Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the careplanned supervision that was necessary to avoid accidents for 1 of 5 residents (Resident 83) reviewed for accidents.Resident 83, who was left unattended on the toilet, sustained a fall where they struck their head and sustained a bump to the back of their head. This failed practice placed other residents with similar care needs at an increased risk of falls and serious injury. Findings included . Review of the facility's policy titled, Fall Management Plan-Safety Awareness Fall Elimination (SAFE) revised 11/06/2024, documented that each resident will be assessed on admission, quarterly and when safety issues occur to identify residents at risk for falls and implement strategies to prevent falls and injury from falls. All staff were to report immediately residents who are restless. Review of the Nursing Home Guidelines, The Purple Book, October 2015 edition documented a substantial injury would be in an area not vulnerable to trauma such as face, neck, back, chest. All injuries (regardless of the extent) occurring in non-vulnerable areas of the body will be considered substantial injuries. Resident 83 admitted to the facility on [DATE] with diagnoses to include dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with psychotic disturbance, anxiety (a mental health condition that involves excessive worry and feelings of fear, dread, and uneasiness), and recent left hip fracture from a fall. Resident 83 required 1 person observation for increased supervision related to impulsivity during their hospital stay 09/30/2024 to 10/07/2024. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident 83 had significant cognitive impairment, lower extremity impairment on one side and required substantial/maximal assistance with toilet transfers. Review of Resident 83's clinical record documented the Morse Fall Scale assessment was 103 days overdue, since 02/08/2025. The resident had a Morse fall assessment on admission [DATE] and missed the quarterly assessment on 02/08/2025 and readmission assessment on 05/05/2025. Review of ADL approaches (guide for nurse's aides on how to provide care) dated 11/09/2024 documented Resident 83 was a high fall risk, very fearful and directed staff to turn and move the resident carefully and required two persons stand pivot assistance for toileting transfers. Review of the resident's High Risk for Falls care plan initiated on 10/10/2024 showed Resident 83 was at high risk for falls related to impaired cognition, limited mobility, limited range of motion to their left lower extremity, actual falls with fractures, incontinence of bowel and bladder and the need for assistance with all Activity of Daily Living (ADL) and was on high risk medications (cardiac, narcotic, antidepressant and Depakote [seizure medication]). On 03/10/2025 signage was placed by the toilet to remind resident to ask for assistance prior to toilet use. Review of a Physical Therapy note dated 02/03/2025 showed Resident 83 was a fall risk with dementia and poor safety awareness, The documentation revealed the resident was currently on high fall risk notification and staffing knew to make frequent checks. The resident required one person assistance for all mobility due to their cognitive deficits. Review of a progress note dated 04/15/2025 at 9:19 AM, documented Resident 83 had an unwitnessed fall that day in their restroom. The resident was being assisted by a Nursing Assistant Certified (NAC) who stepped out of the restroom to grab a needed item. During that short period of time, the resident immediately attempted to self-transfer, fell and hit their head. When the NAC came into the room, the resident was on floor holding onto their head. During the assessment, Resident 83 was noted to have a lump on the left side of the back of their head. Nursing continued 15-minute checks and added neuro checks. Review of the facility incident report dated 04/15/2025 at 8:30 AM, documented Resident 83 was taken into the restroom by the NAC. The resident was scheduled to have a shower that morning. The NAC assisted the resident onto the toilet, then stepped out of the room into the hallway to tell the shower aide that the resident was up and out of bed for their shower. The NAC heard a loud noise and returned to the resident's room to find them on the bathroom floor. The NAC alerted the nurse that the resident had fallen. The incident report documented that the resident was found seated on the floor with their back facing the wall between the toilet and the sink. Their legs were out in front of them towards the door and they were holding their head. The resident stated they hit their head when they fell. The resident stated they just thought they could do it themself. The resident was assessed to have an injury to the back of their head. The level of pain was documented as sad, frightened, frown facial expression, tensed distressed pacing body language and they were distracted. Predisposing physiological factors at time of fall were marked the resident was confused, with gait imbalance and impaired memory with wandering, active exit seeking and they had been ambulating without assistance. Other information included the resident was unable to sit still, was very anxious, even on the toilet and the resident was panicking and anxious 30 minutes prior to the fall. The injury description showed a lump to the left back side of their head. The description did not include color, size or other characteristics of the injury. Review of a witness statement dated 04/15/2025 included in the incident report, Staff K, the assigned NAC documented Resident 83 was restless prior to the fall, they assisted the resident to the toilet for a bowel movement and left the resident for less than two minutes to ask the bath NAC about their shower. Staff K documented when they came back, they grabbed onto the door handle and heard a crash, entered the bathroom to find a fallen wheelchair and the resident on the floor. Staff K documented the resident had been told not to get up without help. The NAC called for the nurse. Review of a comprehensive fall assessment completed on 04/15/2025 showed Resident 83 had difficulty walking, needed supervision or help when transferring, did not understand their limitations, was unwilling or unable to ask for assistance or follow instructions. The assessment documented the resident was easily frustrated, would pace and had a change in their behavior and they desired to walk. The resident was taking medications that may have side effects of dizziness and loss of balance. In an interview on 05/23/2025 at 1:30 PM, Staff D, Licensed Practical Nurse (LPN) stated Resident 83 had very poor short-term memory. Staff D stated the resident would read the signs to staff that were to remind the resident to wait for help, but they did not always comprehend them. Staff D stated Resident 83 may tell staff not to stay with them in the bathroom, but staff have to be close to them for supervision since the resident was quick, had no safety awareness and poor judgment. Staff D stated Staff K, NAC had left the resident on the toilet and the resident cannot be left alone. Staff D stated the resident was restless prior to the fall and the fall resulted in a bump to the back of their head. In an interview on 05/23/2025 at 1:47 PM, Staff T, LPN stated Resident 83 had lots of falls and was a high fall risk. Staff T stated the resident would try to get up independently, so staff needed to stay with them when they are in the bathroom. In an interview on 05/23/2025 at 2:02 PM, Staff B, Director of Nursing Services was asked about Resident 83's fall on 04/15/2025 at 8:30 AM. Staff B stated the NAC stepped outside the bathroom door to find the shower aide, very briefly then the resident fell. Staff B stated they were not sure how the fall could have been prevented when Resident 83 was moving quick. Staff B stated they had updated the care plan after the fall for staff to stay in the bathroom or just outside the bathroom door for supervision. Staff B stated