**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 2> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including heart complications, depression, and anxiety. The comprehensive assessment dated [DATE] showed Resident 2 was readmitted on [DATE] with a significant change (a deterioration or improvement in the physical or mental conditions of a resident) in their health status. Review of Resident 2's PASARR, last completed on 10/25/2021 by Staff D, SSD, showed the resident had SMI of depression and anxiety, and no Level 2 was required at the time the assessment was completed (no Level 1 PASARR had been updated after the resident's change in condition on 12/30/2024). During an interview on 04/09/2025 at 2:32 PM, Staff D, stated the facility's process was to complete a new Level 1 PASARR if a resident had a physical or mental change in their condition. Staff D stated they were not aware Resident 2 had a change in condition around the 12/26/2024 significant comprehensive assessment. Staff D stated the correct process was not followed and that a new Level 1 PASARR should have been completed and a referral sent for a Level 2 PASARR evaluation. During an interview on 04/09/2025 at 3:20 PM, Staff A, Administrator, stated the correct process was not followed regarding Resident 2's change in conditions and a new Level 1 PASARR should have been completed/sent out for an evaluation. Reference: WAC 388-97-1975(5)(7) Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) had the required Level 2 referral sent when residents had a positive Level 1 PASARR and were an exempted hospital discharge in the facility for more than 30 days or had a change in condition in which a new Level 1 PASARR would require completion for 2 of 5 residents (Resident 24 and 2) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate to their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-admission Screening and Resident Review (PASARR or PASRR) Level 1 Screening Process, dated 07/06/2024, showed a positive Level 1 PASARR screen (that would then require a referral for a Level 2 PASARR) was Any of the questions in Section 1A (1, 2, and/or 3) are marked Yes: or sufficient evidence of SMI is not available, but there is a credible suspicion that a SMI may exist; and the requirements for exempted hospital discharge do not apply . Additionally, if requirements for exempted hospital discharge were met but the residents stay changed from less than 30 days to exceeding 30 days, then the facility's responsibility would be to send out positive Level 1 screenings to be evaluated. <Resident 24> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) and anxiety (a feeling of worry, nervousness, or fear, often in anticipation of something unpleasant). The comprehensive assessment dated [DATE] showed Resident 24 had a mildly impaired cognition and an anxiety disorder. Review of Resident 24's PASARR, dated 02/21/2025 showed Resident 24 had a positive SMI for a mood disorder. Further review showed Resident 24's PASARR was marked exempt from requiring a Level 2 evaluation due to a physician certifying that Resident 24 would be requiring less than a 30 day stay in the nursing facility. Additionally, the required Level 2 evaluation had not been completed as of 04/08/2025 (46 days after Resident 24's admission). During an interview on 04/08/2025 at 12:52 PM, Staff D, Social Service Director (SSD), stated when a resident was admitted with an exemption marked on the PASARR for a stay of less than 30 days, and the stay was likely going to be longer, the social service assistant would be responsible for sending out for the Level 2 required screening prior to the 30-day mark. During an interview on 04/09/2025 at 9:50 AM, Staff I, Social Service Assistant, stated they were unable to confirm whether Resident 24's PASARR had been sent out for the required Level 2 screening. During an interview on 04/10/2025 at 9:53 AM, Staff B, Director of Nursing Services, stated the process for sending out the required Level 2 PASARR screening for a resident who came into the facility exempt was that social services were to send it prior to the 30-day mark. Staff B stated that it was not completed for Resident 24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1) identify and monitor individualized targeted behaviors (ITB's), and implement non-pharmacological (methods used to improve health and/or manage a residents conditions without the use of medications) interventions before prescribing a psychotropic medication (a group of drugs that affect brain activities associated with mental processes and behavior), 2) monitor for adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have, that can lead to a decline in an individual's mental or physical condition); and 3) ensure appropriate justification for the use of a psychotropic medication for 1of 5 residents (Resident 19), reviewed for unnecessary medications. This failure placed residents at an increased risk of medical complications, unnecessary side effects, and a deterioration in their mental and physical health. Findings included . Review of the facility's policy titled, Behavior Management/Psychoactive Medication Overview, dated February 2025, showed that residents with mood or behavior symptoms will be assessed to determine potential causes. Assessment of data, observation, resident interviews, and staff feedback will be used to develop a behavior/mood management care plan. Psychotropic medications may be used for behavior/mood