CP showed the resident was at risk for decreased ROM to their bilateral upper and lower extremities due to generalized weakness and medical morbidities. The CP showed Resident 20 had AROM exercises and bed mobility RNPs in place. Review of the 01/15/2024 Rehabilitation to Restorative Nursing - Nursing Recommendation Form showed Resident 20 was assessed to tolerate the AROM and bed mobility RNP up to six days a week. Observation and interview on 07/25/2024 at 10:25 AM showed Resident 20's left upper and lower extremities were flaccid (limp and out of tone). Resident 20 stated they were bed bound and that staff provided them arm/leg exercises about three times a week the most. Review of Resident 20's AROM RNP documentation from 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided once on 07/05/2024 and was declined by the resident twice on 07/03/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided twice on 07/08/2024 and 07/11/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided once on 07/15/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was provided once on 07/23/2024 and was declined by the resident on 07/22/2024. The facility was not able to provide any documentation to support the AROM RNP was offered to Resident 20 by the staff up to six days a week as assessed and planned. Review of Resident 20's bed mobility RNP documentation from 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided four times on 07/03/2024, 07/04/2024, 07/05/2024, and 07/06/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided twice on 07/07/2024 and 07/09/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided twice on 07/18/2024 and 07/19/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was provided twice on 07/23/2024 and 07/25/2024. The facility was not able to provide any documentation to support the bed mobility RNP was offered to Resident 20 by the staff up to six days a week as assessed and planned. In an interview on 07/26/2024 at 10:56 AM, Staff D confirmed there were no documentation to show Resident 20 declined or was not able to participate in their RNPs for the days of the week not accounted for in the RNP documentation. Staff D stated RNPs were not offered to Resident 20 six days in a week as assessed and planned. <Resident 58> According to the 06/25/2024 Significant Change MDS, Resident 58 had clear speech, intact memory, with medical conditions including a brain injury with resulting weakness on the right side of the body, and was on hospice care during the assessment period. The MDS showed Resident 58 was assessed to have functional limitations in their ROM. Review of Resident 58's 04/23/2024 CP showed the resident had limited function and mobility due to their brain injury, and a CP intervention listed was to have therapy evaluation and/or treatment done per PO. Review of the July 2024 POs showed there was no order for therapy evaluation and/or treatment for Resident 58. Observation and interview on 07/24/2024 at 1:55 PM showed Resident 58 had contracted fingers on their right hand; they were stiff and had limited mobility. Resident 58 stated they were not receiving any exercises for their right hand. Resident 58 stated, I would appreciate exercises from them [staff] but they would not do it [RNP] because I am under hospice. Review of Resident 58's medical records showed the resident was not on any RNP. In an interview on 07/26/2024 at 11:08 AM, Staff D stated RNPs could be provided to hospice residents by the facility if they needed or ask for them. Staff D confirmed there was no PO in place for Resident 58. The facility was not able to provide any documentation to support the Hospice Care team was notified of the need for an RNP evaluation for Resident 58's identified limited ROM and function. In an interview on 07/26/2024 at 12:10 PM, Staff T (MDS Coordinator) reviewed the MDS coding for Resident 58 and confirmed the resident had current functional limitation in their ROM. Staff T stated they did not effectively address the identified issue under the Care Area Assessment and that was why no RNP evaluation or ROM exercises was recommended for Resident 58. <Resident 239> According to the 07/18/2024 admission MDS, Resident 239 had clear speech, intact memory, and had medical conditions including cancer of the bladder, lungs, and liver and was on hospice care services during the assessment period. The MDS showed Resident 239 had functional limitation in ROM to one side (upper extremity) of their body. Observation and interview on 07/24/2024 at 12:14 PM showed Resident 239 was lying in bed, wearing a brace on their right hand/wrist. Resident 239 stated they sprained their wrist a while back and was unable to use it effectively, .I can move it [right wrist/hand] but it gives out once in a while. Resident 239 stated they were unsure if staff conduct skin checks underneath their splint. A 07/12/2024 Occupational Therapy (OT) note showed Resident 239 had joint contractures (deformity) on both hands from arthritis (joint inflammation). The note showed Resident 239 indicated they wore a right soft wrist support due to an old fracture they sustained in the past. Review of Resident 239's medical records did not show the resident had any current RNP in place. The facility was not able to provide any documentation to support Resident 239's functional limitation in ROM was assessed and/or evaluated for the need for RNP. Review of Resident 239's POs did not show any order for the use of a brace or skin checks. In an interview on 07/26/2024 at 11:08 AM, Staff D reviewed Resident 239's MDS with Staff T and confirmed they have identified Resident 239's functional limitation in ROM in the assessment, but did not address the situation. Staff D confirmed the presence of the 07/12/2024 OT note regarding Resident 239's wrist brace use, and stated they missed it. REFERENCE: WAC 388-97-1060(3)(d). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to implement the necessary care for 2 of 3 sampled residents (Residents 45 & 26) and 1 supplemental resident (Resident 75) reviewed for Tube Feeding (TF) management including: (1) documentation of the amount of TF being administered, (2) weight monitoring, and (3) maintenance and labeling of TF tubing consistent with professional standards of practice. These failures placed residents at risk of not meeting their nutritional requirements, developing TF complications including infection, and a decreased quality of life. Findings included . <Facility Policy> The Enteral Nutrition policy, revised 01/2023, showed it was a nursing responsibility to document the amount of feeding given on each shift in the Medication Administration Record (MAR). The policy showed the facility would label TF bags with the date, time, initial of the nurse hanging the feeding, and the amount hung to prevent contamination when open feeding systems were used. The policy showed new formula would not be added to formula already hanging, and formula would not hang for longer than eight hours. The Weight and Nutrition Monitoring policy, revised 10/2021, showed the intent was to ensure no resident would have significant unplanned weight loss or gain, unless clinically unavoidable. The policy showed all weights would be recorded in the resident's medical records, to be reviewed and monitored by designated clinicians, including those residents who were identified as at nutritional risk. <TF Volume and Weight Monitoring> <Resident 45> According to the 06/17/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 had clear speech, intact memory, and had medical conditions including heart and kidney failure, uncontrolled blood sugar levels in the body, and a brain injury with resulting weakness in one side of the body and difficulty swallowing. The MDS showed Resident 45 received TF via a surgical opening in their stomach during the assessment period. Review of a 01/16/2024 Nutrition Care Plan (CP) showed Resident 45 was on TF for nutritional support because of the resident's swallowing difficulty. A CP intervention directed the nursing staff to administer the TF as ordered. Review of Resident 45's Physician Orders (POs) showed a 05/17/2024 TF order that read: [a type of TF formula] 1.5 Cal Suspension- Soy Protein, Infuse 30 milliliters/hour via Enteral Tube three times daily for supplement from 8:00 PM to 5:00 AM Review of the July 2024 MAR showed the TF order was scheduled for all three shifts (Day, Evening, and Night shift) and nurses from all three shifts were signing off on the TF order. From 07/01/2024 until 07/29/2024, there was no documentation found to support Resident 45's TF intake was being monitored or the TF amount was being recorded by nurses during each administration. In an interview on 07/30/2024 at 11:10 AM, Staff B (Director of Nursing) stated TF order must be complete and accurately show how much feeding was infused to effectively evaluate tolerance in line with nutritional needs. Staff B reviewed Resident 45's TF order and stated the documentation was lacking and should show the amount administered from 8:00 PM until 5:00 AM. Staff B stated the PO should be written to show exactly the TF amount needed to be administered per the Registered Dietician's recommendation to ensure Resident 45's nutritional needs were met. Staff B stated the PO should not be scheduled for all three shifts because the timeframe of administration indicated in the PO did not fall within the times worked during Day shift. Review of Resident 45's POs showed a 03/21/2024 order for weight monitoring weekly on Tuesdays. Review of Resident 45's weight history report showed from 02/05/2024 until 07/22/2024 showed the resident was not being weighed weekly as ordered. The report showed Resident 45's weight was fluctuating: Weighed 131 pounds (lbs.) on 04/10/2024 and 124 lbs. on 04/24/2024, a weight loss of 7 lbs. Weighed 129.7 lbs. on 06/11/2024 and 136.6 lbs. on 06/24/2024, a weight gain of 6.9 lbs. Weighed 135.2 lbs. on 07/16/2024 and 146 lbs. on 07/22/2024, a weight gain of 10.8 lbs. In an interview on 07/30/2024 at 11:10 AM, Staff B stated they expected staff to obtain residents' weights as ordered and to validate the weight's accuracy by observing the facility's re-weigh protocol. Staff B stated weight monitoring was important and essential for residents on TF in order to identify if the facility's nutritional intervention was appropriate, .so we [staff] could determine if [Resident 45] needed an increase or decrease in their feeding . [TF needs] is hard to assess without accurate weights . Staff B confirmed Resident 45 was not being weighed weekly as ordered and stated the resident was not re-weighed consistently as they should be. <Unlabeled Tube Feeding (TF)> <Resident 75> According to a 06/06/2024 admission MDS, Resident 75 had medical conditions including the loss of the ability to use one side of their body and required the use of a feeding tube to provide at least half of the resident's nutritional intake. Observation and interview on 07/26/2024 at 8:44 AM showed a TF bag was hanging in Resident 75's room that contained some tan colored liquid left in the bag. The bag did not identify Resident 75's name, what product was in the bag, did not include a date/time, or the rate of administration. Staff BB (Licensed Practical Nurse - LPN) entered the room and stated they had just finished administering the TF formula to Resident 75 and hung the bag themselves prior to starting the feeding. Staff BB stated the bag should be, but was not labeled with all of the required information. <Resident 26> According to a 05/20/2024 Quarterly MDS, Resident 26 had medical conditions including the loss of the ability to use one side of their body and required the use of a feeding tube to provide at least half of the resident's nutritional intake. Observations on 07/26/2024 at 9:19 AM showed a TF bag with tan colored fluids was hanging on a pole and was being administered to Resident 26. The TF bag was labeled with the date of 07/26/2024, but did not identify what the fluids were in the bag or the rate at which the TF was to be administered. In an interview and observation on 07/26/2024 at 9:19 AM, Staff CC (LPN) confirmed staff was administering a TF formula to Resident 26 and stated the bag should be, but was not labeled with all of the required information. In an interview on 08/01/2024 at 1:03 PM, Staff B stated their expectation was for staff to label the TF bags in resident rooms with the date, time, rate, and the product being administered. REFERENCE: WAC 388-97-1060 (3)(f). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected multiple residents

<Resident 20> According to the 06/03/2024 Quarterly MDS, Resident 20 had clear speech and their memory was intact. The MDS showed Resident 20 had medical conditions including impaired swallowing...

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<Resident 20> According to the 06/03/2024 Quarterly MDS, Resident 20 had clear speech and their memory was intact. The MDS showed Resident 20 had medical conditions including impaired swallowing following a brain injury and severe malnutrition. Review of the revised 03/11/2024 Nutrition CP showed Resident 20's nutritional needs were at risk due to their history of weight loss and muscle mass wasting. A 12/26/2023 CP intervention directed staff to assess Resident 20's food preferences and incorporate them into the resident's meals and snacks. In an interview and observation on 07/25/2024 at 9:57 AM, Resident 20 stated the daily food menu comes late to be able to use them, .I am not able to request want I prefer, especially during breakfast . Resident 20 handed the facility's order requests form that instructed residents to turn in their request form at least two hours before food service, so their preferences could be accommodated. Resident 20 stated, their [facility] rule is for menu to come at least 2 hours so we could choose, but this is not happening. There was no weekly menu observed in Resident 20's possession, nor with their roommate. Resident 20 stated provision menus was inconsistent. In an interview on 08/01/2024 at 11:16 AM, Staff N, in the presence of Staff A (Administrator), stated the distribution of the weekly menu was the responsibility of the dietary manager but that employee had left the facility. Staff N confirmed the weekly menu was not being distributed in resident rooms and stated it should be, to ensure residents' food preferences were obtained and honored, but was not. REFERENCE: WAC 388-97-1120 (2)(a). Based on observation, interview and record review, the facility failed to provide meals that accommodated resident food preferences for 2 of 4 sampled residents (Resident 31 & 20) reviewed for preferences. This failure placed residents at risk for weight loss, frustration, and a diminished quality of life. Findings included . <Resident 31> According to a 07/12/2024 admission Minimum Data Set (MDS - an assessment tool) Resident 31 had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 31 with no memory impairment. In an interview on 07/24/2024 at 10:07 AM, Resident 31 stated they were unhappy with the food and reported they had to keep returning their meal trays to staff as they continued to serve them food they disliked. Resident 31 stated they informed staff many times they did not like sausage or rice, but stated staff continued to serve them those food items. Observations on 07/26/2024 at 8:37 AM showed Resident 31 had a breakfast tray in front of them with only sausage left on their plate. In an interview at this time, Resident 31 stated, I am not going to touch the sausage, I keep telling them I do not like it. Resident 31 explained they read on the daily communication flyer they needed to notify staff before 7:00 AM if a food alternative was desired. Resident 31 stated they were frustrated because they do not get the daily menu until after breakfast, therefore being unable to make changes most days for breakfast or lunch meals. Review of Resident 31's meal tray tickets showed the resident's preference was for, no sausage. According to a 07/08/2024 pressure ulcers Care Plan (CP) showed Resident 31 was at risk for developing pressure ulcers and gave directions to staff to encourage the resident to eat 75-100 percent of their meals. In an interview on 08/01/2024 at 10:31 AM, Staff N (District Manager/Dietary Services) stated, absolutely when asked if staff should follow resident food preferences. Staff N stated it was important to follow resident food preferences because, it ties in to their whole nutritional experience.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based on observations, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services for all facility residents including assistance with Activities of Daily Living (ADL) and timliness of call light response in accordance with established clinical standards, Care Plan (CP), and resident preferences. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Council (RC)> Review of the 01/24/2024 RC meeting notes showed residents reported poor response times. The notes showed the administrator had coordinated with staff members who were unable to perform the needed duties and the short-term plan was for the facility to stack nursing shifts for supervision and the long-term plan was to hire staff to oversee the weekends and night shifts. During an observation on 07/23/2024 at 2:37 PM, two rooms observed to have call lights alarming. At 2:48 PM, the same two call lights were still alarming while day and evening nurses were observed to be in report during shift change. During an observation on 07/25/2024 at 10:16 AM, Staff D (Director of Rehabilitation) was observed telling the shower aide to help answer the call lights. Two rooms had call lights on and only one caregiver was seen working on the floor. <Resident 27> In an interview on 07/29/2024 at 1:17 PM, Resident 27 stated the call light response time could be 10 to 15 minutes or longer. <Resident 11> In an interview on 07/29/2024 at 1:19 PM, Resident 11 stated they waited up to two hours for care staff, especially during shift changes. Resident 11 stated the shift change between evening and night shifts was the worst, but issues would occur during any shift change. Resident 11 stated they believed it was because the facility was understaffed. <Resident 52> In an interview with Resident 52 on 07/24/2024 at 12:08 PM, Resident 52 stated residents had to wait a long time before care staff would help them during shift changes; mostly between day and evening shifts and between night and day shifts. In an interview on 07/29/2024 at 9:29 AM, Resident 52 stated there was an occurrence when they put their call light on in the bathroom because of a bladder accident. Resident 52 stated they were afraid they would slip on the wet floor and needed assistance with wiping the floor. Resident 52 stated they waited for care staff, but staff did not come right away, and they began feeling sick and they needed to go back to their bed. Resident 52 stated they could no longer wait for staff and put towels on the ground so they could walk back to their bed. <Resident 12> In an interview on 07/25/2024 at 9:13 AM, Resident 12 stated during shift change was an issue for care staff to respond to call lights. Resident 12 stated on one occurrence, care staff did not respond to their call light for a long time and the resident had to yell out for help to get care staff to answer their call light. In an interview on 07/26/2024 at 1:25 PM, Resident 12 stated they had pain in their hips, and sometimes needed help but the facility was occasionally short staffed. In an interview on 07/30/2024 at 1:08 PM, Staff GG (Staff Development) stated the facility was within required staffing ratios and adjusted schedules for call outs. Staff GG stated they used staffing ratios to ensure there are enough nurses and staff on call. Staff GG also stated the facility used agency staffing and contracted staff to support nursing shortages. In an interview on 08/01/2024 at 8:26 AM, Staff M (Registered Nurse) stated the facility may be short staffed and could use more nursing assistants and licensed practical nurses. Staff M stated staffing should not be based on how many residents the facility had but should be more about the care that residents needed. In an interview on 08/01/2024 at 9:11 AM, Staff FF (Licensed Practical Nurse) stated sometimes there is not enough staff and it gets hard to complete tasks. Staff FF stated tasks could take up to one hour, with a half hour give or take to complete. Staff FF stated,staffing should be based more about how hard a resident's care is rather than the amount of people scheduled. REFERENCE: WAC 388-97-1080(9). .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Uncovered Food> Observation on 07/23/2024 at 12:18 PM during meal tray service in Unit C showed the meal cart was parked ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Uncovered Food> Observation on 07/23/2024 at 12:18 PM during meal tray service in Unit C showed the meal cart was parked between rooms [ROOM NUMBERS]. Staff O (Certified Nursing Assistant - CNA) was observed serving the meal tray for room [ROOM NUMBER], passing by an isolation room (room [ROOM NUMBER]) with the dessert left uncovered. Observation on 07/23/2024 at 12:23 PM showed Staff C serve the meal tray for room [ROOM NUMBER], again passing by the isolation room (room [ROOM NUMBER]) with the dessert left uncovered. On 07/23/2024 at 12:27, Staff P (CNA) was observed serving the meal tray for room [ROOM NUMBER] with the dessert left uncovered. Observation on 07/23/2024 at 12:29 showed Staff P serve the meal tray for room [ROOM NUMBER] which was located far and around the corner of the unit from where the meal cart was parked, passing along the isolation room (room [ROOM NUMBER]) with the dessert left uncovered. In an interview on 07/23/2024 at 12:40 PM, when Staff P was asked if it was the facility's practice to leave the desserts uncovered during meal tray service, Staff P stated, Yes, for some desserts .I don't know why .maybe because this cake has frosting and it might be a mess if covered . Staff P stated food left uncovered was at risk for contamination. In an interview on 07/30/2024 at 2:59 PM, Staff Q (Infection Preventionist) confirmed the facility was in a COVID-19 outbreak. Staff Q stated they expected food to be covered during meal service because they did not want to serve residents contaminated food, .we [staff] don't know what is present in the air . In an interview on 07/30/2024 at 3:05 PM, Staff N stated they expected the dietary staff to ensure food was covered appropriately during meal tray service. Staff N stated it was important to ensure food was covered during meal service for temperature control and to protect the safety of the food and prevent cross-contamination. Observations on 08/01/2024 at 8:17 AM showed staff passing out breakfast trays on Unit A from a meal tray cart located near the nurse's station. Staff pulled a meal tray out of the cart, with an uncovered bowl of fruit, and carried the tray past other rooms and residents in hallway to deliver it to room [ROOM NUMBER], the last room on the unit. REFERENCE: WAC 388-97-1100(3), -2980. Based on observation, interview, and record review, the facility failed to ensure resident meals were stored, prepared, and served in a sanitary manner for 1 of 1 kitchens and 1 of 4 unit pantries (Unit 400). These failures left residents at risk for spoiled or contaminated foods, and food-borne illness. Findings included . <Facility Policy> According to the facility's 07/2024 Food Storage policy all food items would be labeled with with a manufacturer's expiration date or the date of receipt. The policy showed refrigerated foods would be discarded using either the manufacturer's expiration date or seven days after the written date. The policy showed all refrigerators used for nutrition would be cleaned weekly by dietary staff. The policy showed food in facility refrigerators should be covered. <Dry Storage> Observation of the facility's dry food storage on 07/23/24 at 9:11 AM showed a box of thickening powder (used to alter the fluids for residents with swallowing difficulties) was left open. The plastic liner was torn open and not resealed and the cardboard flaps were wide open leaving the powder exposed. A large container of granulated garlic was observed to be open with no indication of when the container was opened or a use-by date. In an interview at that time Staff Z (Senior Cook) stated the thickening powder was not stored correctly and needed to be discarded. Staff Z stated the granulated garlic should have been labeled to indicate for how long it was safe to use. <Hair Nets> Observation on 07/23/24 01:36 PM showed Staff DD (Dietary Assistant) preparing a drink in the facility's kitchen. Staff DD's hair was long and was not secured by a hairnet or a hat. Staff DD stated they were not required to wear a hat as they were only in the kitchen briefly. At that time Staff AA (Food Service Director) was standing next to Staff DD. Staff AA interjected and stated that all staff were required to secure their hair prior to entering the kitchen to prevent hair contaminating resident meals. Staff AA stated it did not matter why staff entered the kitchen or for how long. <Unit Pantries> Observation of the 400 Unit Pantry on 07/30/2024 at 8:21 AM showed the pantry contained a refrigerator where resident snacks, leftovers, outside food, and cold beverages were stored, and a handwashing sink. This fridge contained a red plate with a half-eaten quesadilla. This quesadilla was partially covered with a paper towel matching the paper towels from the dispenser by the handwashing sink. Someone wrote 5/29 [Resident 24] 416-2 on the paper towel. The refrigerator also contained an opened bottle of lemonade that was not dated and was not labeled to indicate whom it belonged. The 400 Unit Pantry also contained a water and ice dispensing machine. This machine's clear plastic dispensing chute was observed to have a buildup of a yellow-green slime. In an interview at this time Staff B (Director of Nursing) stated the chute needed to be cleaned and the lemonade and quesadilla needed to be discarded as they were not stored appropriately. <Hand Sanitization> Observation during lunch preparation on 07/30/24 at 9:36 AM showed Staff R (Cook) wearing a surgical mask (the facility had a COVID-19 [a communicable respiratory infection] outbreak at the time) that was lowered below their chin while they spoke to another member of the dietary staff. With a gloved hand Staff R raised the surgical mask back over their mouth and nose. Without washing their hands, using the same (now soiled) gloves, Staff R then wrapped a ham with plastic. Observation on 08/01/2024 at 10:30 AM showed Staff R in the kitchen preparing lunch with their surgical mask again placed below their chin. Staff R observed a surveyor through the kitchen window and raised their mask over their mouth and nose. Without performing hand hygiene Staff R immediately continued preparing lunch In an interview on 08/01/2024 at 10:31 AM Staff N (District Dietary Manager) stated they expected all staff to use appropriate hand hygiene. Staff N stated Staff R should have washed hands and changed gloves after contaminating them by touching their surgical mask. Staff N stated Unit Pantries were the joint responsibility of the dietary and nursing departments, and stated they expected the food to be stored appropriately and the ice/water machine to be kept clean.

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a safe discharge for 1 of 3 residents (Resident 1) reviewed for discharges. The facility failed to ensure the Home Health Agency (HHA) was provided with all required information and documents to initiate home services as expected after discharge and failed to ensure indwelling catheter care education was provided and documented as provided to the Collateral Contact (CC). These failures placed the resident at risk for unmet care needs after discharge, potential for re-hospitalization, distress, and diminished quality of life. Findings included . Review of the facility, Transfer and Discharge policy, dated 04/2024, showed all discharges would be consistent with the needs of the resident and in conformance with the policy. The policy showed transfer documentation and appropriate medical information would be noted in the medical record and include all special instructions or precautions for on-going care. The policy showed the facility would provide sufficient preparation for the resident or the resident representative, in a form or manner they could understand, to ensure a safe and orderly discharge from the facility. <Resident 1> Review of a Discharge Minimum Data Set (MDS, an assessment tool) dated 03/01/2024, showed Resident 1 was able to make their own decisions, their needs known, and had diagnoses that included a left hip fracture and left lower leg fracture that required surgical repair. The MDS showed Resident 1 had impairments to the left side, used a wheelchair, had an indwelling catheter (a flexible tube that eliminates urine from the body), was dependent on a helper for toileting hygiene, and required maximum assistance with lower body dressing and bathing. Review of a discharge Care Plan (CP), dated 02/29/2024, showed Resident 1's plan was to discharge home with a goal of Resident 1, their CC and the caregiver would understand the home discharge regimen. Interventions included assuring that continuum of care was maintained by giving a detailed summary of care needs when discharged and educate the family or caregiver on the home regimen, such as equipment, appointments, and contact information for HHA's. Review of a Discharge Summary and Instructions, dated 03/01/2024, showed under Recommended Services section, with choices of Home Health (HH) services, specialized services, and outpatient services, no areas were marked. A recommended discipline section showed a registered nurse, physical and occupational therapist, and a bath aide were marked. The discharge summary showed a referral was made for HH services. If you do not hear from them after discharge, please reach out to them directly, and listed the HHA name and phone number. In an electronic mail (e-mail) communication dated 03/04/2024 at 5:00 PM, Staff C (Social Services Director) documented that Resident 1's HHA was diverted from one HHA to another due to the original HHA overbooked and unable to accept new patients. During an interview on 03/06/2024 at 11:40 AM, Resident 1 stated they discharged from the facility on 03/01/2024 at 11:30 AM, HH services were expected to start 03/01/2024 at 12:30 PM, and as of 03/06/2024 they have been without HH services for five days. Resident 1 stated upon discharge their CC was not educated on how to provide care for the indwelling catheter, neither Resident 1 or their CC knew about indwelling catheter care, and they did not receive indwelling catheter care. Resident 1 stated Staff D (Advanced Registered Nurse Practitioner) did not complete their discharge orders properly as the form was marked other, so no services were identified, and the HHA required specific information to initiate services. Resident 1 stated they were concerned about how they would be transported to upcoming doctor's appointments as they were wheelchair bound and had a split-level home with two separate flights of stairs, they were not able to maneuver. In an interview on 03/12/2024 at 2:58 PM, the HHA stated on 02/29/2024, when the referral for Resident 1 was received, the referral was missing information the HHA needed to start services. The HHA stated they reached out to the facility to obtain specific information about exact services Resident 1 required but had issues getting the required information. The HHA stated the facility provided and clarified the information on Monday 03/04/2024. Resident 1 was notified by the HHA on Tuesday 03/05/2024. Services started on 03/06/2024. Review of a HHA referral checklist, undated, showed the HHA required information on: why the patient needed HH services, what services were being requested, and what care was associated with each service. The HHA checklist showed when a patient had a catheter the HHA needed to know the size, date inserted, and date it needed to be changed. The HHA checklist showed at the bottom of the page, please provide referral 2-3 days prior to discharge so our team has adequate tine to process, accept, and schedule the patient. During an e-mail communication on 04/19/2024 at 5:35 PM Staff C documented on 03/01/2024 they received an e-mail from the HHA and when they became aware that Resident 1's HHA was diverted to another HHA company. Staff C stated they did not send the referral or any information to the new HHA because the first HHA sent the referral. Staff C stated they did not receive a phone call requesting more information on Resident 1 from the HHA and the facility did not call Resident 1 to inform them of the change in HHA's. Staff C stated they assumed they would receive a call from the HHA. In an e-mail communication on 04/22/2024 at 7:30 PM, Staff B (Director of Nursing Services) documented they could not locate or provide documentation that showed facility staff provided Resident 1 or their CC with indwelling Foley care education on how to properly care and clean the indwelling catheter. Staff B documented they would expect education to be provided and documented as provided to the resident or the CC when they discharged from the facility with an indwelling catheter. REFERENCE: WAC 388-97-0120(3)(a) .

Apr 2023 12 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure 1 (Resident 8) of 3 sampled residents reviewed for Pressure Ulcers (PUs) 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 assess skin integrity, follow Care Plan (CP) Interventions and initiate treatment orders caused harm to Resident 8 who developed an avoidable facility acquired right rib PU and a reopened a tailbone PU. Failure of the facility to complete skin assessments, prevent and treat PUs, placed Resident 8 and all other residents at risk for pressure ulcer development, increased risk for infection, and diminished quality of life. Findings included . <Facility Pressure Ulcer Policy> The facility's 01/2023 PU policy showed that the resident would not develop PU's and the facility would provide care and services consistent with professional standards of practice. A PU refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A PU would present as an open ulcer the appearance of which would vary depending on the stage and may be painful. The injury would occur as a result of intense and/or prolonged pressure. An Unstageable PU: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (dead tissue - If the slough was removed a stage 3 or stage 4 PU would be revealed). A stage 3 PU is full thickness skin loss, and a stage 4 PU is full thickness skin and tissue loss with exposed or directly palpable fascia (a layer of connective tissue below the skin), muscle, tendon, ligament, cartilage, or bone in the ulcer. Avoidable PU: A PU that developed in the facility and the facility failed to do one or more of the following: Evaluate the resident's clinical condition risk factors: define and implement interventions that are consistent with residents needs, goals, and recognized standards of practice; or failed to monitor and evaluate the impact of the interventions or revise the interventions as appropriate. The PU policy listed expectations of staff if a PU developed after admission as follows: Obtain treatment orders, initiate an individualized CP to include new PUs with interventions for evidence of pain at site or during care, add stage, site, and treatment order to Treatment Administration Record (TAR), and document assessment of PU. <Resident 8> According to the 02/27/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 8 was able to make themself understood and able to understand others, had moderate mental decline, and was totally dependent on two staff for physical assistance with moving to and from a lying position, turning side to side, and positioning the body while in bed. The MDS showed Resident 8 had diagnoses of quadriplegia (paralysis from neck down), and a disabling neuromuscular disease of the brain and spinal cord causing communication problems between the brain and the muscles. According to the MDS, Resident 8 was at high risk for developing PUs. Observation on 04/18/2023 at 10:27 AM showed Resident 8 lying on their back, and only able to move their neck and head. Resident 8's arms were bent at the elbows with their hands resting on their chest. Resident 8's elbows were pressed tightly onto their rib cage. Resident 8 was unable to shift their weight or move their body/extremities on their own. Clinical record review showed the physician ordered weekly skin assessments were not completed on 03/30/2023, 04/06/2023, and 04/13/2023. The TAR had an M in the documentation area for these dates. In an interview on 04/21/2023 at 2:11 PM Staff C Manager Long Term Care, Registered Nurse (RN), stated that an M in the documentation area on the resident's administration records meant that the staff missed doing the assigned order for those dates. In an interview on 04/21/2023 at 2:11 PM Staff M Manager Long Term Care, RN stated staff did not complete the weekly skin assessments on 03/30/2023, 04/06/2023, and 04/13/2023. Staff M stated nursing staff were expected to complete a head-to-toe skin assessment including measuring and documenting all skin issues, old and new. Review of the 04/17/2023, 04/19/2023, and 04/25/2023 Pocket Care Guide (PCG) and CPs directed staff to ensure Resident 8's elbows were cushioned with pillows and position Resident 8 either on their left or right side, not on their back to decrease pressure on buttocks. Observations on 04/18/2023 at 10:27 AM, 04/19/2023 at 8: 48 AM, 04/20/2023 8:34 AM, 4/21/2023 at 9:23 AM, 04/24/2023 at 9:38 AM, and 04/25/2023 at 10:18 AM showed Resident 8 did not have pillows under their right elbow according to the CP to prevent pressure between the elbow bone and the right rib cage. Resident 8 was observed lying on back in bed on 04/18/2023 at 10:27 AM, 04/21/2023 at 9:23 AM, 04/24/2023 at 9:38 AM, and 04/25/2023 at 10:18 AM. The 04/17/2023, 04/19/2023, and 04/25/2023 PCG instructed staff to keep Resident 8 off of their back. In an interview on 04/20/2023 at 10:07 AM Staff U Certified Nursing Assistant (CNA), stated the nursing staff use the PCG to direct them on how to care for their assigned residents. On 04/20/2023 at 10:26 AM, the wound care provider verbally gave Staff O the following wound care orders: Cleanse tailbone PU with normal saline, apply AD ointment periwound (skin surrounding wound), apply Hydraferablue (an antibacterial foam dressing), secure with silicone bordered dressing, change every other day and as needed. Cleanse rib PU with wound cleanser apply AD ointment to periwound, apply honey, secure with bordered dressing, change every other day and as needed. When interviewed on 04/20/2023 at 10:26 AM, Resident 8 denied pain when the wound care provider asked if the resident was experiencing any pain because the resident had diagnoses that prevented the resident from feeling pain. A reasonable person, that did not have Resident 8's diagnoses would experience severe pain with the development of an unstageable PU and would not be dependent on staff to prevent PUs as Resident 8 was assessed to require. Clinical record review on 04/24/2023, four days after new PUs were identified, and staff received orders for cares and treatments, showed there were no new treatment orders for the rib and tailbone PU documented in the clinical record or medication record, no nurse assessment documentation of the PUs, and the CP was not updated with new PU treatments. In an interview on 04/24/2023 01:54 PM, Staff O stated they did not document notes on newfound PUs or transfer verbal treatment orders (received on 04/20/2023) into Resident 8's medical record. Staff O stated Resident 8 went four days without wound care or wound monitoring. In an interview on 04/24/23 at 1:22 PM, Staff M stated the expectation of nurses, when they found a new PU, was to complete a head-to-toe skin assessment, measure and document all skin issues, old and new, and document findings in a nursing note in the resident's record. Staff M stated the nurse was expected to complete an incident report, notify the physician to get treatment orders, transfer the orders to the residents' records, notify the nurse manager, and the wound care provider. Staff M stated Staff O was part of the facility's wound care team so the nurses would have Staff O assess the PU and recommend treatment orders when Staff O was on duty. REFERENCE: WAC 388-97-1060(3)(b). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide care in a manner that promoted resident dignity for 1 of 2 (Resident 74) sampled residents. Facility failure to fully dress Resident 74 left them at risk for feelings of embarrassment, helplessness, and diminished self-worth. Findings included . <Resident 74> According to the 03/21/2023 admission Minimum Data Set (MDS - an assessment tool), Resident 74 had diagnoses of dementia, and required extensive physical assistance with activities of daily living including dressing. This assessment showed Resident 74 never or rarely made decisions and required assistance with cues and supervision. According to the 04/17/2023 Pocket Care Guide (a document providing facility staff directions for care) Resident 74 required supervision assistance from staff related to dressing. On 04/18/2023 at 9:30 AM and 04/19/2023 at 8:59 AM, Resident 74 was observed dressed in a t-shirt and brief. Resident 74 was observed ambulating independently around their room from the hallway in t-shirt and brief. The door to their room was open allowing passers-by access to Resident 74's activities. Staff H (Licensed Practical Nurse), Staff S (Certified Nursing Assistant - CNA) and Staff W (CNA), were observed on 04/19/2023 at 11:30 AM walking past Resident 74's room without attempting to assist Resident 74, who was in a t-shirt and brief, with dressing. In an interview on 04/19/2023 at 1:25 PM, Staff R (CNA) stated Resident 74 could dress themselves if clothing was left on the bed. Staff R stated if facility staff prompted Resident 74 to dress, Resident 74 could dress independently. In an interview on 04/24/2023 at 11:28 AM, Staff S stated they would intervene right away if a resident was observed half-dressed and agreed being seen half-dressed from the hallway was undignified. REFERENCE: WAC 388-97-0180(1-4). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

<Resident 234> Review of a 04/12/2023 Significant Change MDS showed Resident 234 was assessed to have multiple medically complex diagnoses including stroke, kidney disease, and difficulty expres...