the plan of care had been followed at the time of fall because there was not a Do not leave the resident unattended on the toilet care plan intervention at the time of the fall. In an interview on 05/27/2025 at 9:48 AM, Staff K stated Resident 83 was a high fall risk since admission and they required more supervision than one person assistance now. Staff K stated the resident would try to get up unattended. Staff K confirmed they were the NAC caring for the resident at the time of the fall on 04/15/2025. Staff K stated the resident was known for self-transferring to the bathroom and was antsy and jittery and they tried to assist them to the toilet as often as possible. Staff K stated the day of the fall they had left the resident on the toilet to go get washcloths for peri care and to talk with the bath aide as the resident was next to get their shower. Staff K stated when they came back the resident had fallen. Staff K stated the resident had been having panic attacks, was restless and very fidgety prior to the fall. Staff K stated when they found the resident, their wheelchair had been tipped over on its side as if the resident had pushed on the left side of the wheelchair and it tipped over and they fell. Staff K stated when they found the resident they said, Oh no and Resident 83 said they thought they hit their head. Staff K said they did not know what the resident injuries were, but the resident complained their left hip was sore after the fall. In a phone interview on 05/27/2025 at 10:04 AM, Staff J, LPN confirmed they were the nurse caring for Resident 83 at the time of the fall on 04/15/2025 at 8:30 AM. Staff J stated the resident had anxiety, was very much a fall risk since admission and they would attempt to get up unattended. Staff J stated the resident was taken into the restroom and left on the toilet while the NAC popped out into the hall to talk with the shower aide. The NAC then heard the resident fall. Staff J could not recall the resident's pain or injuries post fall, but stated they understood the concern with Resident 83 being left unattended on the toilet and could not recall if education was provided to Staff K. In a phone interview on 05/27/2025 at 10:08 AM, Staff L, NAC stated Resident 83 required substantial extensive assistance for ADL's. Staff L stated the resident had always been a fall risk, was quite confused, anxious, had no memory and they would quite often try to get up by themselves. Staff L stated they never leave Resident 83 on the toilet related to their short memory as they forget instantly that they can't transfer themselves. Staff L stated the resident was not modest and did not request privacy in the bathroom. In a phone interview on 05/27/2025 at 12:07 PM, Staff M, Registered Nurse (RN) stated they cared for Resident 83, and they were a fall risk. Staff M stated the resident should not be left alone on the toilet or anywhere. Staff M stated the resident had no short-term memory, was impulsive and restless and made self-transfer attempts. Reference WAC 388-97-1060 (3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate monitoring was conducted for use of an anticoagulant (medication that prevent blood clot) for 1 of 5 residents (Resident 53), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and related complications. Findings included . Review of the facility's policy titled, Anticoagulation Therapy Guideline, revised in 2025, documented all residents receiving anticoagulation therapy will be monitored by LN for signs and symptoms of bleeding and possible food and drug interactions. The policy further documented residents on anticoagulation therapy will have addressed on care plan potential risks related to therapy. Resident 53 readmitted to the facility on [DATE] with diagnoses to include atrial fibrillation (A-Fib - an irregular and often very rapid heart rhythm). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 03/13/2025, Resident 53 was cognitively intact and taking anticoagulant. Review of the Medication Administration Record (MAR) dated May 2025 showed Resident 53 had an order for Apixaban (an anticoagulant medication) oral tablet 5 milligrams (mg-a unit of measurement) to be given twice a day to treat hypertension since 11/07/2024. The MAR showed there was no documentation for monitoring signs and symptoms of bleeding in the MAR. Review of Resident 53's care plan, copy date 05/21/2025 at 1:47 PM, there was no care plan that addressed anticoagulant use or monitoring of sign and symptoms of bleeding and potential risks related to the anticoagulant medication. In an interview and record review on 05/23/2025 at 12:48 PM, Staff U, Licensed Practical Nurse/Supervisor, stated Resident 53 was taking anticoagulant for A-fib rather than hypertension, and staff needed to monitor adverse side effects, sign and symptoms of bleeding, bruises, changing of conscious level, and sign and symptoms of stroke. Staff U reviewed Resident 53's MAR and care plan and stated there was no documentation of monitoring for anticoagulant use and they would add it. In an interview on 05/27/2025 at 10:18 AM, Staff C, Registered Nurse/Supervisor, stated they expected nurses to monitor sign and symptoms of bleeding when residents are receiving anticoagulant medications and document in the MAR and care plan. Reference WAC 388-97-1060 (3)(k)(i)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <DENTAL> <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other mental functions), high blood pressure, and dysphasia (difficulty swallowing). Review of Resident 47's Annual MDS assessment dated [DATE] showed they had no obvious or likely cavity, no broken natural teeth, no facial pain or discomfort, and no inflamed or bleeding gums or difficulty chewing. In an observation on 05/20/2025 at 2:45 PM, Resident 47 gums and teeth appeared to be black in color, with debris in their teeth, and they were missing teeth. Review of Resident 47's dental status assessment dated [DATE] showed the resident had obvious or likely cavities. Review of dental hygienist notes dated 03/26/2024 showed Resident 47 had broken teeth. Review of Resident 47's Significant Change MDS dated [DATE] showed the resident had no obvious or likely cavity, no broken natural teeth, no facial pain or discomfort, and no inflamed or bleeding gums or difficulty chewing. In an interview on 05/23/2025 at 1:19 PM Staff AA, MDS Coordinator-LPN stated they were in the middle of completing a modification to the significant change MDS for Resident 47 in the dental section. Staff AA stated there was an entry error and it was just a key stroke error. No other information was provided. Based on interview and record review, the facility failed to accurately assess 4 of 4 residents (Residents 32, 37, 47 and 72) reviewed for Minimum Data Set (MDS- an assessment tool) assessments. These failures placed the residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings Included . <MEDICATIONS> <RESIDENT 72> Resident was admitted on [DATE] with diagnosis to include Diabetes Mellitus Type 2 (a chronic condition in which your body doesn't use insulin properly, causing high blood sugar levels). Review of Resident 72's physician orders printed on 05/20/2025, documented the resident had an order for NovoLog injection solution (a fast-acting insulin), inject 10 units subcutaneous (fatty tissue layer beneath the skin) three times a day related to diabetes mellitus. Order date 02/18/2025. Review of Resident 72's quarterly MDS assessment dated [DATE], documented that the resident received insulin for seven days. Review of Resident 72's Medication Administration Record (MAR) for March 2025, documented the resident did not receive insulin on 03/26/2025, 03/27/2025 or 03/28/2025 due to the resident being in the hospital. In an interview on 05/22/2025 at 2:05 PM, Staff S, Registered Nurse (RN)/MDS Coordinator stated that to code for medications specifically injections, they review the resident's MAR and count how many times the resident had an injection per day within the look back period (counting back 7 days starting