Does ALDERWOOD POST ACUTE & REHABILITATION have any serious inspection findings?

Yes, ALDERWOOD POST ACUTE & REHABILITATION has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 130 total deficiencies from recent inspections.

What are the staffing levels at ALDERWOOD POST ACUTE & REHABILITATION?

ALDERWOOD POST ACUTE & REHABILITATION has a three-star staffing rating from CMS with 0.78 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ALDERWOOD POST ACUTE & REHABILITATION located?

ALDERWOOD POST ACUTE & REHABILITATION is located in LYNNWOOD, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ALDERWOOD POST ACUTE & REHABILITATION have?

ALDERWOOD POST ACUTE & REHABILITATION has 113 certified beds.

Who owns ALDERWOOD POST ACUTE & REHABILITATION?

ALDERWOOD POST ACUTE & REHABILITATION is a for profit - corporation facility and is part of the HILL VALLEY HEALTHCARE chain.

ALDERWOOD POST ACUTE & REHABILITATION

Name: ALDERWOOD POST ACUTE & REHABILITATION
Address: 3701 188TH STREET SOUTHWEST, LYNNWOOD, WA, 98037, US
Telephone: (425) 775-9222
Rating: 2.0

3701 188TH STREET SOUTHWEST, LYNNWOOD, WA 98037 · (425) 775-9222

For profit - Corporation 113 Beds HILL VALLEY HEALTHCARE Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

0/100

#124 of 190 in WA

Share this report:

ALDERWOOD POST ACUTE & REHABILITATION nursing home in LYNNWOOD, WA - Photo 1 of 5

ALDERWOOD POST ACUTE & REHABILITATION nursing home in LYNNWOOD, WA - Photo 2 of 5

Photo by Carly Salvador

ALDERWOOD POST ACUTE & REHABILITATION nursing home in LYNNWOOD, WA - Photo 3 of 5

Photo by Carly Salvador

ALDERWOOD POST ACUTE & REHABILITATION nursing home in LYNNWOOD, WA - Photo 4 of 5

Photo by Alderwood Post Acute & Rehabilitation

ALDERWOOD POST ACUTE & REHABILITATION nursing home in LYNNWOOD, WA - Photo 5 of 5

1 / 5 photos

View 360° on Google Maps

Last Inspection: August 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Alderwood Post Acute & Rehabilitation has received a Trust Grade of F, indicating significant concerns and a poor overall standing. They rank #124 out of 190 facilities in Washington, placing them in the bottom half of the state's nursing homes, and #13 out of 16 in Snohomish County, meaning only a few local options are better. The facility is showing signs of improvement, with issues decreasing from 41 in 2024 to 40 in 2025, but it still faces serious challenges, including $262,029 in fines, which is higher than 94% of facilities in Washington, suggesting ongoing compliance issues. Staffing is a mixed bag, with an average rating of 3/5 but a high turnover rate of 70%, well above the state average of 46%, which raises concerns about continuity of care. There have been critical incidents, including one where a resident received a 20-fold overdose of Oxycodone due to medication administration errors, and another where the facility failed to provide adequate oversight, leading to unmet care needs and harm to residents.

Trust Score: F
In Washington: #124/190
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 70% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $262,029 in fines. Lower than most Washington facilities. Relatively clean record.
Skilled Nurses: Each resident gets 46 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
Violations: 130 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 41 issues

2025: 40 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Washington average (3.2)

Below average - review inspection findings carefully

Staff Turnover: 70%

24pts above Washington avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $262,029

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: HILL VALLEY HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (70%)

22 points above Washington average of 48%

The Ugly 130 deficiencies on record

2 life-threatening 3 actual harm

Sept 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents were free from abuse for 1 of 1 sampled resident (Resident 1) reviewed for allegation of abuse and neglect. The facility failed to ensure resident protection by allowing alleged staff to continue to work with vulnerable residents, failed to report and investigate an injury of unknown source in a vulnerable area and implement interventions to prevent mental and physical abuse. This failure placed residents at risk for psychosocial harm and a diminished quality of life.Findings included.Review of facility policy titled Abuse, dated 10/20/2022, documented under protection- in the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and representative, and protect the resident and other residents from further harm or incident. Reporting: the organization will immediately report the alleged violations involving neglect, abuse, including injuries of unknown sources. Resident 1 was admitted to the facility on [DATE] with diagnoses to include sepsis (infection in the blood), anxiety disorder, depression, hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body) affecting their left side. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 06/05/2025, indicated the resident had moderate cognitive impairment and required substantial to maximum assistance from staff with toileting.Review of the facilities state reporting log for August 2025, documented on 08/18/2025 Resident 1 had an allegation of abuse, with no injury and the actions taken by the facility included staff training/counseling and care plan revisions.Review of the unsigned facility investigation summary conclusion dated 08/22/2025, documented that Resident 1 reported an allegation of sexual assault on 08/18/2025. The investigation documented that abuse and neglect were ruled out through investigation, and staff and resident interviews, resident skin check resulted no new skin issues and staff member suspended will be educated to follow the care plan and ensure they are properly communicating with the residents while performing care. The conclusion also documented interventions implemented after the allegation that included skin check performed, family and provider notified, care plan updated to reflect female care only and cares in pairs. Review of Resident 1's clinical record showed no documentation that the resident received any thorough assessment to include a skin assessment following the report of an allegation of sexual assault. There was no documented skin check to show the resident was assessed for injuries. There was no documentation that Resident 1 was offered to go to the emergency room for evaluation following an allegation of sexual assault. Further review of the facilities investigation showed a form titled Suspension Pending Investigation, dated 08/18/2025, Staff A documented that Staff E, Nursing Assistant Certified (NAC), was suspended pending investigation on 08/18/2025. Staff A documented Over phone on the line of the form intended for the employee's signature. On 09/03/2025 at 2:00 PM, Staff A reviewed the form and stated that he did not review this form with Staff E until 08/22/2025 but had completed the form himself on 08/18/2025 so that the employee could get paid for their time off while suspended. Staff E's statement was included in the investigation and dated 08/22/2025, four days after the report of the allegation.Review of Staff E's timecard dated 08/18/2025 documented that they worked a full shift from 10:10 PM to 6:20 AM on 08/19/2025, when they should have been suspended. Staff A stated that the prior DNS should have suspended the staff member but did not.Review of a nursing progress note dated 08/23/2025 at 10:35 PM, documented patient having a new skin tear around her left labia. Further review of progress notes showed no further documentation regarding this injury of unknown origin. There was no documentation that a thorough skin check had been completed at the time of this discovery. Review of Resident 1's Treatment Administration Record (TAR) showed that treatment was initiated for the skin tear to the resident's labia on 08/23/2025. Further review showed that male staff documented this treatment as being completed by them on 08/23/2025, 08/25/2025, 08/26/2025 and 08/27/2025, when the Resident was care planned for female care only. In an interview on 09/03/2025 at 12:30 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager stated that they were notified on 08/23/2025 that Resident 1 was found to have a skin tear on their labia, I haven't actually seen this skin tear myself. Staff D stated that this resident has a lot of skin issues in other places, so they felt it was because they have really fragile skin. Staff D stated that due to the fact this skin issue was in a concerning place and the resident's recent allegation of sexual assault this concern should have been reported and investigated but they had not reported or investigated this. Staff D stated that the interventions placed following the initial allegation of sexual assault include female care only and care in pairs. Staff D stated that meant that male staff should not go into Resident 1's room even to answer a call light. When asked about the treatments signed for as being completed by male staff, Staff D was unable to provide further information. In an interview/record review on 09/03/2025 at 1:40 PM, Staff A stated that the prior DNS was the person responsible for investigating the initial report of sexual assault by Resident 1 on 08/18/2025. Staff A stated that part of the investigation process would include suspending the alleged staff member pending investigation as applicable, assessing the resident for injuries, document the findings, place the resident on alert to monitor for psychosocial effects, and obtain statements from staff that worked with the resident in the past 48 hours prior to allegation. Staff reviewed the progress note dated 08/23/2025 that showed the resident was found with a skin tear to their labia and stated that it was the first time they had heard of this and that this should have been reported to the state and investigated. Refer F609 and F610Reference WAC 388-97-0640 (1)

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to the state survey agency allegations of injury of unknown origin in a vulnerable area for 1 of 1 sampled resident (Resident 1) reviewed for abuse. This failure placed residents at risk of undiscovered and potential, continued abuse.Findings include .Resident 1 was admitted to the facility on [DATE] with diagnoses to include sepsis (infection in the blood), anxiety disorder, depression, hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body) affecting their left side. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 06/05/2025, indicated the resident had moderate cognitive impairment and required substantial to maximum assistance from staff with toileting. Review of a nursing progress note dated 08/23/2025 at 10:35 PM, documented patient having a new skin tear around her left labia. Further review of progress notes showed no further documentation regarding this injury of unknown origin. In a phone interview on 08/26/2025 at 1:35 PM Staff B, Former Director of Nursing (DNS) stated that there last day working at the facility was 08/21/2025, they were unaware staff had documented that Resident 1 had a skin tear to their labia and stated this absolutely should have been reported and investigated, especially considering the residents recent allegation of sexual assault made on 08/18/2025. In a interview on 09/03/2025 at 12:30 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager stated that they were notified on 08/23/2025 that Resident 1 was found to have a skin tear on their labia, I haven't actually seen this skin tear myself. Staff D stated that due to the fact that this skin issue was in a concerning place and the resident's recent allegation of sexual assault, this should have been reported and investigated but they had not reported or investigated this. On 09/03/2025 at 2:00 PM, Staff A, Administrator, stated this was the first they were reading this progress note and stated that it should have been reported and investigated. No further information was provided. Staff A was unable to provide an investigation for this allegation, and the allegation was not reported to the state survey agency. Refer to F-600 and F610Reference WAC 388-97-0180-0640 (6)(c)

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate allegations of sexual assault to rule out abuse/neglect, protect residents, and prevent further incidents of abuse for 1 of 1 sampled resident (Resident 1) reviewed for abuse. These failures placed residents at risk for continued abuse, increased risk of harm, having allegations of abuse not being responded to and thoroughly investigated, and a diminished quality of life. Findings included. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause.Resident 1 was admitted to the facility on [DATE] with diagnoses to include sepsis (infection in the blood), anxiety disorder, depression, hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body) affecting their left side. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 06/05/2025, indicated the resident had moderate cognitive impairment and required extensive assistance with activities of daily living including bed mobility, transfers, dressing, toilet use and personal hygiene.Review of the facilities state reporting log for August 2025, documented on 08/18/2025, Resident 1 had an allegation of abuse, with no injury and the actions taken by the facility included staff training/counseling and care plan revisions. Review of the unsigned facility investigation summary conclusion dated 08/22/2025, documented that Resident 1 reported an allegation to a therapist on 08/18/2025. The resident reported that on 08/16/2025 a male Certified Nursing Assistant (CNA) straddled them and reached into their pants with an ungloved hand, like a man does to a woman. The investigation documented that abuse and neglect were ruled out through investigation, and staff and resident interviews. Resident skin check resulted with no new skin issues. Staff member suspended will be educated to follow the care plan and ensure they are properly communicating with the residents while performing care. The conclusion also documented interventions implemented included skin check performed, family and provider notified.Further review of the investigation showed no interview/witness statement from Resident 1, or the staff that worked directly with the resident on the date/time (08/16/2025) of the reported allegation. Further review of the facilities investigation showed a form titled Suspension Pending Investigation, dated 08/18/2025, Staff A, Administrator documented that Staff E, Nursing Assistant Certified (NAC), was suspended pending investigation on 08/18/2025. Staff A documented Over phone on the line of the form intended for the employee's signature. On 09/03/2025 at 2:00 PM, Staff A reviewed the form and stated that they did not review this form with Staff E until 08/22/2025 but had completed the form themselves on 08/18/2025, so that the employee could get paid for their time off while suspended. Staff E's statement was included in the investigation and dated 08/22/2025, four days after the report of the allegation. Review of Staff E's timecard dated 08/18/2025, documented that they worked a full shift from 10:10 PM to 6:20 AM on 08/19/2025, when they should have been suspended. Staff A stated that the prior DNS should have suspended the staff member but did not. Review of Staff E's statement dated 08/22/2025, documented that two other staff members always helped them change Resident 1, they only helped with turning the resident. There was no information included related to the specific day/time of the allegation or the care provided to the resident during the time of the allegation. Review of Resident 1's progress notes for 08/18/2025 through 09/03/2025, showed no documentation that the resident was placed on alert monitoring to assess for psychosocial harm, and that the resident's power of attorney or physician had been notified of the allegation reported on 08/18/2025.Review of Resident 1's skin assessment documentation for 08/18/2025 showed no thorough skin check had been completed following the resident's reported allegation of sexual assault. Review of a nursing progress note dated 08/23/2025 at 10:35 PM, documented patient having a new skin tear around her left labia. Further review of progress notes showed no further documentation regarding this injury of unknown origin. There was no documentation that a thorough skin check had been completed. In an interview on 08/26/2025 at 4:08 PM, Staff E stated that they were unaware of the allegation made by Resident 1 on 08/18/2025. Staff E stated that they worked the night shift on 08/18/2025 and were told by Staff A to just not work with Resident 1, so they didn't. Staff E stated no one told them that they were suspended, no one asked for a statement from them regarding the allegation. Staff E stated the following three days 08/19/2025, 08/20/2025 and 08/21/2025 were their normal scheduled days off and they returned to work on 08/22/2025, and that was when Staff A gave them a copy of the suspension pending investigation form. Staff E stated that it was their first time seeing that form and was unsure why on the employee signature line had writing that said, over phone, when no one had talked to them regarding this form. In an interview on 09/03/2025 at 12:30 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager stated that they were notified on 08/23/2025 that Resident 1 was found to have a skin tear on their labia, I haven't actually seen this skin tear myself. Staff D stated that this resident has a lot of skin issues in other places, so they felt it was because they had fragile skin. Staff D stated that due to the fact that this skin issue was in a concerning place and the resident's recent allegation of sexual assault, this concern should have been reported and investigated but they had not reported or investigated this.In an interview/record review on 09/03/2025 at 1:40 PM, Staff A stated that the prior DNS was the person responsible for investigating the initial report of sexual assault by Resident 1 on 08/18/2025. Staff A stated that part of the investigation process would include suspending the alleged staff member pending investigation as applicable, assessing the resident for injuries, document the findings, place the resident on alert to monitor for psychosocial effects, and obtain statements from staff that worked with the resident in the past 48 hours prior to allegation. Staff A reviewed the progress note dated 08/23/2025, that showed the resident was found with a skin tear to their labia and stated that it was the first time they had heard of this and that this should have been reported to the state and investigated. Refer to F600 and F609Reference WAC 388-97-0640 (6)(a)(b)

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to designate and ensure a full-time Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. This failure could negatively impact the care and services to the residents that could result in potential harm and unmet care needs. Findings included .On 08/25/2025 at 11:35 AM, upon entry into the facility, approached the front desk. Staff C, Receptionist greeted this investigator. Staff C stated that the Administrator had just stepped out of the facility, so they were asked to get the DON. Staff C stated that there was not a current DON as of last week. A review of the facility's list of Key personnel on 08/27/2025 documented that the facility currently did not have a full time DON.On 08/25/2025 at 1:20 PM, Staff A, Administrator stated the facility currently did not have a designated full-time RN to serve as the DON. Staff A stated that the previous DON, Staff B, was termed last week. Staff A stated that there was a corporate nurse covering the DON position as needed until the position is filled. In a follow-up interview on 09/03/2025 at 2:00 PM, Staff A confirmed again that there was not currently a full-time DON at the facility. Staff A stated that they had just interviewed and made an offer to a potential new DON, but the corporate nurse was still covering, however they are not full-time. Reference WAC 388- 97-1080(2)(a)

Aug 2025 27 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0688 (Tag F0688)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate treatment, services and interventions to prevent an avoidable reduction of range of motion (ROM) for 1 of 4 sampled residents (Resident 4) reviewed for ROM. Resident 4 experienced harm as evidenced by moderate pain and decreased functional ability due to the formation of a hand contracture (joint becomes fixed in place) which was not present on admit. The failure to not provide appropriate services/interventions for ROM placed other residents at risk of developing new contractures and/or worsening of existing contractures. Findings included.Review of the undated facility policy titled, Resident Mobility and Range of Motion, documented: During resident's comprehensive assessment, the licensed nurse identifies the resident's current joints ROM, limitation of movement, contractures, pain or other complications could cause or contribute to impaired ROM, underlying contributing factors to ROM such as neurological conditions, e.g. cerebral-vascular accident. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline and/or improve ROM. Interventions include therapies, the provision of necessary equipment, and/or exercises. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Resident 4 readmitted to the facility on [DATE] with diagnoses to include right hemiplegia and hemiparesis (one side weakness or inability to move) following stroke (damage to brain tissue). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 06/06/2025, the resident was cognitively intact, had no diagnosis of contracture or impaired joints, and received no restorative programs or therapies services. In an observation and interview on 08/13/2025 at 11:15 AM, Resident 4 stated they could not straighten out their fingers on their right hand. Resident 4 stated the facility had not provided any exercise or service for their hand and arm. Resident 4 attempted to open their right hand with their left but could not get the hand flat. The second, third and fourth fingers were bent in a fixed position. Resident 4 was observed to have their right elbow bent in a rigid position and held closely to their body and their right hand closed tightly in a fist. Resident 4 stated they could not use their right hand to press the buttons on the TV remote and the call light in the past but no longer was able to. Resident 4 stated it hurt when they tried to open their right hand or move their right elbow and shoulder. In an interview on 08/18/2025 at 9:25 AM, Resident 4 stated they had never had any restorative program or services on their right upper extremity (hand, wrist, elbow and shoulder). In an interview on 08/19/2025 at 9:17 AM, Resident 4 stated they asked to see therapist because they felt their “right hand and arm had more pain and was getting worse than half a year ago.” Resident 4 rated their right upper extremity pain was five on the scale of zero to ten. Review of Resident 4's physician note, dated 08/10/2025 at 1:49 PM, documented the resident had moderate risk for developing contractures if not receiving adequate therapy. Review of Resident 4's physician note, dated 08/13/2025 at 8:39 PM, documented the resident had moderate risk for developing contractures if not receiving adequate therapy. Review of Resident 4's care task list, print date 08/14/2025, showed Resident 4 had no restorative programs for upper body ROM or contracture. Review of Resident 4's care plan, print date 08/14/2025, showed no focus care area about limitation ROM or contracture management. Review of Resident 4's functional abilities and mobility care area assessment, dated 03/11/2025, showed no documentation about Resident 4's limitation of movement, pain or any other risks for complications and/or contributing factors to maintain or prevent a decrease in ROM and mobility. Review of Resident 4's Occupational Therapy (OT) evaluation, dated 03/02/2025, documented Resident 4 had no functional limitations present, no contracture and right upper extremity ROM and strength were WFL (within functional limits-indicate that range of motion is sufficient to perform the daily activities). Review of Resident 4's OT evaluation, dated 08/15/2025, documented Resident 4 was seen due to exacerbation of limited and painful movement and decrease in range of motion. The evaluation documented that the resident had right hand and elbow contractures, and right upper extremity ROM and strength were impaired. In an interview on 08/15/2025 at 12:51 PM, Staff GG, Nursing Assistant Certified (NAC), stated Resident 4 had contracture at right upper arm and could not open their right hand. Staff GG stated Resident 4 complained about pain in their right hand and arm during upper body dressing and repositioning. Staff GG stated the resident had no restorative programs for the contracture and ROM. In an interview on 08/18/2025 at 9:22 AM, Staff N, Licensed Practical Nurse (LPN), stated Resident 4 had a right upper extremity contracture but no restorative program for the right upper extremity. In an interview on 08/18/2025 at 9:30 AM. Staff II, Restorative aide/NAC, stated they did not have a restorative program for right upper arm for Resident 4, and they were not sure if the resident had contractures. In an interview on 08/18/2025 at 9:50 AM, Staff NN, Rehab Director, stated Resident 4 was never seen by therapy for their right upper extremity ROM or contracture prior to 08/15/2025. In an interview on 08/18/2025 at 9:55 AM, Staff RR, OT, stated they just started to see Resident 4 on 08/15/2025 for right hand pain, contracture, and decrease in ROM. Staff RR reviewed all the past therapy records and stated Resident 4 did not have documentation of having a right upper extremity contracture. In an interview on 08/18/2025 at 10:30 AM, Staff L, LPN/second floor Unit Manager, stated Resident 4 had the right upper extremity contracture. Staff L stated Resident 4 had no restorative program for the contracture. Staff L stated there was no care plan about the contracture and ROM. In an interview on 08/19/2025 at 2:53 PM, Staff B, Director of Nursing Services, stated they expected a resident with ROM limitation or contracture to be identified early, evaluated, treated and followed with restorative programs to maintain, improve or prevent further functional decline. Reference WAC 388-97-1060 (3) (d)

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive (AD-a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained and completed for 4 of 21 sampled residents (Residents 3, 4, 22 and 82), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the undated facility policy titled, Advance Directives, documented the social services director or designee will inquire of the resident or family members or legal representatives about the existence of any written advance directives. Information about whether the resident had executed an advance directive shall be displayed prominently in the medical record. The facility staff would offer assistance in establishing advance directives if the resident indicated that he or she has not established advance directives. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. <RESIDENT 3> Resident 3 admitted to the facility on [DATE]. According to the Quarterly Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident had moderate cognitive impairment. Review of Resident 3's electronic health record (EHR) showed no AD documentation or Resident 3 had been provided with assistance to formulate an AD. Review of Resident 3's care plan, print date [DATE] at 1:39 PM, there was no focus care area addressing an AD. <RESIDENT 22> Resident 22 readmitted to the facility on [DATE]. According to the admission MDS, dated [DATE], Resident 22 had moderate cognitive impairment. Review of Resident 22's EHR showed no AD documentation or documentation that AD had been discussed. In an interview and record review on [DATE] at 2:20 PM, Staff G, Social Services, stated they would check for POA documentation and if unable to find documentation they would ask the resident who the contact person would be. Staff G acknowledged there was no AD or documentation of discussion of AD for Resident 22. <Resident 4> Resident 4 readmitted to the facility on [DATE]. According to the Quarterly MDS dated [DATE], the resident was cognitively intact. Review of Resident 4's EHR showed no AD documentation or that the resident had been provided with assistance to formulate an AD. Review of Resident 4's care plan, print date [DATE] at 2:47 PM, there was no focus care area addressing an AD. In an interview on [DATE] at 8:36 AM, Staff F, Medical Records, was asked about the location of AD documentation in the medical record. Staff F stated they would look for it but no further information was provided. In an interview on [DATE] at 10:19AM, Staff H, Social Services, stated they asked residents and/or representatives to bring in the AD during admission and they would follow up in care conferences if there was no copy. Staff H stated they could arrange help if they needed assistance. Staff H stated they would look for AD documentation for Resident's 3 and 4. In an interview and record review on [DATE] at 11:25 AM, Staff H stated they found AD documentations for Resident 3 and 4. Staff H provided copies of the POSLT (Directive if would like CPR if heart stopped) but did not provide evidence of their being a POA or living will or the residents were provided resource to put into place. In an interview and record review on [DATE] at 1:16 PM, Staff H stated they documented AD information in the care conference notes. Review of Resident 3 and 4's care conferences printed by Staff H, there was no documentation whether the facility received copies of AD or provided with assistance to formulate an AD. Staff H stated the received AD would be uploaded into EHR; if not, that meant the facility did not have the copy. In an interview on [DATE] at 9:42 AM, Staff A, Administrator, stated they expected staff to request a copy of the resident's AD for the medical record on the initial care conference, and staff should provide education on how to obtain an AD if residents did not have one in place. Staff A stated they expected the AD information to be documented on the medical record. <RESIDENT 82> Resident 82 was admitted to the facility for hospice care on [DATE] with diagnoses to include cancer. Review of the resident's hospital medical record revealed the resident elected for no Cardio Pulmonary Resuscitation and that the resident had an advanced directive. Review of the facility advance directives tab showed Resident 82 had a Physician Orders for Life-Sustaining Treatment,” POLST developed on [DATE] in place but no AD. POLST as a medical order from a physician, nurse practitioner or physician's assistant to other health professional with instructions that complement an advanced directive. The residents POLST showed they did not want resuscitation attempted and chose comfort-focused treatment. The POLST does not take the place of an Advance Directive or replace the need for or the importance of a durable power of attorney for healthcare. Review of the care conference note dated [DATE] at 3:19 PM, showed no discussion of AD. In an interview on [DATE] at 3:18 PM, Staff A, Administrator, stated they had not located the list of advanced directives as requested including an AD for Resident 82. Staff A stated they were checking with the hospital to see if they had their AD. Review of an email dated [DATE] at 1:36 PM, received from Staff A showed the facility had only located the POLSTS rather than the AD for Resident's 3, 22 and 82. In an interview on [DATE] at 9:52 AM, Staff A stated they were not aware of an issue with advanced directives. Staff A stated their expectation was that at the initial care conference, staff should request a copy of the residents' AD and if they did not have one, then staff should provide education to the residents on how to obtain them. If the resident did have one, they should receive the copy for the medical record. This should be documented in the medical record. Reference WAC 388-97-0280 (1)(3)(a)(c)(ii)

CONCERN (D)

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

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 2 of 5 residents (Resident's 22 and 81) were reviewed for unnecessary medications (a drug that affects brain activities associated with mental processes and behavior). The facility failed to provide a valid diagnosis for the use of psychotropic medications, ensure a consent was obtained, attempt non-pharmacological interventions, and monitor hours of sleep which placed residents at risk for receiving unnecessary psychotropic medications, for adverse events and diminished quality of life. Findings included .Review of the policy titled, Anti-psychotic Medication Use undated stated residents will only receive anti-psychotic medications when necessary and when necessary to treat specific conditions for which they are indicated and effective. Diagnosis of a specific condition for which anti-psychotic medications are necessary to treat will be based on a comprehensive assessment. Nursing staff shall monitor for and report adverse side effects. <RESIDENT 81> Resident 81 admitted on [DATE] with diagnoses to include generalized anxiety disorder and post traumatic stress syndrome (PTSD). Review of the admission Minimum Data Set (MDS), an assessment tool dated 07/29/2025 showed the resident did not show signs of psychosis (delusions and hallucinations). The MDS showed the resident was taking anti-psychotic and anti-anxiety medications. Review of the physician orders documented Resident 81 was taking Seroquel (anti-psychotic medication) twice a day beginning 07/29/2025 for behaviors and insomnia, an inappropriate indication for the medication use. Review of the clinical record showed Resident 81 had no signs of psychosis or insomnia. There was no consent for the Seroquel located in the clinical record. Review of a progress note dated 07/24/2025 at 12:00 AM, showed the resident was assessed for depression and denied trouble sleeping, staying asleep or sleeping too much. Review of the July Medication Administration Record (MAR) directed staff to monitor for behaviors of repetitive questions, withdrawal from activities and expressions of unrealistic fears every shift beginning 07/23/2025. All shifts showed there were no signs of anxiety. There was no sleep monitor in place. Review of the August MAR anti-anxiety monitor showed the resident experienced anxiety on 4 of 55 shifts. The documentation did not reflect which of the behaviors the resident experienced nor what nonpharmacological interventions were attempted. There was no sleep monitor in place. In an interview on 08/20/2025 at 9:52 AM, Staff B, Director of Nursing Services stated they were not aware of issues with psychotropic medications. Staff B stated they audit these medications to make sure they are only giving anti-psychotics for diagnoses that are appropriate. Staff B stated Resident 81's medication without the appropriate diagnosis must have been isolated. They stated they should have consents and non-pharmacological interventions in place. <RESIDENT 22> Resident 22 admitted to the facility on [DATE] with diagnoses to include generalized anxiety disorder and PTSD and readmitted to the facility on [DATE] with additional diagnosis of major depressive disorder. Review of physician orders showed an order dated 08/05/2025 for Hydroxyzine (medication with sedative effects) for anxiety and insomnia daily at bedtime. Review of the August MAR did not show non-pharmacological interventions or monitoring hours of sleep. In an interview on 08/19/2025 at 12:25 PM, Staff DD, Registered Nurse (RN), stated non-pharmacological interventions would be attempted prior to the administration of antianxiety medication and documented on the MAR. Hours of sleep would be monitored for sedative medications and documented on the MAR. In an interview and record review on 08/19/2025 at 12:50 PM Staff Q, Licensed Practical Nurse/Unit Manager stated non-pharmacological interventions should be attempted prior to the administration of psychotropic medication. Staff Q stated they would be included in the physician order and documented on the MAR. They stated that hours of sleep would be documented for sedative/hypnotic medication. Staff Q acknowledged that non-pharmacological interventions and monitoring of sleep hours were not on the physician orders or documented on the MAR for Resident 22. Reference WAC 388-97-0620(1)(b)(4)(a)(b)(c)

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the recommendation of the Level ll Preadmission Screen and Resident Review (PASRR - a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]) evaluation was submitted after a hospital exemption was no longer valid for 1 of 5 residents (Resident 72) reviewed for PASRR. This failure placed residents at risk of behavioral health needs not being met and a diminished quality of life.Findings included.Review of the undated facility policy titled, Long-Term Services and Supports Screening, PASRR Policy, documented that when a resident has a positive Level l screening, the facility will initiate the Level ll screening.<Resident 72> Resident 72 was admitted on [DATE] with diagnoses to include Major Depressive Disorder (MDD), severe with psychotic symptoms and anxiety. In a review of Resident 72's PASRR Level l, it was documented the resident had a serious mental illness (SMI) with mood disorders and that there was evidence that the person exhibits serious function limitations during the past six months related to a SMI. The PASRR Level l indicated a Level ll must be completed if scheduled discharge did not occur. In review of Resident 72's progress notes, it was documented that the resident had a hospital exempt PASRR (if stay at facility was to exceed 30 days, must have a level II completed) by Staff H, Social Services (SS), dated 07/07/2025. On 07/09/2025, it was documented that Resident 72 will be staying at this facility as a long-term care resident by Staff G, SS. In an interview on 08/19/2025, at 2:45 PM, with Staff H, SS stated that if a PASRR comes from the hospital with an exemption but indicated for a Level ll, then the process would be to send in a Level ll for validation. Staff H confirmed no Level ll PASRR was sent in for Resident 72. This is a repeat deficiency from 11/15/2024. Refer to WAC 388-97-1975(5)

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide an environment that was free from accident hazards over which the facility had control for 1 of 3 residents (Resident 5) reviewed for falls. Failure to identify hazards and implement safety interventions in the facility therapy courtyard, resulted in Resident 5 experiencing a fall and placed residents at risk for injury. Findings included.Resident 5 admitted on [DATE] following an orthopedic surgery. Resident 5 was alert and oriented, and was wheelchair bound. In an observation and interview on 08/14/2025 at 9:42 AM, Resident 5 stated they had fallen about a week prior while outside in the courtyard. Resident 5 stated they were in their wheelchair with their back facing what they believed was a paved ramp. Resident 5 stated they began to wheel themselves backwards, and then suddenly fell back off a step, landing on their back on the cement ground. Resident 5 stated they hit their head and were scratched up on their elbows. Resident 5 stated they were very lucky not to have been seriously hurt and stated the step should have been more obvious, it just blended in with the cement. Resident 5 stated after they fell, the facility tied some ribbon across the top of the step. Resident 5 was observed to have several scratched areas on their arms covered with band aids. In an observation on 08/14/2025 at 2:00 PM, the first-floor courtyard was observed to have a cement pathway which included a ramp, followed by a left turn with a straight section which led to the cement step. The cement step area had metal railings on both sides, but no gate or barrier at the top, and no identifying paint or other markings to indicate that it was a step. Orange flag tape had been tied across the hand railings at the top of the step. After stepping up, the path turned left again and returned to the main courtyard near the door. In an interview on 08/19/2025 at 2:19 PM, Staff A, Administrator, stated the configuration of the courtyard was due to it being a “therapy” courtyard, so it intentionally included changes in elevation and the step. Staff A stated the facility had previously not provided supervision when residents were in the courtyard. Staff A stated they wanted residents to be able to use it but had not previously identified the step as a potential hazard. Staff A stated there was a temporary marker in place and a removable solid barrier had been ordered. Reference WAC 388-97-1060 (3)(g)