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<Resident 234> Review of a 04/12/2023 Significant Change MDS showed Resident 234 was assessed to have multiple medically complex diagnoses including stroke, kidney disease, and difficulty expressing speech. In observations on 04/18/2023 at 2:28 PM, 04/19/2023 at 9:04 AM, and 04/20/2023 at 8:38 AM, Resident 234 was noted to have an band aid to the back of their right hand. An observation of Resident 234 on 04/21/2023 at 10:33 AM and on 04/24/2023 at 10:22 AM showed a skin tear approximately one inch in length, held together with two small adhesive skin closure strips used to close a skin tear. A 04/18/2023 late entry progress note showed a nurse identified the skin tear on 04/17/2023. The progress note showed .a small skin tear on right hand . The progress note did not indicate how the skin tear occurred, if the physician was notified, or if the nurse manager was notified of the injury. Review of the facility's investigation report received on 04/24/2023 of Resident 234's skin tear showed physician orders regarding the skin tear were written eight days after the skin tear was discovered. Resident 234's CP was not updated until 04/24/2023, seven days after the skin tear was discovered. The pocket care guide (a document providing facility staff directions for care) was not updated until 04/25/2023, eight days after the skin tear was discovered. The investigation included a facility Skin Observation and Tracking sheet dated 04/21/2023. This form did not indicate or mention the skin tear. There was no Skin Observation and Tracking sheet provided that showed the skin tear was assessed or measured on 04/17/2023. The Event & Occurrence Conclusion Sheet summarized the skin tear appeared older than the date of discovery. The investigation did not include any interviews or staff statements of knowledge about the skin tear. The investigation did not include any statements from Resident 234 or their representative to include their knowledge of how the skin tear occurred. In an interview on 04/24/2023 at 3:23 PM, Staff M (Manager Long Term Care, Registered Nurse) stated they were unaware of the skin tear to Resident 234. Staff M stated it was their expectation an investigation was completed for any new skin changes to a resident. In an interview on 04/25/2023 at 10:43 AM, Staff A stated it was their expectation nurses reported new skin impairment to the nurse manager. Staff A stated when an issue was identified, they would complete their investigation in Datix. Staff A stated investigations were important to rule out abuse and neglect. <Resident 23> According to the 02/07/2023 Annual MDS, Resident 23 was assessed with intact cognition. The MDS showed Resident 23 independently transferred and walked around the facility with a walker (mobility device). Observation on 04/18/2023 at 1:11 PM showed Resident 23 had a dark discoloration on their right wrist and a wound to the back of the left hand. In an interview on 04/18/2023 at 1:11 PM, Resident 23 stated they had a bruise to their right wrist and a wound to the back of their left hand. Resident 23 was unable to provide information on how the bruise and skin tear occurred. Review of the 04/19/2023 Weekly Skin Observation and Ongoing Skin Issue Tracking (a facility skin assessment) showed Resident 23's skin was intact with no issues noted for hands/fingers/nails. In an interview on 04/24/2023 at 11:28 AM Staff S (Certified Nursing Assistant- CNA) stated they were aware of the bruise and skin tear but did not inform the nurse of the alterations. In an interview on 04/24/2023 at 1:00 PM Staff H (Licensed Practical Nurse- LPN) stated they were aware of the bruise and skin tear but did not report the issues to the provider or facility management. The 04/25/2023 right wrist incident report, included no evidence the facility conducted observations, interviews, or record reviews to help identify the cause to prevent Resident 23 from further injury. The investigation did not consider Resident 23's ability to care for themselves, or use of walker that could have caused the bruising. In an interview on 04/25/2023 at 11:00 AM, Staff A stated the bruise and skin tear have been investigated for abuse and neglect. The facility furnished no additional proof regarding the investigation to the skin tear to Resident 23's back of left hand. Refer to F684 Quality of Care. REFERENCE: WAC 388-97-0640(6)(a)(b). Based on observation, interviews, and record review, the facility failed to investigate falls and/or injuries of unknown origin to determine cause, rule out abuse, and implement interventions to prevent reoccurrence for 3 of 18 (Residents 64, 234, & 23) sampled residents reviewed. The failure to initiate and conduct a thorough investigation, initiate appropriate corrective actions, and outline all contributing factors regarding unwitnessed falls (Resident 64), skin tears (Resident 234 & 23), and bruising (Resident 23) placed the residents at risk for recurrent falls with potential for significant injury and unidentified abuse or neglect. Findings included . <Facility Policy> Review of the undated Providence Home and Community Care Event Reporting using Datix [facility's incident reporting system] policy identified the facility's process for investigation of adverse events. The policy showed investigations would include interviewing applicable staff including involved caregivers; inspect, review, and secure all relevant material, equipment, and devices; and document findings, conclusion, and actions. The policy showed a formal analysis of the cause would be conducted for all events. <Resident 64> According to the 01/19/2023 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 64 had medically complex diagnoses including moderate cognitive impairment, anxiety, and a history of falling. The assessment showed Resident 64 had an injury fall while in the facility and sustained a fracture to their right hip during the assessment period. The 01/19/2023 MDS showed Resident 64 had issues with their balance and was not stable without staff assistance during ambulation and transfers. The 03/24/2023 Fall Care Plan (CP) showed Resident 64 was a high fall risk and listed interventions including situating Resident 64 up in the common area when awake for increased visual checks related to the resident's poor safety awareness. Review of Resident 64's progress notes showed a 03/30/2023 Post-Fall Medication Review note completed by the pharmacist and listed Resident 64's fall on 03/21/2023. The note stated Resident 64 had a fall while at the nurses' station and was discovered lying on their left side near the recliner and overbed table. A 03/21/2023 nursing note showed Resident 64 was transported to the hospital. Review of the facility's March 2023 incident log showed this event was not recorded. There was no documentation provided by the facility to indicate Resident 64's fall was investigated or an analysis of the cause was established to prevent reoccurrence of falls. In an interview on 04/24/2023 at 10:56 AM, Staff C (Resident Care Manager/Interim Director of Nursing) stated all falls were expected to be logged in the facility's incident report. Staff C stated the incident report should be accurate to keep track of issues and events including resident falls. Staff C stated investigating falls would establish the cause so that nursing staff could put appropriate preventative measures in place. In an interview on 04/24/2023 at 4:41 PM, Staff A (Administrator) stated there was no investigation documentation found regarding Resident 64's fall on 03/21/2023.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or resident representatives received bed hold notification for 3 of 6 (Residents 7, 58 & 64) residents reviewed for transfers, discharges, and hospitalizations. This failure placed the residents and/or their resident representatives at risk for lack of knowledge regarding their right to hold their bed during transfers, discharges, and hospitalizations. Findings included . <Facility Policy> The 02/2022 Skilled Nursing Facility Bed Hold and Return To Facility policy showed residents and their representatives were provided with bed hold and return information before a hospital transfer. The policy outlined staff were educated about the resident's bed hold and return rights to ensure this information was provided at the time a resident left the facility. <Resident 7> Review of Resident 7's record showed they were transferred to the hospital on [DATE] and returned to the facility on [DATE]. Record review showed no indication a bed hold notification was provided to Resident 7 or their representative. In an interview on 04/21/2023 at 11:12 AM, Resident 7 stated they could not remember if they signed or were offered a bed hold agreement prior to being sent to the hospital. In an interview on 04/24/2023 at 3:13 PM, Staff D (Associate Clerical Assistant) stated they usually received an email report when a resident was sent out of the facility. Staff D stated their process was to call the family or resident the next day to offer a bed hold and would document the conversation in the resident's record. In an interview on 04/25/2023 at 8:52 AM, Staff F (Health Information Manger) confirmed a bed hold was not offered for Resident 7. <Resident 58> Review of Resident 58's record showed they were transferred to the hospital on [DATE]. Record review showed no indication a bed hold notification was provided to Resident 58 or their representative. In an interview on 04/25/2023 at 8:07 AM, Staff D stated providing bed hold notification was important because it gave residents and/or resident representatives the opportunity to save their bed or room or decline to do so when they leave the facility for reasons like emergent hospitalization. Staff D stated bed hold notifications assisted residents and/or representatives with decision-making since holding the bed often came with corresponding fees. Staff D stated bed hold notifications were all the more important for long-term care residents because the residents treated their room as their home. In an interview on 04/25/2023 at 11:52 AM, Staff F confirmed a bed hold was not offered for Resident 58. <Resident 64> Review of Resident 64's record showed they were transferred to the hospital on [DATE]. Record review showed no indication a bed hold notification was provided to Resident 64 or their representative. In an interview on 04/25/2023 at 8:13 AM, Staff D stated a bed hold was not offered for Resident 64. REFERENCE: WAC 388-97-0120(4)(b). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to accurately assess 2 of 18 (Residents 58 & 1) residents reviewed for Minimum Data Set (MDS - an assessment tool) accuracy. Failure to ensure accurate assessments regarding oral status (Resident 58) and special treatment/procedures (Resident 1) placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 58> According to the 03/13/2023 Significant Change MDS, Resident 58 had complex medical diagnoses including a stroke resulting in difficulty swallowing and loss of function on the left arm and left leg. The assessment showed Resident 58 did not have any oral/dental issues. There was no Care Area Assessment (CAA) completed for Resident 58's oral/dental status. On 04/18/2023 at 10:54 AM, Resident 58 was observed to be edentulous (without natural teeth). Resident 58 stated they do not use or have any dentures. In an interview on 04/21/2023 at 11:18 AM, Staff G (Registered Nurse, MDS) stated the accurate assessment of a resident's oral/dental health status was very important for the care planning process and to ensure appropriate interventions were put in place to maintain adequate nutrition. Staff G validated Resident 58's edentulous status was not captured in the assessment. Staff G stated the 03/13/2023 MDS was inaccurate. <Resident 1> According to the 03/03/2023 admission MDS, Resident 1 had diagnoses including kidney failure with dialysis (treatment to filter the blood to remove waste products and extra fluids from the blood). Under the special treatments section of the MDS, the facility staff did not code Resident 1 required dialysis service. Observation on 04/18/2023 at 11:35 AM showed Resident 1 had a fistula (surgically implanted tubing that connects a vein and an artery to allow dialysis) on their left arm and a dialysis catheter site on the right upper chest. In an interview on 04/18/2023 at 11:40 AM, Resident 1 stated they went to the kidney center for dialysis three times weekly on Mondays, Wednesdays, and Fridays since admission. Review of 02/27/2023 physician order showed Resident 1 had dialysis treatments every Monday, Wednesday, and Friday from 6:30 AM to 10:30 AM. In an interview on 04/20/2022 at 1:45 PM, Staff K (Licensed Practical Nurse) stated Resident 1 had dialysis treatments three times a week at the kidney center and the facility arranged transportation. In an interview on 04/21/2023 at 1:34 PM, Staff L (Clinical Program Coordinator) stated they failed to code Resident 1 required dialysis. Staff L stated the MDS was inaccurate, and they should have coded the dialysis treatment. REFERENCE: WAC 388-97-100(1)(b). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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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 for 1 of 5 (Resident 64) residents reviewed for PASRR. 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 64> According to the 01/19/2023 Significant Change Minimum Data Set (an assessment tool) Resident 64 had multiple medically complex diagnoses including anxiety and required the use of an antidepressant medication. Review of Resident 64's records showed a 03/08/2023 admission provider note stating the assessment and plan was to continue an antidepressant medication for anxiety and depression. Subsequent provider progress notes from 03/14/2023, 03/20/2023, 03/23/2023, and 03/27/2023 indicated the assessment and plan continued to include a diagnosis of depression. Pharmacist progress notes on 03/17/2023 and 03/30/2023 indicated Resident 64 was taking antidepressant medications for depression. Review of a 01/18/2023 Level 1 PASRR showed staff identified Resident 64's only Serious Mental Illness (SMI) indicator was an anxiety disorder. Staff did not identify Resident 64 had a diagnosis of depression, as indicated by the provider, and required the use of antidepressant medications. In an interview on 04/24/2023 at 3:57 PM, Staff T (Manager Social Work) stated a new PASRR Level 1 should be completed when a resident was started on new medications or if new mental health diagnoses were added. Staff T confirmed Resident 64's Level 1 PASRR did not have a SMI indicator marked for depression, and stated Level 1 PASRR evaluations should be accurate and updated as required. REFERENCE: WAC 388-97-1975 (1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure comprehensive Care Plans (CPs) had measurable goals, and were complete, accurate, revised as needed, and implemented for 4 of 18 (Residents 31, 68, 64 & 66) sample residents whose CPs were reviewed. Facility failure to ensure CPs were complete, accurate, revised, and implemented left residents at risk for unmet care needs and diminished quality of life. Findings included . <Facility Policy> The 01/2023 Resident Care Plan (CP) facility policy showed the CP was reviewed, updated, and printed for the CP book at least quarterly and in the event of a significant change in condition for long-term care residents. The policy showed the CP would include measurable, specific, realistic, and achievable goals and would include a specific plan reflecting the resident preferences and care needs. The policy indicated facility staff should integrate external providers' CPs with the facility's CP in order to coordinate services with the external health care provider. <Resident 31> According to the 03/28/2023 Admissions Minimum Data Set (MDS - an assessment tool) Resident 31 readmitted to the facility on [DATE] and had diagnoses including an infection/inflammation of an artificial joint. The MDS showed Resident 31 received antibiotic medications intravenously (IV - directly into the veins). Resident 31's Physician's Orders (POs) included a 03/30/2023 order for an IV antibiotic medication 2 MG to be given twice daily. The antibiotic was ordered to treat Resident 31's infection of their artificial left shoulder joint. Resident 31's comprehensive CP included a 02/13/2023 risk for infection of surgical site. Location: Left Shoulder CP that included interventions for treatment/medications as ordered. The comprehensive CP did not include a CP to address Resident 31's use of an IV antibiotic to treat the infected left shoulder prosthesis, and potential adverse side effects. Review of Resident 31's 04/21/2023 Pocket Care Guide (a document providing facility staff directions for care) showed the guide did not identify Resident 31's IV antibiotic use. In an interview on 04/24/2023 at 4:58 PM, Staff M (Manager - Long Term Care, Registered Nurse) stated it was their expectation that all current care was reflected on residents' CPs. Staff M stated each resident's CP should be complete and accurate, including Pocket Care Guides. <Resident 64> According to the 01/19/2023 Significant Change MDS, Resident 64 received one-person limited assistance with transfers and was provided set-up help and supervision during ambulation (walking with or without assistance). The 01/19/2023 Activities of Daily Living (ADLs) Care Area Assessment (CAA) assessed Resident 64 to be stable with their ambulation and transfers without staff. The CAA showed Resident 64 was independent with most of their ADLs prior to a fall with a right hip fracture on 01/07/2023. Review of the 06/21/2022 ADL CP showed Resident 64 was independent with their ambulation. On 04/21/2023 at 12:49 PM, Resident 64 was observed sitting in a recliner by the nurses' station. Resident 64 flagged down Staff Y (Certified Nursing Assistant - CNA) and told them they wanted to go to the bathroom. Staff Y assisted Resident 64 to stand up and pivot into a manual wheelchair and wheeled Resident 64 back to the room. In an interview on 04/21/2023 at 12:51 PM, Staff Y stated Resident 64 was no longer able to walk on their own. Staff Y stated, due to safety, a manual wheelchair was used to bring Resident 64 from point A to point B. In an interview on 04/21/2023 at 12:54 PM, Staff E (Licensed Practical Nurse) validated Resident 64 did not have the ability to walk independently after their injury fall. In an interview on 04/24/2023 at 3:20 PM, Staff G (Registered Nurse, MDS) stated CPs were reviewed and/or revised as necessary after every MDS completion, especially when the assessment completed was a Significant Change MDS. Staff G stated Resident 64's ADLs CP should be updated to reflect their ambulatory status, so staff could provide safe, appropriate ADL care. <Resident 233> According to the 02/01/2023 Quarterly MDS, Resident 233 was assessed to be severely cognitively impaired. This assessment showed Resident 233 identified as very important their activity preferences for having reading materials available, keeping up with the news, and participating in their favorite activities. This assessment showed Resident 233 required physical assistance to move around the unit in their wheelchair. Review of an 11/07/2022 Activities CP showed Resident 233 had a goal to .self-initiate involvement in independent leisure opportunities in preferred setting of [their] room. Interventions included providing leisure supplies for self-directed pursuits of television, offer companionship of family/staff, and encourage verbalization of interests and hobbies. The CP listed past interests of gardening, walking, and visiting with family/friends. Current interests were listed as watching TV, reading the paper, and visiting family. This CP did not include measurable goals for Resident 233. On 04/18/2023 at 9:40 AM, Resident 233 was observed lying in bed, staring out the window. Their television was off, there were no books or reading materials observed in their room. Resident 233 was in the far bed, by the window, with the privacy curtain pulled. Resident 233 was unable to see into the hallway. Similar observations were made on 04/19/2023 at 1:28 PM, 04/20/2023 8:29 AM, 04/21/2023 at 9:07 AM, and 04/24/2023 at 10:26 AM. In interviews on 04/20/2023 at 1:00 PM, Resident 233 stated they enjoyed activities. In an interview and observation on 04/21/2023 at 9:08 AM, Resident 233 was lying in bed, the room was dark, and they were looking out of the window through partially opened blinds to a garden area. The television was off. Resident 233 stated they used to be a gardener and spent most of their life outside. In an interview on 04/21/2023 at 8:52 AM, Staff V (Supervisor Activities Recreation) stated Resident 233 did not participate in activities. Staff V stated when they asked Resident 233 what they liked to do, the resident gave minimal responses. In an interview on 04/25/2023 at 10:58 AM, Staff V stated they needed to read up on cognitive impairment and the CP should be updated so Resident 233 could be prompted to join activities. <Resident 66> According to the 03/28/2023 Significant Change MDS, Resident 66 received hospice services. Resident 66's POs included a 03/13/2023 order for hospice services. Review of the closed record on 04/24/2023 did not show a Hospice Services CP. The data provided by the facility did demonstrate coordination of care was established by the facility and hospice care services. In an interview on 04/24/2023 at 1:08 PM, Staff C (Resident Care Manager/Interim Director of Nursing) stated the facility should have updated the CP to direct staff about hospice care. In an interview on 04/24/2023 at 4:58 PM, Staff M stated CPs should have measurable goals, be complete, accurate, and revised as needed. REFERENCE: WAC 388-97-1020(2)(c)(d). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Oxygen> <Resident 23> According to the 04/15/2023 nursing progress notes, Resident 23 had a change in condition and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Oxygen> <Resident 23> According to the 04/15/2023 nursing progress notes, Resident 23 had a change in condition and was diagnosed with a respiratory infection. Resident 23 had low blood oxygen levels and required supplemental oxygen. Observation on 04/18/2023 at 1:03 PM, Resident 23 was wearing oxygen set at two liters and was being delivered via nasal cannula. In an interview at this time, Resident 23 stated they were not feeling well and had been wearing oxygen since 04/15/2023. Record review on 04/18/2023 showed no POs instructing staff to administer oxygen or how many liters the resident required. In an interview on 04/24/2023 at 1:00 PM, Staff H (LPN) stated POs should be obtained within 24 hours of oxygen administration. In an interview on 04/24/2023 at 1:30 PM, Staff C stated the oxygen order should have been obtained and followed when the oxygen was applied. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). <Resident 234> Review of a 04/12/2023 Significant Change MDS showed Resident 234 was assessed to have multiple medically complex diagnoses including stroke, irregular heart rhythm, kidney disease, and difficulty expressing speech. This MDS did not indicate Resident 234 had a pacemaker. In an interview on 04/20/2023 at 8:40 AM, Resident 234 stated they had the pacemaker for about one year. Review of a 07/12/2022 Risk for pacemaker malfunction CP showed an intervention to check the pacemaker as ordered. Review of Resident 234's records showed no POs to monitor or check the pacemaker. There were no orders indicating Resident 234 had a pacemaker, what type of pacemaker, or directives to staff on what to do if the pacemaker malfunctioned. Review of a 10/06/2022 outside provider report showed Resident 234 had a pacemaker. Review of a 04/20/2023 Pocket Care Guide (a document providing facility staff directions for care) did not identify Resident 234 had a pacemaker. In an interview on 04/24/2023 at 2:28 PM, Staff C stated the facility did have checks for pacemakers and reported pacemakers were reviewed during quarterly care conferences. No documentation was provided by the facility. Staff C confirmed there should be POs for pacemakers. <Bed Siderails> <Resident 58> Record review showed Resident 58 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. According to the 03/13/2023 Significant Change MDS, Resident 58 had complex medical diagnoses including a stroke resulting in cognitive impairment, loss of function on the left arm and leg, and visual and spatial deficits that affected their function and ability to perform activities of daily living. On 04/18/2023 at 10:54 AM, Resident 58 was observed to have bilateral, half-length mobility bed rails attached to the bed. Resident 58 stated they were not sure of the device's purpose and use. Review of Resident 58's medical record showed a Resident Safety Assessment and Consent- Bed Siderails form completed and signed by Resident 58's representative on 10/06/2022. The form showed a reassessment was completed on 12/28/2022 during quarterly review and indicated appropriateness for continued siderail use. The form did not show a reassessment was completed upon Resident 58's return to the facility on [DATE]. In an interview on 04/21/2023 at 1:51 PM, Staff C stated the siderail reassessment was important to identify a resident's current ability and level of function and to determine whether bed siderails were safe to use due to their entrapment risks. Staff C stated a reassessment should have, but was not done for Resident 58 upon their facility return on 03/02/2023 after hospitalization. <Clarify/Follow Physician Orders> <Resident 1> According to the 03/03/2023 admission MDS, Resident 1 had diagnoses including diabetes (inability to control blood sugar levels), liver failure, kidney failure with dialysis (treatment to filter the blood to remove waste product and extra fluids from blood), high blood pressure, and depression. This assessment showed Resident 1 required the use of daily insulin (medication used to treat high blood sugar). Review of Resident 1's 02/27/2023 CP showed they were at risk for high blood sugar related to diabetes, high blood pressure, liver failure, and mood swings related to depression. This CP indicated Resident 1 was at risk for ineffective airway clearance related to chronic lung disease. The CP included interventions to administer medications as ordered by the physician. Resident 1's April 2023 Medication Administration Record (MAR) included an order instructing staff to administer insulin before each meal daily. According to the MAR, staff documented the 7:30 AM dose was held due to resident not in the facility on 04/03/2023, 04/05/2023, 04/07/2023, 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, and 04/19/2023. This MAR showed staff documented the 7:30 AM medications for high blood pressure, liver failure, kidney failure, chronic lung disease, and for depression were held related to Resident 1 being out of the facility on 04/03/2023, 04/05/2023, 04/07/2023, 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, and 04/19/2023. Review of April 2023 POs showed no orders or instructions to hold any medications on dialysis days. In an interview on 04/19/2023 at 2:19 PM, Resident 1 stated they were not receiving morning medications on dialysis days because they left the building at 5:00 AM and came back around 12:30 PM. In an interview on 04/20/2023 at 1:10 PM, Staff K (Licensed Practical Nurse - LPN) stated Resident 1 went to the dialysis center three times per week on Monday, Wednesday, and Friday. Staff K stated Resident 1 should receive medications including insulin on dialysis days as ordered. Staff K stated the facility staff should have clarified with the physician how to adjust the time for these medications on dialysis days, but they did not. In an interview on 04/20/2023 at 1:55 PM, Staff C stated the nursing staff should not hold the medications without POs. Staff C reviewed the MAR and confirmed the staff held the medications for Resident 1 on dialysis days without POs and stated the staff should have clarified the orders with the physician to adjust the administration times. <Resident 68> According to the 04/10/2022 admission MDS, Resident 68 had a diagnosis of diabetes and they received insulin every day. Review of Resident 68's 04/04/2023 POs showed staff were to administer 15 units of insulin at bedtime daily. Review of the April 2023 MAR showed Resident 68 received two units of insulin on 04/07/2023 and one unit on 04/12/2023. In an interview on 04/24/2023 at 10:19 AM, Staff C reviewed the April 2023 MAR and stated the medication was not given as ordered by the physician. Staff C stated the nursing staff should have followed the POs, but they did not. Further review of the April 2023 MAR showed Resident 68 received a diuretic medication (medication to increase the excretion of water from the body) every day for edema (excess fluid in the body causing swelling). There were no instructions about the location of edema or how to monitor the edema. Observations on 04/18/2023 at 10:16 AM, 04/19/2023 at 12:20 PM, 04/21/2023 at 2:26 PM, and on 04/24/2023 at 9:28 AM showed Resident 68 lying in bed wearing compression stockings to treat edema on their lower legs. In an interview on 04/24/2023 at 1:08 PM, Staff C stated they should have clarified the PO to include the location of the edema, and monitor the edema every shift. Based on observation, interview, and record review, the facility failed to ensure nursing services were provided within professional standards of nursing for 6 of 18 (Residents 31, 234, 1, 68, 58 & 23) sampled residents related to bed rails, pacemakers (a small device implanted in the chest to regulate heart rate), and the failure to follow or clarify Physician Orders (POs). Findings Included . <Pacemakers> <Resident 31> According to the 03/28/2023 Admissions Minimum Data Set (MDS - an assessment tool) Resident 31 readmitted to the facility on [DATE]. The MDS showed Resident 31 had diagnoses including atrial fibrilation (irregular/rapid heartbeat), heart failure, and high blood pressure. The MDS showed Resident 31 had a pacemaker. Review of the 02/13/2023 at risk for pacemaker malfunction Care Plan (CP) showed Resident 31 had a goal to maintain a heart rate between 60-100 beats per minute. The CP directed staff to check the pacemaker as ordered. Review of Resident 31's POs showed no orders were in place to check, monitor, or evaluate the functionality of the pacemaker. In an interview on 04/24/2023 at 2:28 PM Staff C (Resident Care Manager/Interim Director of Nursing) stated they would expect orders to check the functionality of a pacemaker to be in place for residents who had a pacemaker. Staff C reviewed Resident 31's CP and POs. Staff C stated there were no orders in place to check the pacemaker.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 23> Review of the 02/07/2023 Annual MDS showed Resident 23 was assessed with intact cognition. The MDS showed Re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 23> Review of the 02/07/2023 Annual MDS showed Resident 23 was assessed with intact cognition. The MDS showed Resident 23 was assessed to be at risk for skin injuries. Observation on 04/18/2023 at 1:11 PM showed Resident 23 had a dark discoloration on their right wrist and a wound to the back of the left hand. In an interview at that time, Resident 23 stated they had a bruise to their right wrist and a wound to the back of their right hand. Resident 23 could not describe how the wounds occurred. Review of the 04/18/2023 POs and CP showed Resident 23 did not have orders to treat or monitor the hand injuries. In an interview on 04/24/2023 at 1:00 PM, Staff H (LPN) and Staff J (LPN) stated skin alterations should be monitored and treated to prevent worsening conditions. In an interview on 04/24/2023 at 3:23 PM, Staff C stated staff should obtain orders to monitor and/or treat the skin conditions. Refer to F610 Investigate/prevent/correct Alleged Violation. REFERENCE: WAC 388-97-1060(1). <Skin Conditions> <Resident 234> Review of a 04/12/2023 Significant Change MDS showed Resident 234 was assessed to have multiple medically complex diagnoses including stroke, irregular heart rhythm, kidney disease, and difficulty expressing speech. In an observation on 04/18/2023 at 2:28 PM, Resident 234 was noted to have a band-aid to the back of their right hand. Similar observations were made on 04/19/2023 and 04/20/2023. An observation on 04/21/2023 at 10:33 AM, showed the back of Resident 234's right hand with an approximately one-inch-long skin tear. The skin was held together with two small adhesive strips used to hold torn skin together. A similar observation was made on 04/24/2023 at 10:22 AM. Record review showed a 04/18/2023 late entry for a 04/17/2023 progress note. The progress note showed a nurse identified a small skin tear on right hand . [medicated skin moisturizer] applied and band aid. The progress note did not indicate how the skin tear occurred, if the physician was notified, or if orders were obtained/implemented to treat the skin tear. Review of Resident 234's POs showed no orders were in place to monitor or treat the skin tear. Review of a 04/21/2023 facility skin check tracking form showed the skin tear was not identified, assessed, or monitored. Record review showed Resident 234 received another skin check on 04/24/2023 completed by Staff K (Licensed Practical Nurse - LPN). This skin check did not identify the skin tear to Resident 234's right hand. In an interview on 04/24/2023 at 1:13 PM, Staff K confirmed they completed the skin check earlier that day for Resident 234. Staff K stated they did not notice the skin tear to Resident 234's hand. At that time, Staff K confirmed there was a skin tear on Resident 234's hand and they missed it during the skin check earlier in the day. In an interview on 04/24/2023 at 3:23 PM, Staff M (Long Term Care Manager, Registered Nurse) stated it was their expectation orders to treat and monitor any newly identified skin impairment were implemented once identified. Based on observation, interview, and record review the facility failed to: implement post-surgical interventions for 1 of 5 (Resident 31) residents reviewed for positioning; treat non-pressure skin in accordance with professional standards and Physicians' Orders (POs) for 2 of 5 (Resident 234 & 23) residents reviewed for non-pressure skin. These failures left residents at risk for avoidable skin issues, discomfort, and pain. Findings included . <Resident 31> According to the 03/28/2023 admission Minimum Data Set (MDS - an assessment tool) Resident 31 readmitted to the facility on [DATE] and was assessed with intact cognition. The MDS showed Resident 31 had diagnoses including an infection of an artificial joint, arthritis, and weakness. The MDS showed Resident 31 did not refuse care. According to a 03/22/2023 progress note, Resident 31 admitted to the facility for treatment of an infection of their left shoulder artifical joint. According to the 03/21/2023 hospital discharge instructions, Resident 31 needed to wear a sling for at least 4 weeks when not doing Physical Therapy [PT] exercises. The discharge instructions indicated Resident 31 needed a pillow positioned under their elbow and hand when resting in bed or their wheelchair. Resident 31's comprehensive Care Plan (CP) included a 02/17/2023 at risk for pain related to surgical procedure . CP that directed staff to give medications as ordered and to monitor for pain and report to the physician if the resident's pain was not relieved in one hour. This CP did not include interventions to use a sling on the left shoulder when not in PT or position a pillow under Resident 31's elbow and hand while in bed or their wheelchair. Review of the 03/21/2023 Baseline CP included an Equipment section that showed Resident 31 used a cane for ambulation (walking with or without assistance). The Baseline CP did not identify Resident 31 required a sling or pillow for positioning. Observations on 04/19/2023 at 8:49 AM and 1:29 PM showed Resident 31 seated in their wheelchair, with no sling on their left arm, and no pillow for positioning. Resident 31 was observed without a sling or pillow on 04/21/2023 at 11:59 AM, and on 04/24/2023 at 9:37 AM and 2:54 PM. In an interview on 04/24/2023 at 4:12 PM, Staff C (Resident Care Manager/Interim Director of Nursing) stated Resident 31 had an order for a sling that was discontinued. Staff C stated Resident 31 could still use the sling for comfort. In an interview on 04/25/2023 at 10:51 AM, Staff C stated the hospital discharge instructions showed Resident 31 required the sling and pillow for comfort, but the facility did not obtain orders for them upon readmission. Staff C stated another nurse missed the bottom part of the form. Staff C stated the failure to obtain orders for the sling and implement the recommendations for the sling and pillow placed Resident 31 at risk for pain. When asked for documentation showing Resident 31 was assessed to no longer require a sling, Staff C stated they would look into it. No further documentation was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure residents with urinary incontinence received the appropriate treatment and services for 2 of 3 (Residents 23 & 67) residents reviewed for urinary incontinence. Failure to provide treatment and services related to incontinence care placed residents at risk for Urinary Tract Infections (UTIs), continued decline in urinary function with potential loss of bladder control, and skin issues. Findings included . <Facility Policy> Review of the 2023 facility policy Promoting Residents' Urinary Health Status showed, the facility was to implement a prompted voiding trial once the resident was identified as incontinent [loss of bladder control]. If the resident was excluded from a prompted voiding [urinating] trial, then alternative care planning approaches were implemented. Alternatives included: bladder retraining, pelvic floor muscle rehabilitation, intermittent catheterization [a process that uses tubing to drain urine from the bladder], medication therapy, or urine containment devices. <Resident 23> According to the 02/07/2023 Annual Minimum Data Set (MDS - an assessment tool), Resident 23 required one person supervision for toileting assistance. The MDS showed Resident 23 was cognitively intact, able to make themself understood and were able to understand others. The MDS showed Resident 23 was frequently incontinent of bladder. Record review showed no instructions for staff to implement a trial toileting program (implementation of interventions to prevent incontinence). According to the facility's 04/17/2023 Pocket Care Guide (PCG - a document providing facility staff directions for care), there was no guidance to staff on interventions to prevent or anticipate Resident 23's incontinence. In an interview on 4/18/2023 at 1:08 PM, Resident 23 stated they didn't have the strength to take themselves to the bathroom independently. In an interview on 04/24/2023 at 1:00 PM, Staff H (Licensed Practical Nurse - LPN) was unable to provide any information on Resident 23's toileting needs. <Resident 67> According to the 03/30/2023 admission MDS, Resident 67 was assessed as dependent on staff and required assistance with their toileting needs. The MDS showed Resident 67 was cognitively intact, able to make themself understood and were able to understand others. The MDS showed Resident 67 was always incontinent of bladder. Record review showed no instructions for staff to implement a trial toileting program. According to the facility's 04/17/2023 PCG, Resident 67 required total assistance for toileting from staff. The PCG did not provide directions to staff on Resident 67's toileting interventions to prevent or anticipate incontinence. In an interview on 04/18/2023 at 1:54 PM, Resident 67 stated staff would provide incontinence care when they had time. Resident 67 stated staff were not providing incontinence care every two to three hours. In an interview on 04/24/2023 at 11:28 AM, Staff S (Certified Nursing Assistant - CNA) and Staff X (CNA) stated they relied on and frequently referenced the PCG to provide instructions on delivering care and services. Staff S (CNA) stated lack of proper incontinence care could lead to UTI's and skin problems. In an interview on 04/24/2023 at 1:10 PM, Staff J (LPN) could not provide any information on Resident 67's toileting needs. REFERENCE: WAC 388-97-1060(3)(c). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 1of 2 nurses (Staff I) to properly administer 3 of 26 medications for 3 of 7 residents (Resident 46, 32,& 64) observed during medication pass resulted in a medication error rate of 11.11%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Resident 46> Observation of medication pass on 04/24/2023 at 9:30 AM showed Staff I (Licensed Practical Nurse) prepare and administer multiple medications to Resident 46, including two tablets of medication intended for constipation. Review of Resident 46's Physicians' Orders (PO) showed staff were to administer one tablet for constipation. The April Medication Administration Record (MAR) showed staff were to administer one tablet twice daily. <Resident 32> Observation of medication pass on 04/24/2023 at 9:40 AM showed Staff I prepare and administer multiple medications to Resident 32. The prepared medications did not include a dietary supplement. Review of Resident 32's PO on 04/24/2023 showed staff were to administer one dietary supplement. The April [DATE] showed staff were to administer one dietary supplement once daily. <Resident 64> Observation of medication pass on 04/24/2023 at 9:50 AM showed Staff I prepare and administer multiple medications to Resident 64, including a non-narcotic pain patch to Resident 64's left shoulder. Review of Resident 64's PO's on 04/24/2023 showed staff were to administer one non-narcotic pain patch to each shoulder. The April [DATE] showed staff were to administer one non-narcotic pain patch to each shoulder once daily. Observation on 04/24/2023 at 9:57 AM showed Staff I applied a non-narcotic pain patch to Resident 64's middle upper back, not a shoulder. Resident 64 stated at that time, What are you doing? They [staff] don't put the patch there. Staff I asked the resident where the patch usually goes, and Resident 64 tapped their left shoulder and said, my shoulders. Staff I then removed the patch from the back and placed the same non-narcotic pain patch to Resident 64's left shoulder then exited the room. In an interview at this time, Resident 64 stated, I generally have two[patches], one on each shoulder. A non-narcotic pain patch was not applied to the right shoulder. In an interview on 04/24/2023 at 4:50 PM, Staff I stated they did not administer the medications as prescribed for Residents 46, 32, and 64, and the risk of not providing medications as prescribed could result in unmet resident needs. REFERENCE: WAC 388-97-1060(3)(k)(ii). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain the commercial cooking equipment for 1 of 1 facility kitchens in a safe operating condition. The failure to conduct maintenance and cleaning of the stove hood per manufacturer's recommendations had the potential to result in fire in the hood due to excessive grease build up which could endanger the residents, staff and/or visitors within the facility. Review of a revised 04/2023 facility Equipment Maintenance policy showed the facility was to properly maintain all equipment to ensure the safety of residents, caregivers, and visitors. This policy showed the Director of Maintenance would oversee the implementation of this policy and maintain records for each piece of equipment, including maintenance schedules, inspections, repairs, and cleaning. During initial kitchen observations on [DATE] at 9:18 AM, a label was observed on the stove hood indicating the last service date was on [DATE]. The label was marked that it would expire six months after the date of service. In an interview at this time, Staff AA (Sous Chef) stated, I noticed it expired a couple months ago, they just forgot to put on a new label. Information was requested for any maintenance records supporting the hood was serviced. On [DATE] at 10:06 AM, when asked for the hood cleaning documentation again, Staff AA stated they were not sure when the hood was actually serviced last. Staff AA provided documentation that showed Staff Z (Manager Facilities) called the hood service company on [DATE] to schedule a hood cleaning service. Review of an undated facility manufacturer's recommendations and a [DATE] work order provided by the facility, showed the hood should have preventative maintenance every six months, and showed it was last cleaned and inspected on [DATE] (over ten months earlier). In an interview on [DATE] at 10:26 AM, Staff Z stated they were in charge of the kitchen cooking equipment maintenance and indicated they used to have the hood cleaned every three months but the service company was changed and they did not notify the facility to set up a schedule. Staff Z stated having the hood cleaned and inspected was important to reduce grease build up and prevent a fire hazard. Staff Z stated the hood should have been, but was not, cleaned and inspected per manufacturer's recommendations, and before the expiration date. REFERENCE: WAC 388-97-2100. .