on the reference date) and that's the number they document in the MDS. Staff S reviewed Resident 72's latest MDS and reviewed Section N, they stated that it was a coding error. The resident did not receive 7 days of insulin due to resident being in the hospital for three days. It should have been coded four and not seven. <BEHAVIOR> <RESIDENT 37> Resident 37 was admitted to the facility on [DATE] with diagnosis to include Vascular Dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Review of Resident 37's quarterly MDS assessment dated [DATE] documented that the resident did not exhibit wandering behaviors during the seven day look back period. Review of the Treatment Administration Record (TAR) for March 2025 showed documentation that the resident had episodes of wandering on 03/19/2025, 03/20/2025 and 03/21/2025 which was within the dates of the 7-day look back period. In an interview on 05/22/2025 at 2:05 PM, Staff S stated that the Social Services Department were the ones that document and completes Section E on the MDS. In an interview on 05/27/2025 at 9:10 AM, Staff R, Social Services, stated that they complete sections A, C, D, E, Q and N in the MDS. Staff R stated, to code for behaviors they review the MARs/TARs to see the behavior documentation done by nurses or Certified Nursing Assistants (NAC). Staff R reviewed the latest MDS for Resident 37 and compared it to the March 2025 TAR for wandering behavior, and stated that it was coded inaccurately. Staff R stated they had not completed that section, and they were unable to state who did. Further review of the MDS Section E, showed that Staff R was the one that signed this section on 03/28/2025 at 2:58 PM. <RESIDENT 32> Resident 32 readmitted to the facility on [DATE]. In an observation and interview on 05/20/2025 at 11:11 AM, Resident 32 had some missing and broken upper teeth, tartar and brownish debris along the gum line, and whitish debris in between upper and lower teeth. Resident 32 stated they had missing and broken teeth for years and they had cavities as well. Review of a progress note, dated 05/07/2024 at 6:42 PM, documented Resident 32 had black fragmented molars with missing teeth throughout. Review of Resident 32's oral status dated 06/03/2024, documented they had many teeth were broken and gone. Review of Resident 32's admission assessment dated [DATE], documented they had natural teeth missing, loose, broken, carious and edentulous. Review of dental consult visit note dated 11/25/2024, showed Resident 32 had active periodontal infection, moderate to severe gum bleeding, and severe gingival inflammation. Review of Resident 32's comprehensive MDS assessment, dated 06/09/2024, documented Resident 32 had no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth, and no dental problem. The care area assessment (CAA) related to dental care was not triggered as no oral/dental problem indicated in the MDS. In an interview on 05/22/2025 at 2:05 PM, Staff S stated the MDS oral/dental status section was data entry error and needed to be modified. In an interview on 05/23/2025 at 10:25 AM, Staff C, RN/Supervisor, stated they expected MDS assessment to be completed timely with accuracy. Reference WAC 388-97-1000 (1)(b)

Based on observation, interview and record review, the facility failed to properly label and/or discard undated, opened ophthalmic medications (drugs specifically formulated for application to the eye). This failure placed the residents at risk of receiving compromised or ineffective medications. Findings included . Review of a facility policy titled, Medication Storage in the Facility, dated 05/09/2018, documented the facility would ensure all medications were stored safely, securely, and properly, following manufacturer's recommendations. Ophthalmic medications, once opened, required an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Review of the updated package insert document for Refresh Tear eye drops, showed to discard the medication 90 days after opening. Review of the updated package insert document for Latanoprost Ophthalmic Solution, showed to discard an opened bottle after six weeks. Review of the updated package insert document for Timolol eye drops, showed to discard an opened bottle with any remaining solution after 28 days. In an observation and interview on 05/22/2025 at 9:57 AM with Staff V, Registered Nurse (RN), observed in the medication cart in cascade unit, one opened Refresh Tears eye drop with no documented open date. Staff V stated the nurse needed to label the medication with an open date. In an observation and interview on 05/22/2025 at 10:43 AM with Staff W, Licensed Practical Nurse (LPN)/Supervisor, observed in the medication cart in rehab unit, one opened Latanoprost eye drop, and one opened Timolol Maleate eye drop that had no open dates, one opened Artificial Tears that had no open date and no resident name. Staff W stated the eye drops needed to be labeled with open dates and residents' names. In an observation and interview on 05/22/25 at 11:15 AM with Staff D, LPN/Supervisor, observed in the medication cart in baker unit, one opened Artificial Tears eye drop that had no open date, one opened Latanoprost eye drop that had no open date, one opened Refresh Tears eye drop that had a date labeled but it was not readable. Staff D stated all eye drops should be labeled with an open date once opened and certain eye drops last for 30 days after opening. In an interview on 05/27/2025 at 10:15 AM, Staff C, RN/Supervisor, stated eye drops needed to be labeled with the open dates once opened and stored in a visualized resident labeled package. In a following interview and record review on 05/27/2025 at 10:35 AM, Staff C showed an email dated 05/22/2025 at 11:50 AM from a consulting pharmacist, documented eye drops should have a date opened label applied to the product with the date written as to when it was opened. Reference WAC 388-97-1300 (2)

Based on observation, interview and record review, the facility failed to prepare food under safe and sanitary conditions in the facility kitchen. The failure to ensure hand hygiene when changing gloves and using food-contact sanitizer to clean gloves, placed residents at risk for cross-contamination and foodborne illnesses. Findings included . In an observation on 05/21/2025 at 11:27 AM, Staff Q, Dietary Staff removed gloves and then put on new gloves without washing their hands. A few minutes later, observed the same staff, Staff Q with gloved hands reach in their left side pocket for a marker, then took their left-hand glove off and placed a new glove on without washing their hands. Then observed Staff Q use the washcloth that came from the red bucket under the sink to wipe their gloves from food debris then continued placing food on the plates without their changing gloves. In an interview on 05/22/2025 at 1:15 PM, Staff P, Chef stated that they change gloves as needed, if they see the gloves were visibly soiled or if they touched their face. Staff P added that they wash their hands after taking gloves off and before putting a new pair of gloves on. Staff P stated that they have two buckets under the sink, the green bucket which was just soap and water, and the red bucket which was a food-contact sanitizer that they used to wipe surfaces such as the kitchen counter or any spillage from the soup bowl or plates. In an interview on 05/22/2025 at 1:23 PM, Staff Q, Dietary Aide, stated that they changed gloves when their gloves were soiled. Staff Q added that they wash their hands prior to putting on new gloves. Staff Q confirmed that they did not wash their hands after they changed their left-hand glove however unable to explain why they did not wash their hands prior to putting on new gloves. Staff Q also stated that they wiped their gloved hands with the food-contact sanitizer because they were told that the chemical will clean the gloves in three seconds. In an interview on 05/23/2025 at 9:28 AM, Staff O, Dietary Manager stated that it was an expectation for kitchen staff to wash their hands prior to putting on