management when other non-pharmacological interventions have been unsuccessful and should be used as a last resort. Routine monitoring for adverse side effects and ITB monitoring will be documented on the resident's medication administration record (MAR). <Resident 19> Review of the resident's medical record showed Resident 19 was admitted on [DATE] with diagnoses including a fracture of the left hip joint and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). Review of the most recent comprehensive assessment, dated 03/22/2025, showed the resident's cognition was moderately impaired and no hallucinations (a false perception where you see, smell, taste or feel things that appear to be real but only exist in your mind) or delusions (a strongly held false belief that conflicts with reality) were present. Review of the physician's orders dated 03/20/2025 (2 days after admission) showed that Seroquel (a specific psychotropic medication commonly used to treat mental health conditions like hallucinations) was ordered to be given to Resident 19 at bedtime for hallucinations. Further review showed that no orders were placed to monitor ITB's nor non-pharmacological interventions to show whether the psychotropic medication was appropriate or effective. Additionally, there were no orders for monitoring adverse side effects related to psychotropic medication. Review of a progress note dated 03/20/2025 showed Staff G, Registered Nurse, documented a new order for Seroquel to address disturbances related to dementia. Staff G documented the provider had spoken to Resident 19's representative (RR) about Resident 19's status. However, no further documentation regarding the psychotropic medication was found in the record from 03/20/2025 to 04/09/2025. During an interview on 04/09/2025 at 11:49 AM, Staff G stated the process for starting any psychotropic medication included placing the resident on alert charting for monitoring of ITB's specific to the residents, to justify the need for the medication. Staff G stated once a psychotropic medication was started, orders would be placed to monitor a residents ITB's, any adverse side effects, and to update the care plan. Staff G stated that the Resident Case Managers (RCM) were responsible for following up on any psychotropic medication orders or changes to ensure the process was followed. Additionally, Staff G confirmed this process was not followed for Resident 19 when the new order for a psychotropic medication was received. During an interview on 04/09/2024 at 1:08 PM, Staff H, RCM, stated the process for starting any psychotropic medications included placing the resident on alert charting for at least three days to monitor specific ITB's, non-pharmacological interventions attempted and any adverse side effects to show the medications effectiveness. Additionally, Staff H stated all nursing staff were responsible for documenting in the resident's medical record. Staff H stated they were not aware that Resident 19 was hallucinating or that the resident had been started on Seroquel. Staff H stated a daily report of all new medications were provided and Staff H was unsure of how Resident 19's psychotropic medications got missed. During an interview on 04/09/2025 at 4:07 PM, the facilities medical provider, stated they were informed by nursing staff that Resident 19 was hallucinating reportedly seeing children out the window and not sleeping well. The provider also stated they had discussed the hallucinations with Resident 19's RR and expected the behaviors to be documented in the medical record, along with alert charting for any adverse side effects, ITB's, non-pharmacological interventions and evaluation of the medication's effectiveness. However, this was not done for (Resident 19). During an interview on 04/09/2025 at 2:28 PM, Resident 19's RR recalled the facility's medical provider spoke with them and stated they had given permission for the Seroquel medication to be started. However, the RR did not remember why the psychotropic medication was being started, and that Resident 19 was acting differently at the time. During an interview on 04/10/2025 at 9:43 AM, Staff B, Director of Nursing Services, stated they expected nurses transcribing psychotropic medication orders to ensure there was adequate justification for use of the medication, initiated ITB's, monitored for any adverse side effects, and implemented alert charting. Additionally, Staff B stated the process was not followed correctly on the implementation of Resident 19's psychotropic medication. Reference: WAC 388-97-1060(3)(k)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nursing staff implemented appropriate infection control practices in the prevention of urinary tract infections (a condition were pathogens like bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) with residents indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) care for 1 of 2 resident (Resident 17), reviewed for infection control. This failure placed the residents at risk of developing an IUC associated UTI and unmet care needs. Findings included . <Resident 17> Review of the resident's medical records showed they were admitted on [DATE] with diagnoses including stroke, neuromuscular dysfunction of the bladder (complication controlling bladder functions) and obstructive reflux uropathy (an obstruction in the urinary tract causing urine to back up into the kidneys). The 03/10/2025 comprehensive assessment showed that Resident 17 had