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 2 of 6 sampled resident's (Residents 3 and 81) reviewed for nutrition, received adequate weight monitoring, and implemented effective interventions to maintain adequate nutrition and hydration. This failure placed residents at risk of ongoing weight loss, poor nutrition, and potential harm. Findings included.Review of the facility policy titled, Weight Assessment and Intervention, dated 10/01/2021, documented the nursing staff will measure resident weights as ordered by the physician/practitioner and recorded in the medical record . The dietary staff will review the weight records, and the treatment team will evaluate negative trends . Unplanned significant weight change will be investigated and analyzed by the interdisciplinary team . Care planning for unplanned wright changes or impaired nutrition risks will be an interdisciplinary effort, including causes of weight loss, goals, time frames and parameters for monitoring . Interventions for significant weight loss include nutrition and hydration needs of the resident, chewing and the need for diet modifications, the use of supplementation .The interdisciplinary team will make additional evaluations including referrals to dental consult. <RESIDENT 81> Resident 81 admitted on [DATE] with diagnoses to include severe protein-calorie malnutrition, gastrointestinal reflux syndrome (acid reflux), electrolyte disturbances and chronic lung disease. Review of the admission transfer orders from the hospital on [DATE] directed staff to weigh Resident 81 daily and provide a pureed diet and nutritional supplements, berry preferred daily. Review of the July Medication Administration Record (MAR) directed staff to weigh the resident on admission on [DATE] and weekly three times, then monthly on Thursdays. Review of the initial nutritional at risk assessment dated [DATE], showed the resident was underweight at 62 pounds and their ideal body weight was 120 pounds. The diet was listed as regular texture rather than the ordered pureed texture. The assessment was incomplete and did not include nutrition education or a mini nutritional assessment that would score the residents nutritional status. Review of the August MAR showed a weight refusal on 08/07/2025 and a weight of 62 pounds on 08/14/2025. There were no further weights recorded. Review of the admission MDS dated [DATE] showed the resident was 64 inches tall, weighed 62 pounds and had no teeth. Review of the nutrition Care Area Assessment (CAA) dated 07/29/2025 showed the resident had a body mass index (BMI) of 10.6 which indicated significantly underweight status, and serious health issues like compromised immune system, increased risk of disease and fatigue. The CAA noted that the resident had poor oral intake. Resident 81's Registered Dietician (RD) notes showed the resident reported feeling okay with fair appetite, denies any gastrointestinal symptoms or issues with chewing/swallowing, though noted poor dentition and they preferred meats and vegetables to be cut into small pieces. The notes documented Resident 81 reported mild stomach discomfort, and they were aware of weight loss but unsure of the amount, and they appeared very thin with signs of possible malnutrition. Resident 81 was at risk for unavoidable weight loss and potential skin breakdown due to their care goals. Weight loss was expected given their poor appetite and inconsistent intake. The focus remained on promoting satiety and comfort, with no current complaints of thirst or hunger and their dietary preferences would continue to be honored. Resident 81 enjoyed cream of rice prepared with two packets of brown sugar and one packet of table sugar. The resident did not consume juice and preferred tea and water. Review of the nutritional care plan dated 07/23/2025 showed the resident was at nutritional risk due to advanced age, goals of care, underweight BMI and past medical history. The care plan included only one intervention for RD consult. The care plan did not include the residents' goals, food preferences, missing dentures, or other interventions. Review of a weight note on 07/31/2025 at 2:25 PM, showed the weight was reviewed with the RD and the RD would evaluate the resident for a weight gain supplement. Review of the progress notes showed there was no further mention or orders for nutritional supplement although ordered on admission. Review of the clinical record showed the resident had the following weights since admission: · 07/23/2025: 62.0 pounds · 07/31/2025: 62.0 pounds · 08/07/2024: 62.0 pounds Review of a progress note dated 08/04/2025 at 12:00 AM from Collateral Contact (CC) 2, Physician Assistant, showed the resident was underweight with severe protein/calorie malnutrition and noted sporadic meal intakes. CC2 documented the resident appeared to have lost their dentures and they were unable to tolerate the regular texture diet. CC 2 downgraded the diet to mechanical soft. In an interview on 08/20/2025 at 9:52 AM Staff B, Director of Nursing Services stated they were aware of nutrition issues. Staff B stated two weeks ago they started having weekly skin and nutrition meetings to look at high risk residents and address issues right away. Nursing documentation did not contain evidence of ongoing assessment, implementation of interventions and re-evaluation of interventions consistent with professional standards. The nursing documentation also did not reflect a proactive approach to weight monitoring and nutritional management. <RESIDENT 3> Resident 3 admitted to the facility on [DATE]. In an observation on 08/14/2025 at 10:17 AM, Resident 3 was observed lying in bed with their eyes closed, the overbed table had their uneaten breakfast tray was present. In an observation and interview on 08/15/2025 at 9:38 AM, Resident 3's breakfast tray was observed in front of them untouched. Resident 3 stated they would not eat because they had no appetite for three months. In an observation on 08/15/2025 at 10:39 AM, Resident 3 was sleeping in the bed, their breakfast tray was still on the bedside table untouched with a half cup of yellow color juice left on the table. In an observation and interview on 08/15/2025 at 12:36 PM, Resident 3's breakfast tray was on the chair at the bedside, and the lunch tray was in front of them. Resident 3 stated they did not eat breakfast and did not want to eat lunch either. Resident 3 stated the nurse did not give them any substitute in the morning and they did not want to eat anything. In an observation and interview on 08/18/2025 at 8:41 AM, Resident 3's breakfast tray was observed on the bedside table in front of them untouched. Resident 3 stated they had dental pain, and they did not want to eat. The food on the tray was observed to be regular texture. Resident 3 stated they started to lose their appetite in April. Resident 3 stated they felt they were losing weight because their clothes got very loose. Resident 3 stated they wanted to “have my appetite back.” In an observation on 08/18/2025 at 9:50 AM, 10:17 AM and 11:43 AM, Resident 3's breakfast tray remained on the bedside table untouched. In an observation and interview on 08/18/2025 at 11:43 AM, Resident 3's lunch had regular textured ham. Resident 3 stated they liked ham, but they could not chew due to their broken teeth and toothache. Resident 3 stated they had teeth problems since admission. Resident 3 stated their only intake today was half cup of orange juice. In an observation and interview on 08/19/2025 at 9:26AM, Resident 3 stated they did not eat anything yesterday and drank about 12-14 ounces liquid the whole day. Resident 3 stated they did not drink enough and wanted to drink more water. There was no water pitcher or cup in the room. Resident 3 stated they had no water to drink; someone took the water pitcher away yesterday morning and did not bring it back. In an observation and interview on 08/19/2025 at 1:15 PM, Resident 3 stated they felt “weak.” Resident 3 stated they still did not eat anything at breakfast and lunch and only drank some fluid. Review of Resident 3's diet order, ordered date 03/17/2025, indicated Resident 3's diet was regular texture. Review of Resident 3's nutritional at risk assessment on 06/14/2025, documented average oral intake was 35% per meal monitor and the goal was to keep their meal intake more than 85%. The assessment documented that a current weight was needed. Review of the physician's orders directed staff to weight the resident on admission, weekly for three weeks, and one time a day every 28 days beginning 07/09/2025. Review of Resident 3's weight record since admission, showed the resident weighed 271.5 lb on 03/17/2025, 258.8 lb on 03/25/2025 and 215.4 lb on 08/01/2025. There was no weight record other than the three weights. Resident 3 had 16.77% weight loss from 03/25/2025 to 08/01/2025. Review of Resident 3's care plan dated 08/15/2025 at 1:39 PM, showed there was no care area addressing nutrition status. Review of Resident 3's care record on 08/19/2025, showed there was no fluid intake amount recorded. Review of a note from Collateral Contact (CC) 2 note on 08/07/2025 at 12:00 AM, directed staff to add a nutritional shake for Resident 3. Review of Resident 3's August 2025 MAR, showed there was no documentation of how much nutritional shake Resident 3 consumed. Review of Resident 3's progress notes from 08/07/2025 to 08/18/2025, did not include documentation of how much nutritional shake Resident 3 had consumed. Review of a dietitian progress note on 08/15/2025 at 1:03 PM, documented Resident 3 had minimal appetite for the past one to two months. In an interview on 08/15/2025 at 1:41 PM, Staff HH, Nursing Assistant Certified (NAC), stated Resident 3 was not eating at all and stated they had a toothache. In an interview on 08/15/2025 at 1:52 PM, Staff O, Registered Nurse (RN), stated Resident 3 had been refusing meals. Staff O stated Resident 3 had a meal intake monitor but not a fluid intake monitor and there was no documentation of how much fluid the resident drank. In an interview on 08/18/2025 at 2:21 PM, Staff L, Licensed Practical Nurse (LPN)/Unit Manager, stated the resident weights were supposed to be monitored on admission, then weekly for three weeks, then monthly. Staff L was not sure why Resident 3 had no weight recorded from 03/25/2025 to 08/01/2025. Staff L stated Resident 3 drank water and juice and nurses were supposed to document and record how much fluid and health shake was accepted by the resident. Staff L stated they were not aware that Resident 3 had dental problems and toothache. Staff L stated the care area of nutrition was supposed to be in the comprehensive care plan. In an interview on 08/19/2025 at 8:35 AM, Staff JJ, Cook, stated they were not aware of Resident 3's dental problems and toothache until yesterday. Staff JJ stated the resident's diet could be downgraded if there was a speech therapy's order or provider's order. In a phone interview on 08/19/2025 at 11:45 AM, Collateral Contact (CC) 5, Dietitian, RD, stated there was lack of obtaining of routine weights in the facility. CC5 stated if Resident 3 had routine weight monitoring, they could do a better assessment and provide better interventions. CC5 stated Resident 3 had lost their appetite for the last two months and they had not been informed. CC5 was concerned about Resident 3's nutrition and protein adequacy. CC5 stated they reviewed Resident 3's laboratory result and they were concerned about hydration status, and the fluid intake monitor should be in place. In an interview on 08/19/2025 at 2:10 PM, CC2, Physician Assistant, stated they were concerned about Resident 3's weight and fluid intake due to the resident taking a diuretic. CC2 stated they were unable to review the weight because there were no weights recorded. CC2 stated they had requested staff to obtain the weight every time they reviewed the resident. CC2 stated they were not informed that Resident 3 had a decreased appetite in the last two months, and they would have started interventions earlier if they knew. In an interview on 08/19/2025 at 2:53 PM, Staff B, Director of Nursing Services, stated they expected monthly weight monitoring for long term residents and there were other ways to monitor weight even if residents refused to use weight scales. Staff B stated they expected there was fluid intake monitoring for residents taking diuretics and poor oral intake. Staff B stated the nutrition care plan was supposed to be included in the comprehensive care plan and the dental concerns were supposed to be identified early and referred to the dentist as soon as possible. In an interview on 08/20/2025 at 9:26 AM, Staff A, Administrator, stated the expectation was to monitor weight at least monthly or more frequently for some clinical situations; and monitor nutritional status, and to identify dental concerns and refer for treatment early. This is a repeat deficiency from SOD dated 11/15/2024. Reference WAC 388-97-1060 (3)(h)

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 101) reviewed for dialysis services received accurate, specific care and monitoring and received coordinated communication and collaboration with the dialysis facility. These failures had the potential to cause unmet care needs and unrecognized medical complications. Findings included.Resident 101 was admitted in February of 2023 with a diagnosis of End Stage Renal Disease requiring hemodialysis (process to filter toxins from the blood). Review of Resident 101's medical record documented that the resident had an indwelling tunneled jugular (IJ) catheter (directly inserted into large vein creating a permanent access for dialysis) in the right upper chest as their dialysis access. The IJ catheter was utilized and accessed only by the kidney center. The facility was to monitor only. In an interview and observation on 08/14/2025 at 09:00 AM, Resident 101 stated they go to dialysis three days a week. Resident 101 pulled down the top right corner of their shirt to show their tunneled dialysis catheter with a clear dressing over the top. Resident 101 stated the staff here weren't doing anything with it, they take care of it at the kidney center. Review of Resident 101's care plan dated 02/03/2025 showed generic interventions in place for dialysis which had not been personalized to state the resident's dialysis access was an IJ catheter. The care plan included interventions and monitoring for an AV fistula (a different type of dialysis access; a surgically created connection between an artery and a vein) which included interventions to monitor for bruit and thrill (turbulent sounds and palpable vibrations specific to AV fistulas which indicate they are functioning properly). Review of the Treatment Administration Record (TAR) dated 02/03/2025 showed an entry instructing nurses that if the resident had a fistula for staff to remove the dressing four hours following return from dialysis. This was not applicable for Resident 101, as they did not have a fistula, yet nursing staff were signing it as completed. The TAR also instructed staff each shift to “check access at right upper chest for lack of bruit/thrill, signs of infection, swelling, or bleeding and report to physician.” The documentation included “y” or “n” with no clarification of what constituted “y” or “n,” and review of the documentation responses for the month of August 2025 (review date 08/18/2025) showed 36 “n” responses, 7 “y” responses, 1 “0” response, and 7 blank responses. In an interview on 08/19/2025 at 12:53 PM, Staff N, Registered Nurse, reviewed the documentation on the TAR for Resident 101. Staff N confirmed they worked full time and stated Resident 101 had an indwelling catheter on their right chest that they monitored. Staff N confirmed that the dialysis center did the dressing changes and managed the care of the catheter. Staff N confirmed their initials on the TAR for Resident 101 and was asked regarding conflicting documentation. On August 1,3,4,5,6,7,10,12,14,15, and 18, 2025, Staff N initialed and charted “n” on the TAR. On August 8 and 13, 2025, Staff N initiated and charted “y.” Staff N stated they were confused about what was meant by “n” or “y,” but stated they meant to indicate that there were no complications. Staff N stated the nurses must be making a mistake when reading it. Staff N stated they had not noticed that the TAR incorrectly directed them to assess for a bruit and thrill that did not apply to the resident. Review of the dialysis communication system on 08/19/2025 showed that the facility sent a paper with the resident's “pre” dialysis vital signs and status with the resident. The “post” dialysis was not completed by the dialysis center, instead it was faxed over to the facility and scanned in the record. The facility also completed an electronic version of the “pre” dialysis and a separate “post” dialysis assessment. The process was inconsistent and did not show an organized system for communication and monitoring of the resident “pre” “during” and “post” treatment between the facility and the dialysis center. In an interview on 08/19/2025 at 1:49 PM, Staff L, Licensed Practical Nurse/Unit Manager, stated they had not noted that the care plan for Resident 101 had not been completed accurately with respect to their dialysis access and monitoring. The care plans were reviewed quarterly and with changes. Staff L stated the dialysis center sent the treatment sheets over separately and did not complete the paper that the facility sent. Staff L stated that Medical Records was sometimes slow to scan in the dialysis sheets and that they had not been auditing whether all of the sections of the assessments were completed in the electronic record. This is a repeat deficiency from 11/15/2024. Reference WAC 388-97-1900

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review, the facility failed to provide nonpharmacological interventions prior to the use of as needed pain medications for 1 of 1 sampled residents (Resident 26) reviewed for pain medication use. The facility failed to provide nonpharmacological interventions These failures placed residents at risk for receiving unneeded mediations, related side effects of medications and a diminished quality of life.Findings included .Review of a facility policy titled Pain Management, undated showed;9. Various strategies and modalities may be utilized to assist the resident in achieving optimal comfort. Such strategies and modalities may include, but are not limited to: a. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: i. Environmental-adjusting the room temperature, smoothing he linens, providing a pressure reducing mattress, repositioning, etc; ii. Physical-ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture, etc.; iii. Exercise-range of motion exercises to prevent muscle stiffness and contractures; iv. Cognitive or Behavioral-relaxation, music, diversions, activities, etc. <RESIDENT 26> Resident 26 admitted to the facility on [DATE] with diagnoses to include arthritis and pain in right hip. Review of Resident 26's physician orders showed the resident receives pain medication as needed (PRN) for pain management. Review of Resident 26's Medication Administration Record (MAR) dated 07/21/2023 through 07/31/2025 showed the resident used PRN pain medication 38 times. Review of Resident 26's MAR dated 08/01/2023 through 08/17/2025 showed the resident used PRN pain medication 43 times. In an interview on 08/19/2025 at 12:25 PM, Staff DD, Registered Nurse (RN), stated non-pharmacological interventions would be attempted prior to the administration of PRN pain medications. In an interview and record review on 08/19/2025 at 12:50 PM, Staff Q, Licensed Practical Nurse (LPN), Nurse Manager confirmed non-pharmacological interventions should be attempted prior to administration of PRN pain medication and would be documented on the MAR. Staff Q acknowledged non-pharmacological interventions were not being provided for Resident 26. In an interview on 08/19/2025 at 3:50 PM, Staff B, Director of Nursing Services acknowledged non-pharmacological interventions should be attempted prior to administering PRN pain medication but would not be documented the MAR. Reference WAC 388-97-1060(3)(k)(i)

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 5 residents (Resident 44) remained free of significant medication errors during medication administration. This failure of administrating expired insulin injection placed residents at risk for unnecessary medication-related complications and diminished quality of life.Findings included. Resident 44 readmitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus (DM - a chronic metabolic disorder characterized by persistent high blood sugar). Review of Resident 44's physician orders dated 11/06/2024 documented to administer Humalog Solution (medication inserted into the body to help regulate blood sugar levels) subcutaneously three times a day for diabetes. In a medication administration observation and interview on 08/14/2025 at 4:24 PM, Staff KK, Registered Nurse (RN) withdrew the insulin vial and was about to administer to Resident 44. The insulin vial had a label with an open date of 07/10/2025. Staff KK was asked how long the facility kept the insulin vial after it had been opened. Staff KK confirmed the insulin was opened on 07/10/2025 as written on the label and they stated the after-open-use date at minimum would be 24 days and could be used until the end of August. Staff KK was stopped prior to administering the expired insulin. In a following joint interview on 08/14/2025 at 4:30 PM with Staff KK, and Staff L, Licensed Practical Nurse/Unit Manager, Staff L stated the insulin vial was good for 28 days after it was opened and this insulin was already expired. Staff KK disposed of the insulin vial and the prepared insulin injection syringe and stated they would have injected the medication to the resident if they had not intervened. In an interview on 08/14/2025 at 4:44 PM, Staff L stated it would be a medication error if the expired insulin had been administered to the resident. In an interview on 08/18/2025 at 2:41 PM Collateral Contact (CC) 1 stated they were the pharmacy consultant for the facility and were there on a quarterly audit removing all the expired medications from the carts there. CC 1 stated they had hoped to complete the audit before the survey. CC 1 had a tablet with multiple expired medications written down for their report to provide to the facility. In an interview on 08/19/2025 at 2:53PM, Staff B, Director of Nursing Services, stated they expected nurses to check the medication expiration date and not administer expired insulin to residents. This is a repeat deficiency from SOD dated 11/15/2024. Reference WAC 388-97-1060-3(k)(iii)

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory (labs) tests were completed as ordered and to provide timely laboratory results to meet the needs of 1 of 3 residents (Resident 33) reviewed for laboratory services. These failed practices had the potential for negative complications related to delay of obtaining and review of lab results. This failure had potential for risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions.Findings included.Review of facility policy titled, Lab and Diagnostic Lab Results dated 10/01/2021 documented the facility will provide notification and follow up of practitioner recommendations regarding labs. <RESIDENT 33>Resident 33 was re-admitted on [DATE] with diagnoses to include iron deficiency anemia secondary to blood loss, a left hip pressure ulcer, cellulitis (infection of the skin) of their right leg and an open wound to their left lower leg.Review of the physician's order on 06/13/2025, directed staff to obtain complete blood count (CBC) with differential and complete metabolic panel (CMP) weekly.Review of the June Medication Administration Record (MAR), showed the nurse signed the CBC and CMP lab had been obtained on 06/03/2025 and 06/20/2025.Review of the clinical record showed CBC/CMP lab results for 06/02/2025, 06/11/2025 and 06/20/2025. There was no lab result for the week of 06/27/2025.Review of the July MAR showed the nurse signed the CBC and CMP lab had been obtained on 07/04/2025 and 07/11/2025.Review of the clinical record showed CBC/CMP lab results for 07/07/2025, 07/14/2025 and 07/29/2025. There was no lab result for the week of 07/21/2025.Review of the August MAR showed the nurse signed the CBC and CMP lab had been obtained on 08/01/2025, 08/08/2025 and 08/15/2025.Review of the clinical record showed CBC/CMP lab results for 08/05/2025 only as of 08/20/2025 at 8:02 AM. There were no lab results for the week of 08/12/2025.In an interview on 08/19/2025 at 9:49 AM, Collateral Contact 2, Physician's Assistant, said they wanted Resident 33 to have their CBC and CMP drawn weekly. CC 2 stated most of the time they get the lab results as ordered. CC 2 stated that sometimes labs were drawn one day and then also the next day, so another lab was drawn which was unnecessary. CC 2 stated they were not sure why Resident 33's labs were not drawn weekly as ordered. CC 2 stated if they noticed there were no lab results that they were expected to review, then they would fill another lab slip out and make sure there was a current lab order.In an interview on 08/19/2025 at 2:37 PM, Staff Q, Licensed Practical Nurse/Unit Manager stated they had heard that Resident 33 had missed some of their weekly labs. Staff Q did not provide any additional information. In an interview on 08/20/2025 at 9:52 AM, Staff B, Director of Nursing stated they were not aware of any lab concerns and Resident 33's missed labs were an isolated event. Staff B stated they checked for lab completion every day.No additional information was provided.Reference WAC 388-97-1620(2)(b)(i)

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food services met the individual food plans, nutritional needs and preferences for 1 of 2 sampled residents (Resident 102) reviewed for nutrition and preferences. The failure placed residents at risk for not having their food choices honored, dissatisfaction with meals, unmet nutritional needs, and a diminished quality of life. Findings included.Review of the facility policy titled, Food and Nutrition Services, dated 10/01/2021, documented food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Resident 102 was admitted to the facility on [DATE]. According to the Annual Minimum Data Set (MDS-an assessment tool), dated 07/13/2025, the resident was cognitively intact. In an interview on 08/13/2025 at 10:27 AM, Resident 102 stated the food served did not match the tray card or what they ordered from the menu. In an observation, interview and record review on 08/13/2025 at 11:59 AM, Resident 102 stated they had no meatballs on their lunch plate. Review of the tray card documented large protein serving and included meatballs/beef, mixed vegetables and oven roasted potatoes. Resident 102's lunch tray did not contain meatballs/beef, no roasted potatoes and no vegetables, but a slice of pizza. Resident 102 stated their slice of pizza was not considered a large protein serving. In an observation, interview and record review on 08/14/2025 at 12:00 PM, Resident 102's lunch tray had a fruit plate including strawberries, grapes and watermelon, 2 small packages of biscuits, one small container of cottage cheese, sherbet and cranberry juice. Review of their tray card documented the lunch should have vegetable stuffed peppers, yellow rice, and asparagus spears. Resident 102 stated the tray did not include the ordered vegetable stuffed peppers, rice or asparagus spears on their plate and they commented they disliked cottage cheese. In an observation, interview and record review on 08/15/2025 at 8:10 AM, Resident 102 stated they were supposed to have pancakes on the breakfast tray. Review of the tray card documented homestyle pancakes. The breakfast tray was observed to include two pieces of bread and no pancake. In an observation, interview and record review on 08/19/2025 at 8:25 AM, Resident 102 stated they were supposed to have four slices of bacon but there were only two on the meal tray and no sausage links. Review of tray card documented 4 slices of bacon and 2 oz sausage links. The breakfast tray only had 2 slices of bacon and no sausage links. In an interview on 08/15/2025 at 9:51AM, Staff K, Nursing Assistant Certified (NAC), stated that at times that Resident 102's meals served did not match the tray card and the resident would get upset about that. In an interview on 08/20/2025 at 9:16 AM, Staff EE, NAC, stated the food served and the tray card did not match sometimes, and they did not understand why. In an interview on 08/19/2025 at 11:45 AM, Collateral Contact (CC) 5, Registered Dietitian, stated their record indicated Resident 102 needed large portions of protein. CC 5 stated they had heard from other residents that they did not get the food served according to their tray cards. In an interview on 08/19/2025 at 3:54 PM, Staff JJ, Cook, stated they were aware that sometimes the tray card and the food served did not match but they were supposed to match. In an interview on 08/20/2025 at 9:26 AM, Staff A, Administrator, stated they expected the food served to match the tray card and match what residents chose from the menu. Reference WAC 388-97-1180(1)-1120 (3)(a)

CONCERN (D)

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the required specialized rehabilitative services for 1 of 2 residents (Resident 1), reviewed for rehabilitation services. This failure placed the residents at risk for the decline in function, unmet care needs and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE], with diagnoses that included a history of a stroke that affected mobility to the left side of their body, muscle weakness, limited activity due to disability, and depression. The admission Minimum Data Set (MDS - an assessment tool) dated 08/04/2025 showed the resident had no cognition impairment, and no refusal of care, and the resident was dependent for toileting care, and required substantial to maximum assistance for transfers. Review of Resident 1's hospital transfer orders dated 07/29/2025, documented orders for evaluation and management for Physical Therapy (PT), and Occupational Therapy (OT). Review of Resident 1's facility physician orders dated 07/29/2025, showed orders for evaluation and treatment as indicated for PT, OT and Speech Therapy (ST). Review of Resident 1's care plan had a focus dated 07/29/2025 that the resident had admitted to the facility for rehabilitation and required assistance with their activities of daily living (ADLs) due to history of a stroke that affected the left side of their body. Interventions included skilled physical therapy, skilled occupational therapy, and skilled speech therapy. Review of Resident 1's PT evaluation dated 07/30/2025 documented recommended treatment for PT would be five days a week. The resident stated their goal was to walk around in their home again. The evaluation documentation showed the resident demonstrated fair potential for rehabilitation with a focus of treatment to be restoration and adaptation. Review of Resident 1's OT evaluation dated 07/30/2025 documented recommended treatment for OT would be five days a week. The resident stated their goal was to increase strength to ambulate again. The evaluation documentation showed the resident had good rehabilitation potential as they were able to follow directions, make their needs known, and actively participate in the skilled treatment. The focus of treatment would be restoration, compensation and adaptation. Review of Resident 1's ST evaluation dated 08/02/2025 documented recommended treatment for three days a week. Resident demonstrated excellent rehabilitation potential. Review of Resident 1's provider note dated 08/12/2025 documented that the resident was admitted to the facility for ongoing PT and OT treatment to improve weakness, and ongoing rehabilitation. In an interview on 08/13/2025 at 10:28 AM, Resident 1 stated they came to the facility from the hospital because they needed more physical therapy so they could walk again. Resident 1 stated they were seen by therapy when they first admitted but have had no treatments since then. Resident 1 expressed concern they would lose ability to stand and not be able to return home. In an interview on 08/15/2025 at 11:25 AM, Staff NN, Director of Rehabilitation (DOR) stated that the facility only conducted evaluations on Resident 1 when they admitted , and that therapy was not treating the resident at this time due to the resident had no insurance to cover therapy services. In a follow-up interview on 08/15/2025 at 12:08 PM, Staff NN stated when the residents admit to the facility for skilled services the facility will obtain Medicare authorization for therapy treatment services prior to admission. Staff NN stated Resident 1 did not have any Medicare days available and was admitted under their state Medicaid insurance. Staff N stated residents that admit with no Medicare funding, the facility must try and request authorization to get approved for therapy reimbursement services through the state Medicaid insurance. Staff NN stated they completed the evaluation and then forwarded that information to the business office, who then request authorization for therapy services. Staff NN stated that without that authorization, they are not allowed to treat the resident as they may not get reimbursement for the services they have provided. Staff NN stated that was why Resident 1 had not had any therapy services since their evaluations, as no authorization had been completed. In an interview on 08/15/2025 at 1:33 PM, Staff OO, Business Office Manager (BOM), stated the therapy department will make a request for state Medicaid insurance reimbursement so they can provide therapy treatment services to a resident. Staff OO stated they were not aware that Resident 1 admitted with physician orders for PT, OT and ST. In an interview on 08/19/2025 at 8:26 AM, Staff L, Licensed Practical Nurse (LPN)/Unit Manager was asked if they we were aware Resident 1 admitted on [DATE] with PT, OT, and ST orders but had not been seen due to their insurance would not cover the reimbursement. Staff L stated they were involved with therapy orders. Staff L was asked if they communicated with the provider, or any other department manager that Resident 1 had not received therapy services as ordered. Staff L stated they were not aware of any communication to get the resident the therapy services as ordered. In an interview on 08/19/2025 at 10:17 AM, Staff OO was asked where they document in the medical record when authorization request was made to the insurance company for therapy reimbursement. Staff OO stated they usually do not document that in the medical record. Staff OO was asked when they requested therapy reimbursement for Resident 1. Staff OO was unable to provide that information and stated Resident 1 was approved for a few PT and ST visits on 08/15/2025, 17 days after the resident admitted . In an interview on 08/19/2025 at 1:29 PM, Staff A, Administrator stated the facility will discuss in their morning interdisciplinary team (IDT) meetings on which residents were admitting that day. Staff A stated they thought Resident 1 was admitted to the facility as a long-term resident as they had no insurance to pay for skilled therapy services. Staff A stated they were aware that the resident had physician orders for skilled therapy, but stated they thought the orders were removed before the resident admitted . Staff A stated they would not have admitted Resident 1 if they had skilled therapy orders and no payor source. Staff A stated they had received approval from insurance to provide some limited visits to the residents for therapy services. Staff A confirmed they would not provide therapy services to the resident without a payor source. Reference WAC 388-97-1280(1)(a-b)(2)

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the facility environment was maintained in a clean, comfortable, homelike and safe environment, for one of two floors (2nd floor), 1 of 1 resident reviewed for missing property (Resident 26), and 2 of 2 residents reviewed for noise complaints (Residents 4 and 102). Failure to ensure the facility maintained comfortable noise levels, ensured security of resident property, maintained flooring and controlled odors placed residents at risk for a decreased quality of life.Findings included .<ODOR> In an observation on 08/12/2025 at 9:23 AM, there was a strong unpleasant odor in the hall for room's 228 to 239. Observation of an area of one-foot by one foot round dark color-stained spot on the carpet in the middle of the hallway. In an observation on 08/13/2025 at 11:36 AM, smelled odor which resembled the odor of mildewed clothes after being left in the washer in the hall for room 's 228 to 239. In an observation on 08/14/2025 at 11:39 AM, smelled urine odor outside of room [ROOM NUMBER]. In an observation on 08/15/2025 at 8:57 AM, The second floor TV lounge room was observed to be missing a flooring transition piece in the doorway where the laminate flooring in the hall transitioned to the carpet in the lounge room. There were also missing flooring transition pieces at resident rooms [ROOM NUMBERS]. A flooring transition piece was present at room [ROOM NUMBER], however it was separated and lifting at the door hinge side. In observations of carpet on 08/15/2025 at 9:04 AM, the second-floor carpeted hallways had a strong musty, mildewy odor throughout. There was a large dark spill stain in the center of the lounge room carpet. There were large dark areas of staining outside resident rooms [ROOM NUMBERS]. Resident room [ROOM NUMBER] showed dark staining from the hallway into the room at and near the resident sink area. In an interview on 08/15/2025 at 9:07 AM and 08/18/2025 at 11:55 AM, Resident 102 stated there always a bad odor in the hall and at the nurses' station. In an interview on 08/19/2025 at 10:05AM, Resident 102 stated the smell from the hall made them nauseous. In an interview on 08/20/2025 at 9:42 AM, Staff MM, Maintenance Assistant, stated they were aware of the odor in the hall. Staff MM stated the odor from the carpet was from when the carpet was cleaned and did not dry fast enough. Staff MM stated the stained spots on the carpet were from the spilled coffee and food. In an interview on 08/20/2025 at 9:26 AM, Staff A, Administrator, stated they were aware of the odor from the carpet. Staff A stated they did not have access to carpet cleaning machine. Staff A stated there should not be any unpleasant odors coming from the carpet. <RESIDENT 26>Resident 26 was admitted to the facility on [DATE]. In an interview on 08/14/2025 at 9:33 AM, Resident 26 stated that they had some missing clothing and blankets, and the staff were aware of the missing items. Resident 26 stated they were unsure if there was a grievance for the missing items and planned to go to the laundry to look for the items. Review of the grievance log date August 2025 did not show a grievance for Resident 26's missing items. In an interview on 08/18/2025 at 1:24 PM, Resident 26 stated they had not received the missing items and Staff U, Environmental Service Manager, was aware and looking for them. In an interview on 08/19/2025 at 9:38 AM, Staff U stated if laundry was reported missing, they would be notified verbally and would keep an eye out for the missing items for about a week. If the missing items were not located, they would notify Staff A who would replace or re-imburse the resident for the missing items. Staff U stated they were aware of Resident 26's missing items and had not been able to find them. In an interview on 08/19/2025 at 2:20 PM, Staff A stated a grievance form would be filled out for reported missing items. A staff member would assist the resident to find the missing items and if the items were not found they would be replaced or re-imbursed. Staff A stated they were made aware of Resident 26's missing items on 08/19/2025 and it will be escalated for replacement or re-imbursement related to the length of time the items had been missing. Staff A acknowledged that there was not a grievance form completed for Resident 26's missing items. <NOISE>In an interview and observation on 08/12/2025 at 9:21 AM, Resident 102 (in room [ROOM NUMBER]) stated the television (TV) was too loud from the room across the hall (room [ROOM NUMBER]) and next door (room [ROOM NUMBER]). Resident 102 stated the facility needed to reinforce the quiet hour time. Resident 102 stated they heard the loud TV almost all the time, day and night, every day. Resident 102 stated they reported to the staff and administrator but there was no change. While speaking with Resident 102, observed the door of room [ROOM NUMBER] was open and TV could be heard clearly in Resident 102's room. In an interview on 08/15/2025 at 9:07 AM, Resident 102 stated the TV was really loud at 4:30 AM. Resident 102 stated the resident in room [ROOM NUMBER] was very mean and nurses did not want to ask them to turn down their TV or close their door because that resident could yell at the nurse. In an observation on 08/18/2025 at 9:17 AM, the TVs were heard from room [ROOM NUMBER] and room [ROOM NUMBER], they could be heard clearly when standing at the nurses' station, which was about 15 feet away from room [ROOM NUMBER]. In an interview on 08/15/2025 at 9:34 AM, Resident 4 (in room [ROOM NUMBER]) stated they could hear the TV from the next-door room [ROOM NUMBER]. In an interview on 08/15/2025 at 9:51 AM, Staff K, Nursing Assistant Certified (NAC), stated Resident 102 reported concerns of loud TVs. Staff K stated the resident in room [ROOM NUMBER] was hard of hearing and did not want to close their door. Staff K stated the resident would get mad and yell at the nurse who tried to close their door. Staff K stated the resident in room [ROOM NUMBER] was also hard of hearing. In an observation and interview on 08/19/2025 at 9:11 AM, Staff K stated the TV was heard pretty loud in the hallway and no wonder Resident 102 complained about it. In an interview on 08/20/2025 at 12:05 PM, Staff A, Administrator, stated they were aware of the grievance of loud TVs. Staff A stated they educated residents about quiet hours and would provide headphones for residents. Reference WAC 388-97-0880 (1)(2)(4)(b)

CONCERN (E)