gloves, to change gloves when visibly soiled, if they touched their face, or when staff were changing tasks such as handling meat then switching to handling vegetables. Informed Staff O was informed of observations of kitchen staff taking left hand glove off and replacing it without washing their hands, Staff O stated, if their hands were not visibly soiled, and did not touch anything prior to putting new gloves that it was acceptable not to wash their hands prior to putting on new gloves. Staff O added that if staff wash their hands all the time prior to putting on new gloves then they would not be able to finish the tray line on time and it would delay them serving lunch to residents. When asked about the staff that wiped their gloves with the food-contact sanitizer, Staff O stated that the food-contact sanitizer was for hard surface areas and not used to wipe their gloves clean. Staff O stated that if gloves were soiled, staff were expected to change gloves. Reference WAC 388-97-1100 (3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a system in which resident's records were complete, accurate, accessible and systematically organized for 4 of 7 residents (Residents 29, 47, 83 and 84) reviewed. This failure included inaccessible hospice visit documentation, hospice plan of care, and incomplete documentation of meal intakes which placed residents at risk for unmet needs, unrecognized changes in condition and adverse outcomes. Findings included . Review of the facility policy titled, Documentation in Medical Record reviewed in (no month and day) 2025 documented each resident's medical record shall contain an accurate representation of the actual experiences of the resident and enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be accurate, relevant, and complete containing sufficient details about the resident's care and or responses to care. Review of the facility policy titled, Nutrition Management reviewed in (no month and day) 2025 documented a systematic approach is to be used to optimize each resident's nutritional status including identifying and assessing each resident's nutritional status and risk factors, evaluating and analyzing the assessment information. Staff were instructed to document the intake of meals. <MEAL MONITORING> <RESIDENT 29> Resident 29 admitted on [DATE] with diagnoses to include major depressive disorder, Multiple Sclerosis (MS, disease that disrupts communication between the brain and body) and lymphedema (tissue swelling from a block). Review of Resident 29's care plan initiated on 09/23/2024 documented a nutritional problem related to MS, acute kidney injury, high blood pressure, chronic diarrhea, and chronic lymphedema. The care plan showed the resident was at risk for malnutrition. The care plan directed staff to provide and serve the diet as ordered and monitor intake and record intake each meal. Review of the meal monitors revealed the resident's meal intakes were not consistently documented. The following meal monitors were omitted: March 2025: At 7:30 AM on 03/03/2025 through 03/07/2025, 03/10/2025, 03/12/2025, 03/13/2025, 03/17/2025 through 03/21/2025, 03/26/2025 through 03/21/2025. At 1:00 PM on 03/02/2025, 03/10/2025, 04/16/2025, 03/21/2025, 03/27/2025, 03/29/2025 and 03/31/2025. At 6:00 PM on 03/18/2025 and 03/31/2025. April 2025: At 7:30 A on 04/02/2025 through 04/04/2025, 04/08/2025, 04/09/2025, 04/16/2025, 04/17/2025, 04/22/2025, and 04/23/2025. At 1:00 PM on 04/01/2025 through 04/04/2025, 04/07/2025 through 04/18/2025, 04/21/2025-04/24/2025 and 04/28/2025 through 04/30/2025. At 6:00 PM on 04/05/2025. May 2025: At 7:30 AM on 05/01/2025, 05/02/2025, 05/06/2025, 05/12/2025 through 05/16/2025, 05/20/2025 through 05/22/2025, 05/26/2025, and 05/27/2025. At 1:00 PM on 05/03/2025, 05/05/2025, 05/06/2025, 05/08/2025, 05/12/2025, 05/13/2025, 05/20/2025, 05/21/2025 and 05/27/2025. At 6:00 PM on 05/18/2025, 05/24/2025, and 05/27/2025. <RESIDENT 83> Resident 83 admitted [DATE] with Alzheimer's disease. Review of the care plan initiated 10/15/2024 showed Resident 83 was at risk for malnutrition related to advanced age, advanced Alzheimer's Disease with cognitive impairment, need for assist with eating at times, limited mobility, actual fracture and polypharmacy. The care plan directed staff to provide and serve the diet as ordered and monitor intake and record intake each meal. Review of the meal monitors revealed the resident's meal intakes were not consistently documented. The following meal monitors were omitted: March 2025: At 7:30 AM on 03/09/2025 and 03/28/2025. At 1:00 PM on 03/09/2025. April 2025: At 7:30 AM on 04/12/2025. At 1:00 PM on 04/04/2025 and 04/25/2025. May 2025: At 7:30 AM on 05/17/2025. At 1:00 PM on 05/11/2025, 05/21/2025 and 05/24/2025. In an interview on 05/23/2025 at 1:28 PM, Staff D, Licensed Practical Nurse (LPN) stated the Nursing Assistant Certified (NAC's) and dining room assistants documented residents' meal intake under tasks in Point of Care (POC, electronic health record). Staff D stated whoever picked up the tray is who is responsible to document the amount eaten and fluids consumed. Staff F stated they never audits the missed documentation but maybe Staff B, Director of Nursing completed audits. In an interview on 05/23/2025 at 2:07 PM, Staff B, Director of Nursing Services (DNS) stated meal monitors were documented in POC by the dietary aides who are responsible to document them. Staff B stated they look at the meal intake documentation for weight review on a weekly basis. Staff B stated the process was the dietary aides pick up the trays and input the information into the POC for meals consumed on hall trays and in the dining room. Staff B stated they were unaware of a documentation issue with meal monitors, and they would talk with Staff O, Dietary Manager about this. In an interview on 05/27/2025 at 9:36 AM, Staff F, Training Development Coordinator stated the dietary staff that pick up the trays are to document the meal intake and Staff O, Dietary Manager was responsible for oversight of the meal monitoring. In an interview on 05/27/2025 at 9:42 AM, Staff H, Dining Room Assistant (DRA) stated they or another DRA would pick up the trays and document on the slip, the meal and fluid intake percentages. Staff H stated when the slips are completed, the dining room hostess would input the meal intakes into the computer. <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other mental functions), high blood pressure, and dysphasia (difficulty swallowing). Review of Resident 47 Electronic Health Record (EHR) showed they started hospice services on 03/27/2025. There were no documents in the EHR, other than the election for hospice benefit, found from hospice related to their plan of care, services, or coordination of care with the facility. Review of Resident 47's paper chart showed care plans from hospice pertaining to Resident 47's care and needs. The paper chart contained plan of care updates for hospice services dates of 4/30-5/13/2025, 4/16-4/29/2025, 04/02-4/15/2025 and 3/27-4/2/2025. In an interview on 05/22/2025 at 1:57 PM Staff D stated there was a paper chart for Resident 47. When asked for the most recent hospice care plan, they printed out a care plan from Resident 47's EHR. Staff D stated the hospice documents from hospice for Resident 47, found in the paper chart was just the hospice notes and not a care plan, and stated they don't do that anymore. Staff D stated they did not know when Resident 47 was last seen by hospice, did not know how often they got notes from hospice and provided no additional information. In an interview on 05/27/2025 10:18 AM Staff EE, Medical Records, stated the day-to-day documents are completed in the EMR and if there were more forms, those were scanned and uploaded into PCC, especially the ones that required signature. Staff EE stated all the documents located in the paper chart are scanned into the EHR. When asked if there were any documents kept in the paper chart that were not scanned into the EHR, Staff EE stated, the thing about electronic records, there