moderately impaired cognition and an IUC. Review of Resident 17's care plan showed the resident had a suprapubic catheter (a specific type of IUC that is inserted through a small incision in the abdomen) in place as was to receive IUC care every shift by nursing staff. Observations on 04/07/2025 at 1:09 PM showed Staff E, Nursing Assistant (NA) and Staff G, NA, performing an incontinence brief change and IUC care on Resident 17. Staff E and Staff G performed hand hygiene and put on gloves prior to starting the resident's care. Staff E started perineal care (cleaning and maintenance of the private areas of the body) on the resident's buttocks and a small wound that had a scant amount of blood was noted. Staff E utilized the same wipe, that had just been soiled from wiping the resident's perineal area, to wipe the blood from the resident's wound. Staff E did not perform hand hygiene or put on new gloves and then assisted in turning and replacing the old, soiled brief with a new clean one. Staff E proceeded to clean the resident front perineal area with the same soiled gloves and then move onto the resident's IUC care without performing a glove change or hand hygiene. During an interview on 04/07/2025 at 1:45 PM, Staff G, NA, stated their process for perineal care would be to remove their soiled gloves and perform hand hygiene after completing care on the resident buttocks area and after care of the resident's frontside perineal area. Staff G stated they would then put on new gloves to continue with IUC care. During an interview on 04/07/2025 at 1:49 PM, Staff E stated they should have completed hand hygiene/changed gloves in between each area of the resident's perineal care and then before moving onto Resident 17's IUC care. Staff E stated they did not follow the correct infection control process for IUC care and could have potentially contaminated the residents IUC. During an interview on 04/09/2025 at 3:42 PM, Staff C, Infection Preventionist, and Staff B, Director of Nursing Services, stated that Staff E did not follow the correct infection control process for Resident 17's IUC care and that hand hygiene/change in gloves should have been performed in between each area of the resident's body to prevent the potential spread of infectious pathogens. Reference: WAC 388-97-1320(1)(a)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written) conveyed during resident council meetings (a meeting of the facility's residents to communicate concerns, request improvements and keep up to date of the facility's activities/events) underwent prompt resolution through to their conclusion or appropriately updated on the grievance progress/conclusion for 4 of 5 residents (Resident 22, 348, 350, 349) reviewed for the grievances process. This failure placed residents at risk for unresolved concerns and unmet care needs. Findings included . Review of the facility policy titled, Grievances Procedure, revised October 2021, showed the facility would .have a process in place for identification, investigation and follow-up of resident/resident representative grievances in a timely manner. The policy showed that grievances would be documented on the grievance logbook and analyzed for identifiable trends within the facility. <Resident 22> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including a bladder infection, diabetes and long-term kidney disease. The 01/06/2025 comprehensive assessment showed the Resident 22 had moderately impaired cognition but was able to make their needs known. <Resident 348> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including a left leg fracture. The 02/17/2025 comprehensive assessment showed that Resident 348 was cognitively intact and able to make their needs known. The resident was discharged from the facility on 02/24/2025. <Resident 350> Review of the resident's medical record showed they were admitted to the facility on [DATE] for rehab following surgery. The 11/19/2024 comprehensive assessment showed that Resident 350 was cognitively intact and able to make their needs known. The resident was discharged from the facility on 01/15/2025. <Resident 349> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (a disease where the body attacks its own nervous system that can cause involuntary muscle spasms and muscle stiffness) and a neurogenic bladder (complication controlling bladder functions). The 12/16/2024 comprehensive assessment showed that Resident 349 was cognitively intact and able to make their needs known. The resident was discharged from the facility on 01/27/2025. Review of the facility's grievance logbook for January 2025 through March 2025 showed that grievances expressed through resident council meetings were not documented on the grievance log for January, February or March 2025. During an interview on 04/08/2025 at 9:01 AM Staff F, Activities Director, stated they were charged with coordination of the resident council meetings and documented the meeting minutes since December 2024. Staff F stated that for all grievances we try to solve right then and there, but that some of the grievances Staff F would have to convey to the Director of Nursing Services (DNS) who would fill out a form. Staff F stated they did not bring the resident's grievances to the facility's grievance officer, Staff D, Social Service Director (SSD) for January 2025 through March 2025 nor had they filled out the facility's official grievance form with resident specific information. During the continued interview on 