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

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer bed holds and provide a written transfer notice upon transfer to the hospital and notify the Office of the State Long Term Care Ombudsman (LTCO) for 5 of 5 residents (10, 12, 82, 108 & 109) who were reviewed for hospitalization. Failure to offer bed holds placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for lack of advocacy, not having an opportunity to make informed decisions about their transfer/discharge rights and possible unidentified or unmet care needs.Findings included .According to the facility's Bed Hold policy, undated, prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. A second written notice will be provided to the resident, and if applicable the residents' representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. The facility will document multiple attempts to reach the residents representative in cases where the facility was unable to notify the representative.According to the facility's Transfer and Discharge policy, dated 10/01/2021, the business office and or social services was responsible for informing the resident, or their representative of the facility readmission appeal rights, bed holding policies, etc.<RESIDENT 82> Review of Resident 82's progress note dated 08/14/2025 at 11:14 AM, documented they returned from the hospital at approximately 11:00 AM after being sent to the hospital the previous night due to coffee ground emesis (a serious symptom of blood in emesis). Review of the progress notes on 08/13/2025 showed there was no documentation the resident had been transferred to the hospital, there was no documentation about bed holds, transfer notice, physician and family notification nor report to the receiving hospital for continuity of care. In an interview on 08/19/2025 at 11:27 AM, Staff P, Licensed Practical Nurse/weekend manager confirmed Resident 82's medical record did not include that they were sent to the hospital on [DATE] nor the bed hold or transfer notice was provided to the resident. Staff P stated social services should document to the discharge. Staff P stated their expectation was that the nurse who sends the resident out to the hospital needed to document why they were sent out, family and physician notification in the progress notes and obtain the bed hold and provide the notice of discharge paperwork to the resident or their responsible party. Staff P stated the nurse should also call the emergency department with a report on the residents' condition. In an interview on 08/20/2025 at Staff A, Administrator stated they were aware there were transfer and bed hold issues. Staff A stated the policy of the bed holds were to be discussed with the residents on admit. If the resident went out to the hospital after hours, the bed hold and discharge paperwork should be sent with them. The nurses needed to make a progress note about why the resident was sent out, and also about the physician and family notification. Staff A stated the day after hospital admission, the business office should reach out to offer the bed hold if it had not been done yet. <RESIDENT 12> Resident 12 was discharged to the hospital on [DATE]. In a review of Resident 12's progress note, on 04/24/2024 at 3:34 PM, Staff BB, Registered Nurse (RN), documented that family member was made aware of the situation and agreed to send Resident 12 to the hospital. There was no documentation provided of the bed hold policy or notice of transfer and discharge to responsible party. <RESIDENT 10> Resident 10 was admitted on [DATE] and was transferred to the hospital on [DATE], and 04/28/2025. Record review of Resident 10's electronic chart did not show any documentation that the facility had notified the state ombudsman of resident's transfers to the hospital. <RESIDENT 108> Resident 108 was admitted to the facility on [DATE] and discharged home on [DATE]. Record review of Resident 108's electronic chart did not show any documentation that they have notified the state ombudsman of resident's discharge. In an interview on 08/18/2025 at 2:16 PM, Staff F, Medical Records, stated that they received copies of discharge packets from the Resident Care Manager (RCM), then they scanned and loaded it in resident's electronic chart. Staff F stated they don't have discharge packets for the residents that got transferred to the hospital. If there were missing documents, they email the RCM requesting them to provide copies of the missing documents. Staff F was not able to provide a copy of the discharge packet for Resident 108 and evidence that they notified the state ombudsman of the resident's discharge. In an interview on 08/18/2025 at 2:29 PM, Staff G, Social Service Department, stated that for residents that discharge from the facility, they would complete the Nursing Home Transfer and Discharge Notice form and fax it to the state ombudsman and then give a copy to Medical Records to be scanned into the resident's electronic chart. A request to Staff G was made to provide a copy of the evidence that the state ombudsman was notified of Resident 108's discharge and a copy of the notification to the state ombudsman of the discharges in the facility. Staff G could not provide any documentation. <RESIDENT 109> Resident 109 was admitted to the facility on [DATE] and left against medical advice on 07/26/2025. Record review of Resident 109's electronic chart did not show any documentation that they have notified the state ombudsman of resident's discharge. In an interview on 08/18/2025 at 2:03 PM, Staff H, Social Services Department, stated that if it's a facility-initiated discharge, they complete the Nursing Home Transfer and Discharge Notice form and fax it to the state's ombudsman and give a copy to Medical Records to be scanned into resident's electronic chart. Staff H stated they also notify the state ombudsman of any unplanned discharges such as hospitalization, leave against medical advice and resident-initiated discharges. A request to Staff G was made to provide a copy of the evidence that the state ombudsman notification on discharges. No documentation provided. In an interview on 08/19/2025 at 11:49 PM, Staff A, Administrator stated that they found out that the facility was not regularly notifying the state ombudsman of the discharges monthly. Reference WAC 388-97-0120

CONCERN (E)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, and included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 4 of 6 residents (Residents 3, 4, 33 and 98) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included .Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, dated October 2024, showed the RAI consisted of three basic components: the Minimum Data Set (MDS - and assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information). The CAAs reflect conditions, symptoms, and other areas of concern that are common in nursing home residents and are commonly identified or suggested by MDS findings. Interpreting and addressing the care areas identified is the basis of the CAA process and can help provide additional information for the development of an individualized care plan. Review of the undated facility policy titled, Care Area Assessments, documented the CAA documentation should include causes and contributing factors for the triggered care areas, the nature of the condition, complications contributing to the are area, risk factors related to the condition, factors considered in developing the care plan, any need for further evaluation by other healthcare provider.<RESIDENT 33> Resident 33 admitted on [DATE] with diagnoses to include chronic pain syndrome. Review of the admission MDS dated [DATE] included a triggered CAA for pain. Review of the MDS assessment, dated 06/06/2025 showed the CAAs did not contain comprehensive summaries or analysis that included the current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's care plan (CP) was needed. <RESIDENT 98> Resident 98 admitted on [DATE] with diagnoses to include spinal stenosis (narrowing of bones in spine), left and right foot drop (inability to lift the foot) and lymphedema (swelling due to excess fluid in body tissue). Review of the admission MDS assessment, dated 08/01/2025, included triggered CAA for pain. Review of the MDS assessment, dated 08/01/2025, showed the pain CAA was blank with the exception of one line that showed Resident 98 complained of pain during interview. In an interview on 08/20/2025 at 9:38 AM, Staff R, Registered Nurse (RN) MDS Nurse stated the CAA's should address anything that is triggered. Staff R stated they did not complete the MDS assessments for Resident 33 and 98. Staff R confirmed the pain CAA's did not address all issues which should include what pain medications they are on, if the resident was experiencing any adverse side effects. <RESIDENT 4> Resident 4 readmitted to the facility on [DATE] with diagnoses to include right hemiplegia and hemiparesis (one side weakness or inability to move) following cerebrovascular disease (stroke-serious condition where blood flow to the brain is interrupted causing brain cell to die). Review of Resident 4's Annual MDS, dated [DATE], showed the Functional Abilities (Self-care and Mobility) CAA was blank. Further reviews of all other triggered CAAs including communication, urinary incontinence and indwelling catheter, nutritional status, dehydration and fluid maintenance, dental care, pressure ulcer/injury did not contain any comprehensive assessments. In an interview and record review on 08/18/2025 at 1:58 PM, Staff R, RN/MDS Nurse, stated they were supposed to summarize actual or potential problems and analyze the findings of Resident 4's functional ability and ROM, triggered contributing and risk factors and referred to therapies if needed. Staff R stated they were not sure why there was no assessment at all for CAAs. <RESIDENT 3> Resident 3 admitted to the facility on [DATE]. Review of Resident 3's admission nursing collection tool on 03/17/2025 at 5:29 PM, documented the resident had broken or loose teeth. Review of Resident 3's MDS summary assessment on 03/18/2025, documented Resident 3 had obvious or like cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, and mouth or facial pain. Review of Resident 3's admission MDS, dated [DATE], showed Dental Care CAA was blank. Further reviews of all other triggered CAAs including cognitive loss/dementia, visual function, functional ability, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer, psychotropic drug use and pain did not contain any comprehensive assessments. In an interview and observation on 08/18/2025 at 11:43 AM, Resident 3 stated they had broken, missing and loose teeth since admission and they had not seen a dentist. Resident 3 stated they had discomfort to their front teeth. Resident 3 was observed to have broken upper front teeth, missing upper and lower back teeth, and loose lower front teeth. In an interview and record review on 08/19/2025 at 1:25 PM, Staff R stated the MDS assessment coded Resident 3 had broken teeth, gum inflammation and pain which triggered dental care CAA. Staff R stated the CAAs were supposed to include analysis of findings, the resident's dental assessment, dental and oral care and assistant level and necessary referral if needed. Staff R stated there was nothing documented under dental CAA which was not supposed to and was not sure why all CAAs had no assessments. In an interview on 08/19/2025 at 2:53 PM, Staff B, Director of Nursing Services, stated they expected the MDS assessment and CAA was complete and accurate. This was a repeat deficiency from SOD dated 11/15/2024. WAC reference: 388-97-1000(1)(b)

CONCERN (E)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 5 of 5 sampled residents (1,11, 22, 81, and 98) reviewed for PASRR. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability. Findings included . Review of a facility policy titled Long-Term Services and Supports (LTSS), Preadmission Screening and Resident Review (PASRR) Policy, undated, showed the organization observed preadmission screening requirements to ensure that :Medicaid-eligible individuals meet required level of care criteria for Long-Term Services and SupportsPeople with known or suspected mental illness, intellectual disabilities, and/or related conditions are not inappropriately institutionalized or marginalized; to make sure that every individual receives the services and supports that will optimize their success in the least restrictive setting. Resident with these specific types of disabilities are admitted or allowed to remain in the facility, only if the facility can provide them with the services they need. <RESIDENT 22>Resident 22 admitted to the facility on [DATE] with diagnoses to include generalized anxiety disorder and post-traumatic stress disorder (PTSD) and readmitted to the facility on [DATE] with additional diagnosis of major depressive disorder. A Level 1 PASRR dated 06/20/2025 was completed prior to admission and did not show SMI. Review of the hospital Discharge summary dated [DATE] showed chronic medical problems of depression, anxiety, and PTSD. Review of Resident 22's medical record showed a progress note dated 07/07/2025, at 1:49 PM, titled “Social Services”, Note Text “PASRR is being sent for invalidation 7/7/25.” There was no other documentation for PASRR in the progress notes. In an interview on 08/19/2025 at 2:20 PM Staff A, Administrator, stated Staff H, Social Services, was responsible for the resident PASRRs. Staff A stated the facility identified that the PASRR coordinator had been emailing the wrong person at the facility and has been corrected. Staff A stated PASRRs are reviewed by admissions prior to resident admission to the facility. If a PASRR is identified as incorrect after a resident had admitted to the facility Staff H would communicate with the PASRR coordinator which takes a long time. In an interview and record review on 08/19/2025 at 2:40 PM, Staff H stated they were responsible for reviewing and following up with resident PASRR's when a resident admits to the facility. Staff H stated if the PASRR received at the time of admission was incorrect they would complete a new PASRR and send it to the PASRR coordinator who would either validate it as a Level I or invalidate it. If the PASRR was invalidated, the PASRR coordinator would interview the resident and make recommendations that would be provided to the facility. Staff H reviewed the resident's medical record and acknowledged Resident 22's diagnoses of depression, anxiety and PTSD and stated Resident 22's PASRR was incorrect. Staff H stated Resident 22's admission PASRR was not corrected but was sent to the PASRR coordinator via email to validate or invalidate the PASSR the first of August 2025. Staff H stated they had not received any further information and was unable to provide any documentation of communication with the PASRR coordinator. Staff H acknowledged a progress note written on 07/07/2025 that Resident 22's PASRR was sent for invalidation and stated they had received nothing further. No further information was provided. <RESIDENT 1>Resident 1 was admitted to the facility on [DATE], with diagnoses that included depression. The admission MDS dated [DATE] showed the resident had moderate depression. Review of Resident 1's physician orders showed the resident was prescribed duloxetine (antidepressant) which started on 07/29/2025. Review of Resident 1's admission PASRR Level 1 dated 07/02/2025 stated the resident had no mental health concerns and no Level 2 evaluation was completed. <RESIDENT 11>Resident 11 was admitted to the facility on [DATE] with no diagnosis of mental health. Review of Resident 11's medical records showed on 08/11/2024 the resident was given a new diagnosis that included anxiety. Resident 11 was then started on an anti-anxiety medication at that time. Review of Resident 11's medical record on 08/15/2025 showed no updates to the Level 1 PASRR were completed after the resident had a new mental health diagnosis and treatment ordered in August of 2024. Review of Resident 11's medical record on 08/16/2025 showed that the resident had a significant change in April of 2025 and was placed on Hospice services and was prescribed two antipsychotic medications. No updates were made to the Level 1 PASRR. In an interview on 08/18/2025 at 2:24 PM, Staff H, Social Services stated they review the PASRRs after the admission to ensure they are accurate. Staff H stated if they are not, they will complete a new one and send them to the PASRR coordinator for validation or invalidation. Staff H stated the expectation was if a resident had a change in condition or a new mental health diagnosis, they are to resubmit a new updated PASRR. Staff H was asked if they reviewed Resident 1's PASRR after their admission for accuracy, Staff H stated they had reviewed it and found it to be inaccurate. Staff H stated they thought they had resubmitted a new PASRR for Resident 1. Staff H was asked where that would be documented, and Staff H was unable to provide any documentation that had been completed. Staff H was asked if Resident 11 was reviewed after their change in mental health in August of 2024 or with the significant change in April of 2025. Staff H stated they were not aware of any updates made to Resident 11's PASRR. <RESIDENT 81>Resident 81 admitted to the facility on [DATE] with diagnoses to include generalized anxiety disorder and PTSD. A Level 1 PASRR dated 07/23/2025 was completed prior to admission showed PTSD was marked and anxiety had not been selected. Review of the skilled nursing facility transfer orders from the hospital on [DATE] showed Resident 81's discharge diagnoses included anxiety and PTSD. Review of the physician orders showed Resident 81 was taking Seroquel, an anti-psychotic medication twice a day for behaviors and insomnia. Review of the comprehensive Minimum Data Set (MDS, an assessment tool) accepted on 08/03/2025, showed the resident had a diagnosis of anxiety and PTSD. Review of the clinical record on 08/15/2025 documentation showed that a new PASRR referral had not been submitted to the PASRR evaluator so they could appropriately assess the resident who was taking Seroquel and also had a current diagnosis of anxiety. <RESIDENT 98>Resident 98 admitted to the facility on [DATE] with diagnoses to include depression and sleep disorder. The resident was ordered to take a medication for the diagnosis of anxiety. A Level 1 PASRR was completed prior to admission showed mood disorder and anxiety had not been selected. Review of the psychotropic informed consent on 07/25/2025, Resident 98 consented to taking Hydroxyzine, medication with sedative effects for anxiety and Trazadone, an anti-depressant for sleep/wake disorder and mental, behavioral or psychosocial symptoms that were persistent and clinically significant. Review of the comprehensive MDS accepted on 08/05/2025, showed the resident had a diagnosis of depression. Review of the clinical record showed that a new PASRR referral had not been submitted so the PASRR evaluator could appropriately assess the resident who was taking medications for anxiety and depression. In an interview on 08/20/2025 at 9:52 AM, Staff A, Administrator, stated they were aware of PASRR issues, and they had been addressing them by reviewing new admission PASRR's for accuracy. This is a repeat deficiency from SOD dated 11/15/2024. Reference WAC 388-97-1915 (1)(2)(a-c)

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 1 of 1 resident (Resident 101) for dialysis management, 1 of 4 resident (Resident 26) for pain management, 1 of 3 resident (Resident 4) for mobility, 2 of 6 resident (Residents 1 and 22) for mood and behaviors, and 3 of 6 residents (Residents 3, 22, and 81) for nutrition. This failure placed residents at risk of not receiving needed care, a decline in their condition, and diminished quality of life. Findings included . Review of the facility policy titled, Care Planning - Interdisciplinary Team, undated, facility was responsible for the development of an individualized comprehensive care plan for each resident. The comprehensive care plan within seven days of completion of the resident assessment. Review of the undated facility policy titled, Resident Mobility and Range of Motion, documented the care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline and/or improve ROM. Interventions include therapies, the provision of necessary equipment, and/or exercises. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Review of the undated facility policy titled, Nutrition Assessment, documented individualized care plans will address the identified causes or risks of impaired nutrition, residents' personal preferences, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment. <RESIDENT 22> Resident 22 admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder and post-traumatic stress disorder (PTSD) and readmitted to the facility on [DATE] with additional diagnosis of major depressive disorder. Review of Resident 22's care plan showed a focus dated 07/07/2025 for PASRR. The care plan did not include person centered goals or interventions for their diagnoses of major depressive disorder, anxiety, or PTSD. Review of Resident 22's nutritional/hydrational status care plan dated 06/25/2025 did not show person centered goals or interventions to monitor or prevent weight loss. The care plan showed two interventions that encouraged the resident to eat and for a RD (registered dietician) consult as needed. In an interview and record review on 08/19/2025 at 2:40 PM Staff H, Social Services stated that the care plan was an interdisciplinary effort, and PASRR Level II evaluation recommendations should be care planned. Staff H acknowledged the PASRR care plan was incomplete and not person centered for Resident 22. In an interview and record review on 08/19/2025 at 10:24 AM, Staff Q, Licensed Practical Nurse (LPN)/Nurse Manager, stated care planning was an interdisciplinary process, and they were responsible for evaluating and updating the care plan. Staff Q stated Resident 22's nutrition care plan was not resident centered. <RESIDENT 26> Resident 26 admitted to the facility on [DATE] with diagnoses to include arthritis and pain in right hip. Review of the Resident 26's opioids care plan was not personalized, had generic interventions and did not show non-pharmacological interventions. In an interview on 08/19/2025 at 3:50 PM, Staff B, Director of Nursing Services (DNS) stated non-pharmacological interventions should be on the care plan. <RESIDENT 101> Resident 101 was admitted in February of 2023 with a diagnosis of End Stage Renal Disease requiring hemodialysis (process of removing toxins from the blood). Review of Resident 101's medical record documented that the resident had an indwelling tunneled jugular (IJ) catheter (directly inserted into large vein creating a permanent access for dialysis) in the right upper chest as their dialysis access. The IJ catheter was utilized and accessed only by the kidney center. The facility was to monitor only. In an interview and observation on 08/14/2025 at 09:00 AM, Resident 101 stated they go to dialysis three days a week. Resident 101 pulled down the top right corner of their shirt to show their tunneled dialysis catheter with a clear dressing over the top. Resident 101 stated the staff here aren't doing anything with it, they take care of it at the kidney center. Review of Resident 101's care plan dated 02/03/2025 showed generic interventions in place for dialysis which had not been personalized to state the resident's dialysis access that was an IJ catheter. The care plan included interventions and monitoring for an AV fistula (a different type of dialysis access; a surgically created connection between an artery and a vein) which included interventions to monitor for bruit and thrill (turbulent sounds and palpable vibrations specific to AV fistulas which indicate they are functioning properly). In an interview on 08/19/2025 at 1:49 PM, Staff L, LPN/Unit Manager, stated they had not noted that the care plan for Resident 101 had not been completed accurately with respect to their dialysis access and monitoring. The care plans were reviewed quarterly and with changes. <RESIDENT 4> Resident 4 readmitted to the facility on [DATE] with diagnoses to include right hemiplegia and hemiparesis (one side weakness or inability to move) following cerebrovascular disease (stroke-serious medication condition where blood flow to the brain is interrupted causing brain cell to die). In an observation and interview on 08/13/2025 at 11:15 AM, Resident 4 stated they could not straighten out their fingers on their right hand. Resident 4 stated the facility had not provided any exercise or service for their hand and arm. Resident 4 attempted to open their right hand with their left but could not get the hand flat. The second, third and fourth fingers were bent in a fixed position. Resident 4 was observed to have their right elbow bent in a rigid position and held closely to their body and their right hand was closed tightly in a fist. Resident 4 stated they could not use their right hand to press the buttons on the TV remote and the call light. Resident 4 stated it hurt when they tried to open their right hand or move their right elbow and shoulder. Review of Resident 4's comprehensive care plan, print date 08/14/2025, showed there was no focus care area about limitation Range of Motion (ROM) or contracture (permanent shortening of the muscles and tendons) management. There were no interventions to maintain or prevent avoidable ROM decline. In an interview on 08/18/2025 at 10:30 AM, Staff L, LPN/Second Floor Unit Manager, stated Resident 4 had contractures and the comprehensive care plan was supposed to address the ROM and contracture management including specific goals and interventions. Staff L was not sure why the care plan was not there. <RESIDENT 3> Resident 3 admitted to the facility on [DATE]. Review of Resident 3's weight record since admission, showed they had 16.77% weight loss from 03/25/2025 to 08/01/2025. There was no weight record in between. Review of Resident 3's comprehensive care plan, print date 08/15/2025 at 1:39 PM, showed there was no care area that addressed the nutritional status. There were no interventions regarding weight monitoring, oral intake monitoring, food preferences, maintaining nutrition and hydration or to prevent malnutrition. In an interview on 08/18/2025 at 2:21 PM, Staff L stated the comprehensive care plan was supposed to include the focus care area of nutritional and hydrational status and they did not know why the care plan did not have it. In an interview on 08/19/2025 at 2:53 PM, Staff B, DNS, stated they expected the care plan to be comprehensive, with ROM, contracture management, and nutritional status be included. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE], with diagnoses that included depression. The admission MDS dated [DATE] showed the resident had moderate depression. Review of Resident 1's physician orders showed an order for duloxetine (anti-depressant medication) for depression. Review of Resident 1's comprehensive care plan, print date 08/13/2025, did not include any person-centered goals, or interventions for the diagnosis and treatment of their depression. In an interview on 08/18/2025 at 12:51 PM, Staff K, Nursing Assistant Certified (NAC) stated they rely on the Kardex (short, condensed version of the care plan) for up-to-date information on what care and services each resident requires. In an interview on 08/18/2025 at 1:38 PM, Staff N, LPN stated the unit nurse managers are responsible for creating and updating the care plans. In an interview on 08/19/2025 at 8:26 AM, Staff L, LPN/Unit Manager stated the comprehensive care plan was an interdisciplinary team effort and stated the specific behaviors and interventions for behavior monitoring should be on the physician orders as well as the care plan. Staff L confirmed the care plan for Resident 1 did not have any person-centered area, goals or interventions for their depression. In an interview on 08/19/2025 at 1:56 PM, Staff B, DNS stated their expectation was that the care plan was comprehensive and completed in the appropriate time frame. Staff B confirmed that each comprehensive care plan should be personalized to each resident. Staff B confirmed Resident 1 did not have person centered goals and interventions for their depression. <RESIDENT 81> Resident 81 admitted on [DATE] with diagnoses to include severe protein-calorie malnutrition, gastrointestinal reflux syndrome (acid reflux), electrolyte disturbances and chronic lung disease. Review of the admission MDS dated [DATE] showed the resident was 64 inches tall and weighed 62 pounds and had no teeth. Review of the nutrition Care Area assessment dated [DATE] showed the resident had a body mass index (BMI) of 10.6 which indicated significantly underweight status, a serious health issues with compromised immune system and increased risk of disease and fatigue. Review of the nutritional care plan 08/14/2025 showed the resident was at nutritional risk due to advanced age, goals of care, underweight BMI and past medical history. The care plan included only one intervention for RD consult. The care plan did not include the residents' goals, food preferences, or other interventions. In a joint interview on 08/20/2025 at 9:52 AM, Staff A, Administrator, said they were not aware of any care plan issues and there was no performance plan in place for care planning. Staff B, DNS stated they are going through new admission and quarterly care plans. Staff B stated they were aware the MDS nurses were using pre-populated interventions, and their expectation was for care plans to be individualized to the residents. This is a repeat deficiency from 11/15/2024 Reference 388-97-1020 (1)(2)(a)(b)

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise quarterly care plans accurately to reflect the resident's needs for 2 of 7 residents (Residents 12 and 72), reviewed for care planning. This failure placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life. Findings included .Review of the facility's undated policy titled, Care Planning - Comprehensive Person-Centered, documents that the care planning/interdisciplinary team is responsible for the review and updating of care plans when goals, needs, and preferences change, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly and after each MDS assessment.<RESIDENT 12> Resident 12 was readmitted from the hospital on [DATE] with diagnoses to include right leg pain. In an observation on 08/13/2025, at 1:11 PM, a green boot for relieving pressure was observed on a chair in Resident 12's room. In an observation on 08/15/2025, at 10:21 AM, and 2:23 PM the green pressure relieving boot was observed in their room on their chair. Review of the Resident 12's Minimum Data Set (MDS, an assessment tool), dated 07/01/2025, documented an unstageable pressure ulcer (wound with necrotic/dead tissue) to right heel. Review of Resident 12's care plan dated 06/12/2025 showed documentation of right heel pressure ulcer did not include pressure relieving devices ordered for resident. Review of Resident 12's physician orders, beginning 06/26/2025 directed staff to apply a right heel floater. In an interview on 08/19/2025, at 10:12 AM, Staff X, Licensed Practical Nurse (LPN)/Admissions Nurse and Collateral Contact (CC) 3, Physician's Assistant (PAC), with contracted wound provider stated that Resident 12 should have had the pressure relieving green boot on their right foot for pressure ulcer healing. In an interview on 08/19/2025, at 10:58 AM, Staff AA, Nursing Assistant Certified (NAC), stated Resident 12 was to wear their boot on the right foot when in bed. Staff AA stated it was not documented in the Kardex. In a joint interview on 08/19/2025, at 1:08 PM, Staff L, LPN/Unit Manager, and Staff H, Social Services (SS), confirmed that Resident 12's pressure relieving boot was not in the care plan or Kardex but should have been. <RESIDENT 72> In an interview and observation on 08/13/2025, at 10:54 AM, Resident 72 stated that both feet have redness. The resident was observed to be wearing non-skid socks and a heel protector boot on their left foot. In an observation on 08/19/2025, at 9:58 AM, Resident 72 was observed in bed with a heel protector boot on their right foot. In a review of Resident 72's care plan on 08/15/2025, it was documented that there was skin impairment to both left and right foot. The heel protector boot was not documented on the care plan. In a review of Resident 72's physician orders on 08/15/2025, directed staff to apply skin prep to both heels and toes every day and evening shift for redness beginning 08/11/2025. In an interview on 08/19/2025 at 11:19 AM, Staff CC, NAC, stated that Resident 72 wore the protective boot for comfort and that sometimes they switched which foot they would like it on. In an interview and observation on 08/19/2025 at 1:08 PM, Staff L, LPN/Unit Manager (UM) confirmed that Resident 72's heel protector boot was not documented in the care plan or Kardex. Observation of Resident 72's right foot with Staff L confirmed there was a scab on their right heel and Staff L stated that was why they did the skin prep order. This is a repeat deficiency from SOD dated 11/15/2025 Reference: (WAC) 388-97-1020 (2)(a)(5)(b)

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 5 of 5 sampled dependent residents (Residents 1, 33, 81, 98, and 99) reviewed for ADLs. The facility failed to provide showers/bathing assistance to residents (Residents 1, 33, 81, and 98), who were dependent on staff for bathing, and failed to ensure Resident 99, who was dependent for splint placement was provided the necessary assistance. These failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Shower/Tub Bath, undated, documented general guidelines that qualified nursing staff would provide two full baths or showers per week, and at a minimum offer a bed bath as needed. Resident preferences would be considered and honored. Review of the facility policy titled, Resident Mobility and Range of Motion, undated, documented all residents will receive the necessary treatment and services to increase and/or prevent a decline in their range of motion. <RESIDENT 81> Resident 81 admitted on [DATE] with diagnoses to include chronic lung disease, severe protein calorie malnutrition, anxiety and pain Review of the admission Minimum Data Set (MDS, an assessment tool) dated 07/29/2025, showed Resident 81 did not reject care. In an observation on 8/13/2025 at 1:57 PM, Resident 81 was in bed with long messy hair. In an observation on 08/14/2025 at 2:25 PM Resident 81 was in bed. Their hair was messy and greasy. In an interview and observation on 08/18/2025 at 9:21 AM, Resident 81 was sitting up in bed. Their hair remained greasy. The resident stated they wondered if the facility had a bathtub, as they had only had “spit baths” here and they would really like a bath as they were not a “shower person.” In an interview and observation on 08/19/2025 at 12:48 PM, Resident 81 was in bed eating lunch. Their long, greasy hair was uncombed with a ball of tangles below their ponytail. The resident stated they thought the facility was ordering aloe vera wipes for them for bed baths. The residents stated they wanted their hair washed and they did not know how or when staff would do that. Resident 81 asked if someone had complained about their lack of bathing. In an interview on 08/19/2025 at 2:37 PM, Staff Q, Licensed Practical Nurse (LPN)/ Unit Manager was informed that Resident 81 stated they had not had their hair shampooed since they admitted last month and their hair was tangled. Staff Q stated that staff could wash the resident hair while they were in bed and there was no excuse not to. In an interview and observation on 08/20/2025 at 9:00 AM, Resident 81 was sitting up in bed eating breakfast. Their hair was down and there was two 5 inch by 5-inch tangled balls of matted hair. The resident stated they finally had a shower last night and two aides tried to use detangler and get the balls out but they couldn't. There was a bottle of hair detangler at the bedside. Review of the first-floor shower schedule showed Resident 81 was assigned to receive showers on Tuesday and Friday evenings. Review of the 30-day shower documentation showed Resident 81 had no showers in July and one bed bath on 08/01/2025 as of 08/19/2025 at 1:21 PM. <RESIDENT 33> Resident 33 admitted [DATE] with open wounds to both legs. Review of the admission MDS dated [DATE], showed the resident did not reject care. Review of the first-floor shower schedule document showed the resident's room was not assigned to a bathing schedule. In an interview and observation on 08/14/2025 at 8:54 AM, Resident 33 was in bed. The room had a foul odor. Review of the plan of care showed Resident 33 was scheduled to have a shower every Monday and Thursday on day shift. Review of Resident 33's documentation report for July 3rd (Thursday) – August 20th (Wednesday) had no showers documented on 07/03/2025, 08/11/2025 and 08/18/2025. In an interview on 08/19/2025 at 10:47 AM, Staff P LPN/Weekend Manager stated they audited shower documentation in the electronic medical record (EMR). Staff P stated there was a report that showed up on the computer when there has been no shower for 3 or 5 days. Staff P stated something must be wrong with the charting. Staff P stated when they see missed showers, then they update the documentation after interviewing the residents. Staff P stated Resident 33 gets at least one shower every week or twice a week, and there was a discrepancy in the documentation. Staff P could provide no further documentation. In an interview on 08/19/2025 at 2:23 PM, Staff S, Nurse's Aide Certified (NAC) stated they were directed to follow the shower schedule for that day. Staff S stated Resident 33 did not refuse care and they had not given them a bath before. Staff S stated there was no designated shower aide and so they had to give two to three showers a shift in addition to their work, and they sometimes could not get three done. <RESIDENT 98> Resident 98 admitted on [DATE] with diagnoses to include spinal stenosis (narrowing of bones in spine), left and right foot drop (inability to lift the foot) and lymphedema (swelling due to excess fluid in body tissue). Review of the admission MDS assessment, dated 08/01/2025, showed Resident 98 did not reject care. Review of the plan of care on 08/15/2025 showed Resident 98 was scheduled to have a shower every Monday and Thursday on evening shift. Review of Resident 98's documentation report for July 24th (Thursday) – August 20th (Wednesday) showed the resident received bathing on 07/31/2025 and 08/07/2025. In an observation on 08/13/2025 at 12:15 PM, Resident 98 was in bed and their hair was greasy. In an observation on 08/14/2025 at 1:15 PM Resident 98 was asleep in bed, their hair remained greasy. In an observation and interview on 08/20/2025 at 9:01 AM, Resident 98 was sitting on the side of their bed. The resident looked at their calendar and stated they were supposed to get baths on Mondays and Thursdays but did not get one on August 4th, 7th, 11th or 14th. They stated their last bath was 08/18/2025. They stated they asked every day for showers and had reported their missed bathing concern to Staff B, Director of Nursing Services (DNS). Resident 98 stated Staff B told them that it was not OK, and they would have their best staff give them a bath. The resident stated they just get baths because the aides told them they were too big to go into the shower room. The resident wiped a tear away and stated they had only had her their hair shampooed once since admit and that was not enough. <RESIDENT 82> Resident 82 admitted on [DATE] with diagnoses to include cancer. Review of the admission MDS dated [DATE], showed Resident 82 did not reject care. Review of the shower documentation report for July and August 2025 showed no showers or bathing occurred. In an interview on 08/19/2025 at 2:37 PM, Staff Q LPN/ Unit Manager stated showers were to be completed by the NACs on the floor. Staff Q stated they looked for alerts on the EMR dashboard if the showers were missed then they would follow up. Staff Q said they were aware of some concerns with showers. Staff Q stated the expectation was that showers were to be given twice a week. Staff Q stated if showers popped up on their alert, the resident had missed a week of showers and sometimes they were not documented. <RESIDENT 1> Resident 1 was admitted to room [ROOM NUMBER] bed A, in the facility on 07/29/2025, with diagnoses that included a history of stroke that affected the left upper side of body. In an interview and observation on 08/13/2025 at 10:28 AM, Resident 1 stated they had been admitted to the facility a couple of weeks ago and had not been given a shower since admission. Resident 1's hair was observed to be disheveled, and greasy. Review of the second-floor shower schedule document on 08/14/2025, showed room [ROOM NUMBER] bed A was scheduled to have a shower every Monday and Thursday on day shift. Review of Resident 1's documentation report for July 29th (Tuesday) – July 31st (Thursday) had no shower documented. Review of Resident 1's documentation report for August 1st – August 19th had no shower documented. In an interview on 08/18/2025 at 12:51 PM, Staff K, NAC stated they followed the schedule in the shower book. Staff K stated when a resident refused a shower they would reapproach and let the nurse know. Staff K was asked where the refusals were documented, and they stated they sometimes documented in the electronic medical record (EMR), but at times they would just let the nurse know. In an interview on 08/18/2025 at 1:45 PM, Staff M, NAC stated Resident 1 did not have a history of refusing care, and if they did, they would document that in the EMR. In an interview on 08/18/2025 at 1:38 PM, Staff N, LPN stated the facility did not have shower aids specifically for showers, the floor NACs were responsible for providing the showers. Staff N stated all showers and refusals should be in the EMR. In an interview on 08/19/2025 at 8:26 AM, Staff L, LPN/ Unit Manager stated the floor NACs were responsible for providing showers to the resident according to the shower schedule. In an interview on 08/19/2025 at 1:56 PM, Staff B, DNS stated it was their expectation that the staff were following and providing the showers as scheduled. Staff B stated if a resident had refused, they would expect the staff to communicate that so they would be able to resolve the issue. Staff B stated they were not aware that Resident 1 had received no showers since their admission. <RESIDENT 99> Resident 99 was admitted on [DATE] with diagnoses to include stroke, hemiplegia (paralysis to one side of the body), and contracture (permanent tightening of muscles which limits the normal movement of a body part) to left hand. During an observation and interview on 08/15/2025, at 8:55 AM, Resident 99 stated that they had a contracture on their left hand from their stroke. Resident 99 said they used to have a splint previously but had not had it in a while. The resident's left hand was observed with a contracture and without a splint applied. In an observation on 08/15/2025, at 9:45 AM and 1:03 PM, Resident 99 was observed with no splint to the left hand. In an observation and interview on 08/18/2025 at 08:57 AM, Resident 99 had a splint to their left hand. Resident stated that the splint was new today. In a record review of Resident 99's MDS dated [DATE], it was documented that they have impairment to one side and required substantial or were dependent for ADLs. In a record review of Resident 99's care plan dated 05/16/2025, it was documented that Resident 99 had a contracture to their left hand and was at risk of worsening contracture, pain and skin breakdown. The care plan directed the staff to apply a palm guard splint to left hand beginning 12/05/2024. In an interview on 08/19/2025 at 11:02 AM, Staff II, Restorative Aide/NAC, stated that resident 99 had a contracture to their left hand and should have had a splint on. They stated the resident used to have a splint. Staff II stated that the aides on the floor would be the ones to assist Resident 99 with splint application. Staff II stated that the splint they have on now was new. This is a repeat deficiency from 11/15/2025. Reference WAC: 388-97-1060(2) (a)(i) (c) (3) (d)