is no need to keep a copy in the hard chart. <RESIDENT 84> Resident 84 readmitted to the facility on [DATE] and elected hospice services on 05/10/2025. In an interview on 05/21/2025 at 9:01 AM, Staff D stated Resident 84 was experiencing end of life delirium and was seen by hospice nurse. In an interview on 05/21/2025 at 11:24 AM, Staff Z, NAC, stated Resident 84 had a new development of behaviors the last couple of days and had been seen by the hospice nurse. Review of Resident 84's EHR through 05/23/2025, showed there were no visit notes from hospice agency staff. In an interview and record review on 05/27/2025 at 9:35 AM, Staff Y, Unit Secretary, stated all medical records were kept in EHR and/or hard copy binders. Review of Resident 84's hard copy binder showed there were no visit notes from hospice agency staff. Staff Y stated there was no hospice agency staff visit notes either in EHR or hard copy binder for Resident 84. Staff Y stated hospice agency staff visit notes needed to be faxed by the hospice agency and the facility also could request for them. In an interview on 05/27/2025 at 10:35 AM, Staff C, Registered Nurse/Supervisor, stated they expected all residents' medical records were kept either in EHR or hard copy binder and unit secretary helped to upload the documentation. Staff C stated the hospice agency faxed the paperwork including the visit notes to the facility and the facility also could easily requested for the paperwork. Reference WAC 388-97-1720(1)(a)(i)(iii)(iv)(2)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure proper hand hygiene and infection control measures were used for equipment sanitation, during staff assistance during meals, personal care and indwelling urinary catheter care for 1 of 1 resident (Resident 32) observed for cares and dining observations. The facility failed to ensure the staff were compliant with appropriate hand hygiene practices while serving meals, and during catheter care. These failed practices placed the residents and staff at increased risk of contracting and/or spreading potential infections. Findings included . Review the facility's procedure titled, Handwashing/Hand Hygiene, revised on 06/08/2020 showed the purpose of the procedure was to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that would aid in the prevention and control of the transmission of infections and diseases. The guidelines included hand hygiene after contact with secretions and mucous membranes, before moving from a contaminated body site to a clean body side during resident care, after contact with resident's intact skin and after removing gloves. <HALL TRAY OBSERVATION> <HAND HYGIENE> In a continuous observation on 05/19/2025 at 12:42 PM, Staff I, Dining Room Assistant (DRA) was observed to remove a lunch tray from the meal cart and deliver the tray to room [ROOM NUMBER]-1. Staff I was observed to place the tray on to the residents over the bed table, remove the lid and exit the room, Staff I did not perform hand hygiene. At 12:45 PM, Staff I then grabbed another lunch tray without performing hand hygiene and entered room [ROOM NUMBER]-1 where they moved some of the residents' used cups to make room for the lunch tray. Staff I was observed to exit the room, without performing hand hygiene. Staff I proceeded to remove another lunch tray from the meal cart and enter another resident room without performing hand hygiene. Staff I placed the lunch tray on the overbed table, placed a clothing protector on the resident and rearranged items on the residents overbed table. They were observed to place the meal tray on the over the bed table, move some of the residents' personal items, and exit the room without performing hand hygiene. At 12:51 PM, Staff G, DRA delivered a lunch tray to 120-2 with no hand hygiene performed prior, in the room or after. At 12:52 PM, Staff N, hospitality aide delivered the meal tray to room [ROOM NUMBER] without performing hand hygiene prior, in the room or after. At 12:54 PM, Staff G delivered a lunch tray to room [ROOM NUMBER] with no hand hygiene performed prior, in the room or after. At 12:55 PM, Staff I returned from the kitchen with a replacement for room [ROOM NUMBER]-1 with no hand hygiene performed prior, in the room or after. At 12:57 PM, Staff I was in the hall and had food on their hands and shook the food off, no hand hygiene was performed after having visibly soiled hands. At 12:57 PM, Staff I delivered to room [ROOM NUMBER], without performing hand hygiene prior, in the room or after. In an interview on 05/21/2025 at 2:48 PM, Staff E, Staff Development Coordinator was informed that on 05/19/2025 at lunch this surveyor had observed no hand hygiene before tray delivery or in between any room during direct observation on the [NAME] Landing unit. Staff E stated the expectation was for hand hygiene in between every room for meal tray delivery. In an interview on 05/22/2025 at 8:33 AM, Staff O, Dietary Manager came into the conference room and said they had heard there were hand hygiene issues on Monday, and they wanted me to verify if it was a staff member who was currently in the dining room assisting a resident with their breakfast. This surveyor stated that staff member did not look like the Staff I observed but that their name tag stated (Staff I) and their title was DRA. Staff O stated that Staff I was a germaphobe so that could not have been the staff I observed. Staff O stated maybe who I observed was not facility staff and a local college student. In a follow up interview on 05/23/2025 at 8:40 AM, Staff O confirmed that the staff member was passing trays without hand hygiene Monday was Staff I. In an interview on 05/23/2025 at 8:48 AM, Staff I stated their process when serving hall trays was that they sanitized their hands, provide a shirt saver and tray for residents who do not need assistance first. Then they deliver the food and make sure the residents have what they need. Staff I stated they carried hand sanitizer in their pocket. Staff I stated that sometimes the residents would ask them to fix something in their room so then they would hand sanitize. Staff I showed their hands and stated, My hands are destroyed by hand sanitizer. Staff I stated they sanitized a lot. Staff I was informed this surveyor did not observe them use hand sanitizer or wash her hands during continuous observation of hall trays on Monday. Staff I stated they did use the hand sanitizer Monday, and they did hand sanitize constantly throughout the day, and sometimes they double sanitized their hands. In an interview on 05/27/2025 at 11:01 AM, Staff A, Administrator stated they were unaware of hand hygiene or mechanical lift sanitation concerns. <EQUIPMENT SANITATION> In an observation on 05/19/2025 at 12:56 PM, a tag located on the Hoyer lift (a mechanical lift) that documented to use Purell Surface cleaner for the soiled utility room, The tag had a picture of the cleaner to be used. In an interview on 05/19/2025 at 12:56 PM Staff DD, Nursing Assistant Certified (NAC) stated the Hoyer's were cleaned with a rag and cleaner located in the soiled utility room after each use. In an observation on 05/22/2025 at 11:18 AM, Staff BB, NAC, left room [ROOM NUMBER] with the Hoyer lift, pushed it down the hall and parked it across from room [ROOM NUMBER] without cleaning it. Staff BB entered room [ROOM NUMBER] without performing hand hygiene. At 11:20 AM observed Staff CC, NAC moving the Hoyer from the hallway across from room [ROOM NUMBER] and entered room [ROOM NUMBER] with it. <PERSONAL CARE> <RESIDENT 32> Resident 32 readmitted to the facility on [DATE]. In an observation on 05/21/2025 at 10:59 AM, Staff X, NAC provided peri-care (the practice of washing the genital and anal area) to Resident 32 with assistance of Staff U, Licensed Practical Nurse (LPN)/Supervisor. After putting on gloves, Staff X opened Resident 32's dirty brief and wiped the perineal area and buttocks. Without performing hand hygiene or changing gloves, Staff X applied a clean brief and a clean purple draw sheet for Resident 32. With the same