Sept 2021 37 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services in a dignified manner for one (Resident 45) of 2 residents reviewed for dignity. Facility staffs' failure to communicate to Resident 45 that their Restorative program would not be provided as scheduled and subsequent failure to follow up on the resident's multiple inquiries about the status of her program, resulted in the Resident 45 feeling unimportant and unvalued. Findings included . Resident 45 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly Minimum Data Set (MDS), the resident was cognitively intact, required extensive assistance with most activities of daily living, and received Physical Therapy on five of the seven days during the assessment period. During an interview on 09/08/2021 at 10:56 AM, Resident 45 expressed staff did not always treat them with respect and dignity, explaining that she needed to be able to stand and take steps to discharge from the facility, but had struggled to reach this goal, due to a fear of standing and lower extremity weakness. Resident 45 stated, Staff W, [Physical Therapy Assistant, PTA who performs restorative programs when not working as a PTA], put me on a one on one [Restorative program] and said we would start Monday, Labor day [09/06/2021] . I waited and waited but no one showed up. Yesterday [Tuesday, 09/07/2021] I asked the nurse why [Staff W] didn't come but [the nurse] just said 'I don't know.' Resident 45 indicated she still hadn't received restorative and no one had come to talk to her about yet. According to 09/07/2021 Restorative schedule, Resident 45 was to receive their Restorative programs on Mondays and Wednesdays. In an interview on 09/10/2021 at 9:03 AM, Resident 45 appeared frustrated and shared that staff still had not provided the Restorative program or contacted Staff W to find out what's going on. Resident 45 indicated they asked multiple staff [over four days] if Staff W was at work, but staff told the resident they didn't know, because Staff W was on a different schedule [Therapy's schedule vs Nursing's schedule]. Resident 45 expressed staffs' failure to show up when scheduled, and to inform them what was going on when they inquired, made them feel Unimportant stating, Sometimes I want to cry . They want [residents] to be ready when it's time [to do Restorative], so we wait for them, and then [for them] to not show up .we are just waiting and waiting, and we have no control over it. In an interview on 09/15/21/ 12:21 PM, Staff W acknowledged that Resident 45 was told their Restorative program would start on Monday (Labor Day, 09/06/2021), but was called by the facility and told not to come in to work on Monday. In an interview on 09/15/21/ 01:10 PM, Staff N, (Director of Rehabilitation Services), confirmed Staff W was called off on 09/06/2021. When informed Resident 45 was upset and felt unimportant when no showed up or informed her Staff N stated, That totally makes sense, it should have been communicated. REFERENCE: WAC: 388-97-0180(1-4) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide accurate Advanced Beneficiary Notices (ABN: a notification provided that lists services that Medicare isn't expected to pay for, along with the estimated costs of the services, so residents/beneficiaries can decide if they wish to continue receiving the services and assume financial responsibility) for two (Resident 30 & 45) of three resident's reviewed for liability notices. The facility's failure to provide an estimated cost of continuing services, detracted from the residents' ability to make informed financial and care decisions. Findings included . Resident 30 Resident 30 re-admitted to the facility on [DATE]. According to the 05/29/2021 Significant Change Minimum Data Set (MDS, an assessment tool), the resident had medically complex conditions and received Speech Therapy (ST), Occupational Therapy (OT), Physical Therapy (PT). Record review showed Resident 30 was issued a Notification of Medicare Non-Coverage (NOMNC) on 06/21/2021 with a last covered day (LCD) of 06/23/2021, and remained in the the facility. An ABN issued 06/21/2021 stated the Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Under Care the facility listed Skilled nursing care. Under Reason Medicare May Not Pay the facility documented You are at your functional baseline and daily therapy has been discontinued. Per medical team, you no longer require daily skilled care. The specific services that would likely not be covered were not identified. Under Estimated Cost the facility documented Participation as determined by DSHS [Department of Social and Health Services]. Resident 30 was not provided an estimated cost of continuing the skilled services, at his own cost, if he chose to do so. Resident 45 Resident 45 admitted to the facility on [DATE]. According to the 05/21/2021 admission MDS, the resident was receiving aftercare for fractures and other multiple trauma, and received ST, OT, and PT services. Record review showed Resident 45 was issued a Notification of Medicare Non-Coverage (NOMNC) on 07/30/2021 with a last covered day (LCD) of 08/01/2021, and remained in the the facility. An ABN issued 07/30/2021 stated the Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Under Care the facility listed Skilled nursing care. Under Reason Medicare May Not Pay the facility documented You are medically stable and do not require daily skilled nursing care. Per the therapy team, you are unable to progress functionally at this time and are not benefiting from daily therapy. Under Estimated Cost the facility documented Daily rate is $394 in extended care. Resident 45 was not provided an estimated cost of continuing the services, if she chose to do so. In an interview on 09/16/2021 at 9:11 AM, when asked why an estimated cost for continuing the services was not provided to Resident 30 & 45 Staff H, (Social Service Manager), indicated she did not know the estimated cost referred to the cost of continuing the services listed on the ABN. REFERENCE: WAC 388-97-0300(1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely initiate and/or thoroughly investigate unwitnessed falls and an injuries of unknown origin for two (Residents 21 and 47) of 12 residents reviewed for incidents and accidents. These failures placed the residents at risk for unidentified abuse/ neglect and recurrent falls and injury. Findings included . According to the facility's 03/2021 Fall Prevention Plan patients identified as high fall risks will have interventions developed and implemented to minimize patient falls and injury. Post fall, nursing will conduct a fall investigation by talking with the patient, caregiver(s) and/or relevant staff about the nature of the fall and injuries. The root cause will be determined, and interventions developed, and care planned. Resident 21 According to a 07/06/2021 Morse Fall Scale assessment, Resident 21 was assessed to be at high risk for falls. Resident 21's 06/04/2016 High Risk for Falls Care Plan stated that Resident 21 is at high risk for falls. According to the 07/21/2021 progress note, at 09:34 AM on 07/21/2021, Resident 21 had an unwitnessed non-injury fall while trying to transfer from the toilet. Resident 21 misjudged the distance between the toilet and their wheelchair and fell slowly to he floor. Resident 21 was discovered by Staff Y, Certified Nursing Assistant, who reported the fall to Staff Z, RN, who assessed Resident 21 for injury and safety. Review of 07/26/2021 fall investigation revealed the facility did not identify or implement any new interventions to prevent recurrence. Review of Resident 21's High Risk for Falls Care Plan showed the most recent intervention added was for frequent rounding (frequent staff observation) on 03/18/2021. On 09/15/21 at 12:23 PM in an interview, Staff B, Director of Nursing stated that the facility tried to balance considerations for Resident 21's safety with honoring Resident 21's rights, and stated that new interventions were not implemented after the 07/21/2021 fall. Resident 47 According to an MDS dated [DATE] showed Resident 47 required one-person extensive assistance with mobility and used a wheelchair. A skin assessment completed on 09/01/2021 showed a new skin injury on Resident 47's left foot. A blister was identified and described as 2.0 x 2.0 cm on the side of left foot from rubbing the foot on the footrest. An observation during wound care on 09/12/2021 at 11:16 AM showed Resident 47 had a new skin tear on the left knee. Staff FF (Licensed Practical Nurse) stated the injury was found on 09/11/2021 and described the skin tear: the top layer of skin was rolled to the side of the open area, skin was blanchable and measured 1.5 x 1.0 cm. Review of Incident accident log 09/15/2021 showed no entry logged for Resident 47 blister on 09/01/2021 or skin tear on 09/11/2021. In an interview on 09/15/2021 at 1:37 PM Staff D (Resident Care Manager) stated all blisters and skin tear injuries are expected to be investigated and logged. Staff D confirmed that the investigation was not completed for the skin tear from 9/11/2021 or the blister from 09/01/2021. REFERENCE: WAC 388-97-0640 (6)(a)(b). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a system that at the time of a resident's transfer to the hospital or for therapeutic leave, provided the resident and/or the residents representative with written notice which specified information regarding the bed hold policy for 1 (62) of 2 residents reviewed for unplanned discharges. This failure prevented the resident or the residents representative from making an informed decision about a bed hold or an opportunity to pay out of pocket for a bed hold. Findings included . Facility Policy Review of the 07/2020 Bed Hold and Return Policy showed that each resident will have the opportunity to reserve their bed upon transfer to the hospital. Staff will contact the resident or residents representative within 3 days after an emergency discharge to the hospital, to discuss the bed hold option and to provide a copy of the bed hold policy. The resident or responsible party will be given 48 hours to respond. Resident 62 Review of the 08/25/2021 Quarterly Minimum Data Set showed the, resident was cognitively intact and able to understand and be understood. Review of the 08/24/2021 residents record of admission showed they were their own responsible party and able to make decisions for themselves. Review of Resident 62's clinical record showed, a nursing note on 09/05/2021 at 4:26 PM that showed the resident had an abnormal blood pressure and heart rate, and complained of chest pain. The note included Resident 62's condition did not improve and they continued to complain of chest pain. The provider was contacted and ordered the resident sent to the emergency room for evaluation. In an interview on 09/16/2021 at 11:22 AM Staff D (Clinical Manager) stated that the resident was able to tell staff they wanted to go to the hospital. In an interview on 09/20/2021 at 12:49 PM Staff B (Director of Nursing) stated the resident was their own responsible party. In an interview on 09/21/2021 at 11:55 AM Staff HH (Admissions Manger) stated the resident was not asked about bed hold because one of the reasons for the hospital transfer was an acute change in condition and mentation. The resident did not have a Power of Attorney (POA) but was in enrolled in a special benefits program, so the manager of the program was contacted and on day four after the resident discharged to the hospital, responded and chose not to financially hold the residents bed, so the bed was released. So the resident was not approached with the opportunity to make an informed decision about a bed hold. The resident re-admitted on [DATE] to another room. During an interview on 09/21/2021 at 4:30 PM Staff HH was asked if the program manager has decision rights for the resident and they replied, I can't assume that. The resident was not capable of making decisions since their hospital stay and the benefits program pays for their bed. When asked what they would do for a resident who is not enrolled in the special program, Staff HH replied we ask staff if they are able to make the decision at the time or call family or residents responsible party, if they have one. Review of Resident 62's facesheet showed three family members listed as emergency contacts and next of kin. In an interview on 09/21/2021 at 4:30 PM Staff A (Administrator) stated the facility normally does not provide the resident written bed hold information upon transfer, it is provided upon admission to the facility. Resident 62 was not asked because of their change in condition and mentation. WAC REFERENCE: 388-97-0120(4).