CONCERN (E)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the failed to ensure that 3 of 3 residents (Residents 12, 40 and 81) reviewed for pressure ulcers (PU), were provided interventions that were required for the prevention of a PU. This failure to implement pressure reducing interventions in accordance with physician's orders placed residents at risk for PU development, prolonged wound healing, and a diminished quality of life.Findings included .Review of the undated facility policy titled, Pressure Injury Prevention and Management, documented that the facility would promote the prevention of PU development, promote healing of exiting PU, and prevent development of additional PU. Preventative interventions included frequent assistance with repositioning, use of pressure reducing devices, and encouragement for adequate nutrition. Treatment protocols outlined in the policy documented that treatments would be ordered by the physician and may include medications to promote healing, special wound dressings, use of supportive devices, referrals to therapy and dietary. The care plan section of the policy documented that a resident centered care plan would be developed and implemented to address the resident's risk for development of a PU and to promote healing if the resident had an existing PU. The NPUAP (2017), Educational and Clinical Resources and PI Prevention Points, advises to inspect the skin at least daily for signs of pressure injury, assess pressure points, reposition all individuals at risk for pressure injury based on support surfaces and individual preference.The Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed:- A stage II PI (ulcer) was described a partial thickness loss of the skin;- A stage III PI (ulcer) was described a full thickness loss of the skin;- An unstageable PI (ulcer) was a full thickness skin and tissue loss was obscured by slough (non-viable tissue) or eschar (dead or devitalized tissue); and- A Deep Tissue Injury (DTI) was described as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration. <RESIDENT 12> Resident 12 readmitted to the facility on [DATE] with diagnoses to include heart failure, right leg pain, diabetes, and peripheral vascular disease (blood circulation disorder). In an observation on 08/13/2025 at 1:11 PM, Resident 12 was observed sitting in their wheelchair and a heel protector boot was placed on a chair in the room. In an observation on 08/14/2025 at 2:44 PM, Resident 12 was observed lying flat in bed with both heels directly on the bed with no heel protector on. A wound was observed to their right heel that appeared to be black and dry, without drainage, and no dressing on. In an observation 08/15/2025 at 11:08 AM, Resident 12 was observed lying on their back in bed with both heels directly on the bed. At 2:23 PM, Resident 12 was on their back in bed, both heels were on the bed without a heel protector boot on. In an observation on 08/18/2025 at 9:03 AM, Resident 12 was observed to be in bed with both heels directly on the bed and their heel protector boot was not on. At 1:35 PM, Resident 12 was in their wheelchair with non-skid socks on without footrests attached and no heel protector on. In an observation and interview on 08/19/2025 at 10:12 AM, the contracted wound provider came to assess and change Resident's 12 right heel wound dressing. Collateral Contact (CC) 3, Physician Assistant Certified (PA-C) and Staff X, Licensed Practical Nurse (LPN) performed wound care. The right heel wound was observed to be black with a new open area. CC3 stated the heel protector boot should have been on while Resident 12 was in bed. Review of Resident 12's progress note dated 05/02/2025 at 12:59 PM, documented a blood blister was present on the right heel. Review of Resident 12's order dated 05/02/2025, directed staff to apply skin prep (a medication wipe that helps protect the skin barrier) to right inner heel blister two times a day and to ensure both legs were separated and floated to reduce pressure. Review of a skin observation assessment dated [DATE], by Staff Y, LPN showed no documentation of any skin conditions. The first skin observation assessment to document a ‘wound' to the right heel was dated 06/24/2025. Review of records for Resident 12's care plan dated 06/12/2025 documented a right medial heel/right distal foot deep tissue pressure injury (DTPI). The care plan also documented that the resident's skin impairment would heal and resolve within the review period. There was no documentation related to the heel protector boot. Review of Resident 12's progress notes on 05/28/2025, at 5:20 PM, CC 3, PA-C from the wound care provider, documented their first evaluation of the right heel wound. CC 3 documented they were asked to evaluate R (right) heel wound. CC 3 documented the wound was discovered over the last week. CC3 documented the current interventions included offloading and repositioning, and tolerance of treatment was reported to be good. CC3 documented the wound classification was a DTPI. On 08/05/2025, at 7:31 PM, CC3 documented that the wound severity was now unstageable. In an interview on 08/19/2025, at 10:58 AM, with Staff AA, Nursing Assistant Certified (NAC), stated that Resident 12 was to wear their boot while in bed. When asked how do they know when the boot was to be on, Staff AA stated the nurse told them and confirmed it was not in the care plan or Kardex (a nursing worksheet that includes daily care schedules/patient specific care needs). In an interview on 08/19/2025, at 1:08 PM, with Staff L, LPN/Unit Manager (UM) was asked who was responsible for the resident's care planning and both stated it was an interdisciplinary team process. When questioned about Resident 12's heel protector boot, Staff L confirmed that it was not in the care plan or Kardex. <RESIDENT 40> Resident 40 was admitted to the facility on [DATE] with diagnoses that included diabetes and schwannomatosis (rare genetic disorder where non-cancerous tumors form along the spinal cord causing pain, numbness and weakness of the entire body). Review of Quarterly MDS dated [DATE] documented the resident was dependent on staff for all activities of daily living, had no active pressure ulcers at the time of the assessment. Review of Resident 40's assessment titled, “Wound Evaluation Weekly,” dated 07/30/2025 documented the resident had a new pressure ulcer injury to their sacrum area that measured 1 centimeter (cm) x 0.5 cm x 0.1 cm. Review of Resident 40's physician orders on 08/15/2025 showed documentation of a preventive treatment of topical ointment to be applied to the resident's coccyx area three times a day to prevent breakdown to that area beginning 05/05/2025, there were no new orders put in place related to the new sacrum wound. Review of Resident 40's care plan on 08/15/2025, that documented revised focus area for skin impairments on 08/07/2025 that documented the resident had a new pressure ulcer to their sacrum area. No new goals of care or interventions were put in place related to the new sacrum wound. Review of Resident 40's progress notes from 07/30/2025 through 08/15/2025 showed there was no documentation that the resident had a new sacrum wound, that the physician had been notified, no new orders implemented and no monitoring of the wound. In an observation and interview on 08/15/2025 at 9:41 AM, Staff T, Registered Nurse (RN) stated they were going to assess the resident's sacrum area. Staff T stated they were not aware the resident had a potential pressure ulcer to their sacrum. Resident 40's sacrum was observed to be non-blanchable, and slightly pink, there was no open area during the observation. In an interview on 08/18/2025 at 12:51 PM, Staff GG, NAC stated that they are educated to notify the nurse if they find an open area on any resident. Staff GG stated the wound nurse was in the facility every Tuesday to round on residents. In an interview on 08/18/2025 at 1:38 PM, Staff N, LPN stated the expectation for new skin concerns were the floor nurse would start an incident report, and inform the nurse manager or DNS. Staff N stated they would usually notify the wound nurse and let the provider know. Staff N stated they would usually implement a treatment plan to start with then place the resident on alert monitoring for three days. Staff N stated Resident 40 had an open area to their sacrum, but stated they thought the wound had closed. In an interview on 08/18/2025 at 1:45 PM, Staff M, NAC stated Resident 40 was fully dependent on staff for all cares. Staff M was not aware of any open area to Resident 40's sacrum. In an interview on 08/19/2025 at 8:26 AM, Staff L stated when a resident had a new skin concern that required wound care, they would be the one to notify the wound nurse. Staff L stated the licensed staff would usually start a treatment for the area, notify the provider, and the wound should be monitored for at least three days. Staff L was asked if the skin/wound process was completed for Resident 40's wound documented on 07/30/2025. Staff L stated the resident had continuous wounds that open and close all the time. Staff L was unable to provide any documentation that the resident was placed on alert, a treatment was set in place, that the wound nurse was notified, or that the plan of care was revised. In an interview on 08/19/2025 at 1:56 PM, Staff B, DNS stated that their expectation at the facility for all skin concerns was the licensed staff were to notify the Unit Manager, and then, start a treatment of the wound, document in the medical record, and report to the provider. Staff B was not aware that Resident 40 had a reported open area to their sacrum on 07/30/2025. Staff B could not provide any further information for the wound management of Resident 40. <RESIDENT 81> Resident 81 admitted on [DATE] with diagnoses to include severe protein-calorie malnutrition and chronic lung disease. Review of the admission orders on 08/14/2025 showed that Resident 81 received oxygen 2 to 4 liters via nasal cannula (flexible tubing that goes around your head into your nose to deliver supplemental oxygen) every shift related to chronic respiratory failure. Review of the admission MDS submitted 08/03/2025, showed Resident 81 weight 62 pounds and had an unhealed pressure ulcer/injury. Review of Resident 81's admission nursing evaluation on 07/23/2025, showed Resident 81 had a stage I sacral pressure ulcer (PU) measuring 9 cm by 7 cm. Review of the admission Braden scale (assessment to determine risk for pressure ulcer development) dated 07/23/2025, showed the resident was a high risk for pressure ulcer development. Review of the nutrition Care Area assessment dated [DATE], showed the resident had a body mass index (BMI) of 10.6 which indicated significantly underweight status, a serious health issue that compromised immune system, and increased risk of disease and fatigue. Review of a weekly skin observation progress note on 08/03/2025 at 11:28 PM, documented a pressure ulcer to coccyx (tailbone) measured 1.1 cm in length and 0.5 cm in width with reddened skin around the pressure ulcer. Review of the skin care plan developed on 07/24/2025, showed the resident had a skin impairment of an unstageable pressure injury to their coccyx. The goal was for the resident not to have any further skin impairment and for the skin impairment to heal. The interventions directed staff to observe for signs and symptoms of infection, wound reviews as indicated, treatment per Treatment Administration Record, weekly skin observation and to keep the skin clean and dry as possible. Review of the respiratory care plan dated 07/23/2025, directed staff to provide oxygen 2 to 4 liters per minute. The care plan did not include an intervention for padding the nasal canula to prevent pressure ulcers. Review of the care plan titled at risk for pressure ulcer dated 07/24/2025, included Resident 81 was at risk for pressure ulcers and skin impairment related to chronic health conditions, end of life stage, immobility, incontinence, protein calorie or vitamin malnutrition. The care plan did not include the pressure ulcer to the sacrum or an intervention for padding the nasal canula to prevent pressure ulcers. Review of the weekly skin assessments showed Resident 81 had the following weekly skin integrity data collection assessments: -07/25/2025 no skin issues noted, -08/01/2025 no skin check was documented in the progress notes, -08/08/2025 no skin check was documented in the progress notes, -08/15/2025 no skin check was documented in the progress notes. Review of a progress note dated 08/19/2025 at 11:49 AM, showed Resident 81's skin was observed, and no skin conditions were noted. In an interview and observation on 08/19/2025 at 12:48 PM, Resident 81 was in bed, they winced and readjusted off their bottom and said the sore on their bottom hurt and they needed a pain pill. Below their oxygen tubing on the left side of their cheek was an indented red line approximately 2 cm in length. The residents touched their left cheek under the tubing and stated they wanted a mirror to see the area because they could feel something there. They stated they were unable to get up to the sink to look in the mirror because they could not walk. In an interview on 08/19/2025 at 1:38 PM, Staff PP, LPN was asked about their documentation that showed no skin issues for Resident 81 at 11:49 AM that day despite the resident was observed to have a red area linear mark/indentation consistent with pressure under their 02 tubing. Staff PP was notified that the resident was complaining of pain to their left cheek where there was an indentation, and they would like to see a mirror. Staff PP stated they would take a look at the resident and fix their charting. At 1:45 PM, Staff PP walked by and showed a package of 02 tubing padding and stated they were going to go add this to Resident 81's 02 tubing. At 1:57 PM Staff PP stated they went and assessed Resident 81's skin and there was a wound to their left cheek that was red and not blanchable. Staff PP stated they had seen this happen before with continuous oxygen. In an interview and observation on 08/20/2025 at 9:00 AM, Resident 81 was sitting up in bed and their 02 tubing was padded to protect their skin. Resident 81 said their left cheek hurt. They pushed on the left cheek area below the oxygen tubing that measured 1 cm, and it did not blanch (skin did not lighten under pressure, signaling a pressure sore). Review of the July and August 2025 Nursing Assistant (NA) documentation showed no documentation the Resident 81 was repositioned. In an interview on 08/20/2025 at 9:52 AM Staff B, DNS stated they were aware of pressure ulcer issues. Staff B stated two weeks ago they started having weekly skin and nutrition meetings to look at high risk residents and address issues right away. Nursing documentation did not contain evidence of ongoing assessment, implementation of interventions and re-evaluation of interventions consistent with professional standards. The nursing documentation also did not reflect a proactive approach to skin management. Reference WAC 388-97-1060(3)(b)

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure 3 of 6 medication carts (Yellow, Blue and Pink Carts) and 1 of 2 medication rooms (second floor medication room) had unexpired medications and/or biologicals, reviewed for medication storage. These failures placed residents at risk of receiving compromised or ineffective medications and biologicals. Findings included .Review of the undated facility policy titled, Medication Storage, showed the facility shall not use discontinued, outdate, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.Review of the undated facility policy titled, Self-Administration of Medications and Treatments, showed residents will be assessed to determine whether self-administering medications and or treatment is clinically appropriate for the resident. Self-administered medications and or treatments supplies will be stored in a safe and secure place, not accessible to other residents. <MEDICATION SECURITY> In an observation on 08/13/2025 at 11:04 AM, the yellow med cart was unlocked. Staff DD, Registered Nurse (RN) was at the nurse's station without direct visualization of the cart. Staff DD noticed after several minutes their medication cart had been unlocked, they walked over and locked it. At 11:07 AM Staff DD acknowledged they had left their cart unlocked and they stated medication carts were supposed to be locked. In an observation on 08/14/2025 at 8:54 AM, Resident 33 was in their bed. There was a prescription ointment and artificial tears eye drops on their overbed table. In an observation on 08/15/2025 at 8:36 AM, while walking down the 120 hall there was a pink round pill on the carpet in the middle of the hall next to the nurse's cart. Staff SS, RN was informed there was a pill on the carpet. Staff SS stated Oh and bent to retrieve it. In an observation on 08/15/2025 at 1:08 PM, the medication cart in the 120 hall was unlocked. There were no staff or residents present. This surveyor observed the cart, then went to the nurse's station and was told the nurse was on their break. At 1:16 PM, Staff SS, RN noticed their cart was unlocked and they locked it. Staff SS stated their medication cart should have been locked. At 1:32 PM, a vial of Tuberculin solution was left unattended and unsecured on top of the 120-hall medication cart. At 1:41 PM, Staff SS returned to their cart and acknowledged the Tuberculin solution was on top of the cart. Staff SS stated the vial should have been secured in their medication cart. In subsequent observations on 08/15/2025 at 1:21 PM, 08/18/2025 at 11:06 AM and 2:35 PM, 08/19/2025 at 1:00 PM the prescription ointment and eye drops remained at Resident 33's bedside. In an interview on 08/18/2025 at 2:41 PM Collateral Contact (CC) 1 stated they were the pharmacy consultant for the facility and were there on a quarterly audit removing all the expired medications from the carts there. CC 1 stated they had hoped to complete the audit before survey. CC 1 had a tablet with multiple expired medications written down for their report to provide to the facility. In an interview on 08/19/2025 at 11:08 AM, Staff P, LPN/Weekend Supervisor with Staff B, Director of Nursing Services (DNS) present, stated they were disappointed there were observations of unlocked medication carts with Staff DD and Staff SS. Staff P stated the expectation was that medication carts should be locked and medications secured. Staff P stated this was very serious and commented it was the agency nurses who failed to secure their medications. They stated that every time a new nurse started, they would show them a sign they displayed that stated PLEASE LOCK CART. Staff P was informed of Resident 33's prescription ointment and eye drop at their bedside. Staff P stated there had been no self-medication assessment (SMP) completed. Staff P stated the residents spouse snuck things in for them. Staff P stated that everyone knows they have to be assessed for SMP, an order from the doctor for the medications at the bedside and the medications needed to be secured. In an interview on 08/19/2025 at 2:37 PM, Staff Q, LPN/Unit Manager stated they were not aware of Resident 33 having medications at bedside. Staff Q stated the resident was very aware of their medications and what they take, and the spouse would sometimes bring in supplies from home. In an observation on 08/20/2025 at 8:50 AM, Resident 33 was in bed. There were eye drops on the overbed table. The nightstand to the left of their bed had two topical creams present. In an interview on 08/20/2025 at 9:52 AM, Staff B, DNS was informed of the observations of the unlocked med carts, unsecured medications on carts and continued observation since 08/14/2025 of resident 33's medications at bedside as well as expired medications. Staff B stated the residents spouse brings in items from home and they would provide education to them on not bringing medications in. Staff B stated their expectation was that the med carts would be locked and there were no expired medications in the carts or med rooms. <MEDICATION CARTS> In an observation on 08/14/2025 at 5:16 PM, reviewed the Yellow Medication Cart on the first floor with Staff LL, Registered Nurse (RN). The cart included one bottle of Narcan (medication that reverses opioid overdose) spray with expiration date 06/28/2025, one bottle of Calcium tablets and a bottle of Vitamin D with expiration date 05/2025, two bottles of Aspirin with expiration date 04/2025, one undated bottle of iron. In an interview on 08/14/2025 at 5:41 PM, Staff B, Director of Nursing Services, confirmed there was no date on the bottle of iron and confirmed other medications were expired. Staff B stated all those medications should be disposed of. In an observation and interview on 08/15/2025 at 10:03 AM, reviewed the Blue Medication Cart on the second floor with Staff O, RN. There were 16 laxative suppositories with expiration date 01/2025 found in the cart. Staff O stated the 16 suppositories were expired and would be disposed of. In an observation and interview on 08/15/2025 at 10:14 AM, reviewed the Pink Medication Cart with Staff BB, RN. One bottle of iron with no expiration date, one bottle of Dakin's solution (medication cleansing solution) with an expiration date 07/2025, one bottle of eye drop solution with opened date 07/12/2025 were found. Staff BB confirmed the bottle of iron had no expiration date and would be disposed with other expired medications. Staff BB stated the eye drops could be used for 90 days after they had been opened per the consulting pharmacy recommendations. In an interview on 08/19/2025 at 11:34 AM, a Collateral Contact (CC)1, contracted Pharmacy Consultant Nurse, stated eye drops were good for 28 days after they are opened. In a follow up email from CC1, confirmed eye drops were good for 28 to 30 days per their research. The eye drops in the medication cart opened on 07/12/2025 were expired. <MEDICATION STORAGE ROOM> In an observation and interview on 08/14/2025 at 2:54 PM, the medication storage room on the second floor with Staff L, LPN/Unit Manager found two bottles of Vitamin E with expiration date 01/2025, one bottle of Vitamin D with expiration date 05/2025, one bottle of Aspirin with expiration date 06/2025, one bottle of Prenatal vitamins with expiration date 01/2025, one bottle of liquid multi-vitamin with expiration date 06/2025 were found in the medication room. Staff L stated those expired medications were not supposed to be in the medication room and would be disposed of. In an interview on 08/19/2025 at 2:53PM, Staff B, DNS stated they expected no expired medication in the medication storage rooms and medication carts. This is a repeat deficiency from 11/15/2024. Reference WAC: 388-97-1300(2)

CONCERN (E)

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

Dental Services (Tag F0791)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dental services were provided for 6 of 6 Medicaid residents (Residents 3, 12, 79, 81, 85, and 101) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to wear ill-fitting dentures. These failures placed residents at risk of difficulty chewing, oral pain, decreased self-image and diminished quality of life. Findings included .<RESIDENT 81> Resident 81 admitted on [DATE] with diagnoses to include severe protein-calorie malnutrition. Review of the admission transfer orders from the hospital on [DATE] directed staff to weigh Resident 81 daily and provide a pureed diet and nutritional supplements daily. Review of the initial nutritional at risk assessment dated [DATE], showed the diet was listed as regular texture rather than the ordered pureed texture. Review of the admission Minimum Data Set (MDS, an assessment tool) dated 07/29/2025, showed the resident had no teeth. Review of the nutrition Care Area Assessment (CAA) dated 07/29/2025, showed the resident had a body mass index (BMI) of 10.6 which indicated significantly underweight status, a serious health issues that compromised immune system and increased risk of disease and fatigue. The CAA noted that the resident had poor oral intake. Per Registered Dietician notes, Resident 81 reported feeling okay with fair appetite and denied any gastrointestinal symptoms or issues with chewing/swallowing. The note stated the resident had poor dentition and preferred meats and vegetables to be cut into small pieces. They reported mild stomach discomfort. Review of the nutritional care plan dated 07/23/2025 showed the resident was at nutritional risk due to advanced age, goals of care, underweight BMI and past medical history. The care plan included only one intervention for a RD consult. The care plan did not include the residents' goals, food preferences, missing dentures, or other interventions. Review of a Hospice handwritten note dated 07/28/25, documented Resident 81 needed their teeth which they had communicated to their nurse. Review of the progress note on 08/04/2025 at 12:00 AM, from Collateral Contact (CC) 2, Physician Assistant showed the resident was underweight with severe protein/calorie malnutrition and sporadic meal intakes. CC2 documented the resident appeared to have lost their dentures and they were unable to tolerate the regular texture diet. CC 2 downgraded the diet to mechanical soft. In an interview and observation on 8/13/2025 at 1:57 PM, Resident 81 stated they ate lunch, and the food was ok, but it was harder to eat without any teeth. The resident stated they lost their dentures someplace and they need new dentures. The resident stated their other dentures were in bad shape and they needed new ones as those were cutting into their gums. The resident stated they told the nurses and also hospice. In an interview and observation on 8/20/2025 at 9:00 AM, Resident 81 was sitting up in bed, and stated they could not eat the ham as they had no teeth. The resident said they loved ham but could not eat it. The resident stated they still did not have dentures, and they talked to the hospice nurse about it. <RESIDENT 12> Resident 12 was admitted on [DATE]. In a record review of Resident 12's admission MDS, dated [DATE], it was documented that they had obvious or likely cavity or broken natural teeth. In an observation on 08/14/2025 at 9:37 AM, Resident 12's teeth appeared to have both missing and discolored teeth. In a review of Resident 12's care plan on 08/18/2025, documentation showed Resident 12 has oral/dental health problems related to obvious or likely cavity or broken natural teeth. Care plan intervention was to refer to a dentist as indicated. In an interview on 08/19/2025, at 1:08 PM, with Staff H, Social Services stated that they offered dental services to every resident for routine services. When in facility dental services occur, the provider will document a report and the results should go into the resident's medical record. Staff H confirmed no documentation in Resident 12's clinical record showed no documentation of any dental services being offered, refused, or completed. Staff H stated the in house dental provider was on site that day and that Resident 12 should be on the list for today. Confirmed with Collateral Contact (CC 6),dental provider on 08/19/2025 at 1:33 PM, that Resident 12 was not on the dental services list for that day. <RESIDENT 85> Resident 85 admitted to the facility on [DATE]. In an interview on 08/13/2025 at 10:56 AM, Resident 85 stated they wanted dentures, they only had 3 teeth on top and would have to go to a hospital for extractions in order to get dentures. Review of a document from outside dental provider dated 02/17/2025 showed Resident 85 would like extractions. In an interview and record review on 08/15/2025 at 1:36 PM, Staff L, LPN/Unit Manager (UM) stated social services was responsible for scheduling and following up for dental appointments. Staff L reviewed the documents from the contracted dental provider dated 02/17/2025, and stated the resident was seen at the facility and they do not extract teeth at the facility. Staff L stated after evaluating the resident the dental provider would give the form to social services. In an interview and record review on 08/15/2025 at 1:42 PM, Staff H, Social Services, stated they were responsible for scheduling dental appointments for residents and reviewed the dental services visit report. Staff H reviewed the contracted dental visit form for Resident 85, dated 02/17/2025 and stated they had recommended the resident for a few extractions. Staff H stated Resident 85 would have to be sent to outside hospital for the extractions due to insurance and need for a mechanical life. Staff H stated Resident 85 was on a waiting list which could take up to six months and the hospital would contact them when an appointment became available. Staff H stated they would follow up with the hospital monthly until an appointment was scheduled and would document in the resident record. Staff H stated the resident was recently seen by contracted dental provider on 08/04/2025 and a referral was sent to the local hospital a couple of days later. Staff H reviewed the resident's medical record and was not able to find documentation of communication with the local hospital or dental provider. Staff H stated Resident 85 would refuse to go out of the facility for extractions but they would schedule the appointment. In an interview on 08/18/2025 at 1:12 PM, Staff H stated they were unable to find documentation of the contracted dental visit on 08/04/2025 and would check with medical records. No further information was provided. In an interview on 08/19/2025 at 3:51 PM, Resident 85 stated they had decided to get dentures and had agreed to go out of the facility for extractions. The resident stated that Staff H spoke with them that morning and stated they would try and set up an appointment for extractions and would let them know when the appointment was scheduled. In an interview on 08/19/2025 at 3:50 PM, Staff B, Director of Nursing Services (DNS) stated social services was responsible for following up on referrals and scheduling appointments for dental services. Staff B stated the facility is trying to improve the system for scheduling appointments and this was a focus. Staff B stated documents from appointments should be uploaded into the resident's medical record. <RESIDENT 79> Resident 79 admitted [DATE] with full upper and lower dentures. Review of the care plan on 08/14/2025 showed the resident had full upper and lower dentures. Review of a dental visit note dated 02/17/2025, stated the resident had been missing their lower denture for several months. The follow up recommendation was to have Resident 79's upper denture re-lined, and to have the lower denture replaced. In an interview on 08/13/2025 at 1:51 PM, Resident 79 stated they were missing their lower denture for quite a while and wanted to have it replaced. Resident 79 stated the denture clinic should still have the molds. Resident 79 stated it went missing here at the facility, but they did not know what, if anything, was being done to get it replaced. Resident 79 stated it was hard for them to eat without their lower teeth. <RESIDENT 101> Resident 101 admitted in February of 2023 and was alert and oriented. In an interview on 08/14/2025 at 9:06 AM, Resident 101 stated that after two years they finally got someone to clean their teeth. Resident 101 stated they had a molar with a crack in it and they needed to get the crack fixed. Resident 101 stated they have not heard about any follow up, they stated it was painful to chew on hard things, so they have to avoid that side. Resident 101 stated they were already missing some teeth so they don't want to lose any more. Review of a dental provider note dated 05/27/2025, showed Resident 101 was identified as having a broken tooth. The recommendation was highlighted stating “Refer to dentist.” Review of Resident 101's record showed a progress note dated 05/28/2025 at 10:53 AM from Staff H, Social Services which stated the resident was seen by the Dental Hygienist that day. The resident had their teeth cleaned and wanted to be referred to an outside dentist for a broken tooth, will make a follow up dental appointment. In an interview on 08/18/2025 at 1:24 PM, Staff H, Social Services, confirmed that they were responsible for making dental referrals and appointments, and Staff H stated they had not been aware of Resident 79 missing their lower denture, so no referrals had been started and no appointments had been made. Staff H stated they would make an appointment for Resident 79 with the facility denturist. Staff H stated following visits from the dental providers, the providers would leave the notes and they would make them aware of residents that needed further follow up appointments. Staff H stated that they had sent a referral out for Resident 101, and they were on a waiting list. Staff H stated it often could take 6 months to get appointments for Medicaid residents. Resident 101's dental appointment had been in February (6 months ago) and Staff H was asked about the status of that referral. Staff H did not have any documentation that a referral was sent, any follow up communication or status of the referral. <RESIDENT 3> Resident 3 admitted to the facility on [DATE]. In an interview and observation on 08/18/2025 at 11:43 AM, Resident 3 stated they had broken, missing and loose teeth since admission and they had not been seen by a dentist. Resident 3 stated they had front teeth pain. Resident 3 stated it was hard to chew food because of their teeth. Resident 3 was observed with broken upper front teeth, missing upper and lower back teeth, and loose lower front teeth. In an interview on 08/19/2025 at 9:26 AM, Resident 3 stated they did not have toothbrushes and did not brush their teeth. Review of Resident 3's admission nursing collection tool on 03/17/2025 at 5:29 PM, documented the resident had broken or loose teeth. Review of Resident 3's admission MDS on 03/23/2025, showed Resident 3 had obvious or like cavities or broken natural teeth, inflamed or bleeding gums or loose natural teeth, and mouth or facial pain. Review of Resident 3's clinical record on 08/15/2025, showed no documentation the resident was referred to a dentist, ever seen by a dentist or offered assistance in arranging dental services. In an observation, interview and record review on 08/19/2025 at 9:43 AM, Staff EE, Nursing Assistant Certified (NAC), stated Resident 3 required set up assistant on oral care. Staff EE could not locate where the resident's oral care items were. Staff EE stated they obtained the oral care instruction from the Kardex (a tool used to provide direction on how to care for a resident). Review of Resident 3's Kardex with Staff EE, verified there was no oral care instruction. Staff EE stated they felt it was difficult to take care of residents when the care instructions were not specific or missing in the Kardex. In an interview on 08/19/2025 at 1:55 PM, Staff Q, LPN/ UM, stated the facility in house dental hygienist visited residents quarterly and the social services department was in charge of enrolling residents and preparing the list for the dental visit. Staff Q stated the facility was supposed to address residents' dental concerns upon admission and social services were responsible for any outside dentist referral and transportation arrangement if residents had a toothache. Staff Q stated Resident 3 had dental concerns and when Resident 3 transferred to a new unit, they informed the unit social worker (Staff H) that Resident 3 required dental services. Staff Q stated they were not aware Resident 3 had a toothache when the resident stayed on their unit and why Resident 3 had not been seen by a dentist. In a joint interview on 08/18/2025 at 2:21 PM, Staff L, LPN/ UM, and Staff H, Social Services, stated they were both not aware of Resident 3's dental concerns and not sure why the resident was not seen by a dentist since admission. In an interview on 08/19/2025 at 11:14 AM, Collateral Contact (CC) 6, Dental Hygienist, stated they provided in house dental visits every three months and Resident 3 was just enrolled that day on their dental services. In a follow up interview on 08/19/2025 at 1:21 PM, CC6 stated Resident 3's had not brushed their teeth and the resident had teeth bone loss which caused pain, missing, broken and loose teeth and gum disease. In an interview on 08/19/2025 at 2:44 PM, Staff L stated the Kardex should include oral care instructions so nurse aides would follow and assist Resident 3 on oral care. Staff L stated they did not know why it was missing. In an interview on 08/19/2025 at 2:53 PM, Staff B, DNS, stated they expected staff to identify oral and dental concerns and referred to dentists as soon as possible. In an interview on 08/20/2025 at 9:52 AM, dental concerns for Resident's 3, 12, 79, 81, 85 and 101 were discussed with Staff A, Administrator and Staff B, DNS. Staff A stated they were not aware of any dental concerns except with Resident 101.Staff A stated they are working on helping those residents that want to use their own dentist and arranging transportation which was cumbersome. Staff A stated their expectation was that they would get a plan in place within the three-day window for dental emergencies. They stated they could not always get the dental appointments at that time so they would come up with an alternate plan. Staff A stated they offered dental visits every three to six months for cleaning and identification of dental issues. Reference WAC: 388-97-1060(1)(3)(j)(vii)

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and interview, the facility failed to store food for residents in accordance with professional standards in 1 of 2 nourishment refrigerators (second floor) reviewed for food service safety. The failure to maintain safe refrigerator temperatures placed residents at risk of foodborne illness. Findings included .In an observation on 08/15/2025 at 9:39 AM, the second-floor nourishment refrigerator door was found to be ajar and the thermometer on the inside of the refrigerator door read 55 degrees. The refrigerator was observed to contain cheese, yogurts, milk, puddings, sandwiches, pitchers of fruit juices and a plastic container of sushi labeled 08/13/2025 and labeled with the name of a facility resident. The temperature log was already signed for the day (08/15/2025) with no time, and the temperature was documented as 39 degrees on the log. In a follow up observation and interview on 08/15/2025 at 10:52 AM, the second-floor nourishment refrigerator door was again found to be ajar and the temperature on the thermometer inside the door read 58 degrees. Items inside the fridge did not feel cold to touch. Staff K, Certified Nursing Assistant, was observed to enter the nourishment room. Staff K was on the way out of the nourishment room, passing the refrigerator on the way out. Staff K was asked if they had noted any issues with the nourishment refrigerator, to which Staff K stated “no.” Staff K was asked if they had noticed any issue with door not being completely closed or any issue with the refrigerator not being cold enough and Staff K stated “no, I have not noticed that.” It was observed that the refrigerator door was now closed. In a third observation on 08/15/2025 at 11:57 AM, the second-floor nourishment refrigerator door was noted to be closed, and the temperature had decreased but still read 48 degrees. In an observation and interview on 08/15/2025 at 12:02 PM, the refrigerator was noted to be slightly open, with no staff having been observed to go into the room since Staff K. Staff J, Staffing Coordinator, was standing near the door to the nourishment room and observed the refrigerator and the thermometer inside the door which was reading 50 degrees. Staff J reviewed the temperature logs and stated they would call maintenance to look at the refrigerator. In an interview on 08/19/2025 at 2:20 PM, Staff A, Administrator, stated that the seal on the refrigerator was found to be broken. The entire refrigerator was replaced and the food items had been removed. Staff A stated the expectation was that staff would report faulty equipment right away. Refer to WAC 388-97-1100 (3)