contaminated gloves, Staff X adjusted Resident 32's upper body clothes, tidied the bed linens and smoothed the sheets. Staff X touched and opened the privacy curtains with the same gloves. In an interview on 05/21/2025 at 11:17 AM, Staff X stated they were supposed to change gloves and perform hand hygiene after cleaning perineal area and bottom, but they had forgot to do that. In an interview on 05/23/2025 at 1:43 PM, Staff E, stated staff needed to change gloves and perform hand hygiene after cleaning resident's perineal area and before applying a clean new brief. In an interview on 05/27/2025 at 10:35 AM, Staff C, Registered Nurse/Supervisor, stated they expected staff to perform hand hygiene and change gloves after cleaning the perineal area and bottom before applying a clean new brief. Staff C stated staff needed to change gloves and perform hand hygiene when providing care from dirty to clean. Reference WAC 388-97-1320 (1)(c)(2)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure policies and procedures for timely reporting of fall for 1 of 4 residents (Resident 51) reviewed for abuse. The facility failed to report to the state agency when a resident fell after, during a transfer, in which their care plan was not being followed. This failure by the facility to identify, report, and investigate for an allegation of potential abuse or neglect placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations. Findings included . Review of the facility policy titled, Reporting Abuse to Facility Management dated 10/24/2022 showed: When an alleged or suspected case of serious injuries of unknown source, or abuse is reported, the facility Administrator or designee, will immediately (within two hours of alleged incident) notify the following persons or agencies of such incident as indicated by regulation; if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury, results will be reported within 24 hours, and results of all investigations of alleged violations will be reported via log within five working days: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The Resident's Representative (Sponsor) of Record; c. Adult Protective Services as appropriate; d. Law Enforcement Officials (when there is suspicion or confirmation of a crime); e. The Resident's Attending Physician (immediately); and f. The Facility Medical Director. Review of the facility policy titled, Abuse Investigations Policy dated 10/24/2022 showed the facility will report allegations of abuse and neglect to state agencies as required per regulation. All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly investigated. Witness reports will be obtained, and the witnesses will be required to sign and date written reports and the resident, and their representative kept informed of the progress of the investigation. Resident 51 admitted to the facility on [DATE] with diagnoses that included symptomatic epilepsy (seizures that are cause by an underlying brain disease), retinal vein occlusion (blockage in a vein that drains blood from the retina), and Alzheimer's Disease (progressive disease that destroys memory and other important functions). Review of Resident 51's Quarterly Minimum Data Set (MDS-an assessment tool) dated 06/04/2024 showed the resident had severe cognitive impairment. Review of Resident 51's care plan dated 06/03/2024 showed they required moderate assistance of two staff members with transfer from their wheelchair to toilet with use of grab bar and to allow them extra time for feet placement and balance before the commode swap transfer was completed. Resident 51's care plan was updated 8/19/2024 for them to use a bed pan/urinal. In an interview on 08/16/2024 at 8:31 AM Collateral Contact 1 (CC1), Resident 51's representative, stated they were notified, recently, by the facility that Resident 51 had a fall in the bathroom . Review of the state incident reporting log for August 2024 showed no entries related to Resident 51's fall in the bathroom on 08/11/2024. Review of the facilities fall investigation dated 08/11/2024, showed Resident 51 experienced a fall in their bathroom after the staff caring for them lost their footing on a Hoyer (a mobile floor lift system that transfers a person from one surface to another) sling, slipped and fell, which resulted in Resident 51 falling on top of the staff onto their bottom. The incident report showed Resident 51's care plan was reviewed, and no new interventions were implemented. The incident report showed Resident 51, prior to the fall, had been changed from a two person assist with a front wheel walker to a Hoyer lift for transfers in/out of bed as they were unable to transfer safely. In an interview on 08/19/24 at 2:26 PM Staff D, Licensed Practical Nurse (LPN), stated Resident 51 sustained a fall in the bathroom after an aide tripped and fell on the Hoyer sling that was located on the resident's wheelchair during a transfer. Staff D stated the staff had not followed the care plan and was by himself during the transfer/care of Resident 51. Staff D stated abuse and neglect were ruled out as Resident 51 had not been harmed during the fall. Staff D stated they were in the process of educating the staff involved in the fall. In a follow up interview on 08/21/2024 at 9:01 AM Staff D, LPN stated they were alerted to Resident 51's fall on 08/11/2024 and they initiated their investigation on 08/12/2024. Staff D stated the facility's policy was to report any allegations of abuse/neglect to the state if they felt that it was abuse/neglect. Staff D stated they spoke to the staff involved in Resident 51's fall, could not recall the date, and they were aware they did not follow the care plan. Staff D stated the definition of neglect included not caring for a resident or providing for their needs. Staff D stated they felt the fall was an accident as the staff involved was providing care to Resident 51 and had no pattern of not providing care to residents. Staff D stated CC1 had not been notified that the staff involved in the fall was not following the care plan at the time of Resident 51's fall. Staff D stated that not following a resident's care plan could be considered neglect. In a joint interview with Staff A (Administrator) and Staff B (Director of Nurses), Staff A stated Resident 51's fall was determined to be an accident and abuse/neglect was ruled out and did not require any report to the state agency. Staff B stated the staff involved in the fall had a pattern of not following resident's care plan where they were reinstructed in June and had struggled early in the year and required extra support and training. Staff B stated the staff involved had no serious disregard for consequences thus neglect was ruled out, they did not willfully show intent to not follow the care plan and they went based on what they thought. Refer to WAC 388-97-0640(5)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure possible allegations of abuse/neglect were thoroughly investigated for 1 of 4 residents (Residents 51), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse or neglect and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse Investigations Policy dated 10/24/2022 stated an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or their designee, will appoint a member of management to investigate the alleged incident. Witness reports will be obtained and be required to sign and date written reports. The individual conducting the investigation would, as appropriate Interview the person(s) reporting the incident and staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Resident 51 admitted to the facility on [DATE] with diagnoses that included epilepsy (seizures that are cause by an underlying brain disease), retinal vein occlusion (blockage in a vein that drains blood from the retina), and Alzheimer's Disease (progressive disease that destroys memory and other important functions). Review of Resident 51's Quarterly Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] showed the resident had severe cognitive impairment. Review of Resident 51's care plan