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**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- a screening process to prevent individuals with mental illness, intellectual disability or related conditions from being inappropriately placed in a Nursing Facility) assessments were accurately completed prior to or upon admission to the facility, for 2 (Residents 24 & 34) of 5 residents reviewed for PASRRs. This failure had the potential to place residents at risk for inappropriate placement and/ or not receiving timely and necessary services to meet their mental health care needs. Findings included . Review of the facility's revised 09/2021 PASRR policy showed the facility was to ensure the receipt of a complete and accurate PASRR for admission from the referring hospital. The policy also indicated the social service staff was responsible for screening the form for accuracy and update for changes as necessary, and referring residents who have qualifying diagnosis. Resident 24 According to the admission Minimum Data Set (MDS- an assessment tool) dated 04/14/2021 the Resident 24 admitted to the facility on [DATE] and had a diagnosis of depression and anxiety and required the use of antipsychotic and antidepressant medications on each day of the assessment period. Review of the 04/07/2021 Level I PASRR, showed Resident 24 was assessed with no mental disorders, including depression or anxiety, and was marked that no Level II evaluation was indicated. It was not until 09/10/2021, a full five months later, after surveyors requested Resident 24's records, that staff completed a revised Level I PASRR. The new PASRR dated 09/10/2021 indicated Resident 24 had serious mental illness indicators and requested a Level II evaluation referral. In an interview on 9/16/21 at 8:15 AM, Staff H (Social Service Manager) stated the admission PASRR dated 04/07/2021 was incorrect. Resident 34 According to the 12/25/2021 Significant Change MDS, Resident 34 admitted to the facility on [DATE] and received antianxiety medications on each day of the assessment period. The 03/17/2021 Quarterly MDS showed the resident utilized antidepressant medications, but no antianxiety medications. The 06/13/2021 and 07/27/2021 Significant Change MDSs showed the resident received both antidepressant and antianxiety medications. Record review revealed 08/03/2018 admission physician orders (PO) included Trazadone (an anti-depressant). A Consent for Psychoactive Medications dated 08/03/2018 was reviewed and showed Resident 34 consented to Trazadone on 08/03/2018. A PASRR dated 08/03/2018 indicated Resident 34 had no serious mental illness and no diagnosis of depression or anxiety. The PASRR was updated on 08/10/2018 to include Resident 34 had a mood disorder, indicating depression. Review of clinical record indicated the 08/10/2018 PASRR was not updated to reflect the resident mental health diagnoses. During an interview on 09/16/2021 at 9:11 AM Staff Q (Social Services) stated that depression was on the PASRR, but anxiety was not and that it should be. Staff Q confirmed Resident 34 had a diagnosis of anxiety. REFERENCE: WAC 388-97-1915(1)(2)(a-c)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 19) reviewed for activities received meaningful activities, which incorporated the resident's interests and religious preferences to maintain or improve the residents' physical, mental and psychosocial well-being. This failure placed Resident 19 at risk for a diminished quality of life. Findings Included . According to the 07/04/2021 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 19 was admitted to the facility on [DATE] with a diagnosis of a subdural hematoma (brain bleed) from a traumatic head injury. The MDS assessed Resident 19 to be cognitively intact with clear speech, able to understand others, and make needs known. The MDS stated that activities were very important to the resident, and identified preferences for activities including going outside for fresh air, participating in religious services, news, music, and pets. Review of the 07/13/2021 Activity Assessment showed Resident 19's activity preferences included music, religion and being outdoors. According to a handwritten copy of Resident 19's 07/13/2021 care plan, Resident 19 liked old westerns on TV, church music on CDs. The care plan also showed Resident 19 needed a pocket talker to assist with communication. Daily observations each morning and afternoon for nine days between 09/07/2021 and 09/15/2021 showed Resident 19 was in bed watching TV. Resident 19 was not observed to use either a pocket talker and no CD player was observed in the resident's room. Observations of the resident's room showed no daily activity calendar was provided. Observation on 09/10/2021 at 08:25 AM showed Staff K doing rounds passing out the daily calendar; Resident 19 did not receive one. In an interview on 09/07/2021 at 10:35 AM, Resident 19 stated they did not get out of bed anymore and did not have anything to do except watch TV. Resident 19 stated they received family visitors every other week and enjoyed the visits a lot. In an interview on 09/10/2021 at 9:00 AM, Staff K (Activity Director) confirmed Resident 19 did not get a daily activity calendar because the resident once stated they did not want one. Staff K stated Resident 19 did not have an admission activity assessment when admitted in April 2021, so it was completed in July 2021 with the quarterly assessment. According to the Activities History Report reviewed on 09/10/2021 at 11:18 AM, the last time Resident 19 was provided with the daily calendar was 08/31/2021, and Resident 19 received them irregularly prior to that date. In an interview on 09/10/2021 at 9:00 AM Staff K confirmed Resident 19's preference for activities was not communicated to the care staff. Staff K confirmed the Resident 19 did not have a CD player or a pocket talker in the room. Staff K further stated Resident 19 does not attend activities and TV is good for him. REFERENCE: WAC 388-97-0940(1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities for 2 (Residents 24 & 19) of 2 residents reviewed for vision/hearing services. Failure to ensure Resident 24 received assistance in obtaining vision services placed this resident at risk for decline in Activities of Daily Living (ADLs). Failure to ensure Resident 19 received assistance with hearing placed this resident at risk for not having needs met and decreased quality of life. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 04/14/2021 admission Minimum Data Set (MDS, an assessment tool) was assessed with moderately impaired vision. According to the Care Area assessment dated [DATE] the resident was identified with, .impaired vision. [They] not able to read the newspaper. According to a Nursing admission assessment dated [DATE], staff assessed the resident was blind in the right eye and had Glaucoma (a disease which impacts vision). In an interview on 09/07/2021 at 1:10 PM, Resident 24 stated, My right eye is blind and indicated they had vision problems with the left eye stating, My vision is so bad on that I can hardly see the TV. I can only partly see TV well enough to see if there is a person on the screen .it's been two or three years since last appointment with an eye doctor. Provider notes dated 04/21/2021 showed an identified problem of Visual impairment .will d/w [discuss with] nurse case manager and MSW [Marionwood Social Worker] accommodations for low vision, may need to wait given [Resident 24] is not in [their] permanent room yet. Consider optometry visit - will see if [Eye Doctor] visits [Providence Marionwood]. While subsequent provider notes (07/23/2021) showed problems of vision impairment there was no further mention of referral for vision services. In an interview on 09/10/2021 at 10:22 AM, Staff AA (Health Information Manager) stated there was no indication in the record the resident was referred to or seen by ophthalmology (vision). In an interview on 09/11/2021 at 11:59 AM, Staff C (Clinical Manager) was asked to provide any documentation to support Resident 24 was referred for or received vision services. Record review showed a 09/12/2021 provider referral for Optometry related to low vision that was not arranged until the need was identified by a surveyor in the 09/11/2021 interview. In an interview on 09/16/2021 at 8:20 AM, Staff AA confirmed there were no other referrals to vision besides the 09/12/2021 provider note. In an interview on 09/16/2021 at 8:18 AM, Staff C indicated that she thought there was a previous referral for vision services. In an interview on 09/16/2021 at 8:22 Staff C indicated Resident 24 had glaucoma (a disease impacting vision) and impaired vision but had no changes since admission. Staff C indicated the resident had the same issues currently as on admission and was unable to explain why the resident wasn't previously referred for the identified vision issues. Resident 19 Resident 19 was assessed to have difficulty hearing and needed a hearing device per the quarterly MDS completed on 07/04/2021. During an interview on 09/07/2021 at 10:34 AM, Resident 19 was unable to hear a clear, loud voice with repeated statements and said I cannot hear you. I have nothing to say for this interview because I can't hear. When asked if he had hearing aids or other hearing devices, Resident stated No. The care plan dated 04/05/2021 showed Resident 19 used hearing aids or a pocket talker (hearing device) to communicate with staff and have daily needs met. The care plan also directed staff to use communication tools such as a communication board, sign language and written communication. Upon daily observations of resident room [ROOM NUMBER]/07/2021 thru 09/15/2021 there was no hearing devices or communication tools available for staff to communicate with Resident 19. In an interview on 09/16/2021 at 10:16 AM, Staff Q (Social Services) acknowledged Resident 19 had hearing loss and needed to use a pocket talker, stating that one is used when Staff Q communicated, but Staff Q confirmed that care staff had not used a pocket talker with Resident 19. REFERENCE: WAC 388-97-1060(3)(a). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide ongoing assessment and monitoring of identified pressure ulcers (PU), and failed to ensure interventions such as specialty wheelchair cushions and mattresses were checked for appropriate inflation and/or function, in accordance with manufacturer's guidelines for 1 (Resident 22) of 5 sample residents, and 1 (Resident 3) supplemental resident reviewed for PUs. These failures placed the residents at risk for unidentified wound decline, a delay in treatment, and potential negative outcomes. Findings included . Resident 3 Resident 3 admitted to the facility on [DATE]. According to the 06/08/2021 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had diagnoses of heart failure, heart disease and mal-nutrition, required extensive assistance with most Activities of Daily Living (ADLs), was at risk for PU development, but did not have any PU. A 08/30/2021 [Resident 3] has a DTI [deep tissue injury] on his right heel care plan, direct staff to turn and reposition the resident every 2-3 hours, apply Prevalon heel lift boots, and observe for changes in pressure ulcer, report to MD if there is an increase in size or stage. According to the 08/30/2021 Event . investigation Resident 3 was assessed with a 3.8 centimeter (cm) x 2.5 cm deep purple non-blanchable area (DTI) to the right medial heel. An order was obtained to cleanse the area with normal saline (NS), pat dry and apply betadine. Resident education was provided about the importance of wearing the Prevalon heel lift boots, to offload the heels Observations on 09/08/21 at 12:03 PM, 09/10/2021 at 11:54 PM and 09/11/21 at 09:00 AM, showed Resident 3 lying in bed on an alternating low air loss (LAL) mattress with a comfort setting of 6, and 10 minute cycles. Prevalon (heel lift) boots were in place to both feet. Staff were observed to periodically assist Resident 3 with with turning and repositioning, resident able to utilize bed control independently to raise and lower head of bed (HOB). Record review on 09/15/2021 revealed a 09/07/2021 weekly Skin Assessment Note, SAN. Review of the SAN showed that it asked if the resident had any skin issues, and if there was any new skin issues. The form then directed staff to document current state of ONGOING skin issue and any treatments being provided. For Resident 3's right heel DTI staff documented ongoing wound care, betadine applied and le[f]t open. The assessment did not include an assessment of the wound characteristics such as length, width, depth, color, tissue type, presence/absence of drainage, pain, periwound (skin tissue around the wound) characteristics, to what stage the PU had developed (e.g. still a DTI). Additionally, no SAN was found for 09/14/2021. Thus, there was no indication facility staff measured or assessed Resident 3's DTI since 08/30/2021, the day it was identified. In an interview on 09/15/2021 at 2:47 PM, when asked if there was documentation to support the facility performed weekly wound assessments Staff D indicated they needed time to look. During an interview on 09/16/2021 at 8:17 AM, Staff D expressed they were unable to find wound assessments for Resident 3 for the past two weeks. Resident 22 Resident 22 admitted to the facility on [DATE]. According to the 07/07/2021 Quarterly MDS, the resident was moderately cognitively impaired, had diagnoses of Multiple Sclerosis (progressive neurological condition) and paraplegia (paralysis of the legs and lower body), was dependent on staff for bed mobility, transfers, and toileting, had a stage IV PU (full thickness tissue loss, with exposed bone, tendon or muscle), and had pressure reducing devices for the bed and wheelchair. Review of Resident 22's 04/14/2021 Pressure Ulcer showed the resident was on a specialty air bed, and staff were directed to leave the bed in the low position, and assist with turning/ positioning every two to three hours. Staff were also directed to frequently check the resident colostomy. Review of the August and September 2021 Treatment administration record (TAR) showed nurses were to check the resident's Envella air fluidized therapy bed every shift for function, sand movement, and soiling. After reviewing the resident's record no weekly wound assessments were located. In an interview on 09/10/2021 at 12:07 PM, Staff D stated that the resident was followed by wound care, and they didn't leave the assessments at the facility the day of the assessment, but would send them over later. On 09/14/2021 at 11:33 PM, Staff AA, (Health Information Director) delivered Resident 22's wound care notes. Review of what was provided for August and September 2021 revealed the wound notes for 08/12/2021, 08/19/2021 and 09/09/2021 were not present. (three of the six wound notes from 08/01/2021 to 09/14/2021 were missing.) When queried about the missing assessments Staff AA stated, I texted her (wound care) let's see. Confirming the facility did not have and staff did not have access to the assessments. In an interview on 09/14/2021 at 11:38 AM, Staff B, (Director of Nursing), acknowledged that facility staff not having access to Resident 22's wound assessments, detracted from their ability to determine if the wound had changed (e.g. declining tissue type, change in exudate, increasing in size etc.), thus affecting the nurses ability to decide if the medical doctor (MD) needs to be notified of a change as instructed in the care planned. Additionally, observations on 09/07/21 at 10:30 AM, 09/08/21 at 10:14 AM, 09/10/2021 at 12:03 PM, 09/11/10/21 at 08:49 AM, 09/11/2021 at 11:09 AM, 09/13/21 at 09:49 AM, 09/13/21 at 11:53 AM, and 09/15/2021 at 10:06 AM, Resident 22 was observed lying in his Envella bed. Observation of the control panel on each occasion showed that the Bed not Down light was flashing and the wrench under transfer mode was also lit up. Observation of the display screen at the foot of the bed showed the following error message 0xA Air filter pressure over limit System error- temperature sensor error. Please contact Hill Rom Technical support for assistance. On 9/15/21 10:21 AM, Staff Z, (Registered Nurse), upon request went to Resident 22's room to check the bed for function, as she was one of the nurses that had been signing off that the bed was functioning appropriately. Staff Z entered the room and looked at the right side of the bed (side facing the door) and indicated that the lights were on (on the side control panel) and read the digital number 23, which represented the degrees the head of bed was elevated. Staff Z required cueing to look at the control panel and display screen at the foot of the bed. Staff Z indicated she was unaware that there was a display screen. Staff Z then Identified the error message and left to contact HillRom technical support, who subsequently came out to repair the bed. REFERENCE WAC: 388-97-1060(3)(b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services were provided to preserve range of motion (ROM) for 2 of (Residents 19 & 24) of 8 residents reviewed for limited ROM. This failure placed the residents at risk for decreased function and quality of life. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 04/14/2021 admission and 07/07/2021 Quarterly Minimum Data Sets (MDS, an assessment tool), was cognitively impaired, required extensive two-person assistance with most Activities of Daily living, and had bilateral lower extremity functional limitation of Range of Motion (ROM). According to this assessment, the resident did not receive any Physical or Occupational Therapy and did not receive any restorative program for range of motion. Observations on 09/07/21 at 1:17 PM showed Resident 24 was able to move their bed sheets to cover their feet utilizing their feet, but stated they couldn't really move their lower legs otherwise. Record review showed no indication Resident 24 was evaluated for interventions to either assess the extent of lower extremity limitations in range of motion, or considered interventions to prevent further decline of the identified functional range of motion limitations. In an interview on 09/16/2021 at 9:15 AM, Staff N (Director of Rehabilitation Services) was asked to review the record to determine if the resident received evaluations regarding ROM. While Staff N was able to provide documents that Speech Therapy took place in April 2021, no information regarding ROM assessments were available. Staff N subsequently provided progress notes dated 04/09/2021 which indicated the resident was offered Physical Therapy (PT) and declined PT or bed mobility tasks .quite sleepy and reports she isn't feeling well . There was no indication facility staff attempted to determine why the resident declined this service, re-offered the service, or attempted interventions to prevent further decline of the limited ROM identified in the MDS. According to fax time stamps dated 09/16/2021 at 12:19 PM, Staff N was able to obtain an Occupational Therapy Assessment which addressed the resident's environment and Durable Medical Equipment (DME) but not ROM. A second OT screening form dated 07/26/2021, obtained on 09/16/2021, identified Resident 24 required total assistance for lower body dressing, but did not address ROM. Staff N completed an evaluation on 09/16/2021 which identified lower extremity range of motion to the ankle, knees and hips, more so on the left than the right. Staff N identified the resident experienced knee pain bilaterally with flexion. In an interview on 09/16/2021 at 1:20 PM, Staff N indicated facility staff should have pursued assessment of the resident's functional ROM and attempted interventions to prevent a decline in ROM. Resident 19 Review of the 07/04/2021 Quarterly Minimum Data Set (MDS- an assessment tool) showed Resident 19 was admitted to the facility on [DATE] with a diagnosis of fracture of the right arm and required two-person extensive physical assistance with all mobility and care. Review of Resident 19's care plan interventions dated 04/05/2021 showed turn and reposition every two to three hours and encourage resident to get out of bed daily and get exercise. The care plan dated 07/08/2021 showed Resident 19 at risk for decreased range of motion on upper and lower extremities related to impaired mobility and generalized weakness with goals to provide two 15-minute programs up to two times a week for the next 90 days and an intervention dated 07/08/2021 showed monitor for stiffness, pain and decline in function and re-evaluate restorative program in 90 days. A therapy note dated 07/08/2021 showed Resident 19 started a restorative program for active range of motion (AROM) and Bed Mobility training 15 minutes each program, scheduled for twice a week. On 07/16/2021 Resident 19 received a physician order to start physical therapy. The 07/16/2021 physical therapy evaluation showed reason for therapy referral was Resident (19) decline in functional mobility, decline in upper and lower extremity function, decline in activity of daily living function, weakness, positioning needs, and joint stiffness and pain. Therapy was discontinued on 08/10/2021 and the restorative program resumed. The August 2021 restorative documentation flow sheet showed the restorative program was only provided on 08/13/2021, 08/25/2021 and 08/28/2021, three of six scheduled restorative program days. The September 2021 restorative documentation flow sheet showed only one restorative program offered on 09/09/2021. The resident received one of four scheduled restorative program days. Resident 19's flow sheet documentation shows 12 days of no restorative program participation from 08/28/2021 to 09/08/2021. A physical therapy evaluation certification was completed on 09/13/2021 and showed the reason for the therapy referral was Resident (19) decline in functional mobility, decline in upper and lower extremity function, decline in activity of daily living function, weakness, positioning needs, and joint stiffness and pain. An observation and interview on 09/07/2021 at 11:26 AM Resident 19 was sitting in bed wearing a gown, hair not combed, teeth with food debris, and not shaven. Resident 19 stated I do not walk anymore since I fell, and I do get out of bed much. Multiple observations throughout day and evening shifts on 09/07/2021, 09/08/2021, 09/09/2021, 09/10/2021, 09/11/2021, 09/12/2021, 09/13/2021, 09/14/2021 and 09/15/2021 showed Resident 19 did not get dressed or out of bed and was either sitting or lying on their back and was not repositioned every two to three hours. Observations showed Resident 19 did not leave the bed on these days. An interview 09/16/2021 at 12:08 PM Staff N (Therapy Director) stated the restorative program schedule states up to two times per week, because of staffing and we cannot get to everyone so we try to prioritize the residents in need, if the resident starts to decline, we will revisit and increase visit schedule. When asked if both restorative programs (AROM and bed mobility) for a resident are expected to be completed each scheduled day, Staff N stated Not really, the resident will do the things they can do, we try to alternate (programs.) It is not an expectation that they do all the programs, but more options to encourage participation. Failure to provide range of motion and bed mobility restorative programs to Resident 19 resulted in decline in physical condition with potential for complications of increased immobility, increased depression, withdrawal, and social isolation. REFERENCE WAC: 388-97-1060(3)(d). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: ensure an environment free of accident hazards; provide resident supervision; confirm planned fall interventions were implemented, functional and effective for 1 (Resident 23) of 12 residents reviewed for accidents. Failure to ensure hazardous chemicals and hot liquids were inaccessible to vulnerable residents, and failure to identify planned fall interventions were not implemented or were non-functional, placed residents at risk for avoidable falls and/or injury. Findings included . According to the facility's Food Service policy, copyrighted 2021, Ideal coffee temperature range is 150-160 degrees Fahrenheit (dF). Coffee temperature will be taken daily and recorded on the food temperature log. Environmental Hazards On 09/10/2021 at 08:10 AM, the doors to the 300 Unit nourishment and shower rooms were observed to be wide open (secured open via magnet to te wall) and no staff were observed in the immediate vicinity. Observation of the shower room on 09/10/2021 at 08:13 AM, revealed an unlabeled green plastic spray bottle sitting on a table to the right of the entrance. The spray bottle contained an unknown liquid. Additionally, a spray bottle of tile cleaner was observed on a shoulder high shelf to the left of the door. During an interview on 09/14/2021 at 11:20 AM, Staff B, (Director of Nursing), observed the shower room and confirmed the presence of the unlabeled green spray bottle of unknown liquid, and the tile cleaner. Staff B indicated no unlabeled bottles of liquid should be present in the building, and confirmed all hazardous chemicals should be secured and not accessible to residents. On 09/10/2021 at 8:21 AM, the door to nourishment room was still propped open, an automated Folgers coffee/hot water dispenser was observed on the counter, and was accessible to independently mobile residents. A test cup of coffee and water were obtained and temp'd. The coffee was 172.6 dF, and the hot water was 176.6 dF. Upon exiting the nourishment room, on 09/10/2021 at 8:23 AM, Staff H, (Social Service Manager), was observed asking residents sitting at the nurses' station whether they wanted beverages. Staff H then walked into the open nourishment room and prepared a cup of coffee and a cup of hot water (for tea) from the automated dispenser. Without checking the temperature of the beverages, Staff H exited the room and delivered them to the residents. At that time, when asked the names of the residents she just provided coffee sand tea for Staff H identified one of the residents by name, then stated, I don't know who the other one is. During an interview on 09/14/2021 at 11:20 AM, Staff B indicated the nourishment room should remain closed and stated, I thought there was a sign posted. When queried why the facility checked and recorded the temperature of coffee, and which sources of coffee should be temp'd Staff B stated that all sources of coffee should be temp'd and explained it was for safety. Staff B also confirmed that prior to providing beverages to a resident, it is important to know who the resident is, as some residents have altered textured liquids. Facility Fall Prevention Policy The facility's 03/2021 Fall Prevention Plan stated patients with a high fall risk will have interventions implemented to minimize patient falls and injury. Additionally, after a fall, a nurse will conduct a fall investigation by talking with the resident, caregiver(s) and/or relevant staff about the nature of the fall and injuries. The root cause will be determined, and interventions developed, and care planned. Resident 23 According to the 02/24/2020 Admissions Minimum Data Set (MDS- an assessment tool), Resident 23 admitted to the facility with a history of a fall with fracture in the month prior to admission. According to the 07/07/2021 Quarterly MDS, Resident 23 had a fall with injury since the prior MDS, dated [DATE]. Resident 23 was assessed to be cognitively intact, and to be able to understand and be understood in conversation. The resident required one person assistance with transfers, ambulation, and toileting, and used a front wheeled walker (FWW) for mobility. Review of the facility's Incident Log showed Resident 23 had unwitnessed falls on 06/12/2021, 07/11/2021, 07/19/2021 and 09/07/2021, and a witnessed fall on 08/03/2021. The facility's investigation into the 06/12/2021, 07/11/2021, 07/19/2021 and 09/07/2021 unwitnessed falls each referred to signage in Resident 23's room encouraging call light usage. Resident 23's 02/18/2020 Falls Care Plan did not include the intervention of signage encouraging call light use. On 09/09/2021 at 12:45 PM, and on 09/10/2021 at 9:46 AM, no signage was observed in Resident 23's room to remind the resident to call for assistance. In an interview on 09/16/2021 at 7:35 AM, Staff B (Director of Nursing), stated the signage was a beneficial intervention that should continue, and that it would not be prudent to remove them. On 09/16/2021 at 10:17 AM Staff B verified with a surveyor that there was no signage reminding Resident 23 to use their call light and wait for assistance in the resident's room, and that there should have been. Staff B stated there were previously three different signs in the resident's room to remind the resident to call for help. Motion Sensor Alarm Resident 23's Fall Care Plan included a 07/07/2021 intervention of a motion sensor alarm. On 09/10/201 at 8:14 AM, Resident 23 was observed ambulating in the room without assistance. Staff G (Registered Nurse), Staff D (Clinical Manager) and Staff DD (Certified Nursing Assistant) were observed at the nurse's station adjacent to the charting room where the motion sensor alarm was located. The resident's alarm sounded. No staff were observed to respond. In an interview on 09/10/2021 at 08:18 AM, Staff BB (Licensed Practical Nurse) stated they heard the motion sensor alarm go off at 08:14 AM, and presumed other staff were delivering breakfast trays. On 09/10/2021 at 08:35 AM, the alarm from the motion sensor sounded. No staff were observed to respond to the alarm. On 09/10/2021 at 10:39 AM, the motion sensor alarm was audible at the nurse's station. No staff were observed at the station and no one responded to the motion sensor alarm. At 10:42 AM on 09/10/2021, the alarm continued to sound. Resident 23 was observed to be seated on the bed, with their wheelchair parked next to them, indicating they transferred without assistance onto the bed. On 09/11/2021 at 9:24 AM Staff BB (LPN) and Staff F (RN) were observed near the resident's room. The alarm was audible at the nurse's station, and Staff BB and Staff F did not respond. In an interview on 09/10/2021 at 10:22 AM, Staff D (Clinical Manager) stated the motion sensor alarm was working and demonstrated that the switch in the charting room where the alarm was located was in the on position. Staff D explained when the green light on the sensor in Resident 23's room flashed, a sound could be heard at the nurse's station. On 09/12/2021 at 9:19 AM the motion sensor alarm for Resident 23 in the Unit C nurse's station was observed to be turned off and did not make an audible tone. The alarm was also observed to be turned off on 09/13/2021 at 8:21 AM, 09:20 AM, 11:30 AM and 01:09 PM, and on 09/14/2021 at 08:35 AM and at 09:43 AM. In an interview on 09/14/2021 at 09:44 AM, Staff BB (Licensed Practical Nurse) stated staff verify the alarm is functional by listening for the alarm tone when the green light that indicates motion is detected flashes; if the tone is heard, it is working. Staff BB stated that the batteries are checked routinely. When asked to demonstrate how it worked by a surveyor, Staff BB instructed Staff CC to verify they could hear the alarm with a gesture when Staff BB activated the sensor. When Staff CC did not make the gesture indicating a tone was heard, Staff BB checked the alarm in the Unit C nurse's station and found the switch to be in the off position. Staff BB turned the alarm on, and a tone was immediately audible. Staff BB verified that the alarm was not on prior and should have been. When asked if the sensor alarm mechanism was checked over the last two days, Staff BB stated they thought [they] heard it yesterday and didn't check the alarm at the nurse's station. In an interview on 09/14/2021 at 11:20 AM, Staff D stated the alarm is only effective if staff respond to it and stated both mechanisms of the alarm need to be checked to ensure they are working properly. During an interview on 09/16/2021 at 07:35 AM, Staff B stated that alarm was harder to hear, the further away from the charting room one was. Staff B stated they were not sure why staff would turn the alarm off. Staff B stated they could not speculate why staff failed to notice the alarm sounding but that a conversation with staff was necessary. WAC REFERENCE: 388-97-1060(3)(g) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to assess resident's urinary status and identify causes of urinary incontinence and ensure a plan for treatment and services to restore as much normal bladder function as possible for 3 (Residents 50, 24 & 23) of 7 residents reviewed for urinary incontinence. Failure to identify types of urinary incontinence, assess residents function and provide treatment and services to restore bladder function placed residents at risk for continued decline in urinary function and embarrassment. Findings included . According to the facility policy on Promoting Resident's Urinary Health Status dated as reviewed 06/2020, A comprehensive assessment of urinary function completed for each resident upon admission and that providers review medical diagnoses and interventions that can effect incontinence. Resident 50 Resident 50 admitted to the facility on [DATE] and according to the 08/11/1021 admission Minimum Data Set (MDS, an assessment tool) was identified as occasionally incontinent of urine and dependant on staff for toileting. According to the Care Area Assessment (CAA) dated 08/11/2021, staff identified the resident had Urinary Incontinence and modifiable factors contributing to transitory urinary incontinence were, [Resident] has weakness and impaired mobility due to a stroke. [They] needs extensive assist with toileting. [They] had urinary incontinence. In an interview on 09/08/21 at 10:04 AM, Resident 50 indicated they needed assistance to get to the bathroom and was occasionally incontinent because, I have to wait for help. Record review showed an undated Bowel and Bladder Assessment labeled for Resident 50 which was completely blank. The assessment prompted staff to identify relevant medical and surgical conditions, medications, urinary continence history and relevant medical conditions which might impact resident's urinary function and aid staff in identifying the type of incontinence experienced and treatment options. In an interview on 09/11/2021 at 11:03 AM, Staff C (Clinical Manager) confirmed staff should have, but did not complete the comprehensive urinary assessment. Staff C stated it was important to compete the assessment and to identify the contributing causes of incontinence and correlating interventions. Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 04/14/2021 admission and 07/07/2021 Quarterly MDSs, was always incontinent of bladder, had no current toileting program or voiding trial, and was dependent on two staff for toileting. According to CAA documents dated 04/14/2012 [Resident] has weakness & impaired mobility due to multiple co-morbidities such as [heart, kidney and liver disease]. [They] needs extensive assist with toileting. [They] was always incontinent with [their] bladder. In an interview on 09/07/2021 at 12:56 PM, Resident 24 stated they did not get out of bed and was dependent on staff to, clean me up after episodes of incontinence. The resident stated they once utilized an indwelling urinary catheter but had been incontinent, for a while. Record review showed an undated Bowel and Bladder Assessment labeled for Resident 24 which was blank. The assessment prompted staff to identify relevant medical and surgical conditions, medications, urinary continence history and relevant medical conditions which might impact resident's urinary function and aid staff in identifying the type of incontinence experienced and treatment options. There was no documentation to support staff assessed or ruled out prompting voiding, scheduled toileting or bladder training to manage the residents urinary continence. Requested documentation and none was provided. In an interview on 09/11/2021 at 11:59 AM Staff C confirmed that nursing staff should have, but did not complete the bladder assessment for Resident 24. Resident 23 According to the 12/28/2020 Significant Change MDS, Resident 23 had occasional urinary incontinence. Review of the 04/19/2021 Quarterly MDS showed Resident 23's urinary incontinence change to frequently incontinent and along with a diagnosis of Benign Prostatic Hyperplasia (BPH- prostate gland enlargement that can cause urination difficulty). In an interview on 09/08/2021 at 12:12 PM Resident 23 stated they were occasional incontinent and sometimes wake up wet. Review of the clinical record revealed a 02/17/2020 Bowel and Bladder Assessment was done on admission. The assessment failed to identify medications contributing to urinary incontinence, urinary incontinence history and many areas of the form where left blank. No further Bowel and Bladder assessments were found in the clinical record. According to the facility 08/2020 Promoting Residents' Urinary Health Status Policy if a resident who is incontinent is eligible for a prompted voiding trial, the prompted voiding protocol is implemented. The policy further stated documentation was required for medication or treatment changes that affect incontinence. In an interview on 09/16/2021 at 8:30 AM Staff B (Director of Nursing-DON) stated we don't have a toileting program here, not sure why we don't. When asked if Resident 23 would be eligible for a bladder retraining program, Staff B stated we don't have that here. When asked why the resident doesn't have a urinal at the bedside, Staff B stated I am not sure if that is their preference. Review of a 04/24/2020 Provider note showed Resident 23 with urge incontinence, they were on Trospium and Oxytrol (used to treat overactive bladder) medications that were not been helpful and were discontinued. The plan was for staff to perform timed voiding. Review of the 05/26/2020 Incontinence Care Plan showed staff should offer to take the resident to the bathroom before and after meals, at bedtime, upon rising in the morning and when the resident awakens during the night and keep call light within reach and answer promptly. In an interview on 09/13/2021 at 1:01 PM Resident 23 stated that staff come in usually once or twice during a shift and offer to assist me to the bathroom, but it doesn't happen all the time. Review of Resident 23's clinical record revealed multiple falls on 6/12/2021, 07/11/2021, 07/19/2021, 08/03/2021 and 09/07/2021, all which occurred when the resident was attempting to get to the bathroom. Failure to thoroughly assess bladder incontinence and develop a plan to maintain or restore Resident 23's bladder function placed them at risk for increased incontinence, increased falls and diminished quality of life. REFERENCE WAC: 388-97-1060(3)(c) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**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 were obtained, evaluated, meal intake assessed, significant weight loss identified, and interventions were developed and implemented for three (Residents 24, 61, & 316) of ten residents reviewed for weight loss/ nutrition. Facility staffs' failure to: obtain and evaluate weights 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 weight loss. Findings included . According to the facility's 10/2020 (Revised) Weight and Nutrition Monitoring policy, all residents will have ongoing monitoring of their weight and nutritional status to ensure optimal nutrition and prevent negative outcomes. This policy directed staff that all residents will be weighed upon admission, then resident will be weighed weekly for four weeks, then monthly, if weights are stable. According to this policy the Registered Dietician will monitor weights on a weekly basis. Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 04/14/2021 admission MDS, Resident 24 weighed 341 pounds (lbs) and had no behaviors of refusals. According to the 07/07/2021 Quarterly MDS the resident demonstrated no behaviors of refusal and weighed 341 lbs. According to the Care Area Assessments dated 04/14/2021, staff assessed, resident leaves significant proportion of meals, snacks and supplements daily for even a few days. Review of weight records showed the resident had a previous admission to the facility, over a year prior, and was assessed to weigh 341 lbs on 02/11/2019. The resident's weight record for the current admission showed only one weight on 04/07/2021 when the resident was assessed to weigh 369 lbs. No further weights were documented in the record through 09/13/2021. Physician Orders dated 04/07/2021 direct staff Weekly weight each morning weekly on Wednesday, compare to prior weight . In an interview on 09/12/2021 at 11:30 AM, Staff C (Clinical Manager) confirmed Resident 24 had no weights done since admission on [DATE]. When asked why no weights were obtained, Staff C stated, Pretty much its because the resident doesn't want to get out of bed. Staff C explained that while the facility's Hoyer (a mechanical lift) lift did have a scale attachment, the resident was out of bed only once since admission. In an interview on 09/13/2021 at 8:26 AM, Resident 24 stated she had no issues with having staff obtain a weight using the Hoyer lift. This information was reported to facility staff at 8:38 AM and observations on 09/14/21 at 9:05 AM showed staff utilized a Hoyer lift to obtain the resident's weight of 321.4 lbs. In an interview on 09/10/2021 at 12:30 AM, Staff C was asked to provide any information to support the facility identified the reason behind staff's failure to ensure weight monitoring or attempted interventions to obtain weights, no information was provided. Resident 61 Resident 61 admitted to the facility on [DATE]. According to the 05/24/2021 Quarterly MDS, the resident had severe cognitive impairment, hemiplegia (paralysis of one side of the body), required total dependence with eating, and artificial nutrition via feeding tube. Review of September 2021 Medication Administration Records (MARs) revealed instruction to administer, Isosource HN (tube feeding) liquid nutritional supplement) give 500 ml (2 bottles) twice a day via bolus feeding. (On 0800 [8:00 AM] and 1700 [5:00 PM].2. Isosource HN (tube feeding) liquid nutritional supplement) give 250 ml (1 bottles) twice a day via bolus feeding. (On 1200 [12:00 PM] and 2300 [9:00 PM]: 3. Active liquid protein 30 ml twice a day. There were no directions to staff to document the amount of enteral feeding infused per day or per shift. Review of September 2021 MAR revealed instructions to administer water flush: Provide additional 200 ml each morning. Minimum goal; 200 ml/day. Water flush at 60 ml before and after bolus feeding during each shift. Review of Dietary order dated 04/29/2021 showed the goal was to provide 1500 ml, 1800 kcal, 80 g protein, 240 grams, consistent carbohydrate CHO, 1907 ml water with flushes per a day. Review the August and September 2021 water intake revealed Resident 61 was not receiving 1907 ml water as ordered by the RD. The average water administered to the resident from 08/10/21 to 09/09/21 was 800 ml per a day. There was no indication why the resident received only 800 ml of the required 1907 ml required. Information was requested to explain why the resident received less than half the ordered water intake. No information was provided. On 09/14/31 at 1:50 PM Staff FF, Licensed Practical Nurse confirmed that the total amount of water administered was not corresponding with the dietician's recommendation per a day. When asked if the staff total the amount of water intake per a shift, Staff FF said No, all extra water given with medication is not accounted for. On 09/15/18 at 2:28 PM, Staff B (Director of Nursing) acknowledged that Resident 61 did not receive the full dose of the feeding per the Registered Dietician orders. When asked if there should be a system/mechanism by which staff monitored the amount of enteral feeding the resident received, given the observation of the resident not receiving or receiving extra water intake. Staff B stated Yes, I will implement one. Resident 316 Resident 316 admitted to the facility on [DATE]. According to the 09/06/2021 admission MDS, was assessed as cognitively intact and required set up help from staff for eating. Review of Physician orders dated 08/30/2021 showed directions to staff to obtain weekly weight, compare to previous weight, and if more than three pounds difference, re-weigh. The order indicated staff were to notify the provider, if the weight was still greater than three-pound difference on re-weigh. Record review on 09/12/2021 of Resident 316's weight report showed staff documented a weight of 172.70 lbs. Four days later on 09/06/2021 staff documented Resident 316's weight as 177.90 lbs, a difference of 5.2 lbs. In an interview on 09/15/2021 at 11:29 AM, after reviewing Resident 316's weights, Staff C stated, We should have notified doctor and obtained a re-weigh the next day. Staff C indicated they were unable to locate notification occurred. REFERENCE: WAC 388-97-1060(3)(h). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 (Resident 24) of 4 residents reviewed for respiratory care, were provided such care, consistent with professional standards of practice. Failure of the facility to ensure CPAP services were provided according to physician placed this resident at risk of impaired sleep. Findings include: Resident 24 admitted to the facility on [DATE] and according to the 04/14/2021 admission and 07/07/2021 Quarterly Minimum Data Sets (MDS, an assessment tool) was assessed with cognitive impairment, was dependent on two staff for most activities of daily living and required the use of oxygen. In an interview on 09/07/21 at 1:28 PM, Resident 24 stated, I have horrible sleep apnea and they won't give me my CPAP (Continuous Positive Airway Pressure- a machine used during sleep to enhance breathing), I don't understand why no one has replaced that piece, they said I refused it, but I want it. At this time the resident was observed lying in bed, receiving oxygen via a nasal cannula (a tube in nose). A CPAP was noted on a bedside stand, no tubing was present but a mask was noted in an open drawer of the bedside stand. In an interview on on 09/12/21 09:32 AM Resident 24 reported using the CPAP historically, but at some point the mask broke, the part that goes over my nose. Please call my mask company, I think they'll give me a new piece so I can use it, no one will call them. I have problems sleeping .it's been over two months. Progress notes dated 05/19/2021 showed, PMW [Providence Marionwood] is requesting different CPAP mask. will coordinate with [sic]. A progress note dated 05/24/2021 indicated, Pt [patient] is not using CPAP and lidocaine patch notified provider and d/c (lidocaine patch was d/c'd). There was no indication staff identified the CPAP was not used related to the need for a new mask. Progress notes dated 06/17/2021 showed, Pt also declined to use CPAP. A second 06/17/2021 note showed the resident reported not liking the CPAP, but received education regarding it's use. Progress notes on 06/19/2021 showed, however patient also declined to use CPAP. The record was not clear that the previous mask was replaced, nor did staff determine the reason behind the declination of the CPAP. Progress notes dated 8/16/2021 indicated, OSA [Obstructive Sleep Apnea- a disease which impacts breathing while asleep] on CPAP. This note did not accurately reflect the resident did not use the CPAP in August. Review of Treatment Administration Records (TARS) dated August 2021, staff were directed to CPAP: Assist patient in applying CPAP at Bedtime. Please ensue that CPAP setting is at . There were no instructions to staff as to what settings the resident was assessed to require. According to the August 2021 TAR, staff documented, H [held] on 29 occasions. While staff documented, resident declined staff did not inquire as to why the resident declined or if further intervention would ensure resident compliance with the treatment. In an interview on 09/10/2021 at 10:05 AM, Staff C (Clinical Manager) was asked to provide documentation regarding the function of Resident 24's CPAP, if repairs or replacements were made and if the machine was functioning. According to progress notes dated 09/10/2021 for late entry for 07/27/2021, pt [patient] does typically decline to use [their] CPAP machine. Facility staff failed to ensure oversight and supervision of the use of the CPAP, ensure physician's orders contained parameters for CPAP settings, assess and provide interventions for the resident's declined use of CPAP and assess for any impact of non use. REFERENCE: WAC 388-97-1060(3)(j)(vi). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a system that ensured ongoing collaboration and communication with the dialysis (HD) center for 1 (Resident 15) of 2 residents reviewed for HD services. Failure to initiate, obtain upon return and complete the facility Dialysis Communication Form, DCF and failure to timely obtain and review HD run sheets precluded the facility staff from identifying if the resident was arriving to HD increasingly over the goal weight, required the removal of more liters of fluid, what if any complications occurred, what medications were administered, and if order changes occurred or follow up was required. The lack of consistent communication and assessment placed the resident at risk for medical complications and potential negative outcomes Findings included . According to the facility's Dialysis Communication policy, copyright 2020, the facility will provide continuity of care and nursing monitoring for all dialysis residents. A routine communication form will be used between the facility and dialysis center to provide both institutions with the needed information to provide coordinated care. The charge nurse will ensure a DCF is sent with resident's when leaving for HD. Vital signs, weight, and any concerns related to the resident are to be documented on the form. The form must be signed and dated by the charge nurse. The form should be with the resident upon return from HD. If the form is not present the Licensed Nurse (LN) on duty will call the HD center and request the form be faxed over. The LN is responsible for assessing the resident and making an entry into the resident's chart. The entry should include a HD site assessment and verbal report obtained from the resident. Care plan (CP) interventions will include: Shunt site (location); Dialysis Center; specific HD days; daily vital signs; and monitoring weights. Resident 15 admitted to the facility on [DATE]. According to the 06/28/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had kidney failure and received dialysis services. A 10/06/2020 HD CP identified the resident's HD center and dialysis days as every Monday, Wednesday and Friday. Staff were directed to: monitor the HD access site for bruit/thrill and notify the doctor immediately, if absent; monitor for signs and symptoms of infection or bleeding at the access site; monitor for edema and shortness of breath; obtain vital signs daily; and do not take blood pressure in arm with shunt/fistula, the left arm. There was no direction to staff about initiating or completing the DCF upon return, and if not present, calling to obtain it. Record review showed only DCFs for 02/24/2021, 02/26/2021, 3/03/2021, and 03/17/2021 were present. Review of the DCFs showed on three of four dialysis session, the dialysis center failed to complete their section DCFs that included: pre/post dialysis weight; blood pressure; medications administered; complications or occurrences during HD, order changes; and follow up needed. In an interview on 09/12/2021 at 10:38 AM, when asked where Resident 15's DCFs and HD run sheets were located Staff BB, (Licensed Practical Nurse, LPN), explained that Resident 15 had a HD binder in the top drawer at bedside. Review Resident 15's HD binder revealed only three DCFs (10/07/2020, 10/14/2020 and 10/30/2020) were present. There was no indication the facility had ensured the completion of a DCF in the past 6 months. Additionally, no HD run sheets were present in the resident's Electronic Health Record (EHR) or physical chart. During an interview on 09/15/2021 at 1:14 PM, Staff AA, (Health Information Manager), stated no DCFs were in Resident 15's overflow record. Staff AA stated the HD run sheets were faxed directly to medical records, and was not able to provide most of the run sheets for the previous two weeks. When asked, Staff AA confirmed that no nurses or medical personnel reviewed the HD run sheets, indicating if she saw an order or that new medication had been administered at HD, they would notify nursing. In an interview on 09/14/2021 at 1:39 PM, Staff A, Administrator, stated that it was the expectation staff follow the facility policy and complete the DCF on each HD day as directed, and acknowledged it had not occurred. REFERENCE: WAC 388-97-1900((1), (6)(a-c) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide trauma related assessments for 2 (Residents 50 & 24) of 2 residents identified for abuse and one supplemental resident (Resident 2) identified with s trauma related issue. This failure placed residents at potential risk for untreated or inadequate treatment of mental health and decreased psycho-social well-being. Findings included . According to the Facility's Trauma Informed Care policy dated 12/2019 showed staff should implement a universal screening for trauma with care planning resident-centered approaches and interventions in response to the universal screening. Resident 50 Resident 50 admitted to the facility on [DATE] and according to the 08/11/2021 admission Minimum Data Set (MDS, an assessment tool), was assessed as cognitively intact with diagnoses of depression and anxiety disorder, and was identified with mood indicators of feeling down, depressed, or hopeless, trouble falling or staying asleep or sleeping too much, feeling tired or having little energy, poor appetite or overeating, feeling bad about yourself or that you are a failure or have let yourself or your family down, trouble concentrating on thing, all experienced with symptom frequency of 12-14 days of the assessment period. According to a mental health evaluation dated 08/20/2021, the resident reports trauma/abuse hx- at age 8 sexual assault by uncle reports [their] parents were aware & did not protect me and that father was inappropriate with me. Record review showed staff did not attempt to identify any triggers for the Resident 50's trauma, or identify any interventions that would lessen the effects of trauma and provide comfort. In an interview on 09/14/2021 at 3:15 PM, Staff A (Administrator) confirmed facility staff did not initiate the Trauma Care screenings on admission. Resident 24 Similar findings were found for Resident 24 who was admitted to the facility on [DATE]. According to the admission MDS dated [DATE] the resident had a diagnosis of depression and anxiety and required the use of both an antipsychotic and antidepressant medication on each day of the assessment period. Record review showed no indication the facility Trauma Screen was completed. Additionally, Provider notes dated 07/28/2021 showed the resident was having hallucinations, seeing parasites, with direction to staff to Refer to psych[iatric] MD for further eval. Record review showed no indication the resident received the ordered mental health referral. In an interview on 09/15/2021 at 1:44 PM, Staff H (Social Services Director) confirmed Resident 24 should have, but did not, receive Mental Health Services as ordered. Resident 2 Resident 2 admitted to the facility on [DATE]. According to the admission MDS dated [DATE] Resident 2 had a diagnosis of anxiety disorder and depression. Resident 2 was assessed as cognitively intact and able to make their own decisions. The hospital Discharge summary dated [DATE] showed admission to the hospital was for mistreatment at prior care setting. Resident 2 was moved out of their prior living situation related to physical abuse, verbal abuse, no heat in the bedroom, poor quality food and not receiving care during the night. A semi-annual assessment completed 07/20/2021 by the primary care practitioner showed Resident 2 had a major event related to hospitalization 05/18-27/2021 (nine days) for an unsafe living situation. In an interview on 09/07/2021 at 1:49 PM Resident 2 stated they moved to the facility from the hospital due to abuse at the prior care setting. Resident 2 described the details of verbal, physical and care related abuse described in the hospital discharge summary. Resident 2 described feeling unsafe and very anxious when abruptly moved out of the care setting and into the hospital until a safe environment could be found. Resident 2 tearfully explained a close family member's death in 06/2021 (after admission to this facility). Resident 2 also stated extreme worry and concerns of another family member's situation. A review of the current care plan dated 09/07/2021 showed no interventions for trauma directed care and no interventions for grief support. In an interview on 09/16/2021 at 11:15 AM Staff B (Director of Nursing Services) agreed situation Resident 2 experienced would be a traumatic event and confirmed the facility failed to initiate the Trauma Care assessment on admission. The facility failed to assess Resident 2 for trauma informed care when identified on the hospital discharge summary and the primary care practitioner assessment. This failure placed Resident 2 at risk for inadequate mental health treatment and decreased psychosocial well-being. REFERENCE: WAC 388-97-0960(1). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure safe and consistent pharmaceutical services, which ensured accurate disposing and administration of controlled drugs to meet the needs of one (Resident 52) of one resident reviewed for medications. Failure to have a procedure in place to dispose medications placed residents at risk for potential abuse, misuse, diversion and accidental exposure. Findings included . Review of Facility Policy dated 01/2020 showed Facility must inventory schedule II, III, IV (Narcotics) .Facility properly dispose of discontinued and or outdated medications .The Food and Drug Administration (FDA) list Fentanyl patches as one of the medications that should be flushed down to the toilet. These patches will be cut up into small pieces before they are flushed to the toilet. The Food and Drug Administration (FDA) and manufacturer instructions dated 10/01/2021 recommend that users dispose of used Fentanyl patches by folding the patch in half with the sticky sides together and flushing the patch down the sink or toilet, due to the life-threatening risks associated with exposure to or ingestion of the patch. According to the significant change Minimum Data Set (MDS an assessment tool) dated 08/13/2021, Resident 52 was assessed as cognitively intact and was using controlled medication for pain management. Review of Resident 34's active orders dated 08/19/2021 reflected Fentanyl 50 mcg HR Patch, extended release (Fentanyl) Apply 1 patch over back of the transdermal daily every 48 hours for pain. ***Fentanyl 12 mcg/1 HR patch for a total dose of 62 mcg/hr.*** On 09/14/2021 at 10:30 AM with Staff Z was observed removing Resident 52's two Fentanyl patches folded to the right hand with groves and placed them to the resident's trash can. Further observation revealed multiple Fentanyl patches disposed in Resident 52's room sharp container. In an interview with Staff Z on 09/15/2021 at 10:45 AM, Staff Z confirmed that the removed Fentanyl patches were wrapped with groves and trashed in resident's trash can, when asked about the process of deposing Fentanyl, Staff Z said, I don't know. In an interview on 09/15/2021 at 2:45 PM with Staff Director of Nursing (DON) revealed that the expectation was Fentanyl Patchs should be cut into small pieces and flushed to the toilet. When asked if the staff followed the facility policy, Staff B, said No. Reference WAC 388-97-1300 (1)(b)(ii), (c)(ii-iv) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a licensed pharmacist completed monthly Medication Regimen Reviews (MRRs) for 2 (34, 29) of 5 residents reviewed for unnecessary medications and 2 (18,23) supplemental residents, and failed to ensure pharmacist recommendations were followed up in a timely manner for 2 (34, 18) supplemental residents. 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 . Facility Policy According to the Facility's 01/2020 Consultant Pharmacist Policy, the consultant pharmacist shall perform MRRs for each resident at least monthly and shall provide written documentation of all recommendations and submit recommendations to the facility for the attending prescriber or the designee's review and response. The policy also stated that the Prescribing Physician or Licensed Designee shall act upon the MRR findings / recommendations in a timely manner of 30 days or less and written documentation and prescriber response shall be considered a permanent part of each of the resident's medical record. Monthly Medication Regimen Review Resident 34 According to the 07/27/2021 Significant Change Minimum Data Set (MDS- an assessment tool), Resident 34 had diagnoses including Depression, Diabetes, Hypertension (HTN-high blood pressure), Hypothyroidism (low thyroid function), and Hyperlipidemia (high cholesterol) and the resident regularly took antidepressants, antianxiety medication, insulin and opiods. Review of the Resident 34's electronic health record (EHR) showed no MMR completed for the month of February 2021. During an interview on 09/16/2021 at 7:35 AM, Staff B (Director of Nursing) stated they could not locate the MMR for February 2021, but there should be one done. Resident 29 According to the 07/19/2021 Quarterly MDS, Resident 29 had diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder and Atrial Fibrillation (A-fib-irregular heart rate). According to the 07/19/2021 MDS, Resident regularly took antipsychotic medication, antidepressants and anticoagulants. Review of Resident 29's EHR showed no MRR completed for the month of August 2021. In an interview on 09/15/2021 at 11:57 AM, Staff B, Director of Nursing (DON), stated that the consult pharmacist did not but should have completed an MRR for Resident 29. Resident 18 According to the 03/31/2021 admission MDS, Resident 18 had diagnoses including Congestive Heart Failure (CHF-failure of heart to pump blood adequately), HTN and A-fib. According to the 09/2021 Physician Orders (PO), Resident 18 regularly took antiarrhythmic and antihypertensive medications. Review of Resident 18's EHR showed no MMR completed for the month of June 2021. In an interview of 09/16/2021 at 7:35 AM, Staff B (DON) stated they were unable to find anything but there should be one done monthly. Resident 23 According to 07/07/2021 Quarterly MDS, Resident 23 had diagnoses including Dementia, Benign Prostatic hypertrophy (enlarged prostate) and Hydrocephalus (fluid build up in brain). According to the 07/07/2021 MDS the Resident received anticoagulant injections. Review of Resident 23's EHR showed no MMR was completed for the month of March 2021. In an interview on 09/16/2021 at 8:00 AM, when asked if there was documentation to support Resident 23's MMR was completed for March 2021 as required, Staff B stated, No. Pharmacist Recommendations Resident 34 Review of Resident 34's EHR revealed a 06/10/2021 Consult Pharmacist Recommendation that requested a Gradual Dose Reduction of Buspirone (an antianxiety). The recommendation was signed by the provider who declined the pharmacist recommendation on 07/21/2021, greater than 30 days after the recommendation was made. Review of Resident 34's EHR revealed a 07/29/2021 Consult Pharmacist Recommendation to discontinue the use of Cepacol (sore throat lozenge). The recommendation was signed by the provider who accepted the pharmacist recommendation on 09/08/2021, greater than 30 days after the recommendation was made. A second 07/29/2021 Consult Pharmacist Recommendation was made for Resident 34 to reduce Losartan (an antihypertensive) and re-check potassium level, as Resident 34's potassium level was increasing. Review of the EHR did not indicate the provider responded to the recommendation. In an interview on 09/16/2021 at 8:00 AM, when asked if there was documentation to support Resident 34's Pharmacy recommendation on 07/29/2021 was reviewed and signed by the provider, Staff B stated, No. Resident 18 Review of Resident 18's EHR revealed a 05/21/2021 Consult Pharmacist Recommendation to check B12 level and consolidate the B12 medication dose to once daily in the morning. On 06/23/2021 the provider responded after 30 days with, will check B12 levels after decreasing dose to 500 mcg (micrograms) by mouth once daily. Further review of the EHR showed the B12 order was not changed and the B12 level was not checked. In an interview of 09/16/2021 Staff B (DON) stated they see the B12 order was not changed and no B12 level was done and they would expect the orders to be carried out. In an interview on 09/16/2021 at 8:00 AM Staff B (DON) stated that the pharmacist should review medications monthly for all residents and a pharmacist recommendation should be carried out within 24-48 hours for non-emergent medication changes. Reference: WAC 388-97-1300 (1)(c)(iii)(4)(c). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**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 1 (Resident 38) of 4 residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs, and a diminished quality of life. Findings included . Resident 38 admitted to the facility on [DATE] and according to the Quarterly Minimum Data Set (MDS, an assessment tool) dated 08/02/2021, was identified with obvious or likely cavity or broken natural teeth. In an interview on 09/08/2021 at 9:40 AM, Resident 38 stated, I haven't had my teeth cleaned in years. The resident denied pain or difficulty chewing at this time and was observed to have white debris around their gumline and to have carious (decayed) teeth. In an interview on 09/15/2021 at 11:45 AM, Staff H (Social Services Director) indicated residents qualify for three dental visits a year, an exam and two cleanings. Facility staff was asked to provide documentation to support the resident was seen by dental in the past year. Facility staff was able to provide a provider note dated 06/22/2021 that indicated for dental follow up with (Dentist) regarding plan no acute pain In an interview on 09/15/2021 at 11:45 AM, Staff H was asked to provide any documentation to support Resident 38 was referred to or seen by a dentist. According to a progress note dated 01/27/2021, Resident 38 was told by PEP (Providence Elder Place - a primary provider) that a dental appointment was scheduled (without prior consultation with Resident 38) for 09:00 AM the following day (01/28/2021). Resident 38 canceled the appointment due to a previously scheduled 2nd COVID vaccination. There was no evidence to support the appointment was rescheduled. When asked about dental services for Resident 38, in an interview on 09/15/2021 at 12:02 PM, Staff C (Clinical Manager) explained that Resident 38 had a medical provider who took the responsibility to ensure medical services, including dental, and made their own referrals stating, residents are sent out for dental .for cleaning for teeth, the program for those residents is all inclusive. In an interview on 09/15/2021 at 12:10 PM Staff H recalled Resident 38 went out to dental for a tooth extraction in the past year but was unable to obtain documentation to support the resident received either twice a year cleaning, or the services related to a tooth extraction. REFERENCE: WAC 388-97-1060 (3)(j)(vii). .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food choices that accommodated food preferences and intolerances for 3 (Residents 45, 316, 317) of 4 residents reviewed for food preferences. The failure to provide foods that met the resident's individual needs, placed residents at risk for weight loss and diminished quality of life. Findings included . Resident 45 Resident 45 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly MDS, the resident was cognitively intact, with clear comprehension, and received a therapeutic diet. In an interview on 09/08/2021 at 11:19 M, Resident 45 expressed concern about the facility food and indicated she doesn't like gravy and is lactose intolerant. The resident stated that she had informed staff and even sent a note to the kitchen but still receives gravy and dairy with her meals. When asked for a specific example Resident 45 stated, I just got tiramisu, and that has dairy, I know I used to make it. Review of Resident 45's tray card showed no gravy with meals was listed as a dislike, and shellfish, shrimp, crab and lactose intolerant were listed under allergies. Under preferences coconut milk with coffee and soy milk were listed. Review of the facility's September 2021 menu, showed the facility served tiramisu with dinner on 09/06/2021. Upon request, the facility provided the recipe for the tiramisu that was served. Under product description ingredients it stated, Mascarpone cheese (CREAM [MILK], MILK CITRIC ACID) At the bottom of the ingredients it again stated, Contains Milk. On 09/16/2021 at 9:34 AM, while passing by Resident 45 stated, They just sent me 2% milk, I just told them to take it back. In an interview on 09/16/2021 at 8:22 AM Staff D, (Clinical Manager), confirmed it was the expectation that resident's dietary preferences be honored. Resident 316 Resident 316 admitted to the facility on [DATE] and according to the 09/06/2021 admission MDS was able to understand and be understood in conversation and was assessed as cognitively intact. Resident 316 had weight loss identified on this assessment. Record review of Resident 316's care plan (CP) dated 09/01/2021 identified the resident had inadequate nutrition related to lack of appetite, intake average at 65%, and a significant 10.4% weight loss times three weeks. CP directed staff to assess food preferences and incorporate into meals and snacks. In an interview on 09/07/2021 at 10:25 AM, Resident 316 stated, The food sucks, there's no variety, and I can't pick what I want. Resident stated they did not speak with anyone yet regarding food preference. Resident reported staff did not provide them with menus or offer alternative choices for meals, stating I get what I get. In an interview on 09/10/2021 at 9:46 AM, Staff L (Dietary Manager), stated they post the menus on Wednesday or Thursday and place them at each nurse's station. Staff L indicated an aide delivers an activity schedule that included a menu to rooms and that dietary slips are available at nurse's station if a resident wants to fill it out for changes. In an interview on 09/11/2021 at 11:05 AM, Resident 316 stated they did not know what a dietary slip was or how to get one and still had not received a menu. Observations on each day of survey showed the activity schedule was unable to be found in resident 316's room until 09/12/2021 at which time the resident stated they received one finally. Resident 316 reported they were still unsure how to order an alternate meal. According to dietary notes dated 09/01/2021 at 12:53 PM, food preferences were reviewed, however review of care plans and dietary tray cards listed no identified likes or dislikes as reflected by resident interview. Resident 317 Similar findings were found for Resident 317 who was admitted to the facility on [DATE] and according to the 09/03/2021 admission MDS, was able to understand and be understood and was determined to be cognitively intact. This assessment showed Resident 317 was admitted with medically complex diagnosis including diabetes and kidney failure. Record review of CP dated 08/30/2021 identified Resident 317 with inadequate nutrition related to lack of appetite and clinically significant weight loss in a month. The CP directed staff to assess food preferences and incorporate into meals and snacks. In an interview on 09/10/2021 at 12:13 PM, Resident 317 stated they do not have access to any menus and reported they had no idea how to find out about making food choice preferences. Resident 317 stated they would love to talk to a dietician as they are new to dialysis and learning about diet restrictions. During an observation at time of interview, Resident 317 had a bowl of fish stew. Resident 317 stated, I grew up not liking fish, but I'm trying to get used to it. In a follow up interview on 09/12/2021 at 8:45 AM, Resident 317 stated, they gave me a menu yesterday for the first time, it was wonderful. You must have said something to them. Resident showed and pointed to the menu delivered and was smiling. Resident then stated they did not know what to do with the menu or how to order alternate food choices. Refer to F803, F805, F812 REFERENCE: WAC 388-97-1120 (2)(a); -1100 (1); -1140 (6).