04/08/2025 at 9:01 AM, Staff F stated that during the January 2025 resident council meeting Resident 350 had a grievance about a Nursing Assistant (NA) with an attitude and Resident 349 had a grievance about an NA that refused to help clean the residents face, but specifics regarding the resident's names and conversations were not documented. Staff F stated that during the February 2025 resident council meeting, Resident 348 had a grievance around medications not being administered timely and that Resident 22 had the same grievance during the March 2025 resident council meeting. Staff F stated that specifics regarding the resident's names and conversations were not documented. Staff F stated they did not have documentation that follow-up was completed for any of the residents. Staff F stated the correct grievance process had not been followed. During an interview on 04/08/2025 at 9:53 AM, Staff D, SSD, stated that all grievances were to come to them so they could be documented on the grievance log, ensure that an investigation was completed, that follow-up was done, which included, grievances during resident council meetings so that patterns/trends could be identified. Staff D stated they were not aware of Resident 22, 348, 350 or 349's grievances from the January through March 2025 resident council meetings. Staff D stated they could not ensure the correct process of a grievance resolution through to its conclusion was conducted for Residents 22, 348, 350 and 349. During an interview on 04/08/2025 at 10:48 AM, Staff B, DNS, stated grievance concerns conveyed by Staff F from the January 2025 through March 2025 resident council meetings were not towards any one resident or staff member and Staff B saw the grievance as a whole and not specific. Staff B stated they did not know the names of the specific residents that had conveyed the grievances during the January 2025 through March 2025 resident council meetings. Staff B stated they did not interview the specific residents or follow-up with the residents on the grievance resolution/conclusion. During an interview on 04/09/2025 at 8:08 AM, Staff A, Administrator, stated they had realized that grievances from the resident council meetings were not being documented on the facility grievance log. Staff A stated they did not know that Residents 22, 348, 350 and 349 were involved in the specific grievances from January 2025 through March 2025 resident council meetings. Staff A stated the correct process was not followed for the Resident 22, 348, 350 and 349's grievances. Reference: WAC 388-97-0460(2)

Based on observation and interview the facility failed to provide a safe, functional, and sanitary (the conditions that affect hygiene and health) environment for residents and staff for 1 of 1 shower room (SR 1), reviewed for a comfortable environment. This failure placed residents and staff at an increased risk for not feeling safe and secure with their environment. Findings included . Observations of the [NAME] hallway SR1 on 05/08/2024 at 7:43 AM showed the main wall had numerous scuff/scrape marks spanning along the entire lower half of the 20 foot (ft, a unit of measure) wall, where three mechanical lifts had been stored. Multiple gouges and tears could be seen in the sheet rock and paint chips from the wall were noted on the floor. The actual shower had three missing tile pieces, two broken trim/edging sections at the entrance to the shower, and a black substance that could been seen all around the inside perimeter of the shower. Additionally, a ½ ft by ½ ft section of wall/sheet rock had been cut out around the shower's cover and valve (controls the flow of water and turns the shower on/off) with the top half of the valve sunk into the wall. During an interview on 05/10/2024 at 11:31 AM, while observing SR1, Staff C, Maintenance Supervisor, stated that all shower rooms were operational and being used. Staff C stated they had been attempting to adjust the shower valve to increase the showers water pressure, did not finish the sheet rock behind the valve, and was not sure how the shower valve had sunk back into the wall. Staff C was shown the black substance around the inside perimeter of the shower along with the missing section of tile and trim. Staff C was not sure what the black substance was, but stated the shower was not in proper working order and the missing section of tile/trim, the shower valve, and the numerous scrape/gouge marks on the main wall all need to be fixed. During an interview on 05/10/2024 at 11:40 AM, after showing observations of SR1, Staff A, Administrator, stated that it all needed to be fixed, that it was not a comfortable environment for the residents, and they would be working to correct it. Reference: WAC 388-97-3220(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure clinical appropriateness for safe self-administration of medication for two of two residents (5 and 192), reviewed for medication administration. Additionally, the facility failed to obtain a physician's order for self-administration of medications for the residents and did not update the individualized care plan. Failure to complete a self-administration assessment and obtain a physician's order placed the residents at risk for medication errors and adverse medication interactions. Findings included . Resident 5. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, stroke, and GERD (gastro-esophageal reflux disease - a digestive disease in which stomach acid or bile irritates the food pipe lining). The 02/20/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for Activities of Daily Living (ADLs). The assessment also showed the resident had a moderately impaired cognition. An observation on 04/17/2023 at 10:03 AM showed the residents over the bed table contained a bag of cough drops, a container of Vicks Vaporub (a topical ointment that temporarily relieves cough), and a bottle of Rolaids (antacid medication to neutralize stomach acid and relieve acid indigestion). A bedside table showed a bottle of Advil ([NSAID] a non-steroidal anti-inflammatory medication that treats fever and mild to severe pain), a bottle of TUMS (antacid), a bag of cough drops, and a container of Tucks Medicated Pads (a pad saturated with medication to relieve the itching and burning associated with hemorrhoids). Additional observations on the following dates showed the same observations: • 04/18/2023 at 8:56 AM; • 04/20/2023 at 7:52 AM; • 04/21/2023 at 7:55 AM. During an interview on 04/21/2023 at 8:33 AM, Staff C, Nursing Assistant (NA), stated that they provided cares for Resident 5. They stated that sometimes resident family members brought in medications for the residents. Staff C stated that if they found medications in a resident room, they let the licensed nurses know. They stated they were not aware of any medications in any resident rooms. During an interview on 04/21/2023 at 8:37 AM, Staff E, Licensed Practical Nurse (LPN), stated that the process for a resident to keep medications at the bedside included obtaining a physician's order. Staff E stated they were responsible for passing medications to Resident 5 and were not aware of any medications kept at the bedside. During an interview on 04/21/2023 at 8:40 AM, Staff F, Registered Nurse (RN), stated that the process for allowing medications at the bedside included placing a call to the physician to ask if its ok. They stated that they would not put in an order for medications at the bedside but might put in a progress note. During an interview on 04/21/2023 at 8:43 AM, Staff G, Patient Care Coordinator (PCC), stated that they were the PCC for Resident 5. They stated that the process for a resident to keep medications at the bedside for self-administration included completion of a medical assessment form to make sure the resident was appropriate for the self-administration. Once the assessment was completed, they would obtain a physician order and place the self-administration order on the Medication Administration Record (MAR). Staff G stated they did not know the resident had medications at the bedside. During a second interview at 9:30 AM, Staff G stated that there was also a prescription bottle of Ondansetron (a medication to prevent nausea and vomiting) that came from an outside pharmacy. Observation showed the bottle was labeled with the name of the drug and a quantity of 20. There were 11 pills left in the bottle. Review of the resident's medical record showed that there was a lack of assessment, no physicians order, and no care area on the individualized care plan for safe self-administration of the medications . Resident 192. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a right hip fracture, mild cognitive impairment, and a need for personal care assistance. The 4/13/2023 comprehensive assessment showed the resident required assistance of one staff member for ADLs. The assessment also showed the resident had a mildly impaired cognition. An observation on 04/17/2023 at 12:50 PM showed a bottle of Refresh eye drops on the residents over the bed table. Review of the medication label showed the medication was filled at an outside pharmacy. The bottle was half full. Additional observations on the following dates showed the same bottle of eye drops on the bedside table: • 04/18/2023 at 8:40 AM; • 04/20/2023 at 9:20 AM; • 04/21/2023 at 8:29 AM. During an interview on 04/17/2023 at 12:50 PM, the resident stated that their doctor stated that they could have their eye drops in their room because they needed them frequently. During an interview on 04/21/2023 at 8:34 AM, Staff D, NA, stated that they were aware of the eye drops in the resident's room. During an interview on 04/21/2023 at 8:43 AM, Staff G stated that they were the PCC for the resident and were not aware of the eye drops at the bedside. They further stated that there was no assessment or physicians order for that resident to keep medications at the bedside. Review of the resident's medical record showed that there was a no assessment, no physicians order, and no care area on the individualized care plan for safe self-administration of the medications. During an interview on 04/21/2023 at 9:57 AM, Staff B, Director of Nursing Services (DNS), stated that if medications were found in a resident's room, it would be reported to the licensed nurses, a physician order would be obtained, and a self-medication assessment would be performed. During a follow-up interview at 11:34 AM, Staff B stated that the facility did not have a policy on self-administration of medications. They stated that they ensure that an assessment had been done and that a physician's order had been obtained. It should have been on the Medication Administration Record. Reference: WAC 388-97-0440, 388-97-1060(1)(3)(l)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard infection prevention and control precautions were implemented by seven of ten staff (H, D, O, I, Q) observed during dining and meal tray delivery