dated 06/03/2024 showed the resident required moderate assistance of two staff members with transfer from their wheelchair to toilet with use of grab bar and to allow them extra time for feet placement and balance before the commode swap transfer was completed. Resident 51's care plan was updated on 8/19/2024 for staff to use a bed pan/urinal for toileting needs. Review of the facilities incident report, dated 08/11/2024, showed Resident 51 experienced a fall in their bathroom after the staff caring for them lost their footing on a Hoyer (a mobile floor lift system that transfers a person from one surface to another) sling, slipped and fell, which resulted in Resident 51 falling on top of the staff onto their bottom. The incident report showed Resident 51's care plan was reviewed, and no new interventions were implemented. The incident report showed Resident 51, prior to the fall, had been changed from a two person assist with a front wheel walker to a Hoyer lift for transfers in/out of bed as they were unable to transfer safely. There was no notation of Resident 51's transfers on/off the toilet. The incident report contained a statement from the nurse and the Nursing Assistant Certified (NAC) involved in the body of the incident report. There were no other statements or follow up interviews. In an interview on 08/19/2024 at 2:16 PM Staff E, NAC, stated they were the staff involved in the fall with Resident 51. Staff E stated Resident 51 was a standard two person assist and then they became a Hoyer transfer and staff were to always have two people in the room when transferring them. When asked about the Resident 51's fall, Staff E stated, they were unaware of the sling in the resident's wheelchair and their foot slipped on the sling buckle while holding Resident 51 and they fell, and the resident fell with them. Staff E stated they were the only staff in the bathroom at the time of the fall, the call light to the bathroom was on, and the nurse came in after the fall. Staff E stated they provided care for the resident once a week to once every two weeks. Staff E stated Resident 51 had been able to stand up by themselves and they used the gait belt. Staff E stated they were not aware Resident 51 care had changed to them requiring a Hoyer lift for transfers. Staff E stated they knew how to care for Resident 51 that day by skimming through the care plan, knew that they needed 2-person assistance and a gait belt and faulted themselves by not reading the care plan thoroughly enough. Review of Resident 51's care plan dated 06/03/2024 showed Resident 51 required moderate assistance of two staff members with transfer from their wheelchair to toilet with use of grab bar and to allow them extra time to for feet placement and balance before the commode swap transfer was completed. In an interview on 08/19/2024 at 2:26 PM Staff D, Licensed Practical Nurse (LPN) stated Resident 51 sustained a fall in the bathroom after an aide tripped and fell on the Hoyer sling located on the resident's wheelchair during a transfer. Staff D stated the staff had not followed the care plan and was by themselves during the transfer/care to Resident 51 while in the bathroom. Staff D stated abuse and neglect were ruled out as Resident 51 had not been harmed during the fall. Staff D stated they were in the process of educating the staff involved in the fall. In an interview on 08/21/2024 at 11:14 AM Staff F, Registered Nurse (RN), stated Resident 51 fell during the prior evening. Staff F entered the room and stated that Resident 51's bathroom call light was on. When they entered the bathroom they saw Staff E on the floor and the resident sitting on top of Staff E. When Staff F asked what had happened the NAC told them they finished toileting Resident 51 and they were dressing them for the night, the NAC lost their footing when their foot became tangled in the Hoyer sling. Staff F stated they reviewed Resident 51's care plan after the fall which showed they were a one person assist with use of a grab bar. Staff F stated they reviewed the paper copy of Resident 51's care plan located at the nurse's station in the binder and did not review the care plan located in the electronic health record for Resident 51. Staff F stated they notified Staff D of the incident through email and text message and started an incident report electronically. Staff F stated they were not interviewed by any facility staff regarding the incident. In an interview on 08/19/2024 at 2:36 PM Staff B stated falls require an investigation to include statements and interviews with staff and residents about what occurred. The investigation would also include completing assessments for injuries and necessary notifications. All the information would be taken and reviewed to conduct a root cause analysis. When asked how abuse and neglect were ruled out for Resident 51 and the fall sustained, Staff B stated there was not a pattern of misconduct and there was no intent by the staff to harm the resident. In a follow up interview on 08/21/2024 at 9:01 AM Staff D stated they were alerted to Resident 51's fall on 08/11/2024 and they initiated their investigation on 08/12/2024. Staff D stated the facility's policy was to report any allegations of abuse/neglect to the state if they felt that it was abuse or neglect. Staff D stated they spoke to the staff involved in Resident 51's fall, could not recall the date, and they were aware that staff had not followed the care plan during this incident. Staff D stated the definition of neglect included not caring for a resident or providing for their needs. Staff D stated they felt the fall was an accident as the staff involved was providing care to Resident 51 and had no pattern of not providing care to residents. Staff D stated CC1 had not been notified that the staff involved in the fall was not following the care plan at the time of Resident 51's fall. Staff D stated that not following a resident's care plan could be neglect. Review of employee file on 08/21/2024 at 9:30 AM, showed Staff E had been reeducated: -On 08/19/2024 to follow residents individualized are plans. -On 06/14/2024 to follow residents individualized care plans. -On 01/09/2024 to follow care plans, in addition to other identified areas. In a joint interview on 08/21/2024 at 2:08 PM with Staff A (Administrator) and Staff B (Director of Nurses), Staff A stated Resident 51's fall was determined to be an accident and abuse/neglect was ruled out not requiring any report to the state agency. Staff B stated the staff involved in the fall had a pattern of not following resident's care plan where they were reeducated in June and had struggled early in the year and required extra support and training. Staff B stated the staff involved had no serious disregard for consequences thus neglect was ruled out, they did not willfully show intent to not follow the care plan and they went based on what they thought. Refer to WAC 388-97-0640 (6)(a)(b)