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely and/or accurately inform the Residents of changes to their treatment plans for 5 (Residents 50, 45, 26, 29 and 47) of 21 residents reviewed for care. This failure placed residents and/or legal representatives at risk for not being fully informed to make decisions about treatment plans, and precluded them from having the opportunity to make an informed decision related to the treatment plan. Findings included . According to the facilities 12/2020 policy for psychotropic medication administration, nursing would review the risks and benefits of psychotropic medications with the resident or representative, and obtain informed consent prior to administration of the medication. Nursing would complete a Consent for Psychoactive Medications [CPM] form, that indicated what psychoactive medication was prescribed, what drug class the medication was, and the potential side effects associated with its use. The information on the CPM would be presented to the resident or their representative, and signed if they consented to the use of the identified medication. Resident 50 Resident 50 admitted to the facility on [DATE], and according to the 08/11/2021 admission MDS, was able to understand and be understood in conversation, was assessed as cognitively intact, and received antipsychotic medication each day of the assessment period. In an interview on 09/11/2021 at 8:37 AM, Resident 50 indicated they did not take antipsychotic medications while in the facility. Record review showed Resident 50 admitted to the facility with orders for Seroquel (an antipsychotic medication) for the treatment of delirium. According to a CPM form dated 08/04/2021, facility staff obtained informed consent for the Seroquel from the resident's Durable Power of Attorney (DPOA). In an interview on 09/10/2021 at 11:17 AM Staff H (Social Services) indicated the DPOA shouldn't be signing consents for Resident 50 stating, [Resident 50] makes their own decisions .[they] can make [their] own decisions. In an interview on 09/10/2021 at 1:10 PM, Staff C (Clinical Manager) was asked to provide documentation to support why the DPOA rather than the resident, who was cognitively intact, was provided informed consent for the antipsychotic medications. No documentation was provided. Resident 45 Resident 45 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly MDS, the resident was cognitively intact, had a diagnosis of depression and received antidepressant medication on seven of seven days during the assessment period. Review of Resident 45's current Physician's Orders (POs) showed a 05/14/2021 order for Duloxetine (an antidepressant medication) daily, for major depression. Record review showed only a blank, undated CPM form was present in the resident's medical record. There was no indication facility staff obtained informed consent from Resident 45 for the administration of Duloxetine. During an interview on 09/16/2020 at 7:58 AM, Staff D, (Clinical Manager), acknowledged the facility had not obtained consent for the use of Duloxetine as required. Resident 26 Resident 26 admitted to the facility on [DATE]. According to the 0713/2021 Quarterly MDS, the resident was cognitively intact, had a diagnosis of depression and received antidepressant medication on seven of seven days during the assessment period. Review of the current POs showed Resident 26 had the following orders for psychotropic medications: a 05/14/2021 order for Nortriptyline (an antidepressant medication) daily, for depression and nerve pain; and a 08/18/2021 order for Ambien (a sedative hypnotic medication) daily, for insomnia. A 01/22/2021 CPM form for Nortriptyline, signed by Resident 26, was found in the medical record. However, review of the CPM revealed facility staff failed to identify the type of medication Nortriptyline was (e.g. antidepressant) and the potential risks and benefits of its use. The failure to present Resident 26 with complete and accurate information about the medication, detracted from the resident's ability to make an informed decision about its use. Similar findings were noted for the 08/18/2021 CPM for Ambien, which was signed by Resident 26. Facility staff again failed to identify the type of medication Ambien was (e.g. sedative hypnotic) and the potential risks and benefits of its use. During an interview on 09/16/2020 at 7:58 AM, Staff D acknowledged both CPMs were incomplete, resulting in a failure to provide Resident 26 complete and accurate information by which an informed decision could be made. Resident 29 According to the 07/19/2021 quarterly MDS, Resident 29 had a diagnosis of Unspecified Dementia with Behavioral Disturbance. Review of Resident 29's orders showed a 07/19/2021 physicians order for Risperidone (an antipsychotic), give 0.75 MG by mouth twice daily for unspecified dementia with behavioral disturbance. Review of Resident 29's chart at 11:39 AM on 09/10/2021 showed the chart did not contain a consent form completed for Risperidone and signed by the resident. In an interview on 09/14/2021 at 10:06 AM, Staff D stated that informed consent had not been obtained and that it should have been prior to administration of an antipsychotic. Resident 47 A 09/08/2021 5:11 PM physician progress note showed a new order for Lorazepam (medication for anxiety) was prescribed. This progress note also showed that Resident 47 was determined to be their own decision maker. The September 2021 MAR showed Lorazepam was administered on 09/09/2021, 09/10/2021, and 09/12/2021. Review of Resident 47's medical record showed no signed consent form for treatment with Lorazepam. An interview on 09/16/2021 at 11:45 AM, Staff B (DNS) stated informed consent and the signed consent form must be obtained before administering an antianxiety medication per the facility policy. This failure prevented Resident 29 and Resident 47 from making an informed decision about their treatment options. REFERENCE: WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to allow 7 (Residents 38, 45, 3, 34, 316, 2 & 19) of 7 sample 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 residents' choice placed these residents at risk for a diminished quality of life. Findings included . Resident 38 According to the Quarterly Minimum Data Set (MDS an assessment tool) dated 08/02/2021 Resident 38 was assessed as understood and able to understand conversation and was cognitively intact. In an interview on 09/08/21 at 8:52 AM Resident 38 stated, I've been here a year .I don't get baths. I complained one time so much, I only got one bird bath in three weeks, that's not enough, they could be more regular with the bed baths, I should be getting two a week. Observation at this time showed the resident was well groomed. Review of Shower Schedule documents showed Resident 38 did not receive bathing twice a week from 08/24/2021 through 09/11/2021 as was his preference. Resident 38 was scheduled for, but did not receive, bathing on 08/27/2021, 08/29/2021, and 09/10/2021. In an interview on 09/12/21 at 11:30 AM, Staff C (Clinical Manager) confirmed the Shower Schedule did not reflect the resident consistently received twice a week showers. Resident 45 Resident 45 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly MDS, the resident was cognitively intact with clear comprehension, required extensive assistance with bed mobility, transfers, and hygiene, demonstrated no behaviors or rejection of care, and the ability to chose between receiving a bed bath or shower was Somewhat important. In an interview on 09/08/21 at 10:54 AM, Resident 45 indicated they were suppose to receive two showers a week, but usually only received one. According to Resident 45's 09/10/2021 Pocket Care Guide (a quick reference version of the comprehensive care plan) showed staff were directed to Offer showers 2xs weekly .Please no bed baths. Review of the Unit C shower flowsheets showed from 08/17/2021 through 09/11/2021, the resident was not provided a shower on the following scheduled days: 08/21/2021; 08/24/2021; 08/28/2021; and 09/04/2021. During an interview on 09/16/2021 at 7:58 AM, Staff D, (Clinical Manager), indicated it was the expectation that residents be provided bathing at their preferred frequency, and acknowledged for Resident 45, this had not occurred. Resident 3 Resident 3 admitted to the facility on [DATE]. According to the 06/08/2021 admission MDS, the resident was cognitively intact, required extensive assistance with bathing and hygiene, and did not reject any care. In an interview on 09/08/21 at 11:48 AM, Resident 3 indicated bathing/ showers were provided very inconsistently, expressing one week you may only get one shower, but another week you could get three. Resident 3 stated if they could have their way, they would prefer to be bathed three to five times a week. Review of Resident 3's September 2021 Treatment Administration Record (TAR) showed a 06/30/2021 order directing staff to provide bathing every Monday and Friday on evening shift. Review of the Unit C shower flowsheets from 08/17/2021- 09/11/2021, showed the facility failed to provide the resident bathing on the following scheduled days: 08/20/201; 08/27/21; 08/30/2021; and 09/10/2021. During an interview on 09/16/2021 at 7:58 AM, Staff D confirmed the facility failed to provide bathing to Resident 3 at his at preferred frequency. Resident 34 According to the Quarterly MDS dated [DATE], Resident 34 was assessed as cognitively intact and indicated it was very important to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident 34's active orders dated 05/20/2021 reflected Bathing hygiene during evening shift weekly on Tuesday, Saturday and document bathing received. In an interview on 09/12/21 at 11:11 AM Resident 81 revealed that showers were not given as often as preferred. I get showers but not as preferred, some week I get one showers and some two showers per a week depending on the shower aide's availability. I would like more showers. Review of Resident 34's Shower/ Bath flowsheets reflected the resident received five showers between 08/02/2021 and 09/10/2021, rather than the twelve showers scheduled per resident preference and CP. Further record review showed no documentation to support why staff did not provide the resident with the assessed preferences for bathing. In an interview on 09/15/21 at 2:30 PM, Staff B (Director of Nursing) confirmed that Resident 34's shower schedule did not reflect the resident pretence and consistently given twice a week showers. Resident 316 Resident 316 admitted to the facility on [DATE] and according to the 09/06/2021 admission MDS was determined to be cognitively intact and was assessed to require extensive physical assistance with personal hygiene and bathing. According to this assessment, Resident 316 revealed it was very important to choose between a tub bath, shower, bed bath, or sponge bath. In an interview on 09/07/2021 at 10:25 AM, Resident 316 stated they preferred showers two times a week. During a follow up interview on 09/13/2021 at 8:33 AM, Resident 316 stated they had not received showers and they felt dirty. Resident 316 reported they were given a bed bath even though they preferred showers. Resident 316 stated they only received two showers since admission. Review of weekly facility Shower Schedule forms on 09/16/2021 showed Resident 316 was scheduled for bathing twice a week on Wednesday and Sunday based on that document. Review of these documents showed facility staff had not showered Resident 316 in the last eight days. On 09/05/2021 staff documented on this shower schedule they had given the resident a bed bath even though their preference was for showers. In an interview on 09/16/2021 at 8:44 AM, Staff C reviewed the shower schedule forms, and confirmed staff had failed to document any showers as completed for Resident 316 since 09/08/2021 and that staff documented they provided a bed bath instead of a shower as the resident preferred. Resident 2 The 09/09/2021 Quarterly MDS showed Resident 2 reported it was somewhat important to choose between a tub bath, shower, bed bath or sponge bath. On 09/07/2021 at 12:33 PM Resident 2 stated they did not have a choice when showers were given. Resident 2 stated that an option for a bath was not offered, nor were there choices for the time of day or frequency of showers provided. Resident 2 stated they would like at least two showers per week and was lucky if they received one per week. Resident 2's September 2021 treatment record showed showers were scheduled on day shift on Wednesdays and Sundays. According to this document, Resident 2 did not receive seven of nine scheduled showers in August 2021 and did not receive three of four showers scheduled for September 2021. Resident 19 On 09/08/2021 at 10:34 AM, Resident 19 stated they were not asked about shower preferences for frequency or time of day. Resident 19 stated, The staff come and tell me when to shower. Resident 19's September 2021 treatment record showed showers were scheduled twice a week, on evening shift Tuesdays and Saturdays. Resident 19 did not receive seven of nine scheduled showers in August 2021 and did not receive three of four showers in September 2021. In an interview on 09/16/2021 at 11:15 AM, Staff B stated it is the expectation that the care staff follow the pocket care guide and care plan to provide resident care. The Shower schedule on the MAR is part of the resident care and is to be completed and documented. REFERENCE: WAC 388-97-0900(1)-(4). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain Advanced Directives (AD) and/or Power of Attorney (POA) documentation, or offer assistance with the development of an Advance Directives, for 10 (Residents 24, 50, 34, 37, 1, 317, 316, 2, 19, 47) of 13 sample and one (Resident 50) supplemental residents reviewed. This failure left residents at risk for losing the right to have their preferences and choices honored regarding emergent and end-of-life care. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 07/07/2021 Quarterly Minimum Data Set (Minimum Data Set, an assessment tool) was able to understand and be understood in conversation and had moderate cognitive impairment. In an interview on 09/07/2021 at 1:13 PM, Resident 24 indicated they would like to develop an AD making one of their two sons Power of Attorney. According to Social Worker Progress notes dated 05/21/2021 . [Resident 24] would also like to create a DPOA [Durable Power of Attorney] for health care and for finances. This will require a notary and SW will discuss this with [resident's son] when [they] calls back as well. Record review showed no indication facility staff attempted to assist Resident 24 to create the DPOA. In an interview on 09/14/2021 at 8:55 AM, Staff H (Social Services Director) confirmed the resident should have been, but was not, assisted with the formation of a POA as requested. Resident 50 Resident 50 admitted to the facility on [DATE] and according to the 08/11/2021 admission MDS was able to understand and be understood in conversation, was assessed as cognitively intact. In an interview on 09/08/2021 at 10:04 AM, Resident 50 indicated they had a DPOA for healthcare. Record review on 09/09/2021 showed no evidence of a DPOA. In an interview on 09//09/2021 at 11:35 AM, Staff H was asked to provide the resident's DPOA paperwork. In an interview on 09/10/2021 at 11:17 AM Staff H (Social Services) stated, It (POA) wasn't in the record, [they] (POA) is bringing it today. Resident 34 Resident 34 admitted to the facility on [DATE] and according to the Quarterly MDS dated [DATE], Resident 34 was assessed as cognitively intact, was able to understand and be understood in conversation. Record review showed no indication facility staff attempted to assist Resident 34 to create or develop AD. In an interview on 09/14/2021 at 2:55 PM Staff H (Social Services Director) confirmed the resident should have, but was not, assisted with the formation of an AD. Resident 37 According to the 07/27/2021 Admissions MDS, Resident 37 admitted to the facility on [DATE]. According to the 07/27/2021 Quarterly MDS, Resident 37 was assessed to be cognitively intact and was able to understand and be understood in conversation. Review of Resident 37's record on 09/08/2021 at 11:35 AM, revealed no AD. In an interview at 01:17 PM on 09/14/2021, Staff H stated that they were unable to locate an AD. Staff H stated that without having the AD available in the record, they could not be sure what directives it included, and that the last time they requested a copy was 2018. Resident 1 Resident 1 was admitted to the facility on [DATE] and according to the admission MDS was able to understand and be understood in conversation and was assessed as cognitively intact. In an interview on 09/09/2021 at 11:57 AM, Resident 1 reported they had Advance Directives and stated, yes, my dad is power of attorney has a copy of everything. Record review on 09/08/2021 at 12:13 PM showed no evidence of a POA. In an interview on 09/13/2021 at 10:25 AM, Staff C stated advance directives are important to have readily available to help with making decisions as needed. Resident 317 Resident 317 was admitted to the facility on [DATE] and according to the 09/03/2021 admission MDS, was able to understand and be understood and was determined to be cognitively intact. In an interview on 09/10/2021 at 12:13 PM, Resident 317 indicated they had ADs and stated, my daughter is DPOA. Record review on 09/08/2021 at 12:15 PM showed no evidence of a DPOA. Resident 316 Resident 316 admitted to the facility on [DATE] and and according to the 09/06/2021 admission MDS was able to understand and be understood in conversation and was assessed to be cognitively intact. Record review on 09/08/2021 at 12:15 PM showed no evidence of a DPOA. In an interview on 09/13/2021 at 8:33 AM, Resident 316 stated they had a POA prior to being admitted to facility. In an interview on 09/13/2021 at 8:59 AM, Staff AA (Health Information Manager) indicated that any AD's should be in the resident's chart. Staff AA stated they would always be in the hard chart or the e-doc (electronic documents) section and stated, they don't exist if we can't find them there. Resident 2 Resident 2 admitted to the facility on [DATE] and according to the admission MDS, was able to understand and be understood in conversation, and was assessed as cognitively intact. In an interview on 09/07/21 at 12:33 PM, Resident 2 indicated they had a DPOA for healthcare. Record review showed no evidence of a DPOA. Resident 19 Resident 19 admitted to the facility on [DATE] and according to the admission MDS, was able to understand and be understood in conversation, was assessed as cognitively intact. In an interview on 09/07/2021 at 10:15 AM, Resident 19 indicated they had a DPOA for healthcare. Record review showed no evidence of a DPOA. Resident 47 Resident 47 admitted to the facility on [DATE] and according to the admission MDS was able to understand and be understood in conversation, was assessed as cognitively intact. In an interview on 09/08/2021 at 10:45 AM, Resident 47 indicated they had a DPOA for healthcare. Record review showed no evidence of a DPOA. REFERENCE: WAC 38-97-0300(1)(b),(3)(a-c). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure carpets, walls and other furnishings were well maintained for residents in 3 of 3 Units reviewed (A, C, and D Units). This failure left residents at risk for diminished quality of life and a less than homelike environment. Findings included . Carpets Observations made from 09/09/2021 at 10:43 AM through 09/16/2021 at 8:25 AM, showed the green carpeting located by the Unit D nurse's station had copious permanent white stains throughout the area, and two small red stains. Further observations on showed the green carpet outside room [ROOM NUMBER] had dark stains measuring 8 inches in diameter. On 09/16/2021 at 8:26 AM, additional large black permanent stains were noted by the Unit D med cart, by the equipment storage area next to the storage room with an ice machine, by the corner near the garbage can and by the fire doors from Unit D to Unit C. On 09/16/2021 at 8:29 AM, innumerable black-ish stains were observed on the green carpet surrounding the Unit C nurse station. On 09/16/2021 at 8:31 AM, the carpet at the Unit A nurse station was observed with numerous dark permanent stains on the carpet where the cart used to collect used meal trays was parked. A large dark stain was observed on the carpet outside the clinical managers' office. During observation rounds made on 09/16/2021 at 9:05 AM, Staff P (Manager of Plant Operations) acknowledged the permanent carpet stains on the three units and indicated that the stains had been here for some time. Padded Border Around Nurses Stations On 09/11/2021 at 10:26 AM, a padded border was observed to be attached along the entire edge of the Unit D nurse's station. The border was observed to be missing large chunks along its length, exposing the interior foam. Observations of the Unit C nurse station showed that the same padding had been installed there also, and this padding was also missing large chunks. In an interview and observation on 09/16/2021 at 9:05 AM, Staff P stated that the foam padding was in disrepair and needed replacement. Walls On 09/07/2021 at 9:30 AM, a large, scuffed area with a hole in the wall that exposed the dry wall was observed by the vent in room [ROOM NUMBER]. On 09/12/2021 at 9:48 AM, in room [ROOM NUMBER], a large hole and scrape was observed by the headboard of the bed nearest the door and a gouge mark was noted on the wall at the foot of the bed at chair height. On 09/16/2021 at 8:05 AM, in room [ROOM NUMBER], a large scrape was observed on the wall between the door and the sink. On 09/16/2021 at 8:07 AM in room [ROOM NUMBER], a scrape was observed on the wall just above the floor, exposing dry wall. Damage to walls in resident rooms was also noted in rooms 108, 112, 116 and 124. In an interview on 09/16/2021 at 9:05 AM, Staff P confirmed the condition of the damaged walls, stating that the walls in some resident rooms needed repair. Wheelchairs According to the facility's 09/2021 Wheelchair Cleaning Process policy, caregivers should gather wheelchairs after residents are in bed and wipe down any visibly soiled wheelchairs. The policy directed staff to return the wheelchairs to the assigned resident once clean. On 09/09/2021 at 10:38 AM, a large wheelchair in the hall of Unit D was observed to have a worn-out seat cushion with holes on the fabric. The chair was observed to have crumbs and debris on the cushion. A second chair was also noted with no cushion cover, exposing the plastic surface of the cushion. This chair was also noted to have dried food particles on the interior surface of the arm rest and around the cushion. In an interview on 09/09/2021 at 1:17 PM, Staff FF (Licensed Practical Nurse) stated that Nursing Assistants on night shift were responsible for cleaning of wheelchairs. A review of the Unit D Cleaning Schedule showed records for regular cleaning of wheelchairs completed in 2019 and 2020, but no record for 2021. REFERENCE: WAC 388-97-0880. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure care plans (CPs) accurately reflected resident care needs for 12 (Residents 24, 50, 45, 3, 15, 2, 46, 317, 54, 23, 18 and 19) of 21 sample residents reviewed. This failure placed the residents at risk for unmet care needs. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 04/14/2021 admission and 07/07/2021 Quarterly Minimum Data Sets (MDS, an assessment tool) with multiple medically complex diagnoses including diabetes and had no locomotion on or off the unit during the assessment periods. In an interview on 09/07/21 at 1:13 PM, Resident 24 stated they preferred bed baths and chose not to get out of bed. According to a 04/08/2021 RISK for constipation CP, staff were directed to encourage [the] resident to get out of bed daily and get exercise. The same intervention was listed on a 04/08/2021 CP which identified the resident was at risk for shortness of breath due to congestive heart failure. In an interview on 09/11/2021 at 10:25 AM, Staff C (Clinical Manager) stated the resident was bed bound and it was not reasonable to encourage the resident to get out of bed daily. Resident 45 Resident 45 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly MDS, the resident was cognitively intact, required extensive assistance with bed mobility, transfers, and hygiene, and received Physical Therapy (PT) services. Review of a 08/24/2021 PT note showed Resident 45 was able to remain standing with contact guard assist for approximately two minutes. According to a 08/11/2021 Risk for inadequate nutrition . CP, Resident 45 being Bedbound placed her at increased nutritional risk. The goal was that the resident would maintain weight (wt), with no significant wt loss from 179 pounds (lbs). Review of Resident 45's wt flowsheet showed a 08/01/2021 wt of 164 lbs. During an interview on 09/16/2021 at 7:58 AM, Staff D, (Clinical Manager), indicated the CP inaccurately identified the resident as bedbound and that Resident 45's goal wt needed to be updated. According to a 06/10/2021 At risk of inadequate nutrition . CP, an intervention was listed as Customize meal for carbohydrate control. However, according to Staff L, (Dietary manager), the facility does not provide a controlled carbohydrate diet. During an interview on 09/16/2021 at 7:58 AM, Staff D, acknowledged the diets the facility offers had changed, and stated that the CP needed to be updated. An At risk for complications related to diagnosis of cancer of the skin CP had a listed goal of Will express pain relief with ordered medications within 30-60 minutes of administration. The CP did not identify the location of the skin cancer, any goals related to the spread of the cancer, or direct staff to observe or monitor the site and/or report changes to the MD. Record review showed it was on the left upper lip, at the line between the lip and normal skin. During an interview on 09/16/2021 at 7:58 AM, Staff D, stated that the CP should be personalized and identify the location of the skin cancer, as well as provide staff direction on how to manage it. When asked if those elements were in place Staff D stated, No. A 08/10/2021 At risk for dehydration . CP, directed staff to encourage fluids. A 08/10/21 Has constipation . CP, also directed staff to encourage fluids. A 08/10/2021 Overactive Bladder . CP, directed staff to encourage to decrease fluids at bed time. Review of the Pocket Care Guide, [PCG] a quick reference version of the CP, provided to nursing assistants because they don't have access to the comprehensive CP, showed no direction to encourage fluids, or to decrease fluid intake at bedtime. During an interview on 09/16/2021 at 7:58 AM, Staff D indicated the [PCG] needed to be updated and the conflicting interventions related to fluids (encourage fluid/encourage a decrease in fluids) should be written more clearly. Resident 3 Review of an 08/30/2021 event investigation showed Resident 3 was observed to have a 3.8 centimeter (cm) by 2.5 cm deep tissue injury (DTI) to the right heel. A 08/30/2021 DTI . CP, directed staff to report changes such as increased size or stage to the MD. However, record review on 08/15/2021 showed no indication any measurements were obtained since the initial measurements on 08/30/2021. During an interview on 09/16/2021 at 7:58 AM, when asked for documentation to support that staff measured the identified DTI since the initial measurement on 08/30/2021, Staff D said no, and acknowledged this precluded staff from implementing the intervention. Review of Resident 3's PCG showed direction to staff to ensure the resident was sitting upright during meals and 30 minutes after meals as tolerated, cue him to take small bites/sips and alternate, bites/sips. On 09/13/2021 at 1:00 PM Resident 3 was observed lying in bed, with the head of bed (HOB)at approximately 30 degrees, attempting to eat lunch. The overbed table was at eye level and the resident was observed stretching his neck in an attempt to visualize the food on his tray. On 09/13/2021 at 1:05 PM, Staff V, (Licensed Practical Nurse), confirmed Resident 3's HOB was at 30 degrees. When asked how staff ensure the residents HOB is upright and the resident alternates bites/sips Staff V indicated the staff provide in/out supervision. Staff V then acknowledged Resident 3's CP was not followed. Resident 15 Resident 15 admitted to the facility on [DATE]. According to the 06/28/2021 Quarterly MDS, the resident had a diagnosis of kidney failure and required dialysis. Review of the resident's current Physician's Orders showed a 03/18/2021 order for a low potassium diet. A 06/29/2021 Inadequate nutrition . CP directed staff to offer nutritional supplement daily(nurses aides were identified as the staff to complete this task.) The type of supplement was not identified. A 01/05/2021 Inadequate nutrition . CP directed staff to offer snacks frequently. There was no instruction on the type of snacks (e.g. low potassium) that should be offered, how frequently, or where the type and amount of snacks given would be documented. During an interview on 09/16/2021 at 7:58 AM, when asked if bananas could be given as a snack, Staff D confirmed the CPs directing staff to provide nutritional supplements and offer frequent snacks, needed to be clarified, given the resident's low potassium diet. A 06/29/2021 Constipation . CP and a 10/06/2021 At risk for internal bleeding .CP, directed staff to encourage fluids and the latter to monitor weight and fluid intake. However, record review revealed no indication facility staff were monitoring Resident 15's fluid intake, other than fluids provided with meals. Review of the PCG for Resident 15, showed no direction to staff to encourage fluids, offer snacks, offer supplements or to monitor fluid intake, even though nurses aides were identified as one of the disciplines to carry out the tasks. During an interview on 09/16/2021 at 7:58 AM, Staff D indicated the CPs and PCG needed to be updated and should reflect each other, but did not. Resident 2 Resident 2's 04/13/2020 Visual Impairment . CP directed staff to keep bed in low position. Observations on 09/07/2021 at 10:30 AM, 09/08/21 10:14 AM, 09/11/10/21 08:49 AM and 11:09 AM , and 09/13/21 09:49 AM and 11:53 AM, showed Resident 2 lying on a Envella air fluidized therapy bed. On each occasion the control panel at the foot of the bed had the bed not down light flashing. According to the Envella quick tips manual, the bed not down light indicates the bed is not in the lowest position. 09/15/2021 10:06 AM, Staff X, (Registered Nurse), confirmed the Bed not Down light was flashing, indicating the bed was not left in the low position as care planned. A 04/08/2021 at risk for complications related to liver disease listed an intervention of weigh every week with follow up as indicated and observe for weight loss. In an interview on 09/11/2021 at 10:25 AM, Staff C confirmed the resident wasn't weighed since 04/07/2021 and the listed intervention wasn't implemented and indicated in the absence of obtaining weights, there were no additional interventions listed to observe for weight loss. A 02/04/2019 CP identified the resident had a urinary tract infection that would resolve within 21 days. This CP included interventions of observe urine for sediment, cloudiness. In an interview on 09/11/2021 at 10:25 AM, Staff C acknowledged the CP was over a year old and it would be difficult to monitor for sediment or cloudiness as the resident was incontinent. A 02/05/2019 (last reviewed 05/08/2019) CP identified the resident at risk for inadequate nutrition with goals of will maintain weight without clinically significant changes and interventions of adjustments made for blood sugar control. In an interview on 09/11/2021 at 10:25 AM, Staff C confirmed the CP was not updated or recently reviewed and did not address facility failure to obtain weights. Staff C was unable to explain what adjustments were made for the resident blood sugar control. A 04/08/2021 CP indicated Resident 24 had a rash which would heal within 21 days. In an interview on 09/11/2021 at 10:25 AM, Staff C confirmed the CP was not updated nor was it marked as reviewed quarterly. Resident 50 Resident 50 admitted to the facility on [DATE] and according to the 08/11/2021 admission MDS was assessed as cognitively intact and had no use of anticoagulant medication. In an interview on 09/11/2021 at 11:05 AM, Resident 50 indicated she had a previous blood clot to the left arm, but prior to experiencing a stroke, had no physical health problems and denied having a seizure disorder. According to CP documents dated 08/06/2021, Resident 50 had a history of blood clots to the left upper extremity. According to listed goals, the resident would be free of leg pain and would not have redness or swelling of the lower extremities. Interventions included the administration of anticoagulant medications and to observe for pain, cyanosis, warmth or redness of the lower extremity and motor for bleeding related to the use of anticoagulants. In an interview on 09/11/2021 at 10:25 AM, Staff C indicated the listed goals were errors and the interventions were incorrect as the resident didn't have blood clots to the lower extremities and was not on anticoagulant therapy while in the facility. According to a 08/06/2021 CP Resident 50 was at risk for injury during seizures. In an interview on 09/11/2021, Staff C confirmed the resident was cognitively intact and a reliable reporter. Staff C indicated the CP needed to be clarified. A 08/17/2021 CP indicated the resident was at risk for depression as evidenced by .moment and energy . In an interview on 09/11/2021 at 10:25 AM, Staff C stated, I am not familiar with that, I think it needs to be revised. A 08/06/2012 CP indicated the resident is on antipsychotic medication and to monitor for delusions, hallucinations, disorganized speech catatonic behaviors Review of Resident 50's 09/20201 Medication Administration Record (MAR) revealed the resident did not currently take an antipsychotic medication. In an interview on 09/11/2021 at 1025 AM Staff C stated the resident no longer received antipsychotic medications and the CP should be updated. Staff C elaborated that the diagnosis for which the resident received the antipsychotic medication was depression and the behaviors staff were directed to monitor for, did not reflect depression. Resident 46 According to the 08/09/2021 Quarterly MDS, Resident 46 had a diagnosis of hemiplegia/hemiparesis (weakness on one side) following a Cardiovascular Accident (CVA, a stroke). The MDS assessed Resident 46 to require supervision for set up at meal times. Review of Resident 46's Post-CVA Potential For Further Decline Care Plan showed a 10/20/2020 intervention for nursing staff to observe during meals for choking, aspiration. In an interview on 09/13/2021 at 01:18 PM, Staff EE (CNA) stated that Resident 46 was independent with eating and required no assistance or supervision. In an interview on 09/14/2021 at 12:57 PM, Staff Y (CNA) stated that Resident 36 did not require any supervision with eating. In an interview on 09/14/2021 10:15 AM, Staff D (Clinical Manager/RN) stated that Resident 46's care plan intervention to observe for choking and aspiration was necessary due to Resident 46's hemiplegia/hemiparesis diagnosis and concerns for dysphasia (a swallowing disorder). Staff D further stated that CNAs should be providing such oversight, and that as they were not aware of the need for it, Resident 46's care plan was not implemented. Resident 317 Similar findings were revealed for Resident 317 who was admitted to the facility on [DATE] and according to the 09/03/2021 admission MDS was determined to be cognitively intact and was assessed to require extensive physical assistance with bed mobility, transfer, personal hygiene, and bathing. Review of CP dated 08/30/2021 revealed Resident 317 was assessed to be at risk for falls due to poor balance, related to weakness and impaired mobility. According to the facility's daily PCGs dated 09/10/2021 through 09/12/2021, Resident 317 had interventions in place for low bed when in bed with bilateral floor mats. During daily observations made 09/10/2021 through 09/12/2021 Resident 317 did not have bilateral floor mats in place. In an interview on 09/12/2021 at 8:50 AM, Resident 317 stated staff do not use floor mats in their room and denied falling since admission. In an interview on 09/13/2021 at 10:00 AM, Staff C stated the PCGs are an extension of the residents CP and should be accurate. Staff C stated Resident 317 did not require floor mats and that CP/Pocket Care Guide should have been, but was not updated by staff as required. Resident 54 According to the 08/19/2021 admission MDS the resident admitted on [DATE] was assessed to be cognitively intact and had diagnoses of stroke with left sided hemiplegia (paralysis). On 09/10/2021 at 7:18 AM Resident 54 was observed sleeping in bed with bi-lateral (both sides) side rails on the bed. Review of the 05/2020 Mobility Devices & Physical Restraints facility policy showed when a mobility device or physical restraint was being considered for the purpose of meeting residents' medical needs, increased safety or greater independence, an assessment was completed, a consent is obtained, a physician's order was obtained, and the care plan was updated. All parameters should be documented in a progress note. Review of Resident 54's 08/13/2021 Care plan showed no bi-lateral side rails were on plan of care and no directions specified for staff regarding the side rails. In an interview on 09/16/2021 at 9:00 AM Staff B stated bedrails would not be on the pocket guide, when asked if they should be care planned Staff B replied, yes. Resident 23 According to the 06/30/2021 Quarterly MDS the resident admitted on [DATE], was assessed to have moderate cognitive impairment and had history of falling. Review of the 02/18/2020 Fall Care Plan showed the resident was a high fall risk and interventions include to place call light within reach, Hourly visual checks and rounding with toileting every third hour and ensure glasses are worn. Review of the 05/26/2020 Vision Care Plan showed an intervention to keep the bed in low position. On 09/10/2021 at 7:17 AM Resident 23 was observed sleeping in bed, the bed was at hip level. On 09/12/2021 at 9:43 AM Resident 23 was observed sitting in the wheelchair at beside and the call light was observed on the floor on the opposite side of the bed, out of residents reach. At 11:22 AM the call light remained on the floor on the opposite side of the bed, out of the resident's reach. On 09/13/2021 at 8:23 AM the resident was observed sleeping in the bed, the bed was at hip level and the call light was under the resident's pillow. Resident unaware of where call light was located. At 9:24 AM the resident remains in bed at hip height and the call light was observed on the floor out of residents reach. During an interview on 09/13/2021 at 1:01 PM Resident 23 stated the staff usually come in once or twice a shift and offer toileting but it didn't happen all the time. Resident 23's glasses were observed on the bed and when asked why they don't wear them the resident sated I only use them to read. On 09/14/2021 at 8:35 AM Resident 23 was observed up in the wheelchair eating breakfast. Resident's eyeglasses were observed sitting on the bedside table. Review of the 09/13/2021 Frequent Rounding Forms at 9:30 AM showed staff had documented for 6:00 AM, no other documentation observed. A second review of the rounding form was observed at 1:34 PM showed entries for 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM and 11:00 AM. In an interview on 09/16/2021 at 8:45 AM Staff B (Director of Nursing) stated staff do hourly rounding and we educate on the importance of the hourly rounding. Resident 18 According to the 06/30/2021 Quarterly MDS the resident admitted on [DATE] with medically complex conditions, including congestive heart failure and was assessed to require one-person physical assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident required set up help with meals. Review of the 03/25/2021 Incontinence Care plan showed interventions to take the resident to the bathroom before and after meals, at bedtime, upon rising in the morning and when awakens during the night. Review of the 03/25/2021 Visual Impairment Care Plan showed an intervention to keep the bed in the low position. In an interview on 09/08/2021 at 11:33 AM Resident 18 stated that they take themselves to the bathroom and wear a depends for incontinence management. On 09/09/2021 at 12:53 PM the resident was observed reading a newspaper in bed, the bed was hip height. Similar observations were made on 09/10/2021 at 7:19 AM, 09/11/2021 at 8:50 AM, 09/12/2021 at 9:24 AM, 09/13/2021 at 9:26 AM and 09/14/2021 at 8:44 AM. During an interview on 09/11/2021 at 8:50 AM the resident stated they were in the bathroom getting ready for the day because no one woke them up until 7:50 AM and they just left the breakfast tray. Resident stated that sometimes it is problematic getting help with setting up meal tray. Some open stuff for me and certainly others do not. Resident observed using a butter knife to puncture orange juice lid and struggled to get the lid off the oatmeal. In an interview on 09/16/2021 at 9:00 AM Staff B stated they weren't sure why Resident18's care plan would say bed in the low position but believe the bed to be an appropriate height for the resident. Resident 19 Resident 19 was admitted to the facility on [DATE] with diabetes and a trauma related subdural hematoma (brain bleed). The MDS dated [DATE] showed Resident 19 required two-person extensive physical assistance with bed mobility and at risk for developing pressure injuries. Heel Boots A care plan intervention dated 07/06/2021 directed staff to Please have resident wear Prevalon (pillow type) boots for skin protection when lying in bed. Observations on 09/07/2021 at 2:43 PM, on 09/08/2021 at 10:34 AM, on 09/09/2021 at 12:43 PM, on 09/10/2021 at 8:25 AM, on 09/11/2021 at 8:45 AM and on 09/12/2021 at 8:40 AM showed Resident 19 not wearing Prevalon boots while in bed. Observation on 09/15/2021 at 2:32 PM showed Resident 19 without Prevalon boots when lying in bed. In an interview on 09/15/2021 at 2:32 PM Staff NN (Nursing Assistant) observed and confirmed Resident 19 was in bed and the Prevalon boots were not on the resident's feet. Staff NN took the boots from the chair and placed the boots on Resident 19's feet. Positioning A care plan intervention dated 04/05/2021 showed Turn and reposition every two to three hours PRN (as needed). Observations on 09/09/2021 showed Resident 19 sitting in bed with head of bed at 45-degree angle at 8:32 AM, 10:34 AM, 12:42 PM, and 1:32 PM. At each observation there was no shifting of weight or offloading buttocks from pressure. In an interview on 09/16/2021 at 11:15 AM Staff B (DNS- Director of Nursing) was asked if a resident on a two to three hour turn schedule as needed should be in the same sitting position for five hours. Staff B stated No. Blood Sugar Monitoring Care plan intervention dated 04/05/2021 showed Monitor blood sugar levels per MD order and notify MD of abnormal findings as indicated. Review of active physician orders signed 09/01/2021 showed no orders for blood sugar monitoring. In an interview on 09/10/2021 Staff FF (Nursing Assistant) stated Resident 19 does not have blood sugar monitoring and the care plan needed to be updated. In an interview on 09/16/2021 at 11:15 AM Staff B (DNS) was asked if the care plan for all residents was expected to be updated, current and followed by all staff. Staff B replied, Yes. REFERENCE: WAC 388-97-1020(2)(c)(d) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure professional standards of practice were met for 12 (Residents 47, 34, 38, 50, 61, 46, 317, 45, 3, 15, 18, 23, 54, 19 & 2) of 21 sampled residents. Facility failure to follow and /or clarify physician's orders when indicated (Resident 38, 50, 34, 45, 61, 46, 317, 18, 15, 23, 2, 19, & 54) only sign, for physician orders performed (Resident 3 & 34), evaluate and monitor fluid restrictions (Resident 47), in accordance with professional standards, placed all residents at risk for medication errors, delays in treatment, and negative outcomes. Findings included . Follow/Clarify Physician Orders (PO) Resident 38 Observations on 09/13/21 at 9:10 AM showed Staff F, Licensed Practical Nurse, prepare and administer Ketotiphen 0.035% eye drops (allergy medication) to Resident 38. According to PO, staff were to administer Ketotiphen 0.025%, the incorrect strength. In an interview on 09/13/21 at 9:39 AM, Staff S confirmed the medication dose administered did not match the PO and indicated nursing staff should have identified the discrepancy and clarified the order. Record review showed Resident 38 was prescribed a low potassium diet prescribed on 3/18/2021. Record review showed the resident was identified with low potassium levels and telephone orders dated 09/02/2021 showed the resident was started on Potassium Chloride (a medication used to treat low potassium levels). In an interview on 09/15/2021 at 11:55 AM Staff C (Clinical Manager) indicated nursing staff should have clarified, with the physician, the continued need of a low potassium diet in the presence of a potassium supplement. Review of September 2021 Medication Administration Records (MAR) showed directions to staff to administer Lispro Insulin 3 units twice a day and to hold the medication if blood glucose less than 150. Review of this MAR showed a blood sugar level of 137 on 09/01/2012. Staff administered the insulin with the resident's blood sugar outside of the physician ordered parameters. In an interview on 09/15/2021 at 11:55 AM, Staff C confirmed staff should have, but did not, follow the physician's order. Review of September 2021 MARs showed an order to apply a Lidocaine patch each morning for pain and a separate order directed staff to remove the patch each evening. According to this MAR, the pain patch was held on three days from 09/01/2021 through 09/08/2021, however evening shift staff signed indicating the patches were removed on days when it was held. In an interview on 09/15/2021 at 9:25 AM, Resident 38 reported they were refusing the patches because they're not effective and indicated they hadn't used the patch in a long time. In an interview on 09/15/2021 at 11:55 AM, Staff C indicated the record shouldn't reflect removal of a patch that was never applied. Record review with Staff C on 09/16/21 09:56 AM showed nursing staff read a skin test for tuberculosis as negative. In an interview at this time, Staff C stated that the nurse should have documented 0 mm if that was the result, not negative. Resident 50 Resident 50 admitted to the facility on [DATE] and according to the admission Minimum Data Set (MDS, an assessment tool), dated 08/11/2021 was able to understand and be understood and was cognitively intact. According to the POs dated 08/05/2021 staff were instructed, left eye care: close left eye with steri strips at bedtime for sleep. Observations on 09/07/2021, 09/08/2021, on 09/09/21 at 10:10 AM showed Resident 50 with three steri strips to the left eye. Observations on 09/10/21 and 09/11/2021 at 8:37 AM and 9:30 AM showed the resident's left eye was taped shut with paper tape. In an interview on 09/11/21 at 9:45 AM Staff S (Registered Nurse) stated, When she first came, she had steri strips; now she will request tape. When asked why the resident's eye was secured closed during the day, rather than the ordered, at bedtime for sleep, Staff S stated, I have to check the order. After reviewing the record, Staff S stated, The order is for nighttime, but she wants it during the day I don't see an order today for the tape .the provider probably forgot to put it in. In an interview on 09/11/2021 at 10:10 AM, Staff C stated nurses should follow the physician orders or get the orders clarified to ensure the orders are what the physician requested and what the resident required. According to September 2021 MARs staff were instructed to obtain weekly weights each morning on Wednesday and if more than 3 lb [pound] difference re-weight. If still greater than 2 lb difference, notify provider. According to this document Resident 50 was assessed as 145.8 lb on 09/01/2021 and 142.6 on 09/08/2021. Record review showed no indication the provider was notified of the more than three lb change in a week. In an interview on 09/11/2021 at 10:10 AM, Staff C was asked to provide information to support nursing staff notified the provider as directed. No information was provided. Resident 45 Review of Resident 45's current orders showed 05/14/2021 orders for: Oxycodone 5 mg (milligram) every four hours as needed for moderate pain; and Oxycodone 10 mg every four hours as needed for severe pain. The order did not include an objective way to quantify the severity of pain. Review of the August 2021 MAR showed: on 08/12/2021 for a pain level of 7, the resident was medicated with 5 mg of oxycodone; but on 08/14/2021 for a pain level of 7, the resident was medicated with 10 mg of oxycodone. During an interview on 09/16/2021 at 7:58 AM, Staff D, (Clinical Manager), stated that the nurse should have clarified the order, and indicated the facility uses a pain scale of 1-10, and an objective range such as 1-4= mild pain, 5-7= moderate pain, 8-10 - severe pain should have been obtained. Record review showed a 05/14/2021 order for weekly weights (wt), with direction to compare to the previous wt, and notify the MD if greater than a 3 lb wt variance. Review of Resident 45's wt flow sheet showed the following: on 07/04/2021-wt was 172.8 lb; on 07/11/2021- wt was 168.7 lb (-4.1 lb). Record review showed no indication the Medical Doctor (MD) was notified as ordered. Additionally, the facility failed to consistently obtain weekly wt as ordered. During an interview on 09/16/2021 at 7:58 AM, Staff D stated that it was the nurse's responsibility to ensure weekly weights were obtained as ordered and acknowledged that staff did not ensure weights were obtained according to physician orders. When asked if there was any documentation to support the MD was notified of the 4.1 lb weight loss from 07/4/2021 to 07/11/2021 Staff D stated, No. Resident 34 According to the Quarterly MDS dated [DATE], Resident 34 was assessed as cognitively intact and indicated it was very important to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident 34's active orders dated 06/08/2021 reflected Wrap Coban (elastic bandage) dressing to bilateral extremities every morning and remove at bedtime. Observations on 09/10/21 at 1:38 PM showed Resident 34 sitting up in a bed in her room and was noted with bilateral (both right and left) edema. At this time the resident stated, They (legs) swell like that . if you take the socks off you can see how puffed up, they are. Similar observations were noted on 09/12/21 at 10:19 AM, 09/13/21 at 8:40 AM, 09/14/21 at 9:02 AM, 09/15/21 at 10:40 AM, and 12:03 PM, when the resident was noted sitting in a wheelchair with feet dependent and not wrapped with Coban dressing Review of the treatment administration record (TAR) dated 08/10/21 through 09/09/2021 morning treatment showed Resident 34's Coban wraps were not applied for seventeen days, and the reason was listed as resident declined. Review of Treatment administration record