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**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 residents' records were complete, accurate, and accessible for 2 of 2 residents (Residents 9 and 85) reviewed for physician visits, 1 of 5 residents (Resident 72) reviewed for unnecessary medications, and 1 of 3 residents (Resident 82) for hospitalizations. The facility failed to ensure the residents' medical records were complete and accurate which placed the residents at risk for medical complications, unmet care needs, and diminished quality of life.Findings included .According to the facility's Transfer and Discharge policy, dated 10/01/2021, nursing services and/or social services are responsible for completing the discharge note in the medical record.In a review of facility policy, dated 10/01/2021, titled, Weight Assessment and Intervention, documented that weights will be recorded in the resident's medical record. <RESIDENT 82> Review of the progress note dated 08/14/2025 at 11:14 AM, documented Resident 82 returned from the hospital at approximately 11:00 AM after being sent to the hospital last night due to coffee ground emesis (a serious symptom of blood in vomit). Review of the progress notes on 08/13/2025 showed there was no documentation the resident had been transferred to the hospital, the physician and family were notified and that a report was given to the receiving hospital for continuity of care. In an interview on 08/19/2025 at 11:27 AM, Staff P, Licensed Practical Nurse/Weekend Manager confirmed Resident 82's medical record did not include any documentation the resident was sent to the hospital on [DATE]. Staff P stated social services should document to the discharge. Staff P stated their expectation was that the nurse who sends the resident out to the hospital needed to document why they were sent out, family and physician notification in the progress notes and obtain the bed hold and provide the notice of discharge paperwork to the resident or their responsible party. Review of the clinical record on 08/20/2025 showed there were no hospital records from the hospitalization on 08/13/2025 in the clinical record. In an interview on 08/20/2025, at 9:52 AM Staff A, Administrator stated the nurses need to make a progress note about why the resident was sent out, and also about the physician and family notification. <RESIDENT 85> Resident 85 admitted to the facility on [DATE]. In an interview on 08/13/2025 at 10:56 AM, Resident 85 stated they wanted dentures, and would have to go to a hospital to get the teeth extracted in order to get dentures. Review of a document from the contracted dental clinic, dated 02/17/2025, showed Resident 85 would like extractions. In an interview and record review on 08/15/2025 at 1:42 PM, Staff H, Social Services, stated they were responsible for scheduling dental appointments for residents. Staff H stated that Resident 85 would have to be sent to the hospital for the extractions and was on a waiting list which could take up to six months. Staff H stated the hospital would contact them when an appointment became available and they would follow up monthly and document in the resident record. Staff H stated the resident was recently seen by contracted dental clinic on 08/04/2025 and a referral was sent to the hospital a couple of days later. Staff H reviewed the resident's medical record and was not able to find documentation of communication with hospital or documentation of the contracted dental appointment from 08/04/2025. Staff H stated they would look for the information and provide if found. In an interview on 08/18/2025 at 1:12 PM, Staff H stated they were unable to find documentation of the contracted dental visit from 08/04/2025 or documentation of attempts to schedule an appointment for extractions for Resident. Staff H stated they would check with medical records. No further information was provided. In an interview on 08/19/2025 at 3:50 PM, Staff B, Director of Nursing Services (DNS) stated social services was responsible for following up on referrals and scheduling appointments for dental services. Staff B stated the facility is trying to improve the system for scheduling appointments and this was a focus. Staff B stated documents from appointments should be uploaded into the resident's medical record. <RESIDENT 72> Resident 72 was admitted to the facility on [DATE]. In a record review of Resident 72's orders, an physician order directed staff to “weigh on admission, weekly times 3, then monthly,” was started on 06/25/2025. In a review of the resident's weight, there was a weight documented on 06/25/2025 and 08/08/2025. In a review of Resident 72's July 2025 medication administration record (MAR), a weight was ordered for 07/03/2025 and was documented “NA.” A weight was ordered for 07/10/2025 and was blank in the MAR. In an interview on 08/20/2025, 9:15 AM, Staff BB, Registered Nurse confirmed that Resident 72 was missing documented weights and the physician's orders were not being followed. <RESIDENT 9> Resident 9 was admitted to the facility on [DATE] with diagnoses to include obstructive uropathy (blockage of the urinary tract), kidney stones, and quadriplegia (unable to move all limbs). Review of Resident 9's physician orders showed an active order for a urinary catheter (tube inserted into the body to drain fluids) with a start date of 06/14/2025. Review of Resident 9's care plan on 08/13/2025 showed a focus dated 07/16/2025 that the resident required a urinary catheter related to their obstructive uropathy. Interventions included changing the catheter per the physician orders, empty as needed, maintain catheter anchor, maintain catheter privacy bag, and enhanced barrier precautions for direct care. In an observation on 08/13/2025 at 1:35 PM, Resident 9 was observed to not have a urinary catheter in place. In an interview on 08/13/2025 at 1:37 PM, Staff T, RN stated that the resident previously had a catheter, but did not now and they were not aware of when or why it was removed. In a review of Resident 9's medical record on 08/14/2025, showed no record of removal or discontinuation of their urinary catheter. In an interview on 08/19/2025 at 8:26 AM, Staff L, Licensed Practical Nurse (LPN)/ Unit Manager stated that when a resident was seen by a provider outside of the facility they will return with after visit summary (AVS) for the staff to review and then medical records would upload it into the medical record. Staff L stated that if they do not receive that information, they will reach out to the provider, or the medical records staff member will obtain that information. In a follow up interview on 08/19/2025 at 9:32 AM, Staff L stated that Resident 9 had their urinary catheter removed when they went to a urology appointment. Staff L was asked where that information would be documented, and they said it would be an AVS in their scanned documents. Staff L was not aware there was no information in Resident 9's medical record related to the discontinuation of the urinary catheter and that the medical record reflected the resident still had a urinary catheter. In an interview on 08/19/2025 at 10:40 AM, Staff U, Medical Records stated they were not aware that Resident 9 had missing items from their medical record. In an interview on 08/20/2025 at 9:52 AM, Staff V, Regional Director of Clinical Services stated that the medical records position had only been a part time position. This is a repeat deficiency from SOD dated 11/15/2024. Reference WAC: 388-97-1720(1)(i-iv)(b)

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 5 residents (Resident's 2, 12 and 116) reviewed for transmission-based precautions (TBP), 2 of 2 staff (Staff AA, Nursing Assistant Certified - NAC and Staff CC, NAC) reviewed for environmental disinfection of equipment, 2 of 2 drainage bags (Resident's 82 and 96) were secured off the floor and 1 of 1 facility water management plan. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriately disinfecting reusable resident equipment, and failed to ensure an appropriate placement of urinary drainage tubing. The facility failed to establish a water management plan for the facility that could place the facility residents and staff at an increased risk for Legionella or other opportunistic waterborne pathogens in the facility's water system. These failures placed all residents and staff at risk of potential infection. Findings included . Review of the facility policy titled, Surveillance for Infections, undated, documented the facility would conduct ongoing surveillance of infection that have potential resident outcomes and require the use of transmission-based precautions .purpose was to identify and guide appropriate interventions and prevent further infections. Review of the facility policy titled, Infection Control Program, undated, documented the facility had an infection control program and committee that would address surveillance, prevention and control of disease and infection, and that it was consistent with guidelines from the Centers for Disease and Control (CDC) and other federal national standards and regulations. Review of the facility policy titled, Water Management Program, undated documented the facility would establish a water management plan for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system .compliance guidelines were to establish a water management team, provide documentation of the facility's water system, complete a risk assessment to identify where potential pathogens could grow and spread, based on the risk assessment develop control points and control measures, testing protocols and limits, verification of process and effectiveness of the water program will be done annually. <ENHANCED BARRIER PRECAUTIONS> In an observation and interview on 08/19/2025, at 10:12 AM, Collateral Contract (CC 3) Contracted Wound Care Provider came to assess and change Resident's 12 right heel wound. CC 3, and Staff X, Licensed Practical Nurse (LPN) with the facility performed wound care. Observed the right heel wound to be open. Confirmed with CC 3 and Staff X that Resident 12 should be on Enhanced Barrier Precautions (EBP – wearing gown and gloves during high-risk activities for all staff). Resident 12 did not have signage or PPE outside of the room to alert staff of the precautions needed during high contact care. In a phone interview on, 08/19/2025, at 12:04 PM, with Staff D, LPN/Infection Preventionist/Staff Development Coordinator and Staff B, DNS confirmed that a resident with a wound would indicate use of EBP. Staff D stated that if a resident is on EBP then a sign would be posted outside of the resident's room with available PPE. Notified Staff D and B of Resident 12's and Resident 2's wound that did not have any EBP signage or PPE available. They both confirmed that they were unaware of the wounds. <RESIDENT 2> Review of Resident 2's medical record on 08/15/2025 documented a chronic wound to the resident's right leg. In an observation of wound care on 08/19/2025 at 10:55 AM, it was confirmed that the resident had a current chronic open wound to the right lower leg and did not have EBP in place to alert staff of the need for PPE during direct contact activities. <DRAINAGE BAGS> <RESIDENT 82> In an observation on 08/13/2025 at 10:58 AM, Resident 82 was in bed. The residents nephrostomy (drain placed to bypass blockage in urinary system) drainage bag was directly on the floor without a privacy cover. <RESIDENT 96> In an observation on 08/14/2025 at 8:45 AM, Resident 96 was visiting with a friend. The urinary catheter (tube placed to collect urine from the bladder) drainage bag was directly on the floor without a privacy cover <DISINFECTING> In an observation on 08/15/2025, at 9:22 AM, Staff AA, NAC was observed to take the Hoyer (mechanical equipment to assist resident transfers) into resident room [ROOM NUMBER]. At 9:32 AM, it was observed that the Hoyer came out of the room and was placed in the hallway without disinfection. In an observation on 08/19/2025, at 3:18 PM, Staff CC, NAC was observed to bring the Hoyer out of a resident's room and placed in the pink hallway without disinfection. In an interview on 08/19/2025, at 11:19 AM, Staff AA, NAC stated that the expectation for sanitizing reusable equipment was to use disinfectant wipes before and after use. Staff AA stated you only to sanitize reusable equipment if using the equipment on a resident on precautions. In a phone interview on, 08/19/2025, at 12:04 PM, with Staff D, LPN/IP/SDC and Staff B, DNS stated that the expectation for sanitizing reusable equipment would be after each resident use. <RESIDENT 116> Resident 116 admitted to the facility on [DATE] with diagnoses that included pressure ulcer of the sacrum region Stage 4 (severe wound, full thickness with exposed bone, tendon or muscle), urinary tract infection, and resistance to multiple organisms. Review of Resident 116's care plan documented a focus area dated 08/15/2025 that the resident required isolation for infection to wound in the sacral region. Interventions were to wear appropriate PPE. In an observation on 08/18/2025 at 8:42 AM, resident room [ROOM NUMBER] had a contact isolation sign and PPE bin outside of the room. The sign instructed all staff to perform hand hygiene, and to wear a gown and gloves prior to entering the room. In an observation and interview on 08/18/2025 at 12:10 PM, Staff M, NAC was observed to enter room [ROOM NUMBER] with a lunch tray. Staff M knocked, then entered the room. Staff M was not wearing a gown or gloves. A couple minutes later, Staff M exited the room. Staff M was asked if Resident 116 was on contact isolation, Staff M replied they were not sure. Staff M then walked back to room [ROOM NUMBER] and read the isolation sign on the wall outside of the room, and replied “I did not know, I should have worn a gown and gloves before I entered the room.” In an interview on 08/19/2025 at 10:47 AM, Staff EE, NAC stated they were not aware of any process for disinfecting resident reusable equipment such as the Hoyer's, and vital carts. Staff EE stated they were not clear on when or why residents would be placed on isolation, they just know they are supposed to follow whatever sign is outside of the room. Staff EE could not explain what EBP stood for. In a phone interview on 08/19/2025 at 12:04 PM, Staff D, LPN/IP stated their expectation was staff were to disinfect all resident reusable equipment such as Hoyer's, and vitals carts after every use, between residents. Staff D stated the facility utilized EBP for residents that have catheters, wounds and other devices. Staff D stated they are to wear gown and gloves for all direct contact interactions with the resident. Staff D confirmed that the staff should wear a gown and gloves prior to entering the room for all residents that were on contact isolation precautions. Staff D was not aware that staff were not following the isolation signs outside of the room for Resident 116. Staff D was unaware that Resident 2 and Resident 12 required the use of EBP for all direct contact care and was not aware they had not been on EBP during survey observations. <WATER MANAGEMENT PLAN> On 08/18/2025 at 9:41 AM, a request to Staff A, Administrator, was made to review the facility's water management plan. On 08/18/2025 at 11:11 AM, the facility provided a policy for their water management plan, no plan was provided. On 08/18/2025 at 11:55 AM, a request to Staff FF, Maintenance Director, for the facility water management plan. Staff FF stated they did not have a formal program or any documentation, they were not tracking any systems for water management. In a phone interview on 08/19/2025 at 12:04 PM, Staff D, LPN/IP stated they were not aware of any water management plan for the facility. In an interview on 08/19/2025 at 1:29 PM, Staff A stated the facility did not really have any areas where there was standing water. Staff A was asked if they had a water management plan, and they stated they did not. This is a repeat deficiency from SOD dated 11/15/2024. Reference WAC 388-97-1320(1)(a)(2)(a-c)(5)(c)

CONCERN (F)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included .Review of the key personnel list, provided by the facility during the entrance conference meeting on 08/13/2025, showed Staff C was listed as the Dietary Services Manager. Staff C was stated to be on leave of absence. During an interview on 08/20/2025 at 09:15 AM, Staff A, Administrator, confirmed that the facility did not have a full-time registered dietician and that Staff C was designated as the facility Dietary Services Manager. Staff A acknowledged that Staff C had not yet completed the required certification for Dietary Services Manager. Reference WAC 388-97-1160 (3)(b)(i)

CONCERN (F)

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

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk for unmet infection control issues and lack of oversite of the facility staff's infection control practices. Findings included . Review of the facility policy titled, Infection Prevention and Control Committee, undated the Infection Preventionist will oversee the Infection Prevention and Control Program and report to the Infection Prevention and Control Committee and/or Quality Assurance and Performance Improvement (QAPI) committee. The Administrator will be responsible for oversight of the Infection Prevention and Control Program. In an interview on 08/13/2025 at 9:30 AM, during entrance conference with Staff A, Administrator, they stated the facilities designated IP was Staff D, Licensed Practical Nurse (LPN)/IP. Staff A stated they would provide Staff D's IP credentials. On 08/14/2025 at 11:06 AM, Staff A provided a certificate for Staff D, that showed they had completed Module 1 of the Center for Disease and Control (CDC) Train Infection Preventionist Program. In a review of CDC Train IP program, the qualifications for completion of their program consisted of the completion of 23 individual modules, a test and certification letter. In an interview on 08/19/2025 at 12:04 PM, with Staff B, Director of Nursing Services (DNS) and with Staff D on the phone, Staff D was asked to provide the remainder of the other 22 modules, and certificate to show they had completed the class. Staff D stated they had already completed them and would provide. Staff B stated they were sure they had completed the course and would get that information to us quickly. In an interview on 08/19/2025 at 1:29 PM, Staff A stated they were under the impression Staff D had completed their training as they had been cited for the same deficiency in March of 2025 and assumed they were done with the course. On 08/19/2025 at 2:11 PM, Staff B, emailed completed Modules for the CDC Train IP program that Staff D had completed. The last Module was dated with a completion date of 08/19/2025. There was no certificate of completion of the course provided. Refer to WAC 388-97-1320(1)(a)

Jun 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a patient-centered discharge planning by the interdisciplinary team, involved resident and/or representative in the discharge planning, direct communication with the resident and/or representative about discharge process, and document required discharge information for 2 of 4 sample residents (Resident 5 and 6) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress and decreased quality of life. Findings included . Review of the facility policy titled, Transfer or Discharge, preparing a Resident for, dated 10/01/2021, documented a post-discharge plan was developed for each resident prior to transfer or discharge and the plan would be reviewed with the resident, and/or family at least twenty-four hours before resident's discharge or transfer from the facility. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] and discharged home on [DATE]. According to the discharge Minimum Data Set (MDS-an assessment tool) assessment, dated 06/07/2025, Resident 5 was cognitively intact. In an interview on 06/17/2025 at 1:55 PM, a Collateral Contact (CC) 1, family of Resident 5, stated both the resident and family did not receive any information about the discharge planning since the admission. CC1 stated they were not sure what the plan was or the timeline of discharge, and Resident 5 kept asking social services, multiple nurses every day for discharge plan update but nobody told them anything. CC1 stated the staff told them Resident 5 could go home abruptly on the discharge day. In an interview on 06/24/2025 at 9:44 AM, Resident 5 stated they did not know about their discharge planning process; was not notified of any update and were not informed about the timeline of discharge during the stay in the facility. Resident 5 stated they kept asking what the discharge plan was, but nobody explained to them. Resident 5 stated the facility told them they could go home on the same day, but they did not even have time to prepare. Resident 5 had to ask to be discharged the next day in order to have time to arrange someone to pick them up. In a follow up interview on 06/26/2024 at 11:01 AM, Resident 5 stated they were frustrated and stressed because they had trouble getting assist for transportation for their medical appointments. Resident 5 stated they were not qualified for home health service which was referred by the facility upon discharge and they had no other resources at this moment. Review of a social services progress note dated 05/09/2025, documented Resident 5 would like to remain in the facility for a short time but wanted to go home and the social service documented to check in with Resident 5 next week. Review of a social services progress note dated 06/06/2025, documented Resident 5 would discharge home with family tomorrow. Review of the electronic health record (EHR) from 05/09/2025 to 06/06/2025, there was no documentation that social services checked in with Resident 5 after 05/09/2025; there was no documentation that a discharge plan was developed from the multidisciplinary team addressed the resident's discharge goals, identified needs, and referrals to local contact agencies; there was no documentation that Resident 5 and the family were involved in discussions regarding their person-centered discharge planning; there was no documentation that Resident 5 and the family were directly communicated about the discharge planning, process and preparation; there was no documentation about how discharge timeline was decided. In an interview on 06/24/2025 at 2:36 PM, Staff F, Social Services, stated they set up the discharge date for Resident 5 because the resident told them they were ready to go home, and the resident was independent. Staff F stated they talked with the nurse manager and rehab therapists if Resident 5 was ready to be discharged but they did not document that and could not provide any information when they talked with the team. Staff F stated they informed the resident and the family that the resident could go home on [DATE], the day before discharge day. Staff F stated they communicated with Resident 5 and the family about the discharge planning and preparation before 06/06/2025 but they did not document it and could not provide any information of when that was. Staff F stated they would get back to the surveyor. No further information provided. <RESIDENT 6> Resident 6 admitted to the facility on [DATE] and discharged home on [DATE]. According to the discharge MDS assessment, dated 06/06/2025, Resident 5 was cognitive moderately impaired. Review of Resident 6's care plan, copy date 06/24/2025 at 3:27 PM, one intervention under discharge focus initiated on 01/19/2025, documented to review and update discharge plans with the resident when needed. Review of the social service initial evaluation dated 12/14/2024, documented Resident 6 would need 24/7 cares to return home under the physician's input regarding discharge. Review of a social services quarterly assessment dated [DATE], documented Resident 6 had declined in cognitive status and mental status. Under the quarterly discharge plan review area, it was blank. Review of the Discharge summary dated [DATE], documented Resident 6 discharged home with the daughter and Resident 6 was very forgetful, using brief, and required assistance with bathing. Review of Resident 6's EHR, after 12/24/2024 till 06/06/2025, showed there was no documentation that directly communication about discharge planning with the resident and/or family; there was no documentation that a discharge planning and the timeline were discussed from the multidisciplinary team and addressed the resident's discharge goals, needs, and referrals to local contact agencies; there was no documentation that Resident 6 and the family were involved in discussions regarding their person-centered discharge planning; there was no documentation if the discharge planning was reevaluated, modified or updated to reflect Resident 6's cognitive status declines; there was no documentation if the family was prepared or received any care giver training before discharge or if there was 24/7 cares available. In an interview and record review on 06/24/2025 at 3:03 PM, Staff G, Social Services, stated Resident 6's family came to the facility on [DATE] and asked to bring the resident home. Staff G stated they did not communicate with Resident 6 and the family about the discharge planning and there was no documentation about the discharge planning since 12/24/2024. Staff G stated they tried to contact the daughter but failed. Staff G could not provide any information when they tried to contact the daughter and stated they should document it but they did not. Staff G stated they asked the rehab therapist about any equipment needed but they did not document it. Staff G stated they could not find any documentation about discharge planning was developed and discussed with the team. In an interview on 06/24/2025 at 5:40 PM, Staff A, Administrator, stated residents required patient-centered specific discharge planning and they expect the social services documented about the discharge planning and process. Reference WAC 388-97-0080 (1)(b)(2)(a)(d)(6)

CONCERN (D) 📢 Someone Reported This

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

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent. 8 medication errors were identified out of 29 opportunities due to the failure of 2 of 2 nurses (Staff B and D) provided medications outside of the scheduled administration time. This resulted in a medication error rate of 27 percent. This failure placed residents at risk of reduced medication effectiveness, worsening of symptoms, and/or complications of medical condition. Findings included . <RESIDENT 1> In an observation on 06/24/2025 at 8:58 AM, Staff B, Registered Nurse, prepared medications to be administered to Resident 1. Staff B administered the medications below to the resident at 9:04 AM. Staff B reported that the medications scheduled for 7:00 AM were administered late. Review of the June 2025 Medication Administration Records (MAR) for Resident 1 showed the following orders: - Levothyroxine (thyroid medication) once a day. Dose scheduled at 7:00 AM. - Acetaminophen (pain reliever) three times a day. Doses scheduled at 7:00AM, 3:00PM and 9:00PM. - Diclofenac gel (pain medication) three times a day. Doses scheduled at 7:00AM, 3:00PM and 9:00PM. <RESIDENT 2> In an observation on 06/24/2025 at 9:14 AM, Staff B prepared medications to be administered to Resident 2. Staff B administered the medications below to Resident 2 at 9:24 AM. Review of the June 2025 MAR for Resident 2 showed the following orders: - Acetaminophen three times a day. Doses scheduled at 7:00AM, 3:00PM and 9:00PM. - Diamox Extended release 12-hour capsule (fluid retention medication) twice a day. Doses scheduled at 8:00 AM and 8:00 PM. - Dorzolamide-timolol (eye pressure medication) twice a day. Doses scheduled for 8:00 AM and 8:00 PM. - Protonix (acid reflux medication) once a day. Dose scheduled for 8:00 AM. <RESIDENT 3> In an observation on 06/24/2025 at 9:38 AM, Staff D, MDS (assessment of resident care needs) coordinator, prepared medications to be administered to Resident 3. Review of the June 2025 MAR for Resident 3 showed an order for Hydrocortisone cream (anti-inflammatory medication) three times a day. Doses were scheduled for 7:00AM, 3:00PM and 9:00PM. Staff D administered the medication to Resident 3 at 9:58 AM. During an interview on 06/24/2025 at 11:17 AM, Staff E, Resident Care Manager, stated medications that are timed for a specific time need to be administered an hour before or an hour after the scheduled time. During an interview on 06/24/2025 at 4:16 PM, Staff A, Administrator, stated the facility did not have a policy for window of time medication was to be administered if medication was ordered at a specific time. Staff A reported the timeframe should be one hour before or after the scheduled time to remain in compliance. Reference WAC 388-97-1060 (3)(k)(ii)

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to provide timely medication administration, provide care without residents having to wait a long time and licensed nursing staff were able to adequately monitor resident's conditions and supervise nursing assistants to ensure care was provided timely for 2 of 2 units (first floor, second floor) reviewed for sufficient staffing. Failures to ensure sufficient nursing staff resulted in delays in nursing staff response to residents' call lights, delays in administering medications, and placed residents at risk for unmet care needs, complications of medical condition and a diminished quality of life. Findings included . Review of an anonymous report to the state agency on 06/10/2025 at 2:01 PM documented a concern of sufficient nursing staff at facility. The report documented that residents were getting their medications late and call lights were not being answered timely. During an observation and interview on 06/24/2025 at 8:51 AM, Staff B, Registered Nurse (RN), was standing at the pink medication cart and had the electronic Medication Administration Record (emar) screen open. Staff B explained that the three residents' profiles showing in red were because those residents' medications were late. Staff B reported they had not had a chance to get to those residents yet because they were short today. Staff B stated they had notified the director of nursing and the staffing coordinator but had not received any assistance to help with resident care or medication pass. During an observation and interview on 06/24/2025 at 8:58 AM, Staff B prepared medications for Resident 1. Staff B stated that Resident 1 had scheduled medications for 7:00 AM, but they were covering two medication carts and had not had a chance to give Resident 1 medications until this time. During an observation on 06/24/2025 at 9:14 AM, Staff B was observed to administer three medications scheduled for 8:00 AM and one medication scheduled for 7:00 AM. During an interview on 06/24/2025 at 9:28 AM, Staff C, Licensed Practical Nurse (LPN), reported that they had completed the morning medication pass for [NAME] medication cart but had not started any of the medications on the blue medication cart that they were sharing with Staff B. Staff C reported that they had too many residents assigned to them today, and they had just as many residents yesterday, 06/23/2025. During an observation on 06/24/2025 at 9:49 AM, Staff D, MDS (minimum data set assessment) coordinator, reported they were covering the medication cart. Staff D administered a medication to Resident 3 that had been scheduled for 7AM. During an observation on 06/24/2025 at 10:01 AM- surveyor observed the emar screen on the blue medication cart. The screen had six resident profiles showing in red. During an interview on 06/24/2025 at 10:12 AM, Staff E, Resident Care Manager, was at the blue medication cart with the facility provider. Staff E reported that they were discussing with the provider, the residents, that had late medications to see if they needed to make any adjustments to the orders for the day. Resident 4 was sitting in their wheelchair next to the medication cart and reported that they wanted their medications for the morning and would like them earlier in the day. Staff E provided Resident 4 with their medications at 10:16 AM. Staff E reported that the medications were scheduled between 6:00 AM- 10:00 AM, so the medications were only 16 minutes late. During a follow-up interview on 06/24/2025 at 11:17 AM, Staff E reported that the emar is color coded: green means residents have all medications provided, Yellow means residents have something scheduled in the window of one hour before or after the scheduled time, and red means the medications are already outside of the administration time and they are late. Staff E reported that they also covered a medication cart on 06/23/2025 and almost all of the residents' medications were late and they had to be placed on alert. During an interview on 06/24/2025 at 11:20 AM, Staff H, Licensed Practical Nurse, stated there were only two cart nurses covering the whole floor with a census of 39 and it had been this way every day for about two weeks. Staff H stated it was too much work and they could not finish the morning medication pass until lunchtime. During an interview on 06/24/2025 at 3:25 PM, Resident 4 reported that they almost always get their medications late. Resident 4 stated that they don't get their medication until 9:45 PM, and she would like to have them earlier so they could go to sleep. Resident 4 stated they tried to stay awake until they had received their medications, so they didn't get missed. <ANONYMOUS STAFF> During an interview on 06/24/2025 at 3:02 PM, Anonymous Staff 1 (A1), stated they have been working short staffed (only two nurses on unit) a few days a week. Staff A1 reported that if there were only two nurses on shift, there was not enough time to get the care done timely. Staff A1 reported that they would stay over to get medications and treatments done, but they were not completed on time. Staff A1 reported when there are three nurses scheduled, they can get their work done in a timely manner, but if only two nurses were working, the nurse was not able to supervise the aides and make sure residents are getting the care they require, not able to give medications timely and not enough time to follow up on resident issues. Staff A1 had reported their concerns to management and the staffing coordinator but stated they hadn't received any assistance. During an interview on 06/24/2025 at 3:12 PM, Anonymous staff 2 (A2), reported they work with one less nurse a third of the time. When they have less nurses on duty, Staff A2 reported they start work on their usual assigned cart and were not able to monitor the other residents for the first 3-4 hours of their shift, which they felt was unsafe. Staff 2 reported they did not have time to spend adequate time with their residents. <STAFFING COORDINATOR> During an interview on 06/24/2025 at 11:00 AM, Staff I, staffing coordinator, explained when there is a full resident census, they have 3 nurses for first floor and second floor on both day and evening shifts. Staff I stated the census was down at this time, so they have to cut a nurse shift each day. Staff I reported that they were instructed to cut an entire nurse each day and not to cut each unit for a few hours. Staff I reported that they had been rotating the shift and the unit that was working with one less nurse. Staff I reported the current resident census on Second floor was 57 residents and the first floor was 39, but they were rehab residents that required more assistance. Review of the facility assignment sheets from 05/24/2025- 06/24/2025 showed: Second floor day shift: 13.5 out of 32 shifts had only two nurses on unit. Second floor evening shift: 8 out 32 shifts had only two nurses on unit. First floor day shift: 12 of 32 shifts had only two nurses. First floor evening shift: 13 of 32 shifts had only two nurses. On 05/29/2025 and 06/09/2025 through 06/24/2025, showed two or more shifts each day where nurses were sharing a medication cart. In an interview on 06/17/2025 at 1:55 PM, Collateral Contact (CC1), family of Resident 5, stated the resident had to wait for one hour or longer to get the call light answered, and it happened on a daily basis. CC1 stated one nurse told them the facility was very short of nursing staff. In an interview on 06/24/2025 at 9:44 AM, Resident 5 stated every time they pressed the call light, nobody answered it, and they had to walk to the nurses' station to ask for help. Resident 5 stated the facility did not have enough nurses. In an interview on 06/24/2025 at 11:05 AM, Resident 8 stated they had to wait for one hour for the nurse to answer the call light and it happened every day on all shifts. Resident 8 stated the facility did not have enough nurses. <GRIEVANCES> Review of a grievance form dated 06/04/2025, Resident 9 reported they had to yell to get help. Resident 9 reported they waited for 45 minutes to one hour to get the call light answered and the staff came in and said they would come back but never return. The facility investigation documented that the licensed nurse staffing was an issue, and the scheduler made some staffing changes. Review of a grievance form dated 06/04/2025, Resident 11 reported they pressed call light at 6:55PM and nobody show up until 7:45 PM. Resident 11 also reported long call light times all evenings. The facility investigation documented scheduling issues noted and the facility assigned more stable staffing. Review of a grievance form dated 06/05/2025, Resident 10 reported they pushed the call button at 3:45 AM for bad spasms and pain and aide did not come until 4:30 AM and they did not get the pain medication until 5:00 AM. The facility investigation documented there was a staffing issue and made some staffing changes. Reference WAC 388-97-1080(1)

May 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review and interview, the facility failed to maintain a completed state reporting log for 2 of 3 (April and May 2025) months reviewed. The facility failed to ensure incidents were logged within 5 days of incident discovery. This failure placed residents at risk of unidentified patterns of alleged violations, which could include neglect, abuse and/or exploitation. Findings included . Review of the Nursing Home Guidelines, also known as the Purple Book, dated October 2015 showed the facility was to report to the state agency and one method of reporting was by the state reporting log. The incident was to be reported via the reporting log within 5 days of discovery. Review of the April 2025 state reporting log documented that twenty incidents were all logged on 04/30/2025. The dates of these incidents ranged from 04/19/2025 through 04/30/2025. Review of the May 2025 state reporting log documented thirty-one incidents were logged on 05/31/2025. The dates of these incidents ranged from 05/01/2025 through 05/25/2025. During an interview on 05/29/2025 at 3:18 PM, Staff A, administrator, stated the April 2025 reporting log had not been updated timely as the facility had a new Director of Nursing Services (DNS). Staff A reported they were not aware that the DNS had not been updating the May 2025 log timely and that they had not updated the log when the DNS had been on vacation for the last two weeks. Reference WAC 388-97- 0640 (2) (b)

Mar 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party for 1 of 3 residents (Resident 1) reviewed for hospitalization. Failure to notify the resident representative of transfer to a hospital placed the resident at risk for not having their representative involved in their health care decision-making with timely care and services. Findings included . Review of an undated facility policy, titled, Change in a Resident's Condition, documented a nurse would notify the resident's representative when the resident was transferred to a hospital. Resident 1 was admitted to the facility on [DATE]. Review of Resident's 1's admission record documented a son as emergency contact #1 and Collateral Contact 1 (CC1), significant other, as emergency contact # 2. During an interview on 03/19/2025 at 9:29 AM, Collateral Contact 2 (CC2), Resident 1's family member, stated that the resident had been sent to the hospital on [DATE] but the family had not been notified. CC2 stated that CC1 had not been notified and went to the facility on [DATE] to visit Resident 1, the day after they had been sent to the hospital. Review of a progress note, dated 03/13/2025 at 3:55 PM, documented that Resident 1 was taken to the hospital by emergency medical staff due to unclear speech and changes in neurological function (system that is responsible for coordinating thoughts, feelings, movements, senses, and basic body functions like breathing and heartbeat.) There was no documentation that any family or responsible party was notified. Review of the facility's visitor log dated 03/14/2025, documented that CC1 had been at the facility to visit Resident 1. During an interview on 03/28/2025 at 12:22 PM, Staff A, Administrator, stated that CC1 was not the #1 emergency contact person for Resident 1, and the facility should have notified the #1 emergency contact person. During an interview on 03/28/2025 at 3:16 PM, Staff A reported that they were not able to find any documentation that Resident 1's emergency contact person was notified when they went to the hospital. Refer to WAC 388-97-0320 (1)(d)