Based on observations, interviews, review of the glucometer manual, and policy review, the facility failed to ensure staff cleansed 2 of 2 (Residents 186 and 187) residents' fingers before performing a fingerstick to obtain a blood glucose reading and failed to cleanse the resident's skin before administering an insulin injection. This had the potential for an increased risk of infection for both residents. Findings included . Review of the facility policy provided by the facility titled, Specific Medication Administration Procedures, revised January 2018 showed the following instructions for administering injections, including subcutaneous injections: .Gather supplies - safety syringe of appropriate volume and with proper needle for the type of injection, gloves, alcohol wipes, bandage, gauze pads, and barrier .Expose the area to be inject and clean with an alcohol wipe . 2. Clean in a circular motion, spiraling out from the center. Review of policy titled, Addendum to injectable Medication Administration Policy, implemented day 04/04/2018, provided by the facility showed, Based on WHO (World Health Organization) Best Practices for Injections and Related Procedures Toolkit, March 2010, Table 2.3 Skin preparation and skin disinfection, for administration of Intradermal [a shallow or superficial injection] and Subcutaneous [under the skin] injections it is not necessary to use alcohol swab prior to injection; may use soap and water. Review of page seven of the glucometer manual provided by the facility revealed: PERFORMING A BLOOD GLUCOSE TEST .Step 1 Wash hands and the sample site with soap and warm water. Rinse and dry thoroughly. In an observation on 04/12/2023 at 11:47 AM, Staff D, Licensed Practical Nurse (LPN), showed they performed a finger stick on Resident 186 and failed to cleanse the resident's finger before piercing their finger with a lancet (a disposable sharp point used to pierce the skin to obtain a drop of blood sample). After testing the blood sample, Staff D administered an insulin injection into Resident 186's left upper arm without first cleansing the injection site. During an interview on 04/12/2023 at 11:54 AM, Staff D was asked why they did not swab Resident 186's finger and the injection site before piercing the resident's skin and stated, it was either or. Staff D clarified that it was their choice whether they swabbed the injection site or the resident's finger and that it was their preference not to clean the injection and fingerstick sites. In an observation on 04/12/2023 at 11:57 AM, showed Staff D performed a finger stick and administered an insulin injection to Resident 187. Staff D failed to clean the resident's finger and injection site prior to performing both tasks. During an interview on 04/12/2023 at 12:17 PM, Staff D stated that they and not cleansed Resident 187's finger nor the insulin injection site, stating that they would only clean the resident's finger before a finger stick if the finger was visibly soiled, and there was no need to cleanse an injection site for a subcutaneous insulin injection. During an interview on 04/13/2023 at 10:40 AM, Staff C, LPN/Infection Preventionist (IP), stated the facility policy covered both cleaning and refraining from cleaning the injection and fingerstick sites. Staff C stated the facility adhered by the Centers for Disease Control (CDC) standards for infection prevention. When asked if CDC guidelines supported not cleansing an injection site before piercing the skin, Staff C stated Staff D should have washed the resident's hand with soap and water before performing a finger stick. Staff C stated the facility's policy revealed to clean injection sites prior to entry (administering the insulin injection). Staff C stated the WHO manual from 2010 mandated cleansing injection sites with soap and water and that the CDC guidelines did not support failure to clean injection and fingerstick sites prior to treatment. Reference: WAC 388-97-1320 (1)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor bathing preferences for one of three residents (1) reviewed for bathing frequency. The failure to honor the resident's bathing choice related to the lack of frequency of bathing placed the resident at risk for poor hygiene, feelings of powerlessness, decreased self-worth, and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] and has diagnoses to include chronic pain, osteoarthritis, anxiety, and depression. Review of the admission Minimum Data Set assessment dated [DATE] showed the resident was cognitively intact, required set up and physical help with bathing and had no rejection of care. Review of the Care Plan focus problem noted that Resident 1 had ADL (Activity of Daily Living) self-care performance deficits related a disorder that causes pain in the lower back and hip which radiates down the back of the thigh into the legs, weakness, and pain with a revised date of 05/20/2020. The Bathing/Showering intervention noted that the resident was able to make their needs known, liked to have a whirlpool bath and would try for two times weekly. Additionally noted was that the resident said that the bath really helped with their pain. The resident preferred their baths after lunch and required a one person standby/limited/extensive assistance with getting in and out of tub. Review of the resident's last two months of bathing records showed the following: • September 2022, the resident went six days without a bath from 09/08/2022 until was bathed on 09/16/2022 and another six days without a bath until 09/23/2022 and • October 2022, the resident went five days without a bath from 09/28/2022 until was bathed on 10/04/2022, seven days without a bath from 10/08/2022 until 10/16/2022 and five days without a bath from 10/21/2022 until 10/27/2022. In a phone interview on 11/01/2022 at 11:21 PM, Collateral Contact (CC) 1, family member stated that Resident 1 had been complaining about not being able to be bathed on their regular schedule. CC 1 stated that Resident 1 would often bathe twice daily prior to moving into the Skilled Nursing Facility. CC 1 stated that the lack of frequent bathing was bothersome for Resident 1. CC 1 stated that the resident had told them that they had not been bathed more than weekly. In an interview on 11/03/2022 at 11:43 AM, Resident 1 stated that they had originally signed up for a bath every third day, on Sunday and on Thursday, but lately have received a bath up to seven days from the last bath. Resident 1 stated that the facility does not have a set time for them to bathe and the facility claimed that they do not have enough staff. Resident 1 stated that they tell the staff, You take a bath every day. Resident 1 stated that when it got up to seven days after the last time they received a bath it really bothered them. In an interview on 11/03/2022 at 2:26 PM, Staff A, Nursing Assistant Certified, stated that they would give an average of 12 baths/showers each day. Staff A stated that some resident's baths would take longer than other residents and, on some days, they would not be able to get everyone on their schedule bathed that day. Staff A stated that if they do not get to a resident on a scheduled bath day they are then placed on the schedule for the following day and their bath would be made a priority. Staff A stated that they documented the resident's showers in the electronic medical record. Staff A stated that they had to bump residents' baths down to once a week in order to provide the residents with a bath at least weekly as they were usually the only one providing showers most of the time. Staff A stated that they had not discussed adjusting resident bathing frequency with the nursing administrative staff. Staff A stated that the residents had complained but they do their best in their position. Staff A stated that there used to be three shower aides but now there was just one. Staff A stated that Resident 1 had complained about their bathing frequency. Staff A stated that Resident 1 would want a bath but they would have to tell them that they did not have time. Staff A stated that when the resident complains about the lack of bathing that they report that to the Unit Coordinators, (UC) and they tell them to do their best. In an interview on 11/03/2022 at 3:03 PM, Staff B, Licensed Practical Nurse/ UC, stated that when the NAC reported that a resident had a complaint of not receiving enough baths that they would investigate why they were not getting enough baths or showers. Staff B stated that if the resident was a resident that they could assist with a bath that they try to step up and help. Staff B stated that they also could reinterview the resident on their likes and choices as they may have missed something. Staff B stated that Resident 1 sometimes forgets that they have had a bath and sometimes they would asked for an extra bath if they were hurting. Staff B stated that they would give residents one bath weekly but Resident 1 perseverates that they were supposed to have two showers a week. Staff B stated that they really did not have the staff available and would really tried to provide residents with at least one bath a week. Reference: (WAC) 388-97-0900(1)(3)