to residents, and one of two staff (J) observed during wound care dressing changes. These failures placed residents and staff at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the facility's policy titled, Centers for Disease Control and Prevention (CDC), Hand Hygiene in Healthcare Settings, dated 01/30/2020 showed that all staff should implemented hand hygiene to help reduce the spread of infections to others. Further review showed that staff should perform hand hygiene for situations like, before contact with a resident or a resident's immediate environment, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after contact with objects in the immediate vicinity of a resident, after removing gloves, and before/after eating or handling food. Additionally, CDC's procedures for hand washing included, lathering the hands with soap, and rubbing them together for a minimum of 15 to 20 seconds. Dining Observation on 04/17/2023 at 11:41 AM showed Staff H, Nursing Assistant (NA), in the dining room serving salad to residents. Staff H was observed serving salad from a large bowel into a smaller salad bowl with utensils and assisted residents in setting up the bowl so that they would be able to eat. Staff H had bare hand contact with their own clothes, resident's used drinking cups and utensils when they were assisting each of the four residents, and did not perform hand hygiene during or after serving residents their food. During an interview on 04/19/2023 at 11:22 AM, Staff H stated that they should have performed hand hygiene in-between each resident when there were serving them salad and theyforgot. During a concurrent observation and interview on 04/18/2023 at 12:00 PM, Staff D, NA, delivered a meal tray to a room. Staff D arranged items on the resident's bedside table, cut up the resident's food, buttered the biscuit, handled the resident's silverware, then exited the room without performing hand hygiene. Staff D proceeded to obtain another resident tray from the delivery cart without performing hand hygiene. Staff D stated that they usually washed their hands before and after meal delivery for each room but had spaced it out that day. Staff D had bare hand contact with the resident's personal items and food throughout the observation. During a concurrent observation and interview on 04/18/2023 at 12:02 PM, Staff O, NA, delivered a meal tray to a resident's room. Staff O performed meal set up, then exited the room without performing hand hygiene. They proceeded to obtain another room tray from the delivery cart without performing hand hygiene. Staff O stated that they always washed their hands before and after delivering trays. Staff O further stated, I forgot and need to go do that now. Observation on 04/19/2023 at 7:44 AM showed Staff I, NA, was in the dining room delivering meal trays to residents. Staff I was observed delivering/setting up three different resident meal trays, touched multiple items/surfaces which included one resident's arm/sleeve and another's wheelchair, and did not perform hand hygiene in-between each resident. During an interview on 04/19/2023 at 8:23 AM, Staff I stated that they should have been performing hand hygiene in-between passing out/setting up trays for residents and was not aware that they had touched multiple surfaces in-between passing out meal trays to residents. During an observation and subsequent interview on 04/21/2023 at 8:06 AM, Staff Q, NA, delivered a food tray to a resident's room. Staff Q did not perform hand hygiene upon entry or exit of the resident's room. Staff Q proceeded to obtain another food tray from the cart and delivered it to Resident 22 in another room. Staff Q set the tray on the bedside table, removed the lids to food and drink containers and left the resident's room with the resident's coffee. Staff Q took the uncovered cup of coffee, with their bare hands, to the physical therapy room and heated it up in the microwave, placed a lid on the cup and carried the cup of coffee back down the hall to the resident's room with their palm over the cup of coffee. No hand hygiene was performed during any part of the process. Staff Q explained that when staff delivered trays to residents in halls, they were to take off the food covers, and place clothing covers on the residents, if requested. Staff Q stated that they forgot to perform hand hygiene during tray delivery. Wound Care Resident 15. Review of the resident's medical records showed that they were admitted on [DATE] after knee surgery for rehabilitation and had developed a wound that required a daily dressing change. Observations on 04/18/2023 at 11:56 AM showed Staff J, Registered Nurse (RN), at Resident 15's bedside for a dressing change on a newly identified wound on the resident's right lower leg in addition to a scheduled daily dressing change on their bottom. Staff J set up a cloth pad under the resident's right leg where multiple soiled gauze pads were observed. Observations on Staff J's dressing changes sequence of events were: • 04/18/2023 at 11:59 AM after removing the resident's soiled gauze dressings Staff J doffed (to take off) their soiled gloves and then proceeded to perform hand washing (without lathering or scrubbing their hands and washed for less than five seconds) at the sink in the resident's room, then donned (to put on) a new pair of gloves. • 04/18/2023 at 12:03 PM after cleaning the residents leg wound, Staff J doffed gloves and performed hand washing (without lathering or