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure there was a qualified Infection Preventionist (IP, responsible for the facility's infection control program that includes early detection, analysis of evidence-based surveillance of infection, implementation, and management of healthcare associated infections by ensuring sources of infections were tracked/managed to isolate/prevent the spread of infection) designated for the facility. The facility was currently in a viral respiratory disease outbreak and this failure placed the residents and staff at risk for transmission of an infectious disease and/or unmet care needs. Findings included . During an interview on 03/19/2025 at 9:55 AM, Staff C, Unit Manager, stated Staff B, IP/Staff Development /Assistant Director of Nursing, was working in the role of IP as the last IP no longer worked at the facility. During an interview on 03/19/2025 at 12:45 PM, Staff B, stated they were hired to do IP/SDC. During an interview on 3/19/2024 at 1:03 PM, Staff A, Administrator, stated that Staff B was the acting facility IP but had not yet had training and did not have any IP certification. During an interview and record review on 3/28/2025 at 12:22 PM, surveyor requested a copy of Staff B's certification for IP. Staff A reported there were no records of Staff B's certification as they had not been enrolled in the certification program yet. Review of the facility's key personnel list, received on 3/28/2025, showed no staff was designated as the IP. No Associated WAC

Mar 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to complete a background check prior to employment for 1 of 5 sampled staff (Staff B) reviewed for staff qualifications. This failure placed residents at risk from interactions with staff who were not qualified to work with vulnerable adults and created the potential for abuse, neglect and exploitation. Findings included . Review of a facility policy titled, Abuse, revised date of 10/20/2022, showed the facility will screen potential employees for a history of abuse, neglect or mistreating residents by completing a background check. Review of Staff B's employment file showed a hire date of 02/25/2025. Review of a report for a background check application, dated 2/20/2025, showed that the background check could not be completed until additional information was received from Staff B, Director of Nursing. Review of Staff B's personnel file showed no further information of the background check being completed. During an observation on 03/04/2025 at 2:13 PM, Staff B approached surveyor in the hallway and introduced self as the Director of Nursing. Staff B was not accompanied by any other staff persons and was then seen walking down the hallway toward resident rooms. During an observation on 03/04/2025 at 2:26 PM, Staff B entered the work area where surveyor was working. Staff B was not accompanied by any other staff at this time. During an interview on 03/04/2025 at 5:21 PM, Staff A, Administrator, stated they were aware that the background check for Staff B was not completed. Staff A stated they had no evidence to show Staff B had been supervised or accompanied by another staff member since they were hired. Refer to WAC 388-97-1800 (2)(a)

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility's governing body failed to ensure that the facility's abuse policy was followed by ensuring the Director of Nursing (DNS) had a completed background check and failed to ensure the DNS had an active professional license prior to employment. This failure placed residents at risk of substandard quality care and placed residents at risk of abuse, neglect and/or exploitation. Findings included . Review of Staff B's, DNS, employment records showed a hire date of 02/25/2025. Review of Staff B's job description, signed by Staff B on 02/20/2025, showed they were the Director of Nursing. During an interview on 03/07/2025 at 10:05 AM, Staff E, Human Resources, stated that they processed the background check applications and verified professional licenses were active and current for potential employees. Staff E stated that Staff B's background check returned stating that the applicant needed to provide additional information prior to the background check being completed. Staff E stated they had reviewed Staff B's Registered Nurse license and discovered it was suspended. Staff E reported that they had notified Staff A of the issue with the background check and the finding of the suspended license. During an interview on 03/07/2025 at 3:46 PM, Staff A, Administrator, stated they had been involved with the first interview of the DNS. Staff A reported they were aware of the license and background issues with Staff B but the decision to hire Staff B was made by the governing body. Refer to WAC 388-97-1620 (2)(c)

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0659 (Tag F0659)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 5 sampled staff (Staff B) had an active professional license. Failure to ensure the Director of Nursing had an active license placed all residents at risk of substandard quality of care as the Director of Nursing was responsible for all residents in the center. Findings included . Review of Staff B's job description, signed by Staff B on [DATE], showed they were the Director of Nursing and supervised the nursing department. Review of the facilities Key Personnel list provided by on the facility on [DATE], showed Staff B listed as the Director of Nursing. During an interview on [DATE] at 2:13 PM, Staff B introduced themselves as the new Director of Nursing to surveyor. During an interview on [DATE] at 3:50 PM, Resident 1 stated they had been notified by Staff A, Administrator, that Staff B was hired as the new Director of Nursing. During an interview on [DATE] at 4:39 PM, Staff C, Licensed Practical Nurse (LPN), stated they were notified a week ago that Staff B was the new Director of Nursing. Staff C stated that if they had an issue with a nursing concern they would turn to Staff B for guidance. During an interview on [DATE] at 4:45 PM, Staff D, LPN/ unit manager, identified the current Director of Nursing as Staff B. Staff D stated Staff B started last week. Staff D stated if they had an issue they could not handle as the unit manager, they would go to Staff B as the current Director of Nursing as they were responsible for resident care and nursing services within the facility. Review of the Washington State Provider Credential Search website showed Staff B's Registered Nurses license was suspended and expired as of [DATE]. During an interview on [DATE] at 3:59 PM, Staff A stated that they were aware Staff B's license was suspended. Refer to WAC 388-97-1660 (1)(a)

Nov 2024 38 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff treated 2 of 2 residents (Residents 84 and 98) in a dignified and respectful manner. This failure placed the residents at risk for experiencing a high level of frustration, embarrassment, and the need to constantly advocate for their care. Findings included . The Cambridge English Dictionary, dated April 28, 1995, defines Dignity as The quality of a person that makes him/her deserving of respect, sometimes shown in behavior or appearance. According to Washington State Long-Term Care Ombudsman Program website 12/15/2023, People who live in long-term care facilities are more vulnerable than people who live independently. In 1987, the U. S. Congress recognized this fact and passed The Nursing Home Reform Act that gave nursing home residents additional legal protections, including a set of Resident Rights. Resident rights include the right to a dignified existence and to be treated with consideration, respect, and dignity, recognizing each resident's individuality. Quality of life is to be maintained or improved. Residents have the right to request, refuse and or discontinue treatment. <RESIDENT 84> Resident 84 admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident had no cognitive impairment. In an interview on 11/05/2024 at 8:56 AM, Resident 84 stated, when they first moved into their new room, the week after September 11th they had issues with Staff F, Nursing Assistant Registered (NAR). Resident 84 stated Staff F was d*** scary. The resident said one night they had to call the aide three times because of diarrhea. The resident stated Staff F told them, You stop calling us. I cannot come in here and keep changing you. Just soil your brief and we will change you when we get to you. Resident 84 said, Do you know how much that makes your butt sore. No one should have to be in a soiled brief. The resident said Staff F told them We have other patients to take care of. Resident 84 said, (Staff F) needs to go work somewhere else. I am afraid of them. Staff F scares me. I haven't been that intimidated since high school, but I was braver then too. I now do not call anyone for help at night because I am scared, (Staff F) will come in. Staff F said they did not want them as their aide at all. Resident 84 stated they reported this to Staff K, Occupational Therapist (OT) who said they could file a complaint and ask for Staff F not to provide care to them. Resident 84 said Staff K came into their room the other night and was very intimidating. In an interview on 11/06/2024 at 1:52 PM, Resident 84 stated they were scared and intimidated by Staff F. In an interview on 11/12/2024 at 9:40 AM, Resident 84 stated staff had been nice lately. The resident stated Staff F was just dreadful. <RESIDENT 98> Resident 98 admitted on [DATE] and had no cognitive impairment. In an interview on 11/04/2024 at 11:53 AM, Resident 98 was observed in their wheelchair in their room. The walls were beige with the overbed light on. Resident 98 said their room was dark and gloomy. They said three weeks ago, there was a vacant room across the hall, so they asked Staff B, Director of Nursing to be moved to it because their room was depressing. The resident said the room light directly above their bed was fluorescent and too bright. The resident said they stared at a wall and out the window they see a brick wall. Resident 98 said Staff B, DNS told them a new resident was going into that room across the hall. Resident 98 suggested to the DNS they move to that room and the new patient come to their room. The resident said Staff B was dismissive and said Why would I move you into that room and give a new resident your room that you don't like? In an interview on11/05/2024 at 10:07 AM, Resident 98 said they had a shower yesterday and they asked Staff P, LPN not to have that aide shower them again. Resident 98 said the aide later identified as Staff Q, NAC told them to just stand up, but they were unable to physically stand. The resident told Staff Q they needed to get a gait belt and assist them. The resident said the shower chair was not comfortable as they had a wound on their buttocks. Resident 98 said Staff Q was on their cell phone on 3 occasions during their shower and the NAC left them alone in the shower room three times which made them nervous. Resident 98 reported they were hurting, and the shower took so much longer since Staff Q kept going into the next stall to whisper into their phone. Resident 98 said they were cold, naked and it made them nervous that staff kept leaving them. The resident said the staff member should socialize while on breaks. At 10:17 AM, Resident 98 reported some staff do not listen to them and they find the staff to be quite rude. The resident stated they remind Staff F, NAR every time to not drag the Velcro across their skin during care. The resident stated Staff F told her that another one of her resident's had the same complaint. Resident 98 responded they told Staff F because the Velcro hurts and Staff F dismissed her concern and responded with It is Ok, it is OK. Resident 98 said Staff F gives them the side eye and will not make eye contact with them which makes them feel vulnerable as they are lying on bed with Staff F standing over them. The resident stated Staff F also makes a tskkk sound which to them is dismissive. In an observation on 11/06/2024 at 9:03 AM, Resident 98 was in bed eating their breakfast when Staff E, NAC came into the room and said they were there to change the resident. Resident 98 said Well I am trying to eat my breakfast. Staff E looked at their watch, tapped it and said, I will give you two minutes. The resident took a deep breath and said Wow, two minutes, you might as well do it now then pushed their overbed table with their meal away. At 9:33 AM, Resident 98 said the interaction with Staff E made them feel crappy, like chopped liver. In an interview on 11/07/2024 at 11:00 AM, Resident 98 said Staff E came into their room and that morning and asked if they needed something since their call light was on. Resident 98 said Yes I am wet and need to be changed. The resident said Staff E said they would be going on their break but would change them after. The resident said why would they not change them before heading to their break, knowing they were soiled. The resident said they told Staff E they should not be left wet. In an interview on 11/13/2024 at 1:44 PM, Resident 98 said when they were on the bus to go to their doctor appointment, an unidentified staff member got on the bus and said, Hey I need to talk to you about the shower incident. Where you naked? The resident said they told the staff yes, they were naked, they were in the shower, and they would not talk to them about it right then. The resident said they were embarrassed as the male bus driver was present for the conversation. In an interview on 11/14/2024 at 1:00 PM Staff A, Administrator was told about Resident 98's concerns regarding Staff E. In a joint interview on 11/15/2024 at 11:45 PM with Staff A, Administrator and Staff B, Director of Nursing were informed of Resident 84 and 98's concerns about treatment by staff including the resident's specific comments on how they felt by the interactions with staff. No additional information provided. This is a repeat deficiency from 12/23/2022 and 12/14/2023 Refer to WAC 388-97-0180)(2)

CONCERN (D)

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

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor a residents' representative's request to schedule a care meeting for 1 of 3 residents' (Resident 5) representative. The failure to honor the resident's representative's request to schedule a care meeting placed the resident at risk for unmet needs and for the resident's representative being unable to advocate for the resident. Findings included . Resident 5 admitted to the facility on [DATE]. In an interview on 11/05/2024 at 11:27 AM, Collateral Contact 2 (CC2), family member of Resident 5, stated they set up an appointment today at 10:00 AM for a care meeting, but it still had not happened. They stated they tried to talk to Staff X, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), but when they tried to talk to them, they just stuck their arm out to them like they weren't going to talk to them. CC2 stated they could have called them and let them know the meeting wasn't going to happen and they would have rescheduled. CC2 stated they needed a meeting to discuss many issues they had with Resident 5's care. CC2 stated they had previously had a conference call with Staff B, Director of Nursing (DON), but that staff was combative, and all they offered was a suggestion that Resident 5 move to a different facility. In an interview on 11/05/2024 at 11:56 AM, Staff X stated they had set up a meeting, but not a time. Staff X was asked if representatives could set up appointments with the facility and the resident's doctor for a specific time, they stated they could, but that didn't happen today. Staff X stated CC2, and Resident 5 were in a meeting with the resident's physician right now. Review of facility notes from a Care Conference/Concern follow-up call, dated 11/14/2024, showed Concern #10 was the 10:00 AM care conference did not occur until 11:30. The notes also indicated Staff X had put their hand up to CC2 and was rude. The notes also indicated there was an issue with Staff B, DON, being rude and just offering that Resident 5 move to another facility. The facility's notes indicated they discussed that Staff A, Administrator, and they would be educating Staff B and Staff X regarding customer service, and that in the future Resident 5's representatives would work with Staff A, Administrator, on their concerns. Refer to WAC 388-97-0240 (7)

CONCERN (D)

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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 sampled residents (Resident 46) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life. Findings included . According to facility policy titled: Resident Participation-Assessment/Care Plans, the resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. An advance notice of the care planning conference is provided to the resident and his/her representative. Such notices are made by mail, telephone, and/or electronically. The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices may include: a. The date, time and location of the conference b. The name of each person contacted and the date he or she was contacted. c. The method of contact (e.g. mail, telephone, email, etc.) d. Input from the resident or representative if they are not able to attend. e. Refusal of participation, if applicable; and f. The date and signature of the individual making the contact. Resident 46 admitted to the facility on [DATE]. According to the Minimum Date Set (MDS - an assessment tool) assessment, dated 10/17/2024 Resident 46 showed they had severe cognitive impairment. However, during my interaction with the resident they were able to make needs known and respond appropriately. In an interview on 11/05/2024 at 9:37 AM Resident 46 stated that they never attended a care conference (a collaborative meeting where a resident's care is disucssed and coordinated by a team of health care providers, family members and residents) and would like to attend one. They also stated that they were not told about their care plan. In an interview on 11/06/2024 at 12:42 PM, Staff FF, Registered Nurse (RN) stated, Resident 46 was alert and oriented but forgetful, and required total assist with care. In a record review on 11/17/2024 Resident 46's Progress Note under Social Work, showed notes of interaction and updates from the Social Worker to the resident and resident's daughter but there were no notes indicating that they were care conference notes. In an interview on 11/12/2024 at 1:03 PM, Staff W, Social Services stated that they do quarterly or annual care conferences with residents and/or representatives and it depends on the residents' and/or representatives' preference. According to Staff W, Resident 46's family prefers annual care conferences and wants it via telephone call. Requested Staff W to show me care conference notes for Resident 46 and they stated that they don't have an actual care conference note and that they document it as a progress note when they provide updates to resident and/or representative. This is a repeat deficiency from 12/14/2023. Refer to WAC 388-97-1020 (2)(e)(f)(4)(e)

CONCERN (D)

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

Deficiency F0603 (Tag F0603)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident's right to be free from involuntary seclusion for 1 of 1 resident (Resident 253). Failure to prevent involuntary seclusion placed the resident at risk for psychological harm. Findings included . Resident 253 was admitted to the facility on [DATE] with diagnoses that included acute cystitis (a bladder infection that begins suddenly and is usually caused by bacteria). In an interview on 11/04/2024 at 3:02 PM, Resident 253 stated they were not allowed to leave their room and they had to stay in their room. Resident 253 stated they get lonely because they were not able to leave their room. Resident 253 stated the nursing staff had informed them they had to stay in their room because of their infection. Review of Resident 253's Minimum Data Set (MDS-an assessment tool) showed resident was interviewed about their preferences for customary routine and activities and reported it was very important to them to do things with groups of people. Resident 253 was noted to be cognitively intact. Review of Resident 253's care plan dated 10/27/2024 showed the resident preferred to participate in self directed activities such as crafts (sewing and needle art), watching movies, and reading. The care plan showed that Resident 253 was on isolation/contact precautions related to extended spectrum beta-lactamases (ESBL-enzymes that make bacteria resistant to many common antibiotics) in their urine. In an interview on 11/12/2024 at 10:01 AM, Staff HH, Activities Director, stated they provided all new admissions with crossword puzzles, a daily chronicle, and magazines. Staff HH stated Resident 253 liked to do their own individual activities and did not want to do anything else but was offered other activities. When asked how an assessment was conducted with a resident on isolation/contact precautions, Staff HH stated they would contact the resident by phone to gather their information needed. In an interview on 11/13/2024 at 8:38 AM Staff V, Licensed Practical Nurse (LPN)-Infection Preventionist (IP) stated Resident 253 was on contact precautions and isolation for ESBL and staff were directed to have the resident in their room until the precautions could be lifted or until completion of antibiotics. Staff V stated they had not met with Resident 253. Staff V stated Resident 253 was incontinent of urine and their main concern was any potential contamination from their incontinence. Staff V stated they obtained the information about Resident 253's incontinence from the nurses and the [NAME] (a tool used to provide direction on how to care for a resident). Review of Center for Disease Control and Prevention guidelines for nursing homes and reducing the risk of ESBL included hand washing and enhanced barrier precautions (for high contact resident care activities use of gown and gloves). In an interview on 11/13/2024 at 11:54 AM Staff S, Social Services Director, stated they had only been in contact with Resident 253 at their care conference and regarding their discharge plan. Review of Resident 253's Nursing Assistant Documentation for October and November 2024 showed resident was documented as continent of their urine. Review of Resident 253's activity documentation for November 2024 showed they engaged in social activities, documented as television. Reference WAC 388-97-0640 (1)(3)(c)

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 14> Resident 14 admitted to the the facility on 08/08/2024, discharged on 08/12/2024 and readmitted to the facil...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 14> Resident 14 admitted to the the facility on 08/08/2024, discharged on 08/12/2024 and readmitted to the facility on [DATE]. Review of Resident 14's progress notes dated 08/12/2024 showed they had been throwing up blood, had low blood pressure and were transferred to the hospital by ambulance. Review of Resident 14's electronic medical record did not contain any information about a notice of discharge/transfer, if the resident or their representative had been given information contained in the notice, and if the Ombudsman had been notified of the resident's transfer to the hospital. In an interview on 11/13/2024 at 11:34 AM, Staff S, Social Services Director, stated they only completed the notice of transfer/discharge for planned discharges from the facility. Staff S stated they did not know who completed them for residents who were hospitalized . In an interview on 11/14/2024 at 11:03 AM, Staff T, Registered Nurse stated when a resident is discharged to the hospital they send the current labs, medication list, the physician order for life sustaining treatment and change in condition documentation. When asked about the notice for discharge/transfer Staff T stated they did not provide the notice and referred to the unit manager. In an interview on 11/14/2024 at 11:06 AM Staff U, Licensed Practical Nurse (LPN)-Unit Manager, stated they had not ever been told to complete a notice for discharge/transfer and they did not know who would be completing it. Refer to WAC 388-97-0120 (2)(a-d) and 388-97-0140(1)(a) Based on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable and to provide a copy of the notice to the state Ombudsman office as required for 2 of 2 sampled residents (Resident 14 and 78) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options. Findings included . Review of an undated facility policy titled, Facility Initiated Transfer and Discharge showed that before a facility transfers or discharges a resident, the facility will notify the resident and the residents representatives of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. The written notice will include a statement of the resident appeal rights, including the name, address (mailing and email) , and telephone number of the entity which received such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsmen. <RESIDENT 78> Resident 78 admitted to the facility 09/20/2024. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the resident had no cognitive impairment. Review of Resident 78's progress note on 09/26/2024 at 2:30 PM, showed the resident was transported to the hospital. The note showed no information regarding what information was given to the resident at the time of the discharge. Review of the medical records showed the nursing facility inpatient notification to Resident 78's insurance plan was submitted late on 09/30/2024. The facsimile informed the facility the insurance plan required inpatient notification within 24 business hours or the next business day. This notice did not provide resident with information on their right to appeal the discharge decision, including contact data for advocacy groups. The medical records did not contain discharge or transfer notices for 09/26/2024 or 10/28/2024. Review of Resident 78's progress note on 10/28/2024 at 11:33 PM, showed the resident was transported to the hospital. The note showed no information regarding what information was given to the resident at the time of the discharge. In an interview on 11/12/2024 at 1:10 PM, Resident 78 stated they did not receive or sign any paperwork when they were transferred to the hospital both times. They said the facility did not tell them about holding the bed or discharge rights and they did not receive any paperwork. In an interview on 11/13/2024 at 9:57 AM, CC 1, family member of Resident 78 said the facility did not talk to them about holding the bed or discharge rights at all. CC 1 said the facility did not give them any paperwork for transfers to the hospital on [DATE] or 10/28/2024. In an interview on 11/14/2024 at 12:44 PM, Staff A, Administrator said the admission director obtained the bed holds and nurses were to complete the transfer discharge paperwork that was to go with the resident to the hospital. Staff A said if the admission director was not here when a resident goes to the hospital, the bed hold and transfer paperwork should be completed by the nurse and sent to the hospital with the resident.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written bed-hold notice, at the time of transfer or within 24 hours of transfer to the hospital, for 1 of 2 residents (Resident 78), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the undated facility policy titled Bed Hold showed that prior to initiated transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The policy showed residents and or representatives will be provided information on the facility's bed hold policy at the time of admission. A second written notice will be provided to the resident, and if applicable the residents representative, at the time of transfer, or in cases of emergency transfer, withing 24 hours. <RESIDENT 78> Resident 78 admitted to the facility 09/20/2024. According to the admission Minimum Data Set assessment dated [DATE], the resident had no cognitive impairment. Review of Resident 78's progress note on 09/26/2024 at 2:30 PM, showed the resident was transported to the hospital. The progress notes showed no information regarding offering a bed hold. Review of the clinical record showed the bed hold notice with a release of the bed was explained to Resident 78's spouse before the resident was transported to the hospital. The notice did not contain a signature from the resident or spouse. The bed hold notice did not show the written notice had been provided upon discharge. Review of Resident 78's progress note on 10/28/2024 at 11:33 PM, showed the resident was transported to the hospital. The note showed no information regarding offering a bed hold. In an interview on 11/12/2024 at 1:10 PM, Resident 78 stated they did not receive or sign any paperwork when they were transferred to the hospital both times. Resident 78 said the facility did not talk to them about holding the bed and they did not receive any paperwork. In an interview on 11/13/2024 at 9:57 AM, CC 1, family member of Resident 78 said the facility did not talk to them about holding the bed. CC 1 said the facility did not give them any paperwork for transfers to the hospital on [DATE] or 10/28/2024. In an interview on 11/14/2024 at 12:44 PM, Staff A, Administrator said the admission director obtains the bed holds and if the admission director was not at the facility, the bed hold should be completed by the nurse and sent to the hospital with the resident. Reference WAC 388-97-0120 (4)

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long t...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and bipolar disorder (a mental health disorder with episodes of mood swings). Review of the PASRR Level I dated 09/08/2024 showed Resident 43 required a level II evaluation for serious mental health. Resident 43 was referred for a PASRR Level II evaluation on 09/08/2024 while admitted to the hospital. Review of Resident 43's progress notes dated 10/16/2024 through 11/04/2024 showed no documentation/notation of a PASRR level II completion. Review of Resident 43's electronic medical record on 11/06/2024 showed no PASRR Level II evaluation. In an interview on 11/07/2024 at 11:19 AM Staff S stated the facility obtained a PASRR from the hospital and reviewed a resident's medical records to gather information about their mental health or developmental disability needs. Staff S stated if a resident admitted to the facility, and they required a PASRR Level II evaluation they would coordinate/contact the evaluator. Staff S stated they had looked at Resident 43's PASRR Level I, progress notes and their email and had not received a PASRR Level II for them. On 11/07/2024 at 1:19 PM Staff S provided a completed PASRR Level II for Resident 43. The PASRR Level II was attached to an email with a date stamp of 11:53 AM. The PASRR had a date of completion of 10/09/2024, eight days prior to Resident 43's admission to the facility. Review of Resident 43's progress notes dated 11/07/2024 showed a PASRR Level II had been received and was uploaded into the electronic medical record. Review of Resident 43's care plan dated 10/24/2024 showed no updated focus/goal/interventions related to the PASRR Level II evaluation. Refer to WAC 388-97-1915 (1)(2) (a-c) Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR)(a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings) was completed as required and that Level two comprehensive evaluations were obtained, and/or implemented, and incorporated into the Care Plan (CP) for 2 of 5 (Resident 43 and 74) residents reviewed for PASRR services. This failure placed residents at risk for not receiving necessary mental health care and services in the most integrated setting appropriate to their needs Findings included . <RESIDENT 74> Resident 74 admitted [DATE] with diagnoses which included anxiety, depression, post traumatic stress disorder and substance abuse disorder. Review of Resident 74's level one PASRR completed on 04/11/2024, identified the resident as having indicators of serious mental illness and substance abuse disorder and showed a referral for level two assessment was required. Review of Resident 74's medical record on 11/07/2024 showed no level two PASRR assessment or invalidation. The record showed only one progress note dated 08/01/2024 stating the PASRR was being reviewed for validation. In an interview on 11/07/2024 at 12:53 PM, Staff S, Social Services Director (SSD), stated the facility was supposed to be conducting audits of resident PASRR's at least quarterly and with significant changes. Staff S reviewed Resident 74's record and stated they could not find any documentation of a level two assessment referral on admission and only the note from 08/01/2024 stating that it was sent for review at that time but no further notes regarding follow up.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement, review and revise care plans for 1 of 14 residents (Resident 46) reviewed for care planning. These failures placed residents at risk for unmet care needs, adverse health effects and diminished quality of life. <RESIDENT 46> Resident 46 admitted to the facility on [DATE]. Diagnosis to include Multiple Sclerosis (a disease that causes the breakdown of the protective covering of the nerves). According to the Minimum Date Set (MDS - an assessment tool) assessment, dated 10/17/2024 Resident 46 showed severe cognitive impairment. Resident was able to verbalize needs and responded appropriately when questions were asked. In an interview on 11/06/2024 at 12:42 PM, Staff FF, Registered Nurse (RN) stated, Resident 46 was alert and oriented but forgetful, and requires total assist with care. <RANGE OF MOTION (ROM -is a term used to describe how far you can move a joint or muscle in various directions) EXERCISES> Review of Resident 46's Care Plan on 11/07/2024 showed under Focus: At risk for loss of ROM related to impaired mobility, weakness. Revised on 07/23/2023. Goal: Will exhibit no decline in ROM within confines of disease processes. Intervention: Encourage to assist resident to do active ROM (the range of movement that a person can achieve by contracting and relaxing muscles without assistance) exercises of bilateral lower extremities twice a day as resident tolerates (see exercise sheets in resident's room or in resident's chart). In an observation and interview on 11/07/2024 at 10:15 AM, Resident 46 was receiving peri care (washing the genitals and anal area), observed her left leg was bent, left knee was close to their chest area. Right leg slightly bent on the knee also. I requested resident to straightened both legs, resident was able to straighten the left leg but once they straightened the left leg, it went back to being bent again. In a joint interview on 11/07/2024 at 10:38 AM, Staff GG, NAC and Staff EE, NAC , Staff GG stated that Resident 46 was not on a restorative program. Staff GG stated that they try to do range of motion (ROM) exercises to Resident 46 but most of the time resident refuses. Staff EE stated that Resident 46 mostly refuses care and only allows specific NAC's to care for her. In an interview on 11/07/2024 at 10:45 AM, Staff X, Licensed Practical Nurse (LPN)/Unit Manager (UM), they stated that activity assistants who were NAC's does restorative program in the facility. Staff X stated Resident 46 is not on a restorative program. Requested Staff X to show me where staff document the ROM exercises for Resident 46 per care plan. Staff X looked in resident's electronic chart and stated they were not able to find any documentation and will work on it. In an interview on 11/08/2024 at 11:07 AM, Staff GG, NAC was not able to find documentation for the ROM exercises for Resident 46. Staff GG was not able to show me the exercise instructions that was either posted on resident's wall or in resident's chart according to the care plan. In an interview on 11/12/2024 at 12:48 PM Staff FF, RN, Resident 46's left lower extremity has some contractures and they try to put pillows under the resident's legs but resident kicks them off. Resident 46 also refuses to get out of bed when they offer. Staff FF does not think resident is on a restorative program. In an interview on 11/13/2024 at 9:57 AM, Resident 46 stated that they don't think they were doing exercises to their lower extremities. They stated they were interested in doing ROM exercises especially on their left leg. They were not sure when their left leg started to bend. In an interview on 11/13/2024 at 10:05 AM, informed Staff X, LPN/UM that the exercise instructions were not in Resident 46's wall or in resident's chart. They stated it is usually posted by the wall in resident's room. Staff X stated they were not aware that Resident 46's left lower extremity may be contracted. They stated that when a resident was at risk for developing a contracture, the NAC or the nurse notifies the Unit Manager. The Unit Manager will then get a doctor's order for Physical Therapy to evaluate resident and obtain recommendations to prevent contracture. Staff X stated that they will look at Resident 46 and follow up regarding possible contractures on their leg. In a joint interview on 11/14/2024 at 12:25 PM, Staff A, Administrator and Staff B, RN/Director of Nursing Services (DNS), Staff B stated that they don't have restorative program, but they have restorative tasks that the NAC does, and they come from the therapy department. Unit managers usually receive the recommendations from the therapy department, and they update the care plan, and the NAC does the exercises with the resident. Staff B was not able to provide me a copy of the NAC documentation regarding the ROM exercises for resident per their care plan. <BED CRADLE> In a record review on 11/7/2024, Resident 46's care plan showed: Focus: Activities of daily living self-care deficit as evidenced by increased weakness and history of multiple falls related to physical limitations-Multiple Sclerosis. Under the Interventions: it states: Resident uses bed cradle on her bed for prevention. In an observation on 11/07/2024 at 10:31 AM while Resident 46's was receiving care, did not see a bed cradle. In an interview on 11/07/2024 at 11:07 AM, Staff GG, NAC stated they did not know what a bed cradle was. In a record review on 11/08/2024, Resident 46's electronic chart in the provider orders section showed: Ok to use bed cradle. Order dated 11/02/2023. Reviewed consent about the bed cradle. In an interview on 11/12/2024 at 12:20 PM, Staff FF, RN, stated that a bed cradle was a contraption that they put at the foot of the bed, so the blanket does not touch the resident's feet. They stated that Resident 46 refused to have the bed cradle on their bed, and it was stored in resident's bathroom. In an interview on 11/13/2024 at 10:05 AM, Staff X, LPN/UM, stated that they were not aware that Resident 46 was not using the bed cradle per care plan and that resident refuse to use it. In an interview on 11/14/2024 at 12:25 PM, Staff B, RN/DNS stated that unit managers were the ones that update the care plans, and they usually do it quarterly unless there were changes. They stated that they don't allow nursing staff to update care plans, due to having many agency staff working. Refer to WAC 388-97-1020 (5)(b) .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary activities of daily living care and services for 2 of 4 residents (Residents 5, and 54) reviewed for bathing. The failure to bathe residents per their bathing care plans placed residents at risk for hygiene issues and for diminished quality of life. Findings included . <RESIDENT 5> Resident 5 admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment, dated 08/07/2024, they had no cognitive impairment, and they needed substantial/maximal assistance with bathing, and they were dependent on staff for tub/shower transfers. In an interview on 11/04/2024 at 10:47 AM, Resident 5 stated they had problems with bathing as the nursing assistant gave them a bed bath using the same soapy water to wash their body, then they used the same soapy water to rinse their hair and they felt itchy after. The resident stated they wanted different water to rinse. In an interview on 11/15/2024 at 9:42 AM, Resident 5 stated a couple of times they had refused to bathe because they were tired so they couldn't do it when asked so they had to wait a week without a bath, and evidently if you miss your bath, you are out of luck. Review of a care conference progress note, dated 06/14/2024, showed Resident 5 stated they were not getting their bed baths, and the social worker who wrote this note documented they showed Resident 5 and their family member their bathing schedule and it showed bed baths were being done. Review of a nursing progress note, dated 11/03/2024, showed Resident 5 had been placed on alert for no bath/shower for five days. Review of Resident 5's bathing documentation for 30 days, print date 11/13/2024, showed they wanted to bathe twice weekly. The documentation showed they had been bathed five times in the last 30 days, and they had three documented refusals. In an interview on 11/13/2024 at 2:18 PM, Staff X, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated they had not known about the resident's bathing refusals, and they thought the resident should have been re-offered to bathe the day following their refusals. <RESIDENT 54> Resident 54 admitted to the facility on [DATE]. According to the admission MDS assessment, dated 07/17/2024, the resident had no cognitive impairment. In an interview on 11/04/2024 at 2:48 PM, Resident 54 stated staff don't let them know in advance when they are going to bathe, and they always came at inconvenient times. Review of 30 days of bathing documentation, print date 11/12/2024, showed Resident 54 wanted to be bathed twice a week, and they had four documented refusals. In an interview on 11/13/2024 at 11:18 AM, Staff X stated they were unable to provide any information about the resident's bathing refusals or their lack of documented bathing. Refer to WAC 388-97-1060 (1)(2)(c ) .