dated 08/10/21 through 09/09/2021 bedtime treatment showed, Resident 34's Coban wraps were removed daily. In an interview on 09/14/21 at 11:30 AM, Staff FF confirmed that Resident 34's wraps were not applied to the resident and the resident missed many days without the leg wraps. When asked what wraps were removed by the evening staff when the wraps were not applied, Staff FF stated that if the wraps were not applied in the morning the nurse will not document removed. In an interview on 09/15/21 at 10:30 AM, Staff D (Clinical Manager) confirmed that Resident 34's wraps were not applied, and the expectation was leg wraps should be applied. If the resident declined multiple times, the physician should be notified to review the treatment. When asked if evening nurses should document leg wraps were removed, Staff D said No, it was not applied. Resident 61 Resident 61 admitted to the facility on [DATE]. According to the 05/24/2021 Quarterly MDS, the resident had severe cognitive impairment, hemiplegia (paralysis of one side of the body) required extensive assistance of two persons assist with hygiene and bathing. Review of Resident 61's dental recommendation dated 04/16/2021 showed Have (MD) check and put on Nystatin, dry lips possible angular cheilitis (redness and cracking at sides of the mouth). This recommendation was not followed or addressed by the physician. In an interview on 09/15/21 at 10:30 AM, Staff C (Resident Care Manager) confirmed that the dental recommendation was not followed by the MD. Nurses are responsible to review dental report and notify the MD with any recommendations. When asked if Resident 61's recommendations were followed, Staff C said, No. Resident 46 Review of Resident 46's POs revealed an 02/15/2021 order for Hydromorphone 2 mg, an opioid (narcotic) pain medication. The order stated to give every four hours as needed for severe pain (7-10 out of 10) and to **GIVE ACETAMINOPHEN FIRST**. Further record review showed Resident 46's Acetaminophen 500 mg order for pain 3-6 out of 10, was discontinued on 7/22/2021, and replaced with an order for Ibuprofen 200 mg for pain. In an interview on 09/14/21 at 10:22 AM, Staff D, Clinical Manager, stated that the change from Acetaminophen to Ibuprofen should have prompted nursing staff to get the order for Hydromorphone updated and clarified, but the Hydromorphone order remained unchanged from that date. Resident 317 Resident 317 admitted to the facility on [DATE] and according to the 09/06/2021 admission MDS, Resident 317 was admitted with multiple complex diagnosis including kidney failure and diabetes. This assessment showed Resident 317 required the use of daily insulin (a medication used to treat diabetes) and dialysis services. Review of Resident 317's care plan dated 08/30/2021 revealed the resident was at risk for hyperglycemia (high blood sugar) episodes secondary to diabetes and included an intervention for insulin injections as ordered by physician. This care plan also indicated Resident 317 was at risk for complications of renal failure and had interventions to go to dialysis center on Tuesdays (T), Thursdays (TH), and Saturdays (SAT). Review of August and September 2021 MARs showed an order instructing staff to administer Lispro (a type of short-acting insulin) 3 units before each meal. According to these MARs staff documented the 7:30 AM dose as held due to resident not in facility, on 08/28/2021, 08/31/2021, 09/02/2021, 09/04/2021, 09/07/2021, 09/09/2021, and 09/11/2021. Further review of these MARs showed staff were also directed to administer Lantus (a type of long-acting insulin) 13 units each morning before breakfast. Staff documented this was not administered on 08/28/21, 08/31/2021, 09/02/2021, 09/04/2021, 09/07/2021, 09/09/2021, and 09/11/2021 due to resident not in facility. In an interview on 09/15/2021 at 11:48 AM, Staff C stated Resident 317 goes to the dialysis center three times a week on T/TH/SAT. Staff C stated residents on dialysis should receive insulin as ordered and that it was not one of the medications typically held on dialysis days. During a follow up interview on 09/16/2021 at 11:40 AM, Staff C stated Resident 317 did not but should have received insulin as ordered by the physician. Resident 18 According to the 06/30/2021 Quarterly MDS Resident 18 had diagnoses of hypothyroidism (low thyroid function). Review of the September 2021 MAR showed Resident 18 took Levothyroxine 75 mcg (micrograms) each morning between 6 and 10 AM for hypothyroidism. On 9/11/2021 at 8:50 AM Resident 18 was observed eating their breakfast of oatmeal and orange juice. On 09/11/2021 at 9:08 AM Staff F (Registered Nurse) was observed administering Resident 18's morning medications, four pills total which included Levothyroxine. The resident was observed taking four pills with yogurt. In a combined interview with Staff F (Registered Nurse) and Staff D (Clinical Manager) on 09/11/2021 at 11:38 AM they were asked if there are special instructions for any of the medications that were given. Staff F (Registered Nurse) replied, Levothyroxine should be given before breakfast and confirmed it was not given on an empty stomach to Resident 18. Review of the September 2021 MAR showed Resident 18 took Protein Shakes, one cup with meals three times a day at 8 AM, 12 PM and 5:30 PM. On 09/10/2021 at 8:39 AM the resident was observed in their room eating breakfast. Resident 18 stated they always send me a protein shake, but I never drink it. When asked why, the resident further explained if they don't care for the food that meal, they will drink it but usually never do. In an interview on 09/13/2021 at 11:01 AM Staff BB (Licensed Practical Nurse) stated they document on the MAR that the resident received the shake, not how much they consumed. At 11:34 AM Staff BB was asked how much Resident 18 consumed of the shake, Staff BB responded, I am not sure, I didn't look. On 09/13/2021 at 1:22 PM Resident 18's lunch tray was observed with the protein shake not consumed. On 09/14/2021 at 11:20 AM Staff D (Clinical Manager) stated we document the 1 cup on the POC (Point of Care) charting. I am unsure if the protein shake is documented separate from other fluids. When asked if Resident 18 was consuming the protein Staff D stated I haven't heard they aren't consuming it. Review of September 2021 POs showed Resident 18 had an order to check weight weekly and to notify the provider of a three lb weight gain or loss. During an interview on 09/14/2021 at 11:20 AM Staff D stated Resident 18 had an order to check weights due to diagnosis of congestive heart failure and chronic kidney disease. Staff D further indicated an M in the MAR or TAR documentation meant missed. Review of the July 2021 TAR showed all M's documented for the month of July. Review of the August 2021 TAR showed one weight was obtained on 08/11/2021 and weights were missed on 08/04/2021 and 08/25/2021. An H was documented for 08/18/2021, indicating hold. In an interview on 09/14/2021 at 11:20 AM Staff D stated they would expect weights to be done on the recommended day and shift. If the weight didn't get done the staff should communicate to the next shift to complete the weight. Staff D stated we document weights on a paper vital signs sheet. Documents were asked to be provided; no additional weights were provided. Review of the weights documented in Resident 18's electronic health record (HER) showed on 06/11/2021 residents' weight was 111.60 lb and on 08/11/2021 resident weighed 115.20 lb., indicating a 3.6 lb weight gain. In an interview on 09/14/2021 at 11:20 AM Staff D verified Resident 18 had a 3.6 lb. weight gain and when asked if the provider was notified of the weight gain Staff D stated they would have to look in the Physician communication book to see if the nurse notified them. Staff D was asked to provide those documents and no further information was provided. Resident 23 Similar weight related findings were identified for Resident 23. The facility failed to obtain weekly weights as ordered. Resident 2 Similar weight related findings were identified for Resident 2. The facility failed to obtain weekly weights as ordered. Resident 19 Similar weight related findings were identified for Resident 19. The facility failed to obtain weekly weights as ordered. Resident 54 Similar weight related findings for Resident 54 and facility failing to obtain weights upon admission and weekly as ordered. Resident 15 Similar weight related findings were identified for Resident 15. The facility failed to obtain daily weights on as ordered. Only Sign Physician Orders (PO) Performed Resident 3 On 09/08/2921 at 11:48 AM, Resident 3 was observed with long (approximately 1/2 inch) yellowing fingernails to each digit on both hands Similar observations were made on: 09/10/2021 at 9:41 AM, and 11:53 AM; 09/11/2021 at 8:47 AM and 10:42 AM; and on 09/12/2021 at 1:00 PM. Review of the September 2021 TAR showed a 07/07/2021 order to perform a weekly skin check. Staff were also directed to ensure Resident 18 was well groomed and facial hair and nails were within normal length. According to the TAR, Staff V signed that facial hair and nail care was completed on 09/07/2021. In an interview on 09/13/2021 at 1:05 PM, Staff V confirmed she had signed that nail care was provided on 09/07/2021. When asked if the nurse had provided the care, Staff V stated, No. A 08/31/2021 5:20 PM nurses note stated that Resident 3's right anterior shin had an open area with dried serosanguinous fluid. The area was covered with a non-stick dressing. Review of the TAR showed there was no order for a non-stick dressing or any indication that one was applied. During an interview on 09/16/2021 at 7:58 AM, Staff D explained that the facility had a wound care protocol (standing orders) but acknowledged the nurse should have written the order onto the TAR, and signed that the treatment was administered, but did not. Resident 34 According to the 06/13/2021 Quarterly MDS showed Resident 34 had diagnoses of Diabetes Mellitus and Hypertension (high blood pressure), and regularly received insulin, antihypertensives and pain medication. Review of the September 2021 PO showed Resident 34 had an order for 20 units of insulin twice a day with parameters to inject 20 units for a blood glucose (BG) of greater than 100 and Inject 10 units for a BG between 70-100. Review of the September 2021 MAR showed on 09/02/2021 at 8:00 AM Resident 34 had a BG of 93 and 20 units of insulin was given. In an interview on 09/16/2021 at 8:30 AM Staff B (Director of Nursing) stated the insulin dose was incorrect, the resident should have received 10 units per the PO. Review of Resident 34's September 2021 POs showed an order for Hydralazine (an antihypertensive medication) 50 mg by mouth three times daily, hold if systolic blood pressure (BP) less than 100. Review of the September 2021 MAR showed Hydralazine was given three times daily at 8 AM, 2 PM and 8 PM. There was no BPs documented with the order. In an interview on 09/16/2021 at 8:30 AM Staff B (Director of Nursing) stated the Certified Nurses Assistants (CNA) document the vital signs on paper. Staff B provided a copy of the Vital signs sheet. Review of the vital sheets revealed staff were checking Resident 34's BP once on day shift and once on evening shift. According to the September 2021 PO the resident's BP should be checked twice on evening shift at 2 PM and 8 PM before administering Hydralazine. No other documents were provided. Review of Resident 34's September 2021 POs showed an order for Oxycodone 10 mg by mouth every six hours as needed for pain. Review of the August 2021 and September 2021 MAR showed Resident 34 received Oxycodone 32 times between 08/11/2021-09/09/2021 and the pain medication effectiveness was followed up on only two occasions. In an interview on 09/16/2021 at 8:30 AM Staff B stated when a pain medication was given the effectiveness should be evaluated roughly 30-45 minutes after. Staff B would expect it to be documented in the medical record on the MAR or in a progress note. Further stating we need to be more consistent with this. Monitor Fluid Restriction Resident 47 According to a 08/09/2021 MDS, Resident 57 was admitted to the facility on [DATE] with a diagnosis of heart failure and kidney disease. Review of the 08/28/2021 PO showed Resident 47 was on a fluid restriction during each shift and could not have more than 1500 milliliters (mL) of fluids in a 24-hour period. Review of the September 2021 fluid intake records showed documentation by the nurse and nursing assistant in two different places. The total intake from the nurse and nursing assistant records was totaled on a 9 day look back period as follows: 09/09/2021 was 2640 mL, 09/08/2021 showed 2080 mL, 09/07/2021 showed 1720 mL, 09/06/2021 showed 1740 mL, 09/05/2021 showed 1940 mL, 09/04/2021 showed 2040 mL, 09/03/2021 showed 2020 mL, 09/02/2021 showed 1680 mL and 09/01/2021 showed 1780 mLs. There were no records provided that showed a 24-hour calculation of total fluid intake. There was no documentation provided that indicated nursing staff reviewed the data to identify if the fluid intake exceeded the physician ordered 1500 mL restriction. In an interview on 09/11/21 at 9:25 AM with Staff EE (NAC) about Resident 47's fluid restriction revealed, the resident is given 120 cc cup of fluid with meals and ice chips and documented on the nursing assistant records for meal intake. In an interview on 09/15/21 01:37 PM Staff D (Resident Care Manager) stated an order for fluid restriction was divided in half. Staff D stated 50% of the allotted amount was provided during meals and the remaining 50% was provided by nursing for medication administration. Staff D stated the intake was recorded by the nurse on the MAR and the pocket guide (CNA resident care resource) tells the nursing assistant which resident is on a fluid restriction. Staff D further stated, The nurses do not do a 24-hour recap; I was not educated on how to do that process. In an interview on 09/16/2021 11:15 AM Staff B (DNS) stated the nurses are expected to document on the MAR the amount of fluid intake each shift when a resident is on a fluid restriction or fluid intake monitoring. The nurse is expected to review the intake total daily and report discrepancies to the practitioner. REFERENCE: WAC 388-97-1620 (2)(b)(i)(ii), (6)(b)(i). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**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 8 (Residents 24, 45, 3, 61,316, 317,19, 18, 54 & 23) of 8 sample residents and 1 (Residents 61) supplemental residents reviewed for Activities of Daily Living who were dependent on staff for care. Failure to provide timely assistance with bathing (Residents 24), oral care (24) and nail care (Residents ) as specified in their care plans did not promote comfort and a sense of well-being for these residents. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 07/07/2021 Quarterly Minimum Data Set (MDS, an assessment tool) was determined to have moderate cognitive impairment and required extensive two person physical assistance with bed mobility, transfers, and personal hygiene an required the assistance of two staff for bathing. In an interview on 09/07/21 at 1:13 PM, Resident 24 reported staff did not assist her with oral care and bathing was not provided as frequently as desired. The resident stated staff did not provide assistance to brush their teeth and was unsure when the last time oral care was received and bathing should be twice a week but wasn't. Observations at this time showed the resident had white debris in the gumline with hair that appeared unwashed. Also noted at this time was an unopened, unused bottle of mouthwash and a plastic sealed, unopened toothbrush in a basin next to the sink. Similar observations of the unopened mouthwash and sealed toothbrush was noted on 09/08/2021, 09/09/2021, 09/10/2021, 09/11/2021, 09/12/2021 and 09/13/2021. During an observation on 09/13/21 at 10:00 AM Staff C (Clinical Manager) confirmed Resident 24 reported that no oral care was provided by staff and confirmed the presence of the unopened mouthwash and toothbrush at the sink. At this time, Staff C looked for, but found no other oral care items in Resident 24's room. In an interview on 09/13/2021 at 10:10 AM Resident 24 stated they hadn't brushed her teeth in a long time and they don't brush their teeth because their gums and teeth are sore and loose. Resident 24 reiterated at this time no oral care was provided either by brushing or by toothettes (a soft sponge on a stick used to provide gentle oral care). In an interview on 09/13/21 at 10:34 AM Resident 24 stated that an aide just provided care and, gave me one of those sponges on a stick. No, I won't use a tooth brush it bothers my teeth, but the sponge thing is good. Review of Medication Administration Records (MARs) showed instruction to staff of Shower Bed bath for hygiene during evening shift weekly on Tuesday, Friday. According to the August 2021 MAR, staff documented M on 08/03/2021, 08/13/2021, 09/20/2021, 08/24/2021, 08/27/2021 and 08/31/2021, six of nine opportunities for the twice weekly bathing schedule. In an interview on 09/09/21 at 11:04 AM, Staff U (Clinical Nurse Manager) explained that the M meant Missing and if the instructions are not implemented and staff don't document anything, an M shows up. In an interview on 09/12/21 at 11:30 AM, Staff C stated that direct care staff documented bathing on a separate Shower Schedule and that residents were scheduled for bathing twice a week based on that document. Staff C confirmed, after review of these documents, Resident 24 was not consistently bathed twice a week and no refusals were documented. Resident 45 Resident 45 admitted to the facility on [DATE]. According to the 08/09/2021 Quarterly MDS, the resident was cognitively intact with clear comprehension, and required extensive assistance with bed mobility, transfers, toileting and personal hygiene. The amount of assistance the resident required with bathing was not assessed, as no bathing was provided during the seven day assessment period In an interview on 09/08/21 at 10:54 AM, Resident 45 indicated she was supposed to receive two showers a week, but usually only received one. Resident 45 then stated, I have a condition in my private area I won't elaborate on, I NEED [my showers] The resident reported that her condition .was improving, but then [staff ] didn't show up [to provide the scheduled showers], so it started to get worse again .I really need at least three [showers] a week. Review of Resident 45's August 2021 Medication Administration Record (MAR), showed the resident had a 06/14/2021 order Miconazole (a topical anti-fungal) cream, to be applied to the groin and perineal area twice daily to treat candidiasis (an infection of the skin and/or mucous membranes caused by the common yeast species Candidiasis). On 08/23/2021, after more than two months of topical treatment, the infection resolved and the treatment was discontinued . However, review of the September 2021 MAR showed on 09/07/2021, 14 days later, an order was obtained to restart the Miconazole, as well as, add Fluconazole (an oral antifungal medication). Review of the Unit C shower flowsheets showed Resident 45 was to be showered twice weekly on Tuesdays and Saturdays. Review of Resident 45's shower record from 08/18//2021 - 09/06/2021, showed Resident 45 was provided just one shower in 20 days (08/31/2021). During an interview on 09/16/2021 at 7:58 AM, Staff D, (Clinical Manager), acknowledged facility staff only provided one shower in 20 days from 08/18/2021- 09/06/2021), to a resident who was dependant on staff for the provision of bathing. Resident 3 Resident 3 admitted to the facility on [DATE]. According to the 06/08/2021 admission MDS, the resident was cognitively intact and required extensive assistance with bed mobility, transfers, bathing and personal hygiene. On 09/08/2921 at 11:48 AM, Resident 3 was observed with long (approximately 1/2 inch) yellowing fingernails to each digit on both hands Similar observations were made on: 09/10/2021 at 9:41 AM, and 11:53 AM; 09/11/2021 at 8:47 AM and 10:42 AM; and on 09/12/2021 at 1:00 PM. During an interview on 09/12/2021 at 1:00 PM, Resident 3 stated that they did not like his fingernails that long but did not have a way to cut them. When asked if facility staff would help, Resident 3 stated, No, they don't do fingernails. The resident then indicated staff could get help for toenails, but not fingernails. On 09/13/2021 at 11:54 AM, it was observed that Resident 3's had been trimmed. In an interview on 09/13/2021 at 1:05 PM, Staff V acknowledged on 09/07/2021 she had signed nail care was provided to Resident 3, but confirmed she failed to do so. Resident 61 Resident 61 admitted to the facility on [DATE]. According to the 05/24/2021 Quarterly MDS, the resident had severe cognitive impairment, hemiplegia (paralysis of one side of the body) required extensive assistance of two persons assist with hygiene and bathing. Review of Resident 61's active orders dated 05/20/2021 reflected Bathing hygiene during evening shift weekly on Wednesday, Sunday and document bathing received. Review of Resident 61's Shower/ Bath flow sheets reflected the resident received four showers between 08/02/2021 and 09/10/2021, rather than the ten showers scheduled and on the CP. Further record review showed no documentation to support why staff did not provide the resident with the assessed for bathing. In an interview on 09/13/21 at 12:30 PM, Staff C confirmed that Resident 61's dependent of staff for activity of daily living including showers, when asked if the resident was provided showers as assessed to, staff C said No, not consistent to resident 61's shower schedule twice a week. Resident 316 Resident 316 admitted to the facility on [DATE] and according to the 09/06/2021 admission MDS was determined to be cognitively intact and was assessed to require extensive physical assistance with bed mobility, transfers, personal hygiene, and bathing. In an interview on 09/13/2021 at 8:33 AM, Resident 316 reported that their fingernails were too long for them and wanted to have them clipped. Resident 316 stated the facility did not trim their nails since admission. Observations at time of interview showed Resident 316 had long fingernails with debris under nails to both hands. During the same interview resident also stated they had not been receiving showers and that they felt dirty. During an observation on 09/13/2021 at 12:47 PM, Staff C confirmed that Resident 316's nails were longer than their stated preference and had not been trimmed by staff since admission. Review of weekly facility Shower Schedule forms on 09/16/2021 showed Resident 316 was scheduled for bathing twice a week on Wednesday and Sunday based on that document. Review of these documents showed facility staff had not showered Resident 316 in the last eight days. In an interview on 09/16/2021 at 8:44 AM, Staff C confirmed, after review of the shower schedule forms, staff failed to document any showers as completed for Resident 316 since 09/08/2021. Resident 317 Resident 317 was admitted to the facility on [DATE] and according to the 09/03/2021 admission MDS was determined to be cognitively intact and was assessed to require extensive physical assistance with bed mobility, transfer, personal hygiene, and bathing. In an interview on 09/08/2021 at 8:22 AM, Resident 317 stated they had not had a shower since admission. The resident said they had requested washcloths a couple times to clean themselves up as they did not like to feel unclean. Resident 317 stated their toenails were too long and they were getting caught on the blankets and reported staff had not clipped their nails since admission. Observations at this time showed Resident 317's fingernails to be long with debris under nails. The left thumb nail was jagged, and the resident stated they wanted them trimmed. During a follow up interview on 09/12/2021 Resident 317 again reported staff had not given them a bath since admission and stated, bathing was not in the staff's schedule. Review of the weekly facility Shower Schedule forms on 09/16/2021 showed Resident 317 was scheduled for bathing twice a week on Tuesdays and Fridays. According to these documents staff documented Resident 317 had only one bed bath in the 20 days since admission. In an interview on 09/16/2021 at 8:44 AM, Staff C confirmed that facility should have, but did not provide Resident 317 showers as scheduled. Resident 19 Resident 19 admitted to the facility on [DATE] with a diagnosis of a traumatic subdural hematoma (brain bleed) and a right arm fracture (dominant side). The 07/04/2021 MDS showed Resident 19 was assessed to require extensive assistance and one person physical assistance while eating. A diet order signed by the physician on 09/01/2021 showed 1:1 assist (with eating) due to (Resident 19) cognition. An observation on 09/07/2021 1:32 PM showed Resident 19 in bed, sitting at 45-degree angle with meal tray on table in front of him. The tray ticket showed 1:1 assist (with eating). No staff was present to assist Resident 19 with eating. An observation on 09/09/21 at 1:32 PM Resident 19's tray was on the cart to be returned to the kitchen. The plate contained a small piece of ham with a bite mark as if picked up and eaten with hands. The corn and mashed potatoes were untouched, and the fork was on the plate. There was an untouched brownie with white whip topping, an unopened Yami yogurt, a strawberry protein shake with lid still in place and an unopened cup of ice cream. When Staff FF (Licensed Practical Nurse) was asked if Resident 19 had assistance with eating, Staff FF replied No. An observation on 09/10/21 8:25 AM Staff II delivered the tray and set up the tray then left the room. Resident 19 was observed eating hot cereal with a spoon. There was no staff physically assisting Resident 19 to eat. After the tray was collected, the finished tray showed the pancake and sausage on plate was untouched and not cut up. The cup of milk was full and covered with a lid. In an interview on 09/10/2021 at 8:49 AM Staff LL stated, Resident 19 eats on their own and we check on them. Staff LL stated the directions for 1:1 assist means supervision not assistance. In an observation on 09/11/2021 at 8:03 AM the breakfast tray was in front of Resident 19 on the bedside table. Resident 19 started eating the eggs and had difficulty reaching the fork to the plate, so they put fork down on the plate and stopped eating. The cup of milk was at the far side of the tray untouched with the lid still covering it. There was no staff present between 8:03 AM and 8:45 AM to assist Resident 19 with eating. In an observation on 09/12/2021 at 8:12 AM Resident 19 was sitting in bed with the tray on the over bed table and eating bacon with their fingers. The tray ticket stated 1:1 assist. There was no staff present between 8:12 AM and 9:02 AM to assist Resident 19 with eating. In an interview on 09/12/2021 at 9:02 AM Resident 19 was in bed with tray on bedside table and stated they were finished eating. The plate still had French toast with blueberry topping, only 1/3 eaten and the remaining food was not cut up to bite size. Resident 19 stated, I am not able to cut it (French toast). Resident 19 confirmed no staff assisted them to eat meals. In an interview on 09/15/2021 at 2:02 PM Staff D (RCM) confirmed 1:1 assist means one person should have been physically assisting (Resident 19) with eating. Resident 18 Resident 18 admitted on [DATE] and according to the 06/30/2021 Quarterly MDS was determined to be cognitively intact and required one-person extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and required one-person extensive assist with bathing. In an interview on 09/16/2021 at 10:24 AM Resident 18 stated I am not getting my showers as I thought. My last shower was on Monday (four days ago), and I usually take them on Tuesday and Friday. The shower lady told me they were trying to catch up on showers for the people on Mondays and Tuesdays. I like to have my shower in the morning but will take one anytime. Resident further stated they refused a few times because it was a male aide offering showers and they do not prefer and will not receive a shower from a male staff member. Review of the August 2021 Treatment administration record (TAR) showed an M indicating it was missed for 08/02/2021, 08/12/2021, 08/16/2021, 08/19/2021, 08/23/2021, 08/26/2021 and 08/30/2021. Review of paper shower documentation for August 2021 showed the resident received showers six times for the month of August, indicating they did not receive showers twice a week as ordered. During an interview on 09/16/2021 at 8:30 AM Staff B (Director of Nursing) stated they would expect showers to be done on the days ordered, if the shower was missed the staff should communicate that to the next shift and the next available opportunity for a shower should be offered. Staff B acknowledged that Resident 18 has not been receiving showers twice a week as ordered. Resident 54 Resident 54 admitted on [DATE] and according to the 08/19/2021 admission MDS was assessed to be cognitively intact and required two-person extensive assist with bed mobility, transfers, dressing, toileting, personal hygiene and required two-person extensive assist with bathing. During an interview on 09/14/2021 at 8:47 AM Resident was in a gown sitting on edge of the bed and resident emitted a sweaty body odor. Review of the August 2021 and September 2021 Physician Orders showed no order for showers. Review of the paper shower sheets showed the resident received showers on 08/17/2021, 08/31/2021, 09/03/2021 and 09/07/2021. The resident did not receive showers twice weekly and received no showers for the week of 8/22-8/28/2021. During an interview on 09/16/2021 at 8:30 AM Staff B was not sure what happened the week of 8/22-8/28/2021 and acknowledged the resident is not receiving showers twice weekly. Resident 23 Resident 23 admitted on [DATE] and according to the 07/07/2021 Quarterly MDS had moderately impaired cognition and required one-person physical assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Similar findings for Resident 23 were identified , no showers were documented as completed for the week of 8/22-8/28/2021. REFERENCE: WAC 388-97-1060(2)(c). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 7 (Residents 3, 15,45) of 18 residents reviewed received the care and services, in accordance with professional standards of practice, that they were assessed to require. The facility's failure to assess and monitor non-pressure skin issues (Residents 3, 50 &47), provide mobility aides to residents who were assessed to require them (Resident 2), and to ensure hand hygiene was provided to residents with contractures (Resident 31), placed residents risk for alterations in skin integrity, unidentified wound decline, a delay in treatment, and decreased quality of life. Findings included . According to the facility's Skin Care policy, revised 05/2021, nurse aides inspect skin daily while providing routine care, any skin problems will be reported to the nurse. The nurse will assess the resident and contact the Physician for treatment orders other than first aide. Resident 3 Resident 3 admitted to the facility on [DATE]. According to the 06/08/2021 admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had diagnoses of heart failure, heart disease and mal-nutrition, required extensive assistance with most Activities of Daily Living (ADLs), and had two venous stasis ulcers. On 09/11/2021 at 8:47 AM, Resident 3 was observed with two discolored Band-Aids on the top of his head. The front Band-Aid had a dime sized area of dried blood. On 09/12/2021 at 10:46 AM, the two discolored Band-Aid were again observed to the crown of Resident 3's head, the dime sized blood stain now appeared black in color. Resident 3 indicated they had a skin biopsy performed earlier in the week. Record review showed a 09/09/2021 Dermatology consult that stated, Anterior crown scalp-we biopsied this lesion and treated the base with electrocautery. [Apply] Vaseline ointment twice daily to the biopsy site until healed. On 09/13/2021 at 1:00 PM, the two Band-Aids on the crown of Resident 3's head appeared heavily soiled and discolored. When asked if anyone removed the Band-Aids and applied Vaseline to the biopsy area Resident 3 stated, No .[the Band-Aid ] were applied at (his 09/09/2021 Dermatology appointment. On 09/13/2021 at 1:05 PM, Staff V, (Licensed Practical Nurse) entered the resident's room. Upon request, Staff V described the Band-Aids as soiled .heavily soiled and dirty, I will change them. Staff V confirmed the Band-Aids were applied by the dermatologist. When asked how staff were applying Vaseline to the biopsy site twice daily, if the Band-Aids were covering the site since 09/09/2021, Staff V shrugged. Record review showed a 08/23/2021, 10:38 PM progress note that stated Resident 3 had a wound on his right shin and bilateral venous stasis [ulcers], not new issues. The note did not include any measurements or further assessment. According to a 08/24/2021 weekly Skin Assessment Note, (SAN) the resident had a stasis ulcer to each shin. The SAN did not include wound measurements, or an assessment of the wound bed, tissue type or exudate. Review of the August 2021 Treatment Administration Record (TAR) showed no treatment orders were obtained for the two identified stasis ulcers An 08/31/2021 5:20 PM progress note identified a right anterior shin wound. A 09/07/2021 SAN, identified Resident 3 had stasis ulcers to his bilateral shins. Again, the SAN failed to include wound measurements or wound assessments. Review of the September 2021 TAR showed, a treatment order still had not been obtained. During an interview on 09/15/2021 at 2:47 PM, when asked if there was any indication or documentation to support the facility was assessing and monitoring Resident 3's stasis ulcers as required, Staff D indicated they would look for them. During an interview on 09/16/2021 at 8:17 AM, Staff D indicated she could not find any. Review of Resident 3's comprehensive care plan (CP) showed the 06/03/2021 At risk for complications related [to an] irregular heartbeat and At risk for for shortness of breath .edema due to CHF [Congestive Heart Failure] and the At risk for hypertension CPs directed staff to Monitor feet and hands for edema .report abnormal finding s to the MD. None of the three CPs identified what Resident 3's baseline edema was. Observation on 09/13/2021 at 1:05 PM showed Resident 3 had darkened discolored skin to their bilateral lower extremities below the knee with trace pedal edema. Record review showed no indication facility staff monitored Resident 3's edema as they were assessed to require. During an interview on 09/16/2021 at 7:58 AM, when asked if there was any indication or documentation to support facility staff were assessing Resident 3's edema as care planned. Staff D stated, No. Resident 15 Resident 15 admitted to the facility on [DATE]. According to the 06/28/2021 MDS, the resident was cognitively intact, had kidney failure and received dialysis services. According to the 10/06/2020 At Risk for Complications Due to End Stage Kidney Disease with Dialysis care plan, staff were directed to Monitor for edema .report any abnormalities to the MD. The care plan did not identify what the resident's baseline edema was, detracting from staff's ability to determine if the edema assessed is abnormal. Record review showed no indication facility staff were monitoring or assessing Resident 15's edema, as he was assessed to require. During an interview on 09/16/2021 at 7:58 AM, Staff D confirmed Resident 15 was at increased risk for fluid retention secondary to kidney failure with dialysis and that the resident's plan of care directed staff to monitor for edema. When asked if she found any indication or documentation to support staff were routinely assessing Resident 15's edema Staff D stated, No. Resident 45 Similar findings were noted Resident 45, who was assessed to require edema monitoring, but for whom the facility was unable to provide documentation to support edema monitoring had occurred. Resident 31 Resident 31 admitted to the facility on [DATE] and according to the 07/26/2021 Quarterly MDS was assessed with multiple medically complex diagnoses including spastic hemiplegia (muscle stiffness affecting one side of the body). This MDS showed the resident had contractures to both upper extremities and required extensive two-person assistance with bed mobility and was totally dependent on staff for transfers and personal hygiene. Review of active physician orders dated 02/08/2019 showed Skin integrity check: Check skin for breakdown in left and right hand/palm; clean daily. In a joint observation and interview with Staff FF on 09/14/2021, the resident's left hand/palm was closed with fingers contracted. Staff FF assessed and cleaned the inside of the palm with a washcloth. The palm had whitish skin and a new open cut inside the base of the third finger. When asked if the hand and palm was cleaned daily, Staff FF said, I don't think so, restorative aides are responsible to clean the hand and palm, when doing range of motion. In an interview on 09/15/2021 at 1;08 PM, Staff N, (Director of Rehabilitation Services) indicated the restorative aides were responsible for performing range of motion, but did not provide hand hygiene, stating that nursing was responsible for cleaning the resident's hand/palm. In an interview on 09/15/21 at 2:30 PM, Staff B (Director of Nursing) indicted that Nursing staff are responsible to clean Resident 34's hands and do assessment daily as directed by the physician orders. Resident 2 Resident 2 was admitted to the facility 05/27/2021 for rehab including physical therapy. The 06/03/2021 Quarterly MDS showed Resident 2 had a diagnosis of Parkinsonism and complications of the nervous system. The assessment showed Resident 2 was cognitively intact, was able to make their own decisions and participated in the assessment. A 06/17/2021 physical therapy discharge summary showed Resident 2 met their maximum potential for mobility and needed devices for modified independence for bed mobility and transfers between the bed and wheelchair. An observation on 09/07/2021 at 10:03 AM and 2:07 PM showed Resident 2 sitting in bed with their head and torso leaning to the right. Multiple observations at varied times of day between 09/07/2021 and 09/15/2021 showed Resident 2 in a leaning position to the right while in bed. In an interview on 09/07/2021 2:07 PM Resident 2 stated it was difficult to move in bed and they asked for a bed rail in May 2021 and still did not have one. Resident 2 stated they could move easier and be more comfortable in bed and be more independent getting in and out of bed with a bed rail to help with mobility. A Resident Safety Assessment form dated 05/30/2021 showed Resident 2 was assessed and signed the consent form for a mobility assist rail to be placed on the bed. An observation on 09/07/2021 showed no bed rail was installed. In an interview on 09/15/2021 at 2:02 PM, Staff D (Clinical Manager) stated after a resident was assessed to have a bed rail and the consent form was signed, then the bed rail could be installed. Staff D confirmed Resident 2 did not have a bed rail installed. The facility failed to provide the bed rail which Resident 2 requested for independence and was assessed to require for highest practicable physical, mental, and psychosocial well-being. Resident 47 According to the 08/09/2021 Admissions MDS, Resident 47 was re-admitted to the facility on [DATE] from the hospital, and had diagnoses of acute respiratory failure and a chronic left foot ulcer. The MDS showed Resident 47 required one-person extensive assistance with mobility and used a wheelchair with footrests. The MDS showed Resident 47 was at risk for developing pressure injuries. A skin assessment completed on 09/01/2021 showed a new skin injury on Resident 47's left foot. A blister was described as 2.0 x 2.0 cm blister on the side of left foot from rubbing foot on the footrest. The skin assessment did not show any interventions implemented to treat the blister or prevent worsening or new injuries. A nursing progress note on 09/01/2021 at 4:35 PM showed identification of a new blister and no interventions implemented for treatment or to prevent worsening of the blister. In an interview on 09/11/2021 at 11:16 AM, Staff FF (LPN) stated the blister started over a week ago and confirmed there was no treatment prescribed. Staff FF stated the surgical shoe was rubbing on the blister, so the blister was covered with a dressing without a physician's order. In an interview on 09/16/2021 at 11:15 AM, Staff B (DNS) confirmed the expectation for a new skin injury is notification of the physician and a treatment started. Staff B confirmed as of 09/16/2021 interventions were not in place to prevent worsening or healing to the blister. Resident 50 Resident 50 admitted to the facility on [DATE] and according to the 08/11/2021 admission MDS was assessed with impaired vision, mobility and was cognitively intact. Observation on 09/09/21 at 8:37 AM showed the resident lying in bed. The resident was noted to reach to the left, reaching for a phone in the top drawer of the bed side stand. The resident was noted with a linear scabbed area approximately one and one half inches long to the left forearm. Observations with Staff C (Resident Care Manager) on 09/11/2021 at 9:45 AM confirmed the resident had the skin issue to the left forearm. Staff C stated direct care staff should report alterations in skin integrity during the provision of care and that someone should have reported this prior to now. Staff C elaborated it was important to establish how residents obtain injuries so staff could implement interventions to prevent further injury. REFERENCE: WAC 388-97-1060(1) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary foot care and treatment in accordance with professional standards. Failure to provide timely foot/nail care for 3 (Residents 24, 316 & 317) of 5 sample and one supplemental (Resident 47) residents reviewed for Activities of Daily Living, placed residents at risk for decreased quality of life and negative health outcomes. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 07/07/2021 Quarterly Minimum Data Set (MDS, an assessment tool) had moderate cognitive impairment, required extensive two person physical assistance with bed mobility, transfers, toilet use and personal hygiene and required the assistance of two staff for bathing. This assessment showed Resident 24 had multiple medically complex diagnoses including diabetes. In an interview on 09/07/21 at 1:13 PM, Resident 24 stated, My toenails are long. I need a podiatrist but I understand they don't have that service here. The resident stated they had requested nursing staff to trim their toenails but the nursing staff reported they didn't provide diabetic foot care. Observations at this time showed the resident's first toes bilaterally were long. The resident stated at this time they wanted their nails trimmed. During observations on 09/13/21 at 10:00 AM Staff C (Clinical Manager) confirmed Resident 24 had long toenails that would benefit from trimming. At this time, Staff C explained that the facility's nursing staff did not provide foot care to diabetic residents and Social Service staff typically arranged podiatry for diabetic residents but that Resident 24 had Providence Elder Place as a provider and they didn't pay outside vendors for services. Staff C elaborated that residents with this provider, .go out to see the podiatrist, [Providence Elder Place] arranges the appointment for podiatry. In an interview on 09/13/2021 at 10:15 AM, Staff H (Social Service Manager) explained Resident 24 was enrolled in a particular health care provider system and they were responsible for providing podiatry services to their residents. In an interview on 09/13/21 at 10:22 AM Staff AA (Medical Records) stated there was no indication in the record the resident was referred to or seen by podiatry since admission on [DATE]. Resident 316 Resident 316 admitted to the facility on [DATE] and according to the 09/06/2021 admission MDS had multiple complex diagnosis including diabetes. This assessment determined Resident 316 was cognitively intact and assessed to require extensive physical assistance with bed mobility, transfers, personal hygiene, and bathing. In an interview on 09/13/2021 at 8:33 AM, Resident 316 reported their toenails were too long and wanted them trimmed. Resident stated staff had not trimmed their nails since admission. Observations at this time showed Resident 316 had long toenails to both feet. During an observation on 09/13/2021 at 12:47 PM, Staff C confirmed Resident 316 reported their toenails were too long and requested for them to be trimmed and confirmed the nails needed trimming. Resident 317 Resident 317 was admitted to the facility on [DATE] and according to the 09/03/2021 admission MDS had diagnoses including diabetes and was assessed as cognitively intact. This assessment showed the resident required extensive physical assistance with bed mobility, transfer, personal hygiene, and bathing. In an interview on 09/08/2021 at 8:22 AM, Resident 317 stated their toenails were too long and they were getting caught on the blankets. Resident 317 reported staff had not clipped their nails since admission. During an observation at the time of this interview, Resident 317 showed bilateral toenails were long and jagged. During observations on 09/13/2021 at 10:30 AM, Staff C confirmed Resident 317's toenails were long and the resident requested the toenails to be trimmed. At the time of this observation, Resident 317 reported the right big toenail was hurting them. Staff C stated the resident required a podiatry referral. Resident 47 The facility policy Coordination of Health Care Services dated 09/2021 showed staff will coordinate health care services with external providers by communicating with external providers on a regular basis to ensure that resident's health needs are met. According to the 08/09/2021 admission MDS, Resident 47 had multiple complex diagnoses including diabetes. This assessment showed Resident 47 was cognitively intact and able to communicate needs. On 09/11/2021 at 11:16 AM observations showed Resident 47's toenails were long, thick, and jagged. Resident 47 stated their toenails were too long. Staff FF (Licensed Practical Nurse) was present and confirmed the toenails were long and required trimming. Staff FF stated the resident had an Elder Place podiatrist appointment on 09/14/2021. Review of the 09/14/2021 podiatrist report showed Resident 47 had nine elongated and discolored toenails with a diagnosis of onychomycosis (fungus of toenail). Report showed a picture of long jagged nails on left foot. The report showed no documentation of toenail care provided at the appointment. A joint observation and interview on 09/16/2021 at 11:15 AM, Staff B (Director of Nursing Services) and Staff FF confirmed the toenails were long, thick, and jagged and were not treated by the podiatrist on 09/14/2021. REFERENCE: WAC 388-97-1060(3)(j)(viii). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Intravenous (IV- a small tube inserted into a vein through which fluids and / or medications are administered) Services were provided in accordance with professional standards of practice for 3 (Resident 38, 3, 1) of 3 residents reviewed. Failure to provide appropriate directions, treatment and care for IV fluid treatments, including Peripherally Inserted Central Catheters (PICC-specialized intravenous access devices), placed the resident at risk for line occlusion. The facility failed to accurately identify the type of PICC lines residents had, to ensure physician's flushing orders were based on the type of catheter used as directed in the facility policy, or that measurements of arm circumference and external catheter length was accurately performed as directed in facility policies. Additionally, facility nurses initiated IV access without identifying or documenting the location and administered IV fluids without a rate of infusion. These failures placed residents who required IV services at risk for loss of vascular access and not receiving the correct amount of fluids/medications intended by the physician. Findings included . Resident 38 Resident 38 re-admitted to the facility after a surgical procedure on 08/24/2021 and according to the Quarterly Minimum Data Set (MDS, an assessment tool) dated 08/02/2021 required the use of IV medications. According to September 2021 Medication Administration Records (MARs) Resident 38 received Ceftriaxone and Daptomycin (antibiotics) through a Tunneled PICC line (a specialized IV line tunneled under the skin in the chest to infuse medications close to the heart) once a day for infection. Physician Orders dated 08/24/2021 showed, IV- Tunneled Cath: assessment, flushes & maintenance per policy during each shift. Further instructions were Flush catheter before & after any medication administration & at least once daily. The order did not provide any direction for the type or amount of flushing. The order also directed, change injection cap when visibly soiled if removed for bl . The instructions were incomplete. A separate order dated 08/24/2021 directed staff to do a dressing and injection cap change per policy at bedtimes on Mondays and document the location, number of lumens, length of external catheter, arm circumference, condition of insertion site and type of dressing applied. On 08/30/2021 and 09/06/2021 staff failed to document the type of dressing applied. Review of the MARs and Treatment Administration Records (TARs) showed no direction to staff to flush the second port or if the amount, frequency and type of flush differed for maintenance of the second port versus the port used daily for the antibiotics. Observations on 09/07/21 at 1:25 PM showed Resident 38 had multiple syringes of Heparin (a blood thinning medication) and Normal Saline (NS a solution used to flush IV devices) in a bag hanging from an IV pole at the bedside in addition to 8 syringes of Heparin noted at the bedside. Similar observations of medications at bedside were noted daily from 09/08/2021 through 09/14/2021. Per request, facility staff provided a Providence policy and procedure for PICC line/ IV flushing and locking on 09/14/2021. This policy directed, Review the patient's medical record to confirm the catheter type and size and the location of the catheter tip because the flush protocol depends on the type and size of the catheter. In an interview on 09/15/21 at 10:08 AM, Staff B (Director of Nursing) indicated that the Providence policy provided on 09/14/2021 was a [NAME] (a prominent Nursing Manual) procedure and, that's not accurate we're going from the one (policy) I gave to you today. the PICC policy provided on 09/15/2021 indicated staff should verify provider's order regarding flush solution before use of PICC line. Staff B, in an interview on 09/15/2021 at 10:08 AM stated it didn't matter about the type size or location of the catheter, all flushes were to be saline. In an interview on 09/15/2021 at 10:14 AM, when asked if flush protocols differed depending on the type, size and location of the catheter or if it's valved or non valved, Staff JJ (Infusion Pharmacist), stated Yes. Staff JJ indicated the record should reflect the treatment and services provided to maintain PICC lines. In an interview on 09/22/2021 at 12:05 PM, Staff JJ and Staff KK (Pharmacy Nurse Manager) confirmed it was important to obtain insertion reports as, It is necessary to confirm tip placement. Resident 1 Similar findings were noted for Resident 1 who admitted to the facility on [DATE] and according to the 08/27/2021 admission MDS was assessed to require IV antibiotics on each day of the assessment period. Physician Orders dated 08/20/2021 showed, IV- Midline: assessment, flushes & maintenance per policy during each shift. Further instructions were to Flush catheter before & after any medication administration & at least once daily. The order did not provide any direction for the type or amount of flushing. The order also directed, change injection cap when visibly soiled if removed [as for blood dr . The instructions were incomplete and gave no directions to staff regarding what medications should be used for the flush. Further review of records revealed no IV insertion report was available in Resident 1's records. In an interview on 09/10/2021 at 8:23 AM, Staff F stated, We flush after IV medications with Normal Saline [NS] and Heparin. Observations on 09/10/2021 at 8:37 AM, Staff F prepared and administered a 10 milliliters (mls) NS flush and then administered 5 mls of Heparin 10 units/ ml syringe through Resident 1's IV line. Additional observations on 09/14/2021 at 8:32 AM, showed Staff S (Registered Nurse), prepare and administer 10 mls NS flush followed by 5 mls of Heparin 10 units/ ml, after resident had received their antibiotic medications. In an interview on 09/14/2021 at 8:32 AM, Staff S stated they had a standard protocol to do NS and Heparin, we use the SASH [NS, antibiotic, NS, and Heparin] protocol. When asked if the nurse can find the protocol, Staff S clicked around on computer and then stated, I can't find it. Staff S reviewed Resident 1's physician orders and was unable to locate any orders to direct staff what flush protocol to administer. Resident 3 According to a 08/19/2021 1:05 AM progress note, Resident 3 was noted with a low blood pressure of 64/43. An order was obtained to administer an IV bolus of 500 cubic centimeters (cc) of 0.9% NS. After the infusion was completed Resident 3's blood pressure was assessed at 77/53. A second order was obtained to administer an additional 500 cc of NS IV bolus. Review of the August 2021 TAR showed the order was transcribed as, Give NS 0.9% 500 cc IV bolus x 1, establish an IV line. Neither the progress note or the TAR identified the type and location of the venous access, or the rate of the infusion. In an interview on 09/15/2021 at 2:10 PM, Staff D, (Clinical Manager), reviewed Resident 3's IV order and acknowledged the order was incomplete. Staff D stated that the nurse should have asked for a rate of infusion. When queried whether the type and location of the venous access should have been identified Staff D stated, yes and acknowledged it was not. REFERENCE WAC: 388-97-1060(3)(j)(ii). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure six (Residents 24, 29, 50, 54 & 34) of 12 residents reviewed for unnecessary medications, were free from unnecessary psychotropic drugs related to the failure to: adequately monitor through individualized target behaviors and adequate indication for the use of psychotropic medications. These failures placed residents at risk to receive unnecessary medications and/or adverse side effects. FACILITY POLICY The Facility's 12/2020 Psychotropic Medications Policy stated that residents receiving antidepressant medications must have an individualized care plan . to address depressive symptom [sic] and resident needs, including grief and loss, spiritual distress, socialization needs, need for meaningful activity etc. Resident 29 According to the 07/19/2021 Quarterly MDS, Resident 29 had diagnoses including Unspecified Dementia w/behavioral disturbance, Epilepsy, Major Depressive Disorder and Alzheimer's Dementia, and was assessed to have significant cognitive impairment. Review of Resident 29's September 2021 MAR showed an order for Sertraline (an antidepressant) 50 MG for Major Depressive Disorder. Resident 29's MAR included monitoring for the following target behaviors related to depression: 1) verbalization, 2) Insomnia, 3) Lack of appetite, 4) Self-isolation, 5) Lack of interest in activities. These target behaviors were identical to those identified for Residents 50, and 24 were not individualized as directed by facility policy. Resident 50 Resident 50 admitted to the facility on [DATE] and according to the 08/11/2021 admission MDS was cognitively intact and assessed with multiple medically complex diagnoses including anxiety disorder and depression. This MDS showed the resident utilized both antidepressant and antipsychotic medications on each day of the assessment period. Record review showed Resident 50 admitted to the facility with orders from the hospital for Seroquel for the treatment of delirium. Review of Resident 50's September 2021 MAR showed an order for Seroquel (an antipsychotic) 50 MG for Major Depressive Disorder, not delirium as reflected in the hospital records. Resident 50's MAR also included monitoring for the following target behaviors related to depression: 1) verbalization, 2) Insomnia, 3) Lack of appetite, 4) Self-isolation, 5) Lack of interest in activities. Non drug interventions included: 1)Redirect, 2) 1:1 contact, 3) Activity, and 4) Offer snack. In an interview on 09/11/2021 at 8:37 AM, Resident 50 indicated they did not take antipsychotic medications while in the facility but had issues with delirium while in the hospital. Resident 50 indicated they had a history of depression and currently took Lexapro to treat depression. According to September 2021 MARs, Resident 50 received Lexapro 10 mg each (an antidepressant) each day for anxiety disorder. Target behaviors identified which required the use of this medication were: 1) Excessive Worry, 2) Excessive fear, 3) Feeling of impending doom, and 4) Insomnia. According to the September 2021 MAR, the resident's Lexapro dose was doubled to 20 mg each day. According to provider notes the dose increase was required due to resident's statements of depression. Review of target behaviors monitors showed the resident did not demonstrate any of the target behaviors listed. In an interview on 09/11/2021 at 11:10 AM Staff C (Resident Care Manager) confirmed resident's target behaviors for depression were not, but should be, individualized. Staff C confirmed it was important to ensure target behaviors were accurate because the target behaviors were the behaviors that residents demonstrated which required the use of psychotropic medications. In an interview on 09/14/2021 at 8:47 AM Staff H (Social Service Director) indicated TBs were established by nursing staff, and it was nursing staff who monitored for these behaviors. When asked, Staff H stated that, Each person is different, yes they (Target Behaviors) should be individualized. Additionally, Resident 50, according to the September 2021 MAR, received Melatonin (a mediation used to track sleep/wake cycles) each evening as a supplement and whose care plan directed staff to monitor for insomnia, but no sleep monitor was found. In an interview on 09/11/21 at 11:10 AM Staff C indicated if the resident was monitored for insomnia, the resident would have a sleep monitor. If cp says to monitor for insomnia as a se how do you track that then i put it specifically for we have the doctor indicated the resident reported feelings of depression and so he increased the medication it should reflect the reason we are giving it . Resident 24 Similar findings were found for Resident 24 who was admitted to the facility on [DATE]. According to the admission MDS dated [DATE] the resident had a diagnosis of depression and anxiety and required the use of both an antipsychotic and antidepressant medication on each day of the assessment period. Review of the September 2021 MAR showed an order for Sertraline (an antidepressant) 100 mg for Major Depressive Disorder. Resident 24's MAR also included monitoring for the following target behaviors related to depression: 1) verbalization, 2) Insomnia, 3) Lack of appetite, 4) Self-isolation, 5) Lack of interest in activities. Non drug interventions included: 1) Redirect, 2) 1:1 contact, 3) Activity, and 4) Offer snack. The facility did not individualize target behaviors as directed by facility policy. Resident 54 According to the 08/19/2021 admission MDS Resident 54 admitted on [DATE] and was assessed as cognitively intact with diagnoses of stroke, depression and post traumatic stress disorder (PTSD). The MDS showed the resident utilized antidepressant medications on each day of the assessment period. Review of the clinical record showed the resident was admitted with Venlafaxine (an antidepressant) 75 mg (milligram) by mouth daily for treatment of major depressive disorder. Review of Resident 54's September MAR showed an order to monitor target behaviors each shift, which included 1) Verbalization, 2) Insomnia, 3) Lack of appetite, 4) Self-isolation, 5) Lack of interest in activities and non drug interventions to 1) Redirect, 2) One on one contact, 3) Activity, 4) Offer snack Review of the August and September MAR revealed the resident had no documented behaviors related to depression. Resident 34 According to the 06/13/2021 Quarterly MDS the resident admitted on [DATE] and was cognitively intact with medically complex conditions including Depression. This MDS showed the resident utilized antidepressant and antianxiety medications on each day of the assessment period. Review of the September 2021 MAR showed the resident was taking Buspirone (an anxiolytic-treats anxiety) 10 mg (milligrams) by mouth twice daily for anxiety and depression, Bupropion (an antidepressant) 300 mg by mouth daily for major depressive disorder and Duloxetine 90 mg by mouth daily for major depressive disorder. Resident 34's MAR also included to monitor for target behaviors of depression during each shift to include 1) Verbalization, 2) Insomnia, 3) Lack of Appetite, 4) Self-Isolation, 5) Lack of interest in activities. Non drug interventions included 1) Re-direct, 2) one on one contact, 3) Activity, 4) Offer snack. Resident 34's MAR also included to monitor for target behaviors of anxiety during each shift to include 1) Excessive worry, 2) Excessive Fear, 3) Impending doom, 4) Insomnia Review of the July 2021, August 2021 and September 1st through the 9th 2021 MAR revealed no documented behaviors for depression or anxiety. Review of the Resident's clinical record showed a 06/10/2021 Gradual Dose Reduction (GDR) from the Consult pharmacist for Bupropion, Buspirone and Duloxetine. The provider responded on 07/21/2021 indicating a GDR attempt is clinically contraindicated at this time. No rationale was given on how or why any attempted dose reduction would likely impair the resident's function or exacerbate an underlying medical or psychiatric disorder. REFERENCE: WAC 388-97-1060(3)(k)(i) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Two (Staff F & Staff S) of 5 Licensed Nurses made 3 errors during 25 opportunities, for 2 (Residents 38 & 1) of 7 residents observed for medication pass. This resulted in an error rate of 12%. This failure placed residents at risk for not receiving the intended therapeutic effects of physician ordered medication. Findings included . Resident 38 Observations on 09/13/21 at 9:10 AM showed Staff F, Licensed Practical Nurse, prepare and administer Ketotiphen 0.035% eye drops (allergy medication) to Resident 38. According to Physician Orders, staff were to administered Ketotiphen 0.025%. In an interview on 09/13/21 at 9:39 AM, Staff F confirmed the medication dose administered did not match the physician orders, stating, They should match (order and what is administered). Failure to administer the concentration of medication ordered constituted one medication error. Resident 1 According to the 08/27/2021 admission Minimum Data Set (MDS- an assessment tool) Resident 1 was assessed to require Intravenous (IV) antibiotics (medications used to treat infections) on each day of the assessment period. In an interview on 09/10/2021 at 8:23 AM, Staff F stated, We flush after IV medications with Normal Saline [NS] and Heparin. Observations on 09/10/2021 at 8:37 AM, showed Staff F prepare and administer a 10 milliliters (mls) NS flush and then administered 5 mls of Heparin 10 units/ ml syringe through Resident 1's IV line. Additional observations on 09/14/2021 at 8:32 AM, showed Staff S (Registered Nurse) prepare and administer 10 mls NS flush followed by 5 mls of Heparin 10 units/ ml, after the resident received their antibiotic medications. In an interview on 09/14/2021 at 8:32 AM, Staff S stated they had a, standard protocol to do NS and Heparin, we use the SASH [NS, antibiotic, NS, and Heparin] protocol. When asked if the nurse can find the protocol, Staff S clicked around on computer and then stated, I can't find it. In an interview on 09/14/2021 at 8:50 AM, Staff B (Director of Nursing) stated that the current facility protocol for flushing IV/PICC lines was to only use saline and staff were not to use heparin unless the physician specifies it should be used. Record review showed no direction to staff to utilize heparin to flush the IV. Administration of heparin in the absence of Physician Orders or direction by facility policy / protocol constituted two medication errors. REFERENCE: WAC 388-97-1060(3)(k)(ii). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were secured for 3 (Resident 38 & 1) of 16 residents reviewed. Facility staff failed to ensure medications were properly secured for 2 of 3 nurses stations reviewed, which placed residents at risk for accidental ingestion. Observations of 2 of 3 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. Additionally, the facility failed to consistently check the temperatures of 1 of 2 medication refrigerators, which precluded staff from confirming the medications were stored at an appropriate temperature. Findings included . Medications at Bedside Observations on 09/07/21 at 1:25 PM showed Resident 38 had multiple syringes of Heparin (a blood thinning medication) and Normal Saline (NS a solution used to flush Intravenous (IV) devices) in a bag hanging from an IV pole at the bedside in addition to 8 syringes of Heparin, two bags full of NS syringes, and an opened undated container of normal saline noted at the bedside. Similar observations of medications at bedside were noted daily from 09/08/2021 through 09/14/2021. Similar findings were noted for Resident 1 who was observed on 09/08/21 at 10:24 AM with 2 syringes of heparin hanging from a bag attached to the IV pole at bedside, 17 syringes of Heparin and 11 syringes of NS in a box on an empty bed in the residents room. In an interview on 09/10/21 at 8:25 AM Staff F (Licensed Practical Nurse) verified the medications at bedside were Heparin and NS, stating, We keep them there since we flush after the IV with Heparin and NS. In an interview on 09/14/2021 at 8:50 AM, Staff B (Director of Nursing) stated that medications should not be left at bedside and their expectation was for staff to go into a room with medications, administer, and remove if not used. Staff B verified and removed medications that were left at bedside for Resident 1. 100 Unit Medication Cart Observation of the 100 unit Medication Cart on 09/07/21 at 10:36 AM with Staff S (Registered Nurse) showed a syringe of injectable lidocaine with no resident name and an expiration date of 06/06/2021. An open container of Lacrilube eye drops was open and undated. Artificial tears for Resident 50 were open but not not dated. Ketotiphen (eye drops to treat allergies) was noted for Resident 38 as open and not dated. According to Staff S, these medications should have been dated when opened as the eye drops would be expired 28 days after it was opened and the expired lidocaine should have been removed from the cart. Also identified was an open undated container of Nyamyc (an antifungal medication) with no labeling for whom the treatment was intended. A bottle of Hibiclens oral rinse was open but not dated, Staff S stated the bottle should have been dated when opened. 400 Unit Medication Cart Observation of the 400 Unit Medication Cart on 09/07/21 at 11:27 AM with Staff FF (Licensed Practical Nurse) showed Nasal spray for Resident 62 was open and undated, Artificial tears for Resident 34 was open and undated, Latanoprost (eye drop that treat glaucoma) was open and updated for Resident 41, a bottle nitroglycerine tablets expired 08/06/2021, Hydralazine 25 mg (blood pressure medication) card with 30 tablets for Resident 32 expired 06/26/21. Staff FF stated that these the eye drops should be dated when opened as they expire 28 days after opening and the expired Hydralazine medication should have been removed from the cart. 400 Unit Medication Room. On 09/07/21 at 11:27 AM observation in the medication Room with Staff FF revealed the following medication were in the medication room fridge and expired. Shingrix Vial Kit expired 06/16/2020 for Resident 46. Epogen (medication which treat low red blood cell count) vials in a box expired 05/13/202, Genotropin expired 08/30/20, facility house stock 2 boxes influenza vaccine expired 06/30/202. The following medications were in the medication room for residents who were discharged : Losartan 650mg, expired 3/2021, Losartan card expired 11/10/2020 levothyroxine expired 9/30/2020, l-lysine over the counter (OTC) 05/202, Isosorbide Monoitrate expired 2/19/2021, On 09/07/21 at 11:27 AM Staff FF confirmed the medications for discharged residents and the expired medications should have been either destroyed or returned to the pharmacy. When asked about drug disposal, staff FF indicated that a pharmacist comes every month and removes all expired medication for disposal and provides monetary credit for discharged residents when applicable. 300 Unit Medication Refrigerator Observation of the 300 Unit medication refrigerator on 09/07/21 at 1:30 PM, with Staff D, (Clinical Manager), showed multiple specific medications were present. Review of the refrigerator temperature log, which was located outside of the medication room on the Code Cart, showed facility staff only checked/recorded the temperature on 19 of 31 days in August. In an interview at that time Staff D indicated staff should have checked the temperature daily, to validate the medications were stored at the correct temperature, but failed to do so. 100 Unit Medication Refrigerator Similar findings were noted when reviewing the August 2021 temperature log for the 100 Unit medication refrigerator. showed facility staff only checked/recorded the temperature on 19 of 31 days in August. Facility staff only checked the medication refrigerator temperature on 12 of 31 days. In an interview on 09/07/2021 at 1:45 PM, Staff D stated, I know that one is not complete either. 300 Unit Treatment Cart On 09/07/21 at 10:32 AM the 300 Unit Treatment Cart was observed outside of room [ROOM NUMBER] and was unattended and unlocked. Multiple medicated creams were noted in the cart. No nurse was observed in the area until 10:46 AM, when Staff V, Licensed Practical Nurse, returned to the Medication cart parked next to it. In an interview at that time, Staff V confirmed the Treatment cart was left unlocked and unattended. 100 Unit Medications at Nurse's Station Observations made on 09/11/2021 between 9:30 AM and 10:00 AM revealed one red and two blue tote bins sitting on the ground by the nurses station's doorway. During observation period staff left bins unattended allowing the potential for unauthorized access. On 09/11/2021 at 9:57 AM, Staff C identified the bins were full of medications, called pharmacy, and requested them to be picked up. At 10:00 AM Staff C moved the bins into a locked location. In an interview on 09/11/2021 at 10:05 AM, Staff C stated the tote bins were usually kept in the locked med room and staff should not have left bins out unattended on unit. REFERENCE: WAC 388-97-1300(2). .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview and review of facility menus, the facility failed to ensure written menus were followed for Residents. Failure by the facility to follow written menus and accurately serve planned menu items placed residents at risk for fewer calories than planned, or receiving foods inconsistent with their current diet. Findings included In an interview on 09/07/21 at 8:55 AM, Staff J (Sous Chef) was asked to provide a copy of 10 days of the break out menu described as the instructions on the menus for portion sizes and amounts of each food served for each type of diet. No information was provided. In interviews on 09/09/2021 and 09/10/2021 Staff A (Administrator) and Staff J were asked to provide menus which included portion sizes and food variations based on the type of diets. In an interview on 09/10/2021 at 9:39 AM Staff L (Dietary Service Manager) indicated a new system was implemented in April 2021 and that each diet type based on food and fluid texture was coded with a number. Upon reviewing an example traycard, Staff L indicated that MM [Moist and Minced] diet was equivalent to a mechanical soft diet. When asked about the color coded symbols on the traycard, Staff L stated, I don't quite understand the little signs, we go by the words after [the symbols]. When asked if it was important to know what the symbols on the traycard meant, Staff L replied, Theoretically I agree with you, but it never causes any confusion. When asked if the symbols directed staff to perform a particular task, Staff L replied, I will look at the guidelines and see what the symbols mean. While Staff L was able to describe what small (1/2 serving of each food item), large (1 1/2 serving of each food item) and double (two services of each food item), Staff L was not able to clearly describe what the initial portion size should be and reiterated there was no menu with portion sizes specified. When asked again for a menu which would detail serving sizes, Staff L indicated there was no such menu and eventually explained portion sizes were typically four ounces. Lunch Observation on 09/14/2021 According to the posted menu, lunch on 09/14/2021 consisted of Salmon with Asian Sauce, [NAME] Rice, Roasted Cauliflower with an alternate of chicken fried Steak, Mashed potatoes with Country Gravy and Broccoli. Observation of meal preparation on 09/14/21 at 9:40 AM showed Staff J cut and prepare the salmon fillets. Staff J cut pieces of salmon, placing them on a scale stating, they need to be four ounce fillets, I cut them to approximately 4-4/12 ounces. According to a break out menu provided by Staff M (cook) after meal service, staff were to serve 3 ounces of salmon rather than the 4 - 4 1/2 ounces of whole salmon served. Review of the recipe for the baked Salmon showed staff were to brush fish lightly with lemon juice then generously with margarine and season lightly with salt and parsley. Observation of the fish preparation showed no application of lemon juice, margarine, salt or parsley. Observation of the preparation of pureed salmon showed Staff J place cooked salmon into the Robocoup blender, added broth from the pan in which it was cooked, then added two scoops of thickener to the blender. Staff J then added more salmon and another scoop of thickener. Staff J was not noted to reference a recipe when preparing the pureed salmon. Similar observations of not referencing a recipe were noted in the preparation of the pureed cauliflower, in which Staff J put roasted cauliflower and an undetermined amount of fluid from the cooking pan into the blender and added approximately three and one half scoops of thickener. In an interview on 09/14/2021 at 10:54 AM, the staff member preparing the altered texture dessert, cheesecake with chocolate drizzle stated, I didn't have quite enough (cheesecake) so I added chocolate putting to it, then added whipped cream to it . According to the menu, both ground and pureed consistency diets were to receive chocolate pudding. Observations at 09/14/21 at 11:38 AM showed Staff J place green portion sized scoops in the containers of rice and mashed potatoes and gray scoops for the pureed fish and mechanical soft fish. In an interview at this time, Staff J indicated the gray scoop was six ounces, but the menu called for three ounces of altered texture fish. When asked, in an interview on 09/14/2-21 at 12:37 PM, how they knew what size scoop to use Staff J replied, It's suppose to be 3-4 oz protein and 3 1/2 ounces in the vegetable. According to the menu provided by Staff M, the roasted cauliflower serving was to be a 4 ounce size. At this time, Staff J showed that two of the green scoops were of different size, but was unable to tell how many ounces each scoop served. The different green scoop sizes were confirmed at this time by Staff J and M. In an interview on 09/14/2021 at 12:40 PM when asked why peas were served instead of the broccoli called for by the menu, Staff J stated, We didn't have it, they [other staff] used it and didn't read the menu. In an interview on 09/15/2021 at 3:35 PM, Staff L confirmed that peas were not the nutritional equivalent of broccoli and that the posted menu did not reflect what was served. When asked, in an interview on 09/14/21 at 1:27 PM with Staff L and Staff A, what the scoop colors and sizes were, Staff L replied, So we use a three ounce to four, in the kitchen in the main one is the green one, but we have observed if we textured diet we observe we are adding fluid so we use a little bigger scoop so we get the same amount . Staff L was not able to describe which scoops served what portion size. Staff L was asked if the kitchen staff have two different sizes of green scoops, what were the volume dispensed by each and how did staff identify this as there were no markings on the scoops that would reflect the size? Staff L replied, Sometimes we weigh it. We weight it the dry scoop we use a cup. We tested it the other day. Staff L did not answer the question. When asked if the kitchen staff had a recipe that they followed for pureed cauliflower, Staff L replied, Let me check. No further information was provided. In an interview on 09/14/2021 at 1:55 PM, Staff A confirmed there were issues in the kitchen that needed work. In an interview on 09/15/21 at 8:29 AM, when asked if the system for dietary menus and therapeutic diets was intact, Staff A stated, No. REFERENCE: WAC 388-97-1100 (1), -1220. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve foods in the appropriate form and/or nutritive content as prescribed by a physician to support the resident's treatment plan for 8 (Residents 24, 38, 7, 47, 9, 46, 317, & 15) of 21 residents reviewed who required speciality diets. The failure to ensure the menus clearly reflected the needs of residents in accordance with established national guidelines, specifically Low Potassium, Magnesium and Controlled Carbohydrate diets, placed residents at risk for alteration in nutrition and metabolic imbalances. Findings included . Resident 24 Resident 24 admitted to the facility on [DATE] and according to the 04/14/2021 admission and 07/07/2021 Quarterly Minimum Data Sets (MDS, an assessment tool), Resident 24 demonstrated significant weight loss in the past six months. Physician Orders (POs) dated 04/09/2021 directed staff to serve Resident 24 a Low magnesium [Mg] diet. Review of the resident's traycard showed directions to staff, No whole [wheat] for low Mg diet. Review of facility menus (directions to staff on what foods to serve in what consistency to different diet orders) showed no menu for a low Mg diet. According to healthline.org, beans and nuts are in the top three common foods containing magnesium. Observations on 09/13/2021 showed Resident 24 was served two packets of peanut butter with breakfast and a large portion of Black Bean Burger for lunch. In an interview on 09/14/21 at 1:27 PM, Staff L was asked what constituted a low magnesium diet for Resident 7, Staff L stated, We restrict dark chocolate .some meats are high in magnesium . When asked if the instructions no wheat constituted a therapeutic low magnesium diet, Staff L did not reply. Resident 38 Resident 38 admitted to the facility on [DATE] and according to the Quarterly MDS dated [DATE] had multiple medically complex diagnoses including diabetes and was assessed as cognitively intact. Record review showed POs for a Low Sodium and Low Potassium diet. The resident's traycards (dated 09/12/2021 and 09/14/2021) reflected the order for the Low Potassium diet with instructions of No Banana, Orange Juice, Pasta. Observation of the breakfast meal on 09/10/2021 showed Resident 38 was served a bowl of sliced oranges. In an interview on 09/10/2021 at 8:25 AM, Resident 38 stated they didn't get orange juice or bananas because they had diabetes. At this time they stated they were unsure why oranges were served but orange juice was not. Review of facility menus showed no menu for a Low Potassium diet. In an interview on 09/14/21 at 1:27 PM, when asked what constituted a Low Potassium diet, Staff L replied, no oranges, no bananas, no milk, no potatoes, and no tomato. Staff L was unable to explain how staff omitting oranges and bananas constituted a low potassium diet or why orange juice should not be served but oranges were allowed. Resident 7 Observation of meal service on 09/14/2021 at 12:10 PM showed Staff J (Sous Chef) prepare and serve a salmon filet covered with Teriyaki sauce, rice, and roasted cauliflower. According to the traycard and current POs, Resident 7 had a Finger Food diet. Review of facility menus showed no menu or directions to staff on what food should be served to a resident with a Finger Food diet. When asked, in an interview on 09/14/21 at 1:27 PM asked what a prescribed finger food diet entailed, Staff L replied, For the resident they are able to use their fingers, they are able to hold with their hands it could be a sandwich or if they can pick up and chew carrots, celery. When asked if chicken nuggets and french fries would be finger foods Staff L stated, Yes. When asked if rice and salmon covered with a sticky sauce was finger food Staff L did not reply. When asked if residents on a finger food diet might be served fish sticks instead of rice and sauce covered salmon, Staff L did not reply. Resident 47 According to the admission MDS dated [DATE] Resident 47 had multiple medically complex diagnoses including diabetes. According to a Special Care of Diabetes and Renal patients information sheet dated 09/09/2021, A separate Controlled CHO [a diet in which carbohydrates are limited] menu is available for the kitchen staff to follow. A separate undated Special care for Diabetes and Renal Patients information sheet indicated, Provide Controlled carb[ohydrate] diet. RD [Registered Dietician] writes the portion size on the tray cards. Based on individual condition, after RD assessment, removal of dessert could be considered . According to Resident 47's traycard dated 09/10/2021, staff were directed to serve a Controlled CHO menu. There were no portion sized indicated on the tray card. Review of facility menus showed no menu for a Controlled CHO diet but directed staff to serve residents on regular diets three ounces of jasmine rice. A separate Fall/winter cycle Menu provided by Staff L on 09/10/2021 showed residents with Controlled CHO diets should receive 2/3 cup [NAME] rice for the 09/14/2021 lunch meal. Observation of the lunch meal showed the same size scoop was used for both regular and Controlled CHO diets. Resident 9 Similar findings were identified for Resident 9, whose tray card indicated Lactose Restriction and the facility menu specified no directions regarding how a Lactose Restriction diet differed from a regular diet. Resident 46 Similar findings were identified for Resident 46 whose traycard indicated, Controlled CHO, see special MENU. Observation of the lunch meal on 09/14/2021 at 12:20 PM showed Resident 46 was served the regular diet of Salmon, rice, vegetables with cheesecake. There was no indication the Controlled CHO diet differed from the regular diet menu. Resident 317 Resident 317 admitted to the facility on [DATE] and according to the admission MDS dated [DATE] had multiple medically complex diagnoses including diabetes and kidney disease. According to the resident's traycard, the resident was prescribed a Renal [kidney] diet with direction s of Renal diet, use liberalized diet menu, SF [sugar free] diabetic, no Salmon, no dessert . Observation of the lunch meal on 09/14/21 at 11:50 AM showed Resident 317 received peas and rice but no protein substitute for the salmon that was called for on the menu. Review of the menu utilized by kitchen staff for meal services showed no direction on how the renal diet differed from the regular diet. Resident 15 Similar findings were identified for Resident 15, whose traycard indicated a Liberalized Renal diet Observation of the lunch meal service on 09/14/2021 showed Resident 15 was served chicken fried steak, mashed potatoes, peas and gravy. Review of the menu utilized by kitchen staff for meal services showed no direction on how the renal and liberalized renal diets differed from the regular diet. In an interview on 09/15/21 08:29 AM when asked if the system for dietary menus and therapeutic diets was intact, Staff A (Administrator) stated, No. Refer to F803, F806, F812. REFERENCE: WAC 388-97-1100(1), -1220. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to store and prepare food under sanitary conditions. Failure to date food products when they were opened, ensure damaged cans were removed from circulation, use appropriate hand washing and glove use, ensure staff restrained their hair, and to maintain a system by which dishes and food service utensils were properly sanitized, placed residents at risk for potential sources of food-borne illness. Findings included . Initial Kitchen Rounds on 09/07/2021 During initial kitchen observation on 09/07/2021 at 8:55 AM, showed a standing fan blowing air over the steam tables and a second standing fan blowing air from the dirty to the clean side of the dishwashing area. Observation of the walk in fridge at 9:11 AM showed a silver bin of cooked bacon that was cold, but uncovered. Also noted was a bin of cooked hamburger which was uncovered and not dated. Two cans with substantial dents at the lids were noted in the rack of canned foods. In an interview on 09/07/2021 at 9:15 AM, Staff J (Sous Chef) stated that dented canned goods should be removed from food storage. In dry storage there were multiple containers of spices with open lids (Curry powder, Cayenne, etc), multiple gravy mixes (3), graham crackers, and cocoa containers that were open and undated. A bag of flour was noted on the floor. In an interview at 9:37 AM on 09/07/2021, Staff J stated, No, that isn't suppose to be on the floor. Observations of the Lunch Meal on 09/14/21 Observations on 09/14/21 at 9:30 AM showed Staff R (Kitchen Staff) preparing and plating cheesecake for the lunch meal. While Staff R wore a pink baseball cap, their hair hanging loose and unrestrained. Observation on 09/14/21 at 9:43 AM showed Staff L (Dietary Service Manager) enter the kitchen and conferred with Staff R, who left the kitchen, returned at 9:49 AM wearing a hair net under the baseball cap. Observation on 09/14/21 at 9:40 AM showed Staff J (Sous Chef) use a plastic wrapped scale to weigh salmon fillets. Staff J was noted to place the scale back on the shelf without changing or removing the plastic wrap. Additional observations made during meal service on 09/14/2021 showed Staff L repeatedly (10:21 AM, 10:34 AM & 10:55 AM) make gloved hand contact to their face/mask and return to preparing food without glove changes. Failure to Sanitize Dishes In an interview on 09/14/2012 at 9:42 AM, Staff L was asked if the facility dishwasher was high or low temperature and what chemical was used to sanitize the dishes. Staff L replied, I don't know the special chemical and indicated the temperature should be, three hundred [degrees] I think .I don't have that answer. Observations on 09/14/21 at 9:42 AM showed Staff O (Food Service Aide) utilizing the dishwasher to process breakfast dishes. After three loads of dishes were observed run through the dishwasher, Staff O was asked to test the dishwasher for sanitizer. After dipping the Chlorine test strip in the dishwasher water, it remained white. Staff O stated, Its' suppose to turn purple, it's not. These are the chlorine strips, for some reason it's not turning purple. Staff O confirmed after testing three strips, there was no color change and the strips remained white. Observations on 09/14/2021 at 9:51 AM showed Staff O troubleshoot the machine, removing dishwasher arms stating, Sometimes there's something stuck in the washer arms sometimes there's something there, maybe that's what's causing it (test strip) to not turn purple . Staff O then tested for Chlorine again and upon examining the test strip stated, It's not turning purple, not even lavender . Staff O correctly stated, It's (Chlorine test strip) suppose to be between 50 and 100 ppm [parts per million]. Observations on 09/14/2021 from 10:20 AM through 10:40 AM showed Staff O continued to run dishes through the dishwasher despite knowing there was insufficient sanitizer to ensure the dishes were clean. At 10:42 AM, Staff O was observed to place insanities plates, plate covers, and silverware at the beginning of the tray line to be utilized for the lunch meal and continued to process breakfast dishes as they came into the kitchen. In an interview on 09/14/2021 at 10:43 AM, when asked if the dishwasher was now sanitizing the dishes, Staff O replied, No, I didn't get it to turn purple When asked if the dishes should be used if they weren't clean, Staff O replied, I don't know. On 09/14/21 at 10:46 AM Staff A (Administrator) was informed soiled dishes were being put back into circulation for resident use. Observation on 09/14/21 at 10:55 AM showed Staff O was still running dishes thorough the dishwasher. Uncovered or Improperly Stored Food Observation on 09/14/21 at 9:35 AM showed a rack containing multiple cookie sheets containing what appeared to be peanut butter cookies, as well as four pies in an uncovered tray rack. Similar observations of the uncovered desserts were noted at 10:11 AM and at the end of meal service at 12:40 PM. Observation at 9:25 AM showed a plastic bin containing a light yellow semi solid substance covered in plastic wrap and containing a purple scoop. In an interview on 09/14/2021 at 10:33 AM Staff J indicated the bin with the light yellow substance and a purple scoop covered with plastic was the Fortified Butter which was used for breakfast and would be used for lunch. In an interview on 09/14/2021 at 11:38 AM Staff J confirmed the Fortified Butter was a dairy product with protein powder added. The Fortified Butter was added to the trays of resident's whose diets read 'Fortified. The Fortified Butter was unrefrigerated and not on ice from 9:25 AM through meal service at 12:40 PM on 09/14/2021. Improper Sanitizing of Thermometer Observation on 09/14/2021 at 11:25 AM showed Staff J test the temperatures of the food on the steam table. After removing the thermometer from each food item (they were noted to clean the thermometer probe with a San-Cloth Germicidal Disposable wipe Instructions on this product included, To disinfect nonfood contact surfaces only, WARNING Keep out of reach of children and Hazards to Humans and Domestic Animals .wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco or using restroom. Call a poison control center or doctor for treatment advice . In an interview on 09/14/2021 at 1:27 PM, when asked if the sanitation wipes used by Staff J were the appropriate cleaning mechanism for the thermometers which were then dipped into food for consumption, Staff L (Dietary Service Manager) stated, Let me check. After examining the SaniCloth packet, Staff L stated, I would rinse it (thermometer) under water . At this time Staff A (Administrator) indicated it wasn't appropriate to use this sanitizer during food service. Refer to F803, F805, F806. REFERENCE: WAC 388-97-1100(3), -2980. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate records for each resident (Residents 24, 29, 21, 50, 3, 45). The facility failed to ensure: physician orders were clear/accurate, bathing & bowel records were clear/accurate, assessment documents accurately reflected resident condition, behaviors were monitored, Informed Consents signed/dated and resident inventory lists were complete. Failure to ensure clinical records were complete and accurate placed residents at risk of not having their needs met. Findings include: Refer to CFR: 483.10(f)(1)-(3)(8), F-561, Self Determination. Late Entries To Residents' Health Records Resident 24 Record review showed Elder Place Providers (Contracted Healthcare services) consistently failed to ensure timely entries in resident records. On 09/10/2021 multiple late entry Elder Place progress notes for 07/27/2021, 07/28/2021 and 08/10/2021 encounter dates. Record review showed that on 08/01/2021 Elder Place staff entered notes as late entry for services provided on 07/23/2021. Additional record review showed Elderplace physician notes dated 07/07/2021 showed a late entry for 06/30/2021. Similar findings were identified when Elderplace providers made resident record entries on 04/23/2021 for service dates of 04/21/2021. In an interview on 09/16/2021 Staff N (Director of Rehabilitation Services) confirmed that Resident 24 was seen by Occupational Therapy on 07/26/2021, but the records of this service visit was not available in the resident's record and was obtained on 09/16/2021, seven weeks after the service was provided. Similar findings were identified for Occupational Therapy Services provided on 04/28/2021 but not obtained until 09/16/2021. Resident 29 Similar findings were found for Resident 29. Record review showed the following late entries into the Resident's health record: a Provider progress note marked as late entry for 08/23/2021 was added on 08/26/2021; a Provider progress note marked as late entry for 08/11/2021 was added on 08/17/2021; a Provider progress note marked as late entry for 07/23/2021 was added on 07/27/2021; a Provider progress note marked as late entry for 07/09/2021 was added on 07/13/2021; an Activities/Therapeutic Recreation progress note was marked as late entry for 05/08/2021 was added on 07/11/2021. Resident 21 Similar results were found for Resident 21. Record review showed the following: a Provider progress note was marked as late entry for 09/01/2021 was added on 09/04/2021; a Provider progress note marked as late entry for 07/14/2021 was added on 07/19/2021. Resident 47 Similar findings showed Resident 47 did not have provider records in facility Wound care records of the Elderplace visit on 07/21/2021 was not in the resident record until 09/14/2021. Podiatrist records from visit on 08/09/2021 was not in the facility record until 09/14/2021. Emails coordinating resident wound care between the facility, Elderplace therapist, Elderplace wound care nurse and Elderplace primary care practitioner during the dates of 07/21/2021 to 09/16/2021 were not found in the resident's progress notes or in e-documents until the investigation on the wound began on 09/16/2021 and the emails were identified by the facility. Resident 19 Similar findings showed Resident 19's physician/nurse practitioner records showed late entries to the resident's progress notes. A visit from a Team Health nurse practitioner on 07/19/2021 was entered into the record on 07/19/2021. A visit date from the physician on 07/28/2021 was entered on 08/01/2021. Another visit date on 08/04/2021 from a Team Health nurse practitioner with orders written, and delayed, due to notes entered on 08/09/2021 Resident 2 Similar findings showed Resident 2 did not have provider records in facility records. An Elderplace social worker assessment dated [DATE] was not in the resident record until facility requested it on 09/21/2021. An Elderplace nurse practitioner encounter note dated 07/20/2021 was not in the resident record at the facility until requested on 09/21/2021. Resident 2's hospital Discharge summary dated [DATE] was not in the resident record until requested by the facility on 09/21/2021. A late entry MD IPN note dated 07/28/2021 was entered into e-documents on 09/08/2021. Acting Upon Referrals Resident 50 Record review showed a referral for mental health services for Resident 50. Record review showed no indications the resident received this service. In an interview on 09/09/2021 at 11:20 AM, Staff C (Resident Care Manager) was asked to provide evidence of the mental health referral. Staff C reviewed the record and was unable to this document in either the electronic or physical medical record. Staff C indicated the mental health visit was provided through the Elderplace providers and the documents to support consults through this provider were not always provided to the facility to become a part of the resident's record. A 08/20/2021 psychiatry consult document, not previously available in the resident record, was provided by facility staff on 09/09/2021 Record review showed Resident 50 experienced a fall on 08/08/2021. According to investigative documents, facility staff implemented interventions of Do not leave alone in BR [bathroom] until compliant with calling. Review of Care Plan (CP) documents showed this was not listed as an intervention to prevent falls. In an interview on 09/12/2021 at 10:30 AM, Staff C stated the intervention was placed on the Pocket Care Guide [instructions for care to direct care staff ]. Staff C explained the Pocket Care Guides were updated daily but the changes on these guides were not included in the resident's medical record. Bathing Records Resident 3 In an interview on 09/08/2021 at 11:17 AM, Staff D, (Clinical Manager), stated that Resident 3's bathing was documented on the Treatment Administration Record (TAR). Review of Resident 3's August 2021 TAR showed for eight of the nine scheduled showers in the month, facility staff documented M. In an interview 09/09/2021 at 8:35 AM Staff C indicated M stood for missed. Staff C later provided a Unit Shower schedule that had each unit room numbers listed from top to bottom and Monday through Friday across the top. In the top left hand corner it stated Week of: ex. 8/30/21-9/5/21. The form contained no resident names and was not part of the resident's medical record. Staff C indicated this was the documentation of bathing that the facility had. Resident 45 Similar findings were noted for Resident 45, who did not have the bathing order on her TAR. The only documentation provided by the facility was the Unit Shower schedule which was not part of the medical record.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility effectively implement an Infection Control program, including failure to utilize appropriate PPE (personal protective equipment), failure to maintain barrier use during medication pass, and failure to perform hand hygiene between tasks. This failure left residents at risk for contracting communicable diseases, and other health risks. Findings included . Medication Administration Observation of medication pass on 09/13/2021 at 11:36 AM showed Staff F (Licensed Practical Nurse) prepare medications for administration to Resident 24. Staff F placed medications and a glucometer (a machine used to test blood sugar levels) in a plastic bin, and placed the bin on Resident 24's bed. After administering the medication and testing the resident's blood sugar, Staff F placed the glucometer back in the bin, and then placed the bin on top of the medication cart prior to sanitizing the glucometer and placing it back in the medication cart. Staff F placed the contaminated plastic bin on a second area of the medication cart without sanitizing the bin, or the top of the now contaminated medication cart. Similar observations of lack of barrier use was noted on 09/08/21 at 10:57 AM when Staff S (Registered Nurse) prepared and administered inhalers to Resident 48. Staff S was noted to place the Spiriva Inhaler on the resident's over bed table, then place the inhaler next to the sink during handwashing, then place the inhaler in a cup with a second inhaler, for transport back to the medication cart. Resident 61 Record review of Resident's care plan dated 12/16/19 reflected Resident 61 was incontinent of urine related to post effects of stroke. Intervention: check for incontinent hygiene needs every 3-4 hours and bedtime. Provide adult brief/assist as needed. On 09/11/21 at 10:44 AM. Observed Staff MM, Nursing assistant certified (NAC), washed their hands and applied gloves. Staff MM removed Resident 86's wet brief, provided incontinent care, and applied clean new brief. Staff MM did not change gloves or perform hand hygiene in between changing briefs and incontinent care. Staff MM removed gloves,picked up, soiled trash bag and left the room without performing hand hygiene after cares. In an interview on 09/11/21 at 10:44 AM, Staff X confirmed that hand hygiene was not performed in between tasks and stated I forgot In an interview with Staff B, Director of Nursing on 09/15/21 at 2:37 PM indicated the expectations are nursing assistants are required to do hand hygiene in between tasks to avoid spread of infections. PPE USE According to the Facility's 08/06/2021 COVID-19 Handbook, cloth face coverings (face masks) are not considered PPE, and masking applies to all employees whether they provide direct care or in-direct [sic] care to patients and residents. On 09/09/2021 at 12:21 PM, Staff T was observed in Unit D wearing a cloth mask, rather than a surgical mask. 09/13/21 10:43 AM Staff T was observed wearing a cloth mask on the C Unit hallway. Staff T was observed to lower their cloth mask momentarily while talking with a resident outside room [ROOM NUMBER]. On 09/14/2021 at 01:10 PM, Staff T was observed at the Unit D nurses station, interacting with residents, wearing a cloth mask rather than a surgical mask. On 09/13/2021 at 11:15 AM, Staff U, Infection Preventionist (IP), stated that the minimum requirement is for staff to wear a surgical mask and eye protection in resident areas. Staff U added that this applied to all employees, regardless of role. Foam Border To Nurses Station On 09/11/2021 at 10:26 AM, the Unit C nurses station table was observed to have a foam padding attached along its entire length. This foam border was observed to have chunks of its smooth exterior surface either worn or torn off throughout the length of the border, exposing areas of porous foam. Multiple observations made between 09/07/2021 at 12:47 PM and 09/10/21 at 08:38 AM showed that the Unit C nurses station was routinely used by residents to dine at meal times. In an interview and observation on 09/16/2021 at 9:33 AM, Staff U, Registered Nurse/Infection Preventionist (RN/IP) observed that the foam padding was not intact and could not be effectively disinfected. REFERENCE WAC: 388-97-1320(1)(c), -1320(1)(a). .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $110,562 in fines. Review inspection reports carefully.
• 76 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $110,562 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
• Grade F (3/100). Below average facility with significant concerns.