scrubbing their hands and washed for less than five seconds) at the sink in the resident's room for the second time. • 04/18/2023 at 12:08 PM Staff J changed gloves (after finishing cleaning the wound and had contact with the soiled/contaminated gauze pads) and did not perform hand hygiene before donning new gloves. Staff J then proceeded to open clean dressing supplies that were used to cover the wound and wrap the resident's leg. Additionally, Staff J changed and wrapped the resident's leg with the clean dressing without removing the soiled gauze pads that were still under the resident's leg and did not have a separate clean and dirty space. During an interview on 04/20/2023 at 10:33 AM, Staff J, stated that they did not follow the correct process for hand washing and should have lathered and scrubbed their hands for 20 seconds. Further, Staff J stated that they had not followed the correct process for the clean dressing change on the resident's leg. Staff J stated they should have removed the soiled dressings from the area under the resident's leg before applying the clean dressing. Additionally, Staff J stated that they should have performed hand hygiene in-between each glove change and forgot to do it. During an interview on 04/20/2023 at 1:56 PM, Staff B, Director of Nursing Services, stated that they expected all staff to perform hand hygiene in between each resident meal tray delivery, handling of food or entering/exiting resident's rooms. Staff B also stated that Staff J had not followed the correct standard infection control process for wound care and dressing changes and that they would expect all staff to perform hand washing by lathering the hands with soap and scrubbing them together for 20 seconds. Additionally, Staff B would expect all staff to perform hand hygiene in between every glove change. Reference: WAC 388-97-1320(1)(c)(2)(b)

Based on observation, interview and record review, the facility failed to periodically test the sanitizing agent used to ensure proper sanitation of food preparation surfaces in accordance with professional standards for food service safety, for one of one kitchen reviewed for food service safety. This failure placed all residents, staff, and visitors that ate from the facility's kitchen at risk for food borne illnesses and the spread of infectious diseases. Findings included . Review of the March 1, 2022, Washington State Retail Food Code, showed the concentration of the sanitizing solution must be accurately determined by using a test kit or other device. Review of the Pureforce Food Contact Quat Sanitizer product label instructions for use, dated 2012, showed the concentration of sanitizer used in the solution for sanitizing stationary, hard, nonporous surfaces, such as sinks and countertops, should be mixed at a ratio of 0.25 - 0.68 ounces of Food Contact Quat Sanitizer product per gallon of water, to achieve a concentration of 150 - 400 parts per million ([ppm] - a unit of measurement that is used to ensure proper dilution) active quat. During an interview on 04/20/2023 at 9:50 AM, Staff M, Dietary Manager, stated that they used the buckets of sanitizing solution to sanitize the preparation (prep) areas in the kitchen. They stated that the solution used to be tested, they had a testing kit that contained test supplies and forms to complete, but it was stored in an inconvenient location and was now lost. During an interview on 04/20/2023 at 9:53 AM, Staff L, Cook, stated that they used the solution with a clean rag to clean the prep areas of the kitchen. They stated that they used to test the solution but had not done it for a while. A concurrent observation and interview on 04/20/2023 at 9:55 AM, showed a bucket of sanitizing solution in the sink in the dishwasher area of the kitchen. Staff K, Dietary Aide (DA), stated that they were never trained to test the sanitizing solution and had not seen any forms or testing supplies. During an interview on 04/20/2023 at 12:38 PM, Staff M, stated that they could not find the testing logs for the sanitizing solution. They stated that testing was done, and staff knew how to test, but the log had been lost and no one reported the missing log. Staff M stated that they expected that the sanitizing solution in the buckets would have been tested every 2 hours. During an interview on 04/21/2023 at 10:56 AM, Staff M stated that they used the sanitizing solution in the buckets to wipe down all the areas that were soiled during meal prep. During an observation and interview on 04/21/2023 at 11:59 AM, showed Staff N, DA, in the dishwasher area of the kitchen with Staff M present. There was a bucket of sanitizing solution in the sink. Staff N stated that they had just started their shift and was not sure if the solution had been changed. Staff N performed a test on the solution, which showed the solution passed at 200 ppm. They emptied the bucket and refilled it from the automatic solution delivery device. Staff N then performed a test on the clean solution which passed at 400 ppm. During the same observation and interview, Staff M stated that the testing of the solution was a failed system. Record review showed sporadic testing of the sanitizing solution with the last documented test in December of 2022. During an interview on 04/21/2023 at 11:34 AM, Staff A, Administrator, stated that they understood the failure and was looking into purchasing new buckets that continuously monitored the sanitizing solution. Reference: WAC 388-97-1100(3)