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <FALL> <RESIDENT 37> Resident 37 admitted to the facility on [DATE] with diagnoses that included bilateral below the...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <FALL> <RESIDENT 37> Resident 37 admitted to the facility on [DATE] with diagnoses that included bilateral below the knee amputations, type two diabetes mellitus (long term condition in which the body has trouble regulating blood sugar) and high blood pressure. In an interview on 11/05/2024 at 11:41 AM Resident 37 stated they had a fall recently and did not why they had fallen. Review of Resident 37's care plan dated 10/15/024 showed they were at risk for falls related to their balance problems, weakness, obesity, and right and left below the knee amputation. The goal was for Resident 37 to be free from falls. Interventions included anticipating Resident 37's needs, physical therapy evaluation and treatment, and ensure their call light was within reach. In an interview on 11/12/2024 at 9:25 AM Staff L, Registered Nurse (RN)-Unit Manager (UM), stated they were not aware that Resident 37 had fallen. Review of Resident 37's electronic health record showed no documented falls. In a follow up interview on 11/13/2024 at 11:21 AM Resident 43 stated they had a fall during a therapy session. Resident 37 stated they had some pain but was otherwise alright and had just spoken with Staff L today about the fall. In a follow up interview on 11/13/2024 at 11:26 AM Staff L, RN-UM, stated they had spoken to Resident 43, and they had fallen over a weekend with therapy. Review of physical therapy notes dated 11/02/2024 showed Resident 43's right knee buckled while in a therapy session and was lowered to the floor with no injury. In a review of an incident report provided 11/13/2024 showed Resident 43 had an assisted fall while in therapy on 11/02/2024. In an interview on 11/13/2024 at 11:28 AM Staff B stated Resident 43 had a fall while in session with a physical therapist on 11/02/2024, an incident report was not initiated at the time of the fall, and the physical therapist had been educated that any involuntary loss of elevation was considered as a fall and needed to be reported to nursing. This is a repeat deficiency from 12/14/2023 and 08/07/2024. Refer to WAC 388-97-1060(1),(2)(3)(b)(h) Based on observation, interview and record review, the facility failed to provide necessary care and services for 1 of 3 residents reviewed for non-pressure skin conditions (Resident 2), 1 of 2 residents reviewed for falls (Resident 37) and 2 of 4 residents reviewed for medication management (Residents 24 and 88) The failure to provide monitoring and assessment related to wounds, medication management, fluid restrictions and fall prevention placed residents at risk for adverse outcomes and diminished quality of life. Findings included . <SKIN ASSESSMENT> <RESIDENT 2> Resident 2 admitted [DATE] and was a long term resident with diagnoses which included diabetes and chronic ulcer of the lower leg. Review of Resident 2's physician's orders on 11/14/2024 9:31 AM showed the resident received dressing changes to a wound on the left posterior calf (present since admission) twice per week and an order showed wound/measurement by the licensed nurse once per week. Record review Resident 2's care plan on 11/07/2024 showed a care plan problem was not initiated until 11/05/2024 showing venous stasis ulcer to the left calf and instructed staff to follow treatment orders, refer to wound care as needed and conduct wound reviews. Review of Resident 2's clinical record on 11/07/2024 showed the most recent entry for a skin/wound assessment was on 10/22/2024 and stated only no skin concerns. Review of a skin/wound assessment dated [DATE] showed resident 2 had wounds on both legs with no further documentation included. Review of the scanned documents showed no wound specialty documentation in the prior year. In an interview on 11/14/2024 09:55 AM, Staff X, Licensed Practical Nurse, Resident Care Manager, stated Resident 2 had chronic wounds that would come and go and was seeing an outside provider. Staff X could not locate any documentation of the outside provider visit summaries or notes in the record. Staff X stated the facility should be documenting assessments of the wounds on the resident's skin check day. After review of the resident skin check notes, Staff X stated they were not there. Staff X stated the resident used to be followed by the in house wound team but was not being followed any longer and the nursing staff should be following and assessing the wounds for Resident 2. Staff X was not able to determine the current status or when the last thorough assessment of Resident 2's leg wounds had been done. <MEDICATION PARAMETERS> <RESIDENT 24> Resident 24 admitted on [DATE] with diagnoses to include high blood pressure. Review of Resident 24's physician orders directed staff to administer Amlodipine 10 MG once a day for hypertension and to hold the medications if the Systolic Blood Pressure (SBP) was below 110. Review of Resident 24's November Medication Administration Record (MAR) showed the medication was not held on 11/12/2024 for a blood pressure of 100/61. <RESIDENT 88> Resident 88 admitted on [DATE] with diagnoses to include multiple cardiac conditions. Review of Resident 88's physician orders directed nurses to administer Furosemide 40 MG daily, Spironolactone 25 MG daily, Metoprolol Succinate ER twice a day and Sacubriti-Vaslatran twice a day. Each medication directed staff to hold them medication if the SBP was less than 110. In an interview on 11/15/2024 at 8:28 AM, Staff B, Director of Nursing brought in copies of Resident 88's November MAR that was highlighted and said the nurses had received education on following medication order hold prompts. The November MAR showed; -On 11/05/2024 at 8:00 AM, the four medications were not held and administered when the BP was 97/64. - On 11/06/2024 at 8:00 AM, the four medications were not held and administered when the BP was 103/60. The resident received Metoprolol and Sacubitril-Valsartan was administered at 8:00 PM for a BP of 103/60. -On 11/10/2024 at 8:00 AM, the four medications were not held and administered when the BP was 92/57. The resident received Metoprolol and Sacubitril-Valsartan was administered at 8:00 PM for a BP of 92/57. In an interview on 11/08/2024 at 11:19 AM, Staff P, LPN said they take the residents vital sings and if the doctors order showed they should hold the medication for a specific systolic blood pressure, they would hold it. In an interview on 11/14/2024 at 4:48 PM, Staff AAA, Agency RN said they check blood pressures before administering medications that have parameters and they would hold the medication if the blood pressure was too low. In an interview on 11/15/2024 at 11:48 AM, Staff B, Director of Nursing (DNS) said that they talked with a few nurses who said that at the other facilities they worked at, they needed to hold medications for systolic less than a 100. Staff B said they told those staff they needed to read the entire order and hold the medications as instructed. Staff B said weights should be obtained per orders. <WEIGHT MONITORING> Review of Resident 88's physician orders beginning 09/09/2024 directed staff to weigh the resident daily for 3 days , them weekly for 4 weeks then monthly. Review of the medical record showed Resident 88 had three weights since admit (08/26/2024, 08/2024 and 11/13/2024).

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure oxygen (O2) tubing was appropriately maintained, changed regularly, and dated consistently according to with professional standards of practice for 1 of 1 sampled resident (Resident 43) reviewed for O2 tubing. Additionally, the facility failed to ensure 1 of 1 sample resident (Resident 43) physician's orders were followed related to O2. These failures placed the residents at risk for contact with contaminated care equipment, potential respiratory infections, and respiratory distress. Findings included . Review of the facility policy titled, Oxygen Administration, undated, showed the procedure for O2 administration included verification of physician orders and review of the resident's care plan. <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and atrial fibrillation (an irregular heart rate), and obstructive sleep apnea. On 11/06/2024 at 8:41 AM observed Resident 43 wearing a nasal cannula (device used to deliver supplemental oxygen through the nose), the tubing was not dated, and the concentrator was set to 3 1/2 liters per minute (LPM). In an interview on 11/06/2024 at 8:41 AM Resident 43 stated they had a feeling their oxygen would be taken away during and changed to just at night because their oxygen levels go down at night and have low blood pressure. Resident 43 stated they thought their O2 was set at 2 LPM. On 11/07/2024 at 11:07 AM observed Resident 43's O2 tubing not dated. Review of Resident 43's order summary dated 10/22/2024 showed a physician order for O2 at two LPM every night at bedtime. Review of Resident 43's care plan dated 10/24/2024 showed they used O2 at two liters per minute (LPM) by nasal cannula,every night at bedtime. In an interview on 11/12/2024 at 9:29 AM Staff L, Registered Nurse-Unit Manager stated when a resident was ordered O2 they go over all the orders, get orders put in place, put a concentrator in place and the route, how many liters they are on and why they were on it. Staff L stated they make sure there was everything available for the resident and the orders were clear. Staff L stated O2 tubing should be changed weekly but did not know the current process or how it is monitored. Staff L stated they checked Resident 43's record and they were to have O2 at night at bedtime. Reference WAC 388-97-1060 (3)(j)(vi)

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (was one way to treat advanced kidney failure) center for 1 of 1 resident (Resident 43) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre and post dialysis assessments and lack of consistent communication between the facility and the dialysis center about what occurred during HD, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes. Findings included . In a review of the facility's policy titled, End Stage Renal Disease-Care of Resident undated, showed the facility would care residents with end stage renal disease (ESRD) according to recognized standards of care including the immediate monitoring and documentation of the residents condition and access site upon return from the dialysis treatment center. Additionally, the policy outlined agreements between the facility and contracted ESRD facility would include all aspects of how the resident's care would be managed to include: -development of a comprehensive integrated care plan -the communication process between the nursing facility and the dialysis center would reflect ongoing communication, coordination and collaboration <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and atrial fibrillation (an irregular heart rate), and end stage renal disease (when the kidneys permanently fail to work). In a review of Resident 43's dialysis care plan, dated 10/24/2024, showed they were at increased risk for complications due to requiring hemodialysis. Interventions included, weights and vitals before and after dialysis and observation for signs and symptoms of complications related to dialysis. In review of Resident 43's order summary dated 10/18/2024 showed and physician order for nursing to complete a post dialysis assessment to include vital signs and to review the dialysis communication form for any recommendations or new orders at bedtime every Monday, Wednesday, and Friday. Review of the post dialysis assessments in the User-Defined Assessments (UDA) in Resident 43's medical record showed no entries for the following dialysis days: 10/18/2024, 10/23/2024, 10/28/2024, 10/30/2024, 11/01/2024, and 11/06/2024. Only one dialysis communication form was in Resident 43's electronic medical record dated 10/21/2024. In an interview on 11/12/2024 at 9:42 AM Staff L Registered Nurse-Unit Manager stated nurses should be completing the UDA in the resident's medical record when they return from dialysis. Staff L stated there used to be a communication form that was sent to the dialysis center and returned with them, but that is not the process any longer. Staff L stated they did not know who monitored the completion of the UDA's. In an interview on 11/15/2024 at 11:07 AM Staff A, Administrator stated they do not have a contract with the dialysis center in which Resident 43 attended. Reference WAC 388-97-1900(1)(6)(a-c)

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 5 Residents (Resident 74) reviewed for unnecessary medications were free from unnecessary psychotropic medications. Failure to provide complete and accurate informed consent for medications and identify/monitor target behaviors for as needed antipsychotic medication placed residents at risk to receive unnecessary psychotropic medications and experience adverse side effects. Findings included . Resident 74 admitted [DATE] with diagnoses to include anxiety and depression. Review of the admission Minimum Data Set, dated [DATE] showed Resident 74 was their own decision maker. Review of Resident 74's physician's on 11/12/2024 orders showed: An order for Trazodone (an antidepressant medication) dated 04/12/2024. The informed consent provided and signed by the resident on 04/12/2024 failed to include the category of medication or potential side effects. An order for Duloxetine (an antidepressant) dated 08/10/2024. No informed consent was found for this medication. An order for Vistaril (an antianxiety medication) dated 04/12/2024. The informed consent provided and signed by the resident on 04/12/2024 failed to include the category of medication or potential side effects. An order for Ativan (an antianxiety medication) dated 10/24/2024. The informed consent incorrectly checked the category of medication as an antidepressant; therefore, the resident's informed consent did not include the correct potential side effects for antianxiety medications. This medication was ordered every 12 hours as needed for anxiety for 14 Days. Review of the November Medication Administration record on 11/07/2024 showed there was no documentation of target behaviors or non-pharmacological interventions attempted with each administration of the as needed antianxiety medication. In an interview on 11/13/2024 at 12:02 PM, Staff Z, Registered Nurse (RN) stated the facility had an admission nurse and that person or the Resident Care Manager (RCM) would do the admission medication orders and medication consents when a resident admitted . The nurse on the cart should verify that the consent had been done before they administer a medication. Staff Z stated if a new order was received after the resident admitted the cart nurse or the RCM would complete the consents with the residents or the representative. Staff Z stated for psychotropic medications there should be a symptom monitor in the medication administration record. Staff Z stated Resident 74 had symptoms of anxiety every day and took their as needed anxiety medication close to every 12 hours every day. Staff Z reviewed the documentation for Resident 74 and stated there was a symptom monitor for anxiety which was shown to be completed once per shift. Review of that symptom monitor with Staff Z showed most shifts were documented with zero symptoms of anxiety. Staff Z stated if the staff completed the monitor there was no way to go back and add to it, they would have to delete the entry and start over. Staff Z stated there was an auto generated note in the progress notes when the medication was administered and whether it was effective or not, but those notes showed no resident specific symptoms, triggers or non- pharmacological interventions attempted prior to the administrations of the antianxiety medication for Resident 74. In an interview on 11/14/2024 at 10:10 AM, Staff X, Licensed Practical Nurse, RCM, stated medication orders should be reviewed at the time they are entered to ensure there are consents completed and monitors in place. Refer to WAC 388-97-1060(3)(k)(i)

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 1-unit refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants, the maintenance to ensure the kitchen refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . <WALK IN REFRIGERATOR> During an observation 11/04/2024 at 9:48 AM the main refrigerator located in the kitchen had a temperature log on the front door showed no logged temperatures for the PM for 10/28/2024, 10/29/2024, 10/30/2024 and AM and PM for 10/31/2024. During a walk through of walk-in refrigerator on 11/04/2024 at 9:48 AM showed several undated and expired food items: - balsamic vinegar with a use by date 08/25/24 -bag of everything bagels opened not dated -pickle chips opened with a month and day, but no year documented -a container labeled applesauce with a green lid with a preparation date 10/02/2024 -shredded cheese mozzarella in an open bag with no date <WALK IN FREEZER> During an observation 11/04/2024 at 9:48 AM the main freezer located in the kitchen had a temperature log on the front door showed no logged temperatures for 10/28/2024, 10/29/2024, 10/30/2024 and 10/31/2024. During a walk through of walk-in refrigerator on 11/04/2024 at 9:48 AM showed several undated and expired food items: -a bag of frozen unidentified items not dated, located on the second shelf from the top -2 bags of yams not labeled or dated <KITCHEN FOOD PREPARATION AREA> During an observation on 11/04/2024 at 9:48 AM the cooking and meal preparation area there was a handwashing station with a trash can next to it, the flooring soiled with debris. In a follow up visit to the kitchen on 11/12/2024 at 11:08 AM the same debris was observed on the flooring next to the trash. <TRAY LINE> In observation on 11/12/2024 at 11:24 AM observed Staff HHH, Cook, during tray line, took tongs and pushed their glasses up with them, they explained aloud they were doing that in an effort to avoid changing gloves, then plated food on a plate, dropped a piece of cooked cauliflower into the chicken and used the same tongs and took the cauliflower out of the chicken and placed it back into the cauliflower. In an observation on 11/12/2024 at 11:20 AM Staff III, Dietary Aide, placed the desserts on each tray, uncovered, then place the tray into the cart to be delivered. In an interview on 11/12/2024 at 11:35 AM Staff G, Dietary Manager stated they didn't cover the dessert (fruit cup) because they are placed in the cart and the cart was designed to go from room to room when meals were delivered. Staff G stated they used to cover everything and then were told to stop. In an observation on 11/12/2024 at 12:44 PM a test meal tray was received and the dessert (fruit cup) was delivered uncovered, the cart not in sight, In an interview on 11/13/2024 at 9:00 AM Staff G stated all opened items in the refrigerator and freezer are required to be tabled with the date opened and the use by date. Staff G stated the temperature logs were to be filled out daily in the AM and PM and the end of October 2024 was missing the temperatures at which time they provided their staff with education. <NOURISHMENT REFRIGERATOR> In an observation on 11/06/2024 at 2:00 PM, the nourishment refrigerator on the second floor had spilled sticky orange matter down the inside of the door. There was gooey brown melted matter on the bottom of the fridge. In an interview on 11/06/2024 at 2:-05 PM, Staff EE, Nursing Assistant, stated they did not know who was responsible to clean the refrigerators. Refer to WAC 388-97-1100(3)

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 14> Resident 14 admitted to the the facility on 08/08/2024 with diagnoses that included dependence on renal dial...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 14> Resident 14 admitted to the the facility on 08/08/2024 with diagnoses that included dependence on renal dialysis, fracture of the patella (kneecap), and heart disease. Review of Resident 14's progress notes at admission, dated 09/29/2024 at 5:12 PM, showed they readmitted to the facility with no skin issues. Review of Resident 14's skin assessment dated [DATE] showed they had an open area to right buttock. Review of Resident 14's progress notes showed multiple instances of inconsistent information with regard to their skin to include: -A progress note dated 11/13/2024 at 3:19 PM showed the resident had a pressure ulcer. -A progress note dated 11/13/2024 at 3:17 PM showed the resident's skin check yielded no skin issues. -A progress note dated 11/12/2024 at 2:16 PM showed the resident had no skin issues. -A progress note dated 11/12/2024 by the wound care nurse showed the resident had pressure ulcers. In an interview on 11/13/24 11:28 AM Staff B, Director of Nursing (DNS) stated they were not aware of the inconsistencies in Resident 14's electronic medical record. Staff B stated there are electronic form that are built into the medical record and nursing staff might be entering data too quickly without thinking. <RESIDENT 253> Resident 253 admitted to the facility on [DATE] with diagnoses that included acute cystitis (a bladder infection that begins suddenly and usually caused by bacteria). Review of Resident 253's care plan dated 10/31/2024 showed they were on contact precautions related to colonization of extended spectrum beta-lactamases (ESBL-enzymes that make bacteria resistant to many common antibiotics) in their urine and to strictly follow these precautions posted at their door entrance. Review of Resident 253's progress notes showed multiple instances of inconsistent information with regard to the precautions they were on to include: -A progress note dated 11/07/2024 at 7:35 PM showed Infection/Isolation: No active infections noted. Please use standard precautions. -A progress note dated 11/06/2024 at 3:51 PM showed Infection/Isolation: noted to have an active infection: Please use contact precautions -A progress note dated 11/05/2024 at 6:41 PM showed Infection/Isolation: No active infections noted. Please use standard precautions. -A progress note dated 11/04/2024 at 7:10 PM showed Infection/Isolation: No active infections noted. Please use standard precautions. In an interview on 11/15/2024 at 9:42 AM Staff JJJ, Medical Records, stated they had not been completing any audits for nursing records and their access to residents' Electronic Medical Record did not include some of the nursing components. Refer to WAC 388-97-1720(1)(a)(i)(ii)(iv)(4)(a) Based on interview and record review, the facility failed to maintain complete and accurate clinical records for 4 of 4 residents (Residents 41,5,14 and 253) reviewed for care and services. The failure to ensure thorough and consistent documentation of care and services placed residents at risk for unmet needs and diminished quality of life. Findings included . <RESIDENT 41> Resident 41 re-admitted to the facility on [DATE]. Review of Resident 41's September 2024 Medication Administration Records showed an order dated 09/19/2024 for daily weights for three days, and a licensed nurse had signed off they had done the daily weights on 09/19/2024, 09/20/2024, and 09/21/2024. Comparison of this documentation with documented weights showed no documentation these weights had ever been done. In an interview on 11/13/2024 at 2:28 PM, Staff X, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), was unable to provide any information regarding the licensed nurse signing off they did daily weights on 09/19/2024, 09/20/2024 and 09/21/2024. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] In an interview on 11/15/2024 at 9:42 AM, Resident 5 stated they had issues with getting their Glucerna (nutritional shakes) and their daughter had to bring in some protein drinks because they couldn't get them here. Review of Resident 5's breakfast tray card on 11/07/2024 showed the resident was to have Glucerna on their tray. In an observation on 11/07/2024 at 8:23 AM, there was no Glucerna on the resident's breakfast tray. In an interview on 11/07/2024 at 12:30 PM, Resident 5 stated last night was the first time they ever got their nutritional shake. Review of Resident 5's Medication Administration Records (MARS), from 11/01/2024 - 11/07/2024 showed an order dated 10/01/2024 for a Nutritional Shake: no sugar added with meals for supplement and it had a box for the nurse to document the percentage of the shake consumed, but that box always had an X instead of a percentage actually consumed. In an interview on 11/07/2024 at 2:41 PM, Staff AA, Registered Nurse (RN), stated the kitchen usually supplied the nutritional shakes with breakfast and lunch, so they just signed off on the MARs. Staff AA stated they thought they saw the resident drinking a nutritional shake, but now they were not sure. In an interview on 11/07/2024 at 3:00 PM, Staff G, Dietary Manager, stated the kitchen supplied nutritional shakes with meals if they received the order and it said to go with meals. Staff G stated they did not know the resident had an order for a nutritional shake with meals because they never received a communication sheet from nursing staff. Staff G stated their system never showed an order for the nutritional shake. In an interview on 11/07/2024 at 3:02 PM, Staff AA was asked about their documentation of an X on the MARS for amount of nutritional shake consumed, they stated it shouldn't be an X, that it should have been a number percentage.

CONCERN (E)

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to act, respond, and resolve the organized resident group's concerns for 1 of 1 Resident Council groups. The facility administration's failure to respond to the organized group's concerns resulted in an extended period where reported resident care needs went uninvestigated, unidentified and unmet due to the facility's systemic failure to investigate the concerns reported during the Resident Council meetings from May, June, July and August 2024. Additional failed practice included the facility failure to maintain complete and accurate Resident Council meeting minutes that included all concerns and grievances voiced during Resident Council meetings, and failures to log, report, investigate, and resolve concerns voiced by the Resident Council. The non-responsive facility administration's pattern of inaction placed all residents at risk for unidentified, unmet care needs and diminished quality of life. Findings included . In an interview with Resident Council representatives on 11/07/2024 at 10:00 AM: -Resident 50, Resident Council representative, stated overnight call light response times were slower than they should be, and there was a shortage of night shift staff. -Resident 19, Resident Council representative, stated residents were not getting the food they requested, and the facility was not following their menu. Resident 50 stated they thought the facility didn't have all the food on their menus and that staff were not entering their food choices accurately onto their tray cards. Resident 50 stated they thought the problem also was that staff didn't read the menus and they were so hurried with trying to get all the residents their food that they were not accurate. Review of the facility concern/grievance reporting log for May 2024 showed three Resident Council concerns entries, dated 05/23/2024: 1) Aides not hanging clothes in closet, 2) want someone present at nursing stations 24/7, 3) not getting what is on the menu. Review of a Grievance/Suggestion Communication Form, dated 05/23/2024, showed there were four Resident Council grievances: 1) Night shift wait for a long time, 1 hour, for (staff) to come, 2) Aides don't hang clothes in closet when they take them out, they threw clothes in a pile or left them in a chair, 3) nursing station 24/7 someone to be present, 4) diet slips issue, food items missing, not getting what they ordered. This form had boxes to check for who the issues were referred to, but they were all blank. The form had a box to document actions taken to address the concern/complaint/suggestion, but they were all blank. There were no resident names to identify which resident had made the allegations or to identify who could be followed up with during an investigation or to verify resolution. The form indicated it was completed by Staff HH, Director of Activities (DOA). Review of Resident Council meeting minutes, dated 05/23/2024, showed there was no documentation of any of the four grievances listed in the 05/23/2024 Resident Council grievance form completed by Staff HH. Review of three Grievance/Suggestion Communication Forms, dated 05/23/2024, all three prepared by Staff A, Administrator, regarding: 1) the aides not hanging up clothes in the closet, 2) residents wanting someone to be present at the nursing station 24/7. The facility response was to send a letter to residents to update concerns and for activities to follow-up with Resident Council. An attachment to the grievance indicated the facility response was if they did this, it would pull from the floor (staff) and maybe make call-light times longer, and to please ask why they would like someone at the nursing station. Did not find any documentation they had asked why residents wanted staff at the nursing station, and did not find documentation the Resident Council's concern was resolved. 3) residents not getting foods they ordered. The facility response was to send a letter to residents to update concerns and for activities to follow-up at the next Resident Council meeting. There was no documentation any residents had been interviewed to see if their food concerns had been resolved. Review of the next Resident Council meeting minutes, dated 06/27/2024, showed there was still a concern, as residents were missing items on their trays and not what they ordered. Review of the May 2024 incident reporting log showed there was no Resident Council entries for the month of May. In an interview on 11/12/2024 at 8:47 AM, Staff HH, was interviewed regarding the Resident Council Grievance/Suggestion Communication Form, dated 05/23/2024, that did not have any specific resident names listed, they stated if there were no resident names than it was the entire resident council that had issues with that concern. Staff HH stated they had reported the resident council's concern of one hour night shift call light response times to Staff A, Administrator. In an interview on 11/12/2024 at 9:01 AM, Staff A was interviewed regarding the 05/23/2024 grievance regarding the night shift call lights taking an hour for staff to come, they stated the facility had not done anything to investigate those concerns, and they had not logged the concern. Staff A stated they were the facility grievance official. Review of the Resident Council meeting minutes, dated 06/27/2024, showed council concerns about nursing that call lights were taking too long to answer and for dietary there was a council concern about missing items on trays and foods they received were not what they ordered from their menus. There were no attached grievance/concern forms that could be related to these council concerns. Review of the facility concern/grievance reporting log for June 2024 showed the facility had not logged the Resident Council's concerns voiced at the 06/27/2024 Resident Council meeting. Review of Resident Council meeting minutes, dated 07/25/2024, showed Staff B, Director of Nursing, had attended the meeting, and there were nursing concerns of long call light waiting times and personal phones of night shift staff. There was no documentation the last months minutes of the meeting were read and approved, and there was no documentation of resolutions of concerns from the previous month meeting. Review of the facility concern/grievance reporting log for July 2024 showed the facility had not logged the Resident Council's concerns voiced at the 07/25/2024 Resident Council meeting. Review of the Resident Council meeting minutes, dated 08/29/2024, showed council concerns of the night shift call lights taking too long to answer. There were no attached grievance/concern forms that could be related to this council concern. Review of the facility concern/grievance reporting log for August 2024 showed the facility had not logged the Resident Council's concerns voiced at the 08/29/2024 Resident Council meeting. In an interview on 11/12/2024 at 9:36 AM, Staff HH, was interviewed regarding the 05/23/2024 Resident Council minutes that did not have any information about the four Resident Council grievances dated 05/23/2024, they stated if there was a grievance they did not document it in the Resident Council minutes, that they did a grievance form. We discussed that the 06/27/2024 Resident Council minutes showed a concern that call lights were taking too long to answer, Staff HH stated they had not filled out a grievance form, that the minutes were all they had. Regarding the 07/25/2024 Resident Council meeting minutes, stated they didn't think they had filled out a grievance form regarding the council concerns of long call light waiting times and issues with the personal phones of night shift nursing staff. Regarding the 08/29/2024 Resident Council minutes, they stated they didn't think they had filled out a grievance regarding the council concerns of night shift call lights taking too long to answer. In an interview on 11/12/2024 at 10:05 AM, Staff A, stated Resident Council concerns were supposed to be documented in both the Resident Council meeting minutes and on a concern form. Staff A stated the 05/23/2024 Resident Council grievance regarding call lights taking long time/one hour to answer was an allegation that needed to be reported and investigated. In an interview on 11/13/2024 at 9:15 AM, Resident 50, stated staffing and call lights were issues that had never been resolved and nights were the biggest problem. Resident 50 stated they thought there were still issues with night shift and call lights, and they thought that staff maybe took their breaks at the same time as there were times when staff just was not available. Resident 50 stated they thought it was an ongoing issue with night shift and residents not getting their pullups and diapers changed and it just didn't get done for all residents. Resident 50 stated they thought the facility was running short-staffed. Resident 50 stated they had talked to administration about staffing, but not a lot as they were not sure who to go to. In an interview on 11/14/2024 at 8:13 AM, Staff A, stated all grievances were to be reported on the grievance log and they didn't know why the food concerns reported at the June Resident Council meeting did not get logged. Staff A was unable to provide any information why all Resident Council grievances did not get documented on the Resident Council meeting minutes and the grievance form. Staff A stated Staff HH should have reported the night shift staffing concern reported by the Resident Council in May. In an interview on 11/14/2024 at 10:33 AM, Staff HH, stated Staff B attended the July 2024 Resident Council meeting. Staff HH also stated every month after the Resident Council meetings they gave a copy of the meeting minutes to Staff A. Staff HH stated they knew Staff A had been aware of the call lights issues and staffing concerns from May to August as they had given Staff A the meeting minutes. Refer to WAC 388-97-0920 (4)(5)

CONCERN (E)

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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 37> Resident 37 admitted to the facility on [DATE] with diagnoses that included bilateral below the knee amputat...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 37> Resident 37 admitted to the facility on [DATE] with diagnoses that included bilateral below the knee amputations, type two diabetes mellitus (long term condition in which the body has trouble regulating blood sugar) and high blood pressure. In an interview on 11/5/2024 at 9:15 AM Resident 37 stated they were missing a tee shirt, the shirt had cost them around fifty dollars, had told several staff about it, was upset that it was missing and nothing had been done about it. Review of Resident 37's Minimum Data Set (MDS-an assessment tool) dated 10/22/2024 showed their cognition was intact. <Resident 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and atrial fibrillation (an irregular heart rate). In an interview on 11/06/2024 at 9:00 AM Resident 43 stated their favorite pajamas were missing. Resident 43 stated they had informed a staff member, a nursing aide, and there was nothing to do about it. When asked if the aide had provided information about the grievance process to find their missing pajamas, Resident 43 stated they were not aware of the facility grievance process. <RESIDENT 255> Resident 255 admitted to the facility on [DATE] with diagnoses that included high blood pressure and fracture of the left leg. In an interview on 11/04/2024 at 3:19 PM Resident 255 stated they were missing two ice packs and covers for the ice packs that they had brought in from home. Resident 255 stated they reported it to the facility staff, and they had not been found to date. Review of the facility grievance log for September, October and November 2024 showed no entries related to missing belongings for Resident 37, 43 and 255. In an interview on 11/06/2024 at 12:59 PM Staff JJ, Nursing Assistant Certified (NAC) stated they had been working at the facility for about two weeks. Staff JJ stated they did not know of a specific process for missing items but would try to locate a missing item if they were told about it. In an interview on 11/06/2024 at 1:34 PM, Staff II, NAC, stated resident names are written on their clothing. When asked what the process was for when a clothing item goes missing, Staff II stated they would try to locate the missing item, take the resident who was missing the item to laundry, ask housekeeping. Staff II stated they were not aware of a form in which missing items were reported or tracked. In an interview on 11/06/2024 at 1:03 PM Staff N, Registered Nurse, stated they had not received any recent reports of missing items from residents. Staff N stated if a resident reported missing clothing, they would check laundry for the missing item(s). In an interview on 11/06/2024 at 1:56 PM Staff A, Administrator, stated missing items are documented on a grievance form. Staff A stated staff are trained on the grievance process upon hire and at least annually. Staff A stated grievance forms located at nursing stations and in the front lobby. Refer to WAC 388-97-0460 <RESIDENT 2> In an interview on 11/04/24 at 1:51 PM, Resident 2 stated they had personally purchased bed pads and stated they disappeared. Resident 2 stated they tell the aids, and the nurses and staff have told them they are still looking for them. Resident 2 stated they were not aware of any formal grievance being completed related to their missing items. Review of the facility grievance log on 11/05/2024 showed no logged entry for Resident 2 related to missing property concern. Based on interview and record review the facility failed to recognize, record and promptly resolve grievances for 5 of 5 residents (Residents 2, 37, 45, 98 and 255) reviewed for grievances. Failure to implement their grievance process placed the residents at risk for anxiety, undue stress, and a diminished quality of life. Findings included . Review of the undated facility policy titled, Grievances/Complaints-Staff Responsibility showed staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. The procedure showed staff members may inform the resident or the person acting on their resident behalf that he or she may file a grievance or complaint with the Administrator or other government agencies as noted on posting in the facility, without fear oof threat or any form of reprisal. <RESIDENT 98> Resident 98 admitted to the facility on [DATE]. In an interview on 11/04/2024 at 11:53 AM, Resident 98 stated they requested to have a half bed rail placed on her bed, but staff would not let them and said bed rails were deemed illegal by the state. Resident 98 said they asked the staff to position two-winged back chairs up to the bed so they could use them to reposition in bed. Resident 98 said they had asked Staff B, Director of Nursing Services (DNS) to be moved to the room across the hall three weeks ago and they had not been moved nor received an update on when a room change would occur. In an interview on 11/05/2024 at 10:27 AM, Resident 98 said their call light was not working from the first day they admitted until last week. The resident said their air mattress kept breaking at 12:00 AM to 1:00 AM in the morning a couple of times a week. They said the compressor on the bed pump did not come on and then they are lying on the metal frame and when the bed is flat their sciatica kicks in. The resident said they felt bad for the staff because they do not have time to deal with their mattress at night and the pump beeps all night long. Resident 98 said multiple aides and nurses were aware and they had also called the receptionist and asked to be transferred to the maintenance extension where they left two messages about their malfunctioning bed. Review of the concern log showed there were no grievances for Resident 98 regarding their mattress concerns. In an interview on 11/06/2024 at 2:31 PM, Staff J, Maintenance Director said they had not heard a thing about Resident 98's mattress. Staff J said they reviewed the TELS log (platform for staff to report maintenance concerns) and there were no entries about the mattress. Review of the TELS report showed staff had requested with medium priority for maintenance to fix Resident 98's bed air pump that kept beeping loudly on 10/21/2024. Review of the TELS report showed staff had requested with medium priority for maintenance to fix Resident 98's bed and call light that were not working on 10/29/2024. In an interview on 11/07/2024 at 11:00 AM, Resident 98 said they asked staff again about the side rail and were told they were illegal and there was a [NAME] Administrative Code (WAC) about it and the state nurse did not know what they were talking about. Resident 98 came up with the wing chair placement to be able to reposition themselves since using their overbed table was not safe as it moved. The resident said the maintenance man did come in and tell them the mattress issue had not been reported to them or logged but they had called the maintenance line twice. In an interview on 11/12/2024 at 9:29 AM, Resident 98 said they were still awaiting side rails and staff placed a wheelchair at bedside to use for turning. Resident 98 said they had their daughter bring in their skin medications last Thursday (11/07/2024) so they could show the nurse so they could request orders for them. Resident 98 said the nurses have lost two of their three medications including their expensive Clobetasol and Nystatin. The resident said the nurses keep telling them they are looking for them. Resident 98 said they were unaware if a grievance had been completed for their concerns. In an interview on 11/13/2024 at 1:44 PM, Resident 98 stated they had received their new mattress. The resident said Staff I, Social Services came in and asked if they had any grievances and she responded Yes, my missing medications. In an interview and observation on 11/14/2024 at 9:33 AM was sitting in their wheelchair smiling. Resident 98 said they loved their new room where they can watch the birds, courtyard activity and see the sunshine. The resident said the room move had improved her mood. Resident 98 said they did not know why they couldn't be moved over three weeks ago when they initially asked, and they remarked the initial request for the room move was a negative experience. The resident said they were still awaiting side rails, and no one had offered them reimbursement for the medications. In a joint interview on 11/15/2024 at 11:48 AM with Staff A, Administrator and Staff B, Director of Nursing said they were unsure why grievances were not created for Resident 98's concerns.