Bottom line: Trust Score of 3/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Marianwood's CMS Rating?

CMS assigns MARIANWOOD HEALTH AND REHABILITATION an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Marianwood Staffed?

CMS rates MARIANWOOD HEALTH AND REHABILITATION's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Washington average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Marianwood?

State health inspectors documented 76 deficiencies at MARIANWOOD HEALTH AND REHABILITATION during 2021 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 74 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Marianwood?

MARIANWOOD HEALTH AND REHABILITATION is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by PROVIDENCE HEALTH & SERVICES, a chain that manages multiple nursing homes. With 117 certified beds and approximately 90 residents (about 77% occupancy), it is a mid-sized facility located in ISSAQUAH, Washington.

How Does Marianwood Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, MARIANWOOD HEALTH AND REHABILITATION's overall rating (1 stars) is below the state average of 3.2, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Marianwood?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Marianwood Safe?

Based on CMS inspection data, MARIANWOOD HEALTH AND REHABILITATION has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Marianwood Stick Around?

Staff turnover at MARIANWOOD HEALTH AND REHABILITATION is high. At 56%, the facility is 10 percentage points above the Washington average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Marianwood Ever Fined?

MARIANWOOD HEALTH AND REHABILITATION has been fined $110,562 across 3 penalty actions. This is 3.2x the Washington average of $34,184. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Marianwood on Any Federal Watch List?

MARIANWOOD HEALTH AND REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 117
Avg. Residents: 90
Occupancy: 77.5%
Ownership: Non profit - Corporation
Chain: PROVIDENCE HEALTH & SERVICES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
1 Actual Harm citation: -5
76 Deficiencies: -10
Fines ($110,562): -15
Final Score: 3/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505418