CONCERN (E)

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure residents were free from abuse and neglect due the facility failure to respond to and resolve nursing care, staffing and food services grievances voiced by 1 of 1 organized resident groups over a four-month period from May to August 2024. Facility administration chose to address only select grievances and opted not to address reported nursing staffing and food service concerns. The facility administration's systematic failure to investigate and act on residents' reported concerns deprived an unknown number of residents necessary nursing care and food service support, the extent of which could not be ascertained due to a gross lack of documentation and overt failures in the facility's Resident Council/Grievance procedures. The facility failure to ensure the necessary processes, procedures and structures were in place to prevent abuse and neglect placed all residents at risk for ongoing abuse and neglect, unmet needs, weight loss and diminished quality of life. Findings included . In an interview with Resident Council representatives on 11/07/2024 at 10:00 AM, Resident 50, Resident Council representative, stated overnight call light response times were slower than they should be, and there was a shortage of night shift staff. Both Residents 50 and 19 voiced concerns about the facility food service program as residents were not receiving the foods they had requested. Review of the facility concern/grievance reporting log for May 2024 showed three Resident Council concerns entries, dated 05/23/2024: 1) Aides not hanging clothes in closet, 2) want someone present at nursing stations 24/7, 3) not getting what was on the menu. Review of a Grievance/Suggestion Communication Form, dated 05/23/2024, showed there were four Resident Council grievances: 1) Night shift wait for a long time, 1 hour, for (staff) to come, 2) Aides don't hang clothes in closet when they take them out, they threw clothes in a pile or left them in a chair, 3) nursing station 24/7 someone to be present, 4) diet slips issue, food items missing, not getting what they ordered. This form had boxes to check for who the issues were referred to, but they were all blank. The form had a box to document actions taken to address the concern/complaint/suggestion, but they were all blank. There were no resident names to identify which resident had made the allegations or to identify who could be followed up with during an investigation or to verify resolution. The form indicated it was completed by Staff HH, Director of Activities (DOA). Review of Resident Council meeting minutes, dated 05/23/2024, showed there was no documentation of any of the four grievances listed in the 05/23/2024 Resident Council grievance form completed by Staff HH. Review of three Grievance/Suggestion Communication Forms, dated 05/23/2024, all three prepared by Staff A, Administrator, regarding: 1) the aides not hanging up clothes in the closet, 2) residents wanting someone to be present at the nursing station 24/7. 3) residents not getting foods they ordered. There was no documentation any residents had been interviewed to see if their food concerns had been resolved. Review of the next Resident Council meeting minutes, dated 06/27/2024, showed there was still a concern, as residents were missing items on their trays and not what they ordered. In an interview on 11/12/2024 at 8:47 AM, Staff HH was interviewed regarding the Resident Council Grievance/Suggestion Communication Form, dated 05/23/2024, and stated that the form did not have any specific resident names listed, they stated if there were no resident names than it was the entire resident council that had issues with that concern. Staff HH stated they had reported the resident council's concern of one hour night shift call light response times to Staff A. In an interview on 11/12/2024 at 9:01 AM, Staff A was interviewed regarding the 05/23/2024 grievance regarding the night shift call lights taking an hour for staff to come, and they stated the facility had not done anything to investigate those concerns, and they had not logged the concern. Review of the Resident Council meeting minutes, dated 06/27/2024, showed council concerns about nursing that call lights were taking too long to answer and for dietary there was a council concern about missing items on trays and foods they received were not what they ordered from their menus. There were no attached grievance/concern forms that could be related to these council concerns. Review of the facility concern/grievance reporting log for June 2024 showed the facility had not logged the Resident Council's concerns voiced at the 06/27/2024 Resident Council meeting. Review of Resident Council meeting minutes, dated 07/25/2024, showed Staff B, Director of Nursing, had attended the meeting, and there were nursing concerns of long call light waiting times and personal phones of night shift staff. There was no documentation of resolutions of concerns from the previous month meeting. Review of the facility concern/grievance reporting log for July 2024 showed the facility had not logged the Resident Council's concerns voiced at the 07/25/2024 Resident Council meeting. Review of the Resident Council meeting minutes, dated 08/29/2024, showed council concerns of the night shift call lights taking too long to answer. There were no attached grievance/concern forms that could be related to this council concern. Review of the facility concern/grievance reporting log for August 2024 showed the facility had not logged the Resident Council's concerns voiced at the 08/29/2024 Resident Council meeting. In an interview on 11/12/2024 at 9:36 AM, Staff HH was interviewed regarding the 05/23/2024 Resident Council minutes that did not have any information about the four Resident Council grievances dated 05/23/2024, they stated if there was a grievance they did not document it in the Resident Council minutes, they completed a grievance form. We discussed that the 06/27/2024 Resident Council minutes showed a concern that call lights were taking too long to answer, Staff HH stated they had not filled out a grievance form, that the minutes were all they had. Regarding the 07/25/2024 Resident Council meeting minutes, Staff HH stated they didn't think they had filled out a grievance form regarding the council concerns of long call light waiting times and issues with the personal phones of night shift nursing staff. Regarding the 08/29/2024 Resident Council minutes, Staff HH stated they didn't think they had filled out a grievance regarding the council concerns of night shift call lights taking too long to answer. In an interview on 11/12/2024 at 10:05 AM, Staff A stated Resident Council concerns were supposed to be documented in both the Resident Council meeting minutes and on a concern form. Staff A stated the 05/23/2024 Resident Council grievance regarding call lights taking long time/one hour to answer was an allegation that needed to be reported and investigated. In an interview on 11/13/2024 at 9:15 AM, Resident 50, Resident Council Representative, stated staffing and call lights were issues that have never been resolved and nights were the biggest problem. Resident 50 stated they thought there were still issues with night shift and call lights, and there were times when staff just was not available. Resident 50 stated they thought it was an ongoing issue with night shift and residents not getting their pullups and diapers changed and it just didn't get done for all residents. Resident 50 stated they thought the facility was running short-staffed. Resident 50 stated they had talked to administration about staffing, but not a lot as they were not sure who to go to. In an interview on 11/14/2024 at 10:33 AM, Staff HH stated Staff B came to the July Resident Council meeting. Staff HH also stated every month after the Resident Council meetings they gave a copy of the meeting minutes to Staff A. Staff HH stated they knew Staff A had been aware of the call lights issues and staffing concerns from May to August as they had given Staff A the meeting minutes. Refer to WAC 388-97-0640 (1)

CONCERN (E)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 50> Resident 50 admitted to the facility in 2022. Review of Resident 50's clinical record on 11/12/2024 showed...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 50> Resident 50 admitted to the facility in 2022. Review of Resident 50's clinical record on 11/12/2024 showed an incident note dated 10/31/2024 showing the resident alleged that a nursing assistant left them in the bathroom for over an hour with their call light on 10/27/2024. Review of the state reporting log showed the facility failed to report Resident 50's allegation to the state agency as required until 11/07/2024. Based on observation, interview, and record review, the facility failed to ensure systems were in place for staff following and implementing abuse and neglect policies & procedures for reporting, investigation, and protection for 3 of 11 residents (Residents 15, 50, and 84), reviewed for abuse and neglect. The failure to identify potential abuse, timely report allegations of potential abuse, complete timely and thorough investigations of the potential abuse, assess and monitor the residents for physical and psychosocial harm, notify responsible parties and providers, and to document the allegations and revise resident care plans placed residents at risk for injury, fearfulness, frustration, humiliation, and further potential abuse. Findings included . A review of the facility's policy titled, Abuse dated 10/01/2021, showed the organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom. The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of resident and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The policy directed facility staff to: 1. Screening: The organization will screen potential employees for a history of abuse, neglect or mistreating residents including background screening, employment/reference checks. 2. Training: Facility employees will be required to complete the comprehensive orientation program that includes how staff should report their knowledge of allegations without fear of reprisal and what constitutes abuse, neglect, mistreatment of and misappropriation of resident's property. 3. Prevention: The facility will not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect .or mistreatment of individuals by a court of law. The organization will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and or misappropriation is more likely to occur. The supervision of staff to identify inappropriate behaviors, such as derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in the beds. 4. Identification: Staff are encouraged to identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure that resident needs are being met in accordance with the plan of care . Administrative and facility leadership staff will supervise staff to identity inappropriate behaviors, action and response to resident needs. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure that resident needs are being met in accordance with the plan of care, that residents are being supervised and that the environment is free of hazards. 5. Investigation: Designated staff will immediately review and investigate all allegations or observations of abuse. The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 6. Protection: ln the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. Other residents who may have potentially been affected or at risk will be identified and a plan of care will be developed or revised as appropriate to ensure their safety. When specific staff is identified as being allegedly involved in the abuse allegation, the staff may be reassigned or suspended during the investigation. 7. Reporting: The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services. < RESIDENT 15> Resident 15 admitted on [DATE] with diagnoses to include kidney failure requiring dialysis (procedure to remove excess water and toxins from blood when kidneys are no longer functioning properly), depression, muscle weakness and right above the knee amputation. Review of the 08/01/2024 Fall Care Area Assessment (CAA) showed Resident 15 was a fall risk related to factors including weakness, poor trunk control and assistance was needed with all mobility and transfers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident 15 was cognitively intact and had lower extremity impairment on one side. In an observation and interview on 11/05/2024 at 1:25 PM, Resident 15 was observed sitting in their wheelchair with their right stump on the elevating leg rest. Resident 15 stated, It takes too d**n long to get your call light answered. An hour or two usually. The day before yesterday, the aide left me on the bedside commode for 45 minutes after lunch time. The aide told me to put my call light on when I was done. I did but waited and waited for 45 minutes. My butt was killing me. It hurts to be sitting on that (commode) and trying to stay up right. I was so mad. I told my nurse about it. Resident 15 stated their sitting balance was not good. Review of the concern and incident reporting logs on 11/05/2024 showed they did not include any concerns related to Resident 15. In an interview on 11/05/2024 at 1:54 PM, Staff A, Administrator and Staff C, Administrator in Training said they had not been informed about this allegation. In an interview on 11/05/2024 at 2:53 PM, Staff K Occupational Therapist (OT) was asked about Resident 15. Staff K said last week on Thursday (10/31/2024) or Friday (11/01/2024) essentially one of our therapists was walking by and had heard a noise from Resident 15's room, so they knocked, and Resident 15 reported they had been on the bedside commode for 40 minutes. Staff K said after that the resident was then hesitant to do toilet training during their therapy session that day which was unfortunate because that is what the resident needed to work on. Staff K commented that the commode is not the softest surface and 40 minutes is a long time sitting down. Staff K said they left a note about the resident's concern on their manager's desk. Staff K said they were not sure if their training had included neglect. <RESIDENT 84> Resident 84 admitted on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident had no cognitive impairment. In an interview on 11/05/2024 at 8:56 AM, Resident 84 stated, when they first were moved into their new room, the week after September 11th they had issues with Staff F, Nursing Assistant Registered (NAR). Resident 84 stated Staff F was d**n scary. The resident said one night they had to call the aide three times because of diarrhea. The resident stated Staff F told them, You stop calling us. I cannot come in here and keep changing you. Just soil your brief and we will change you when we get to you. Resident 84 said, Do you know how much that makes your butt sore. No one should have to be in a soiled brief. The resident said Staff F told them We have other patients to take care of. Resident 84 said, (Staff F) needs to go work somewhere else, I am afraid of them they scare me. I haven't been that intimidated since high school, but I was braver then too. I now do not call anyone for help at night because I am scared, (Staff F) will come in. Staff F said they did not want them as their aide at all. Resident 84 said they said they reported this to Staff K, who said they could file a complaint and ask for Staff F not to care for them. Resident 84 said Staff F came into their room the other night and was very intimidating. In an interview on 11/05/24 at 2:50 PM, Staff K stated they needed to report allegations to their superior. Staff K said they would report concerns to Staff RR, Director of Rehab (DOR). They said if the allegation occurred over a weekend there may be a manager of the weekend, and they would report it to the Medicare team. Staff K said there were some concerns about a caregiver reported to them. They said they were told to report no matter how big or small the concern was. Staff K said two weeks ago, Resident 84 had concerns about their care, so they reported it to the unit managers. Staff K said Resident 84 reported to them that when they were in the other room, they had a concern about Staff F. The resident said they were no longer walking to the bathroom at night and Staff F told the resident to just go to the bathroom in their brief. Staff K said they wrote up a grievance and went to give it to the unit manager, but they were not at the facility, so they left it on their desk with a note. Staff K said they remembered it very vividly. Staff K said Resident 84 received improper care since during the day, the day aides or they would help the resident to the toilet. Staff K said the resident should have been supervised to the bathroom. In an interview on 11/06/2024 at 1:52 PM, Resident 84 stated they were scared and intimidated by Staff F. In an interview on 11/12/2024 at 9:40 AM, Resident 84 stated staff had been nice lately. The resident stated Staff F was just dreadful. In an interview on 11/14/2024 at 11:28 AM, Staff A, Administrator said Staff F would not be returning to work in the facility. Staff F was unable to be interviewed. <STAFF INTERVIEWS> In an interview on 11/05/2024 at 2:30 PM Staff XX, LPN stated they were aware of their responsibility as a mandated reporter, but reported all allegations to their manager or the DNS only and they would then report it to the state hotline. In an interview on 11/05/2024 at 2:37 PM Staff VV, Nursing Assistant Registered, stated if a resident reported they waited for two hours to get their brief changed, they would help the resident and then notify the nurse. Staff VV stated they were not aware of any other reporting requirements. In an interview on 11/05/2024 at 2:53 PM, Staff K OT stated they filled grievance forms when there was a concern voiced by residents and left for their manager or the unit nurse managers. Staff K stated they reported all allegations to their superior, Staff RR. In an interview on 11/05/2024 at 2:19 PM Staff KK, OT, stated they had not called in any allegations of abuse/neglect to the state hotline, they fill out grievance forms for any resident complaints, and the management would make a report to the hotline. In an interview on 11/05/2024 at 2:18 PM DDD, NAC stated if a resident reported they waited for two hours to get their brief changed, they report to the department of health and the nurse. In an interview on 11/05/2024 at 2:30 PM Staff N, RN stated the facility's policy was to report abuse and if there was an allegation they would report it to a manager. Staff N stated if a manager was not available such as over the weekend, they would just report it to the hotline. In an interview on 11/08/2024 at 10:39 AM Staff RR stated they had been at the facility for 13 years and the long-standing culture of the facility was to report all allegations to Administration (DNS and Administrator), and they would decide when and if a report to the hotline would be done. In an interview on 11/08/2024 at 11:10 AM, Staff P, LPN said if a resident reported they had not been changed in an hour that would be neglect. Staff P said they would report the concern to their unit manager and report the NAC's license. In an interview on 11/08/2024 at 11:25 AM, Staff LL, NAC said if they could not solve the issues, they would discuss allegations with their superior, nurse or charge nurse. Staff did not verbalize the need to report to the hotline. <RESIDENT COUNCIL> Review of Resident Council meeting minutes and/or Resident Council Grievance/Suggestion Communication forms, dated: -05/23/2024: showed there was a resident care issue with night shift and waiting for a long time, 1 hour, for staff to come. -06/27/2024: showed a concern with nursing and call lights taking a long time to answer. -07/25/2024: showed a nursing concern of long call light waiting. The Resident Council minutes also indicated Staff B, DNS had attended that council meeting. -08/29/2024: showed a nursing concern of night shift call lights taking a long time to answer. Review of the incident reporting logs for May - August 2024 showed the facility had not logged any of the Resident Council's concerns about night shift, call lights taking too long to answer. In an interview on 11/12/2024 at 9:01 AM, Staff A, Administrator, stated the facility had not done anything to investigate or log the 05/23/2024 Resident Council allegation of night shift call lights taking an hour for staff to answer. In an interview on 11/12/2024 at 10:05 AM, Staff A, Administrator, stated the allegation of call lights taking long time/one hour was an allegation that needed to be reported and investigated. In an interview on 11/13/2024 at 9:15 AM, Resident 50, Resident Council Representative, was asked about the Resident Council's call light and staffing issues the Resident Council had reported to the facility from May - August 2024, they stated staffing and call light issues had never been resolved and they thought that nights were the biggest problem. The resident stated at night sometimes staff just were not available. Resident 50 stated they had concerns with residents' pullups and diaper changes sometimes didn't get done for all residents and it was kind of an ongoing issue that residents could not get changed and could still be wet in the morning. The resident thought the facility was running short-staffed. Resident 50 stated they had talked to administration about staffing, but not a lot of them because they didn't know who to go to, and they stated they had also talked to the director of nursing. In an interview on 11/14/2024 at 8:13 AM, Staff A, Administrator, stated Staff HH, Director of Activities, should have reported the night shift staffing concerns voiced by the Resident Council in May 2024, and Staff H had not reported them. In an interview on 11/14/2024 at 10:33 AM, Staff HH, Director of Activities, stated they knew Staff A, Administrator, was aware of the call light issues and staffing concerns from May - August, because they themselves had given them the resident council minutes. Staff HH state they had not reported the resident council's concerns to the abuse/neglect hotline, but they did know they were a mandated reporter. Staff HH stated they knew they were in a key role as residents did come to them for issues regarding their care. In an interview on 11/05/2024 at 2:32 PM, Staff TT, NAC, did not know they were to report allegations of abuse or neglect to the state survey agency hotline. Review of an incident investigation, dated 11/13/2024, showed the facility had conducted an investigation, but it was not thorough as there were no interviews or witness statements from Staff A, Administrator, Staff B, Director of Nursing, or Staff HH, Director of Activities, regarding their roles in the facility's non-response to four months of documented Resident Council staffing concerns. The investigation was also not thorough, as there were no interviews or witness statements from the Resident Council President, [NAME] President, or any other Resident Council representatives that could have provided information about the council's concerns and what their concerns had been from May to August. The investigation did not include any documentation whether the facility had substantiated abuse/neglect. The investigation really was not focused at all, as the investigation indicated it addressed the past three months of Resident Council concerns, but the council meeting minutes and related grievances showed documented council concerns from May to August. The investigation did not indicate if the council's concerns had been verified and it did not include any documentation of corrective actions taken regarding the facility's failure to respond to documented council concerns. This is a repeat deficiency from 12/14/2023 and 06/07/2024. Refer to WAC 388-97-0640 (2)(a)(b)(5)(6)(a)(b)(7)(a)

CONCERN (E)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 46> Resident 46 admitted to the facility on [DATE] with diagnosis to include Multiple Sclerosis (a disease that ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 46> Resident 46 admitted to the facility on [DATE] with diagnosis to include Multiple Sclerosis (a disease that causes the breakdown of the protective covering of the nerves). Resident was able to verbalize needs and responded appropriately when questions were asked. In an interview on 11/06/2024 at 12:42 PM, Staff FF, Registered Nurse (RN) stated, Resident 46 was alert and oriented but forgetful, and requires total assist with care. In an interview on 11/06/2024 at 1:20 PM, Resident 46 stated that it bothered her that staff did not respond to her yelling and that they waited for an hour and a half before staff responded when they fell on [DATE]. Record review on 11/13/2024 of an allegation of neglect investigation for Resident 46 dated 11/05/2024 at 7:25 AM, showed resident had a fall and reported that they were on the floor for 2-3 hours. According to their final review and summary, it stated that Resident 46 sustained a fall on 11/5/2024 and was heard yelling for assistance. Staff B, RN/Director of Nursing Services (DNS) was the first responder to the scene and stated that they heard resident yelling for assistance and when they entered the room, found resident on the floor and resident stated that they were on the floor for 2-3 hours and later on, resident stated 5-6 hours to the State Surveyor. A statement from Staff M, Nursing Assistant Certified (NAC), an agency staff, who was the alleged perpetrator (AP), stated that resident 46 declined staff to be in her room overnight and they did not hear any yelling when they walked by resident's room multiple times during the night. The summary ruled out that resident was on the floor for a long period of time due to resident did not sustain any deep tissue injury. Staff M will no longer be allowed to return to the facility due to concerns about customer service and rounding in resident rooms. Reviewed interviews made to other residents, the questions staff asked to resident were if they felt their needs were taken care of in a timely manner on day shift, and if they felt good about the care, they received that day. It did not have the date of when the interview occurred, and it did not ask about the care they received at night shift which was the shift the AP was working. There were no documents of interviews made to the staff that worked with the AP at the time of the incident. In an interview on 11/14/2024 at 12:10 PM, Staff B, RN/DNS stated that they don't remember if they got statement from the nurses and NAC's that worked with the AP at the time of the incident, but they will look into their file and will give it to me if they find them. Received and reviewed a witness statement from a nurse on 11/15/2024 but there was no date on when the statement was written, and the statement was not signed. There were no interviews or statements from the NAC's that worked with the AP and the day shift staff present at the time of the incident. The investigation made by the facility was not thorough, there were no statements from the staff that worked with AP and specific residents that were assigned to the AP when the incident happened. <RESIDENT 6> Resident 6 was admitted to the facility on [DATE] with diagnoses to include stroke with left side hemiplegia (muscle weakness or paralysis on one side of the body), left hand contracture (a permanent tightening of muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) and right above knee amputation. According to the quarterly Minimum Date Set (MDS - an assessment tool) assessment dated [DATE] resident had mildly impaired cognition. In an interview on 11/12/2024 at 1:08 PM, Resident 6 stated they did not know how they got the bruise on their left arm. They added that the NAC that helped them in the shower was very short and frustrated during care. Resident also stated a police officer came and talked to them about the incident during shower and about their bruise and took pictures of their arm. Resident denied any more interaction with the staff that was rude to her. Review of the incident and investigation report on 11/13/2024 showed that the alleged abuse happened on 11/07/2024 at 8:42 AM. It stated that Resident 6 reported she had issues with the shower aid during their last shower and resident felt the NAC was verbally inappropriate and felt disrespected. There was a noted bruise from unknown origin after the reported shower. The report stated that they suspended the staff, but it did not name who the staff was. According to the report, resident was on 2 blood thinner medicines making them susceptible to bruising. It stated in the report that the NAC/AP was going to give shower to resident and during transport to the shower room, resident had bowel incontinence, then when shower was done, resident had another bowel incontinence and while the NAC/AP was cleaning resident that the NAC appeared irritated. It stated that the NAC/AP was educated related to dignity and respect. The note stated that resident repeatedly denied staff being rough or abusive and abuse and neglect was ruled out. Reviewed the printed copy of a text message from Staff UU, NAC/AP, no date, time was 7:22 PM. The text stated that Staff UU gave Resident 6 a shower and had bowel incontinence during transport to shower room and after shower before transferring resident off the shower chair. It stated that resident was very apologetic, and Staff UU told resident that there was no need to be sorry. Staff UU also stated that there was another NAC with her when they transferred resident to and from the shower chair. There was no statement seen for the other NAC that helped the AP. There were no statement from the resident's room mate. There were no other statements from any other staff that worked with the AP. Reviewed 2 pages of Counseling and Education form for Staff UU, NAC/AP and they were not signed. In a yellow highlighter, there was a note stating: copy, pending education. The investigation note stated they had educated staff related to dignity and respect. There were interviews and observations of residents and staff interviews, and they were dated 11/14/2024 which was 7 days passed the incident date. None were specific questions related to the incident. In a joint interview on 11/14/2024 at 12:10 PM, Staff A, Administrator and Staff B, RN/DNS, Staff A stated that they have not done their education and counseling with Staff UU, NAC/AP and they have not yet determined whether they will have Staff UU continue to work or not. Staff B was not able to give me copy of a statement from the NAC that was with Staff UU. There were no other interviews done with other staff that worked with Staff UU on the day of the incident. The facility failed to provide a thorough investigation, investigation was not completed at the time frame required. Based on observation, interview and record review, the facility failed to conduct a thorough investigation for 17 of 20 resident investigations (6, 15, 46, 78, 84, 454, 58, 2, 80, 31, 11, 56, 19, 66, 62, 46, 12) and 1 of 1 organized resident group (the Resident Council) reviewed for accidents and allegations of potential abuse and/or neglect . The facility failed to identify the root cause, and all contributing factors related to allegations of abuse and/or neglect placed residents at risk for injury, and additional abuse/neglect. Findings included . <RESIDENT 15> Resident 15 admitted on [DATE] with diagnoses to include cardiac disease, right above the knee amputation (AKA), muscle weakness and diabetes. The resident was alert and oriented with no cognitive impairment and required two-person extensive assistance for toileting. In an interview on 11/05/2024 at 1:25 PM, Resident 15 was sitting in a wheelchair with their right stump on an elevating leg rest. Resident 15 said It takes too damn long to get your call light answered. An hour or two usually. The day before yesterday, the aide left me on the bedside commode for 45 minutes after lunch time. They told me to put my call light on when I was done. I did but waited and waited for 45 minutes. My butt was killing me. It hurts to be sitting on that and trying to stay up right. I was so mad. I told my nurse about it. The resident said his sitting balance is not good. They pointed to their stump and said they couldn't get this d**n thing to cooperate. Review of an abuse allegation investigation for Resident 15 dated 11/05/2024 at 4:35 PM, showed the resident reported being left on the commode for 45 minutes and no one answered the call light. The summary showed multiple aides interacted with this resident that day and at no time did the resident express concerns with being on the commode too long. The summary included a statement that the resident was on the commode for no longer than 30 minutes, the time their NAC was on break. The residents statements of being left on the commode for 40-45 minutes was consistent during their investigation. In an interview on 11/05/2024 at 2:53 PM, Staff K, OT said Resident 15 had reported to them that last Thursday or Friday they were left on the bedside commode for 40 minutes. Staff K said another therapist heard a noise while walking by Resident 15's room and went into the room at which time Resident 15 reported they were on the commode for 40 minutes. Review of a statement included with the investigation from Staff K, OT on 11/05/2024, showed they did not assist Resident 15 on or off the commode on 11/03/2024. Review of the statement from Staff ZZ, NAC dated 11/05/2024 showed they answered the call light and where unsure what time, with their orientee and assisted Resident 15 to the commode with the sit to stand machine , made sure the resident had their call light , and left their room. Staff ZZ said they told Staff M, Agency NAC that they had put Resident 15 on the commode and Staff M told Staff ZZ and their trainee they had it from there and would take care of the resident when they were done. Review of a statement from Staff E, said that on Sunday before lunch they answered Resident 15's call light and the resident said they were done on the commode, so Staff M and Staff E assisted him. Review of a statement from Staff M, Agency NAC on 11/05/2024 at 4:21 PM showed they helped Resident 15 onto the commode and took their lunch break and informed other staff they were going on their break. Staff M said when they returned, they assumed everything was fine as Resident 15 did not say anything. Staff M said Resident 15 used the commode multiple times that day and they were not exactly sure what time the complaint was. Review of a second statement from Staff M, Agency NAC received on 11/06/2024 at 8:23 AM showed before their lunch break, they communicated to the other NAC's they were stepping away. Resident 15 had said he needed to use the commode and Staff ZZ, NAC said they would assist them. When Staff M returned from their break, they found Resident 15 still on the toilet visibly upset. Resident 15 yelled at them and said they had been on the toilet for a long time. Staff M told them they had been on break and someone else should have assisted them. The facility failed address conflicting statements from Staff M. The investigation did not include a statement from the Staff YY, NAC present for the transfer. The investigation did not include a timeline as some statements did not include times. <RESIDENT 78> Resident 78 admitted on [DATE] and was cognitively intact. Review of a grievance dated 10/29/2024 written by Staff K, OT showed CC 1, spouse of Resident 78 reported on 10/28/2024 they were upset with staff because the hospital stated Resident 78 was dehydrated and the nurses do not provide enough water. The grievance was not immediately escalated to an abuse or neglect investigation. Review of an investigation on 11/06/2024 at 4 PM, showed Resident 78 reported staff was not giving them enough water, they wait an hour for toileting assistance, they fell, and no one answered the call light, and the nurse did not know how to administer medications through their enteral tube (surgically implanted tube to administer nutrition). Review of the investigation included a note on 11/12/2024, two days after the investigation was to be completed. The notes showed the resident was to receive nothing by mouth but did not address that the resident had fluid needs through their enteral tube and orders to provide these fluids. There was an attached Medication Administration Record for October that showed wide variances in the water flushes from none to 30 ml to 1700 ml. There was no analysis of the fluid intake in correlation to the allegations. The investigation showed they were unable to rule out or substantiate a fall. Staff B, Director of Nursing documented after a review of notes from the facility and hospital , there was no mention of a fall. Review of the physician hospital note on 09/27/2024 showed the resident reported a fall yesterday when they felt like they were choking and lost their balance and fell and hit their right forearm. In an interview on 11/13/2024 at 2:53 PM, Resident 78 said Staff D, Registered Nurse( RN) had given them pills and they were in a hurry, so they told the aide (an unidentified male who had long hair in a ponytail) to watch her swallow the pills because she needed supervision. Resident 78 said when the NAC left, they choked on their baclofen pill. They said they couldn't reach the call light as it was on the other side of the bed, they fell and their tray of food went flying, it was loud and there was food all over the floor. Resident 78 said Staff D came in and said, You scared me and they helped me off the floor. In an interview on 11/13/2024 at 9:57 AM, Collateral Contact (CC1) , spouse of Resident 78 said the second day here, Resident 78 said they needed to go to the bathroom, and they called for an hour, and no one showed up. CC 1 said he asked the nurse why his loved one called, and no one came in when their light was on. Review of the progress notes did not show a choking incident or fall for Resident 78. Review of the incident reporting log showed no fall or choking event for Resident 78. The investigation did not include statements from staff about the allegations of dehydration, fall, a choking episode, or their call light not being answered while at the facility. In an interview on 11/13/2024 at 4:28 PM, Staff A, Administrator said they were unaware Staff D, RN did not document or report the fall or choking event both of which would need to be further investigated. <RESIDENT 84> Resident 84 admitted on [DATE] and was cognitively intact. In an interview on 11/05/2024 at 8:56 AM, Resident 84 stated, when they first were moved into their new room, the week after September 11th they had issues with Staff F, Nursing Assistant Registered (NAR). Resident 84 stated Staff F was damn scary. The resident said one night they had to call the aide three times because of diarrhea. The resident stated Staff F told them, You stop calling us. I cannot come in here and keep changing you. Just soil your brief and we will change you when we get to you. Resident 84 said, Do you know how much that makes your butt sore. No one should have to be in a soiled brief. The resident said Staff F told them We have other patients to take care of. Resident 84 said , (Staff F) needs to go work somewhere else. I am afraid of them. Staff F scares me. I haven't been that intimidated since high school, but I was braver then too. I now do not call anyone for help at night because I am scared, (Staff F) will come in. Staff F said they did not want them as their aide at all. Resident 84 said they said they reported this to Staff K, Occupational Therapist who said they could file a complaint and ask for Staff F not to care for them. Resident 84 said Staff K came into their room the other night and was very intimidating. Review of an incident investigation dated 11/04/2024 at 12:09 PM showed the resident reported to the state that around the time they moved to a private room (09/17/2024) they had diarrhea and Staff F, NAR told them to stop calling them as they had other patients to take care of and to soil their brief. In an interview on 11/05/2024 at 2:50 PM, Staff K, OT said they would report concerns to their supervisor and if it was the weekend they would report to them. Staff K said Resident 84 reported to them concerns with Staff F, NAR told Resident 84 to just go to the bathroom in their brief. Staff K said they wrote up a grievance went to give it to the nurse manager but there were not there, so they left a note on their desk. Review of a email from 11/05/2024 at 1:23 PM to Staff F, NAR from Staff B, Director of Nurses showed a request for a statement regarding Resident 84 who reported they told them to have a bowel movement in their brief and were unpleasant in their interactions and Resident 98 reported you scratched them with Velcro and do not clean their peri area well and they also stated that you have an unpleasant attitude when interacting with them. Review of an electronic statement received from Staff F on 11/05/2024 at 3:51 PM, showed they didn't tell Resident 84 to have a bowel movement in their brief. Review of the investigation did not include a through statement Staff F. There was no statement from Staff K or the unit managers. There was no additional information to clarify the other concerns in the allegation. <RESIDENT 454> Resident 454 admitted on [DATE]. Review of an investigation dated 11/06/2024 at 3:13 PM, showed Resident 454 reported the nurse brought them pain medications four hours late and they were in pain. Review of the November Medication Administration Record (MAR) showed the resident reported a pain score of 10 on the 1 to 10 scale at 10:00 AM, and 5 at 2:00 PM on 11/05/2024. The investigation did not include the narcotic ledger to reveal when the medications were retrieved from the medication cards. On 11/15/2024 at 9:00 AM, Staff B, Director of Nursing provided the narcotic ledger that showed conflicting times between the MAR and the narcotic ledger for dates 11/04/2024, 11/05/2024, 11/06/2024 and 11/07/2024. Included in the investigation were staff interviews about rough handling, resident rights rather than pain management timeliness. Education provided to staff was in regards to resident rights. The investigation failed to identify additional concerns with narcotic documentation discrepancies. <LATE MEDICATION INCIDENT INVESTIGATIONS> <RESIDENTS 58, 2, 80, 31, 11, 56, 19, 66, 62, 46, 12> In an interview on 11/08/2024 at 10:10 AM, Staff BB, Licensed Practical Nurse, stated they were late with administering morning medications to 16 of their residents. Review of 11 incident investigations for Residents 58, 2, 80, 31, 11, 56, 19, 66, 62, 46, 12, dated 11/08/2024, showed they all had late medications. The investigations were not thorough as they lacked witness statements from the licensed nurse (s) that administered late medications, there were no witness statements from any nurse managers, there was no documentation whether the licensed nurse (s) had notified their supervisor they were late passing medications, there was no documentation or analysis why the medications were administered late, there was no documentation which medications were administered late, there was no documentation which resident medication rights had been violated, there was no documentation what the facility planned to do to ensure resident medications were administered timely in the future, and there was no documentation whether the facility had substantiated abuse/neglect. <RESIDENT COUNCIL> Review of Resident Council meeting minutes and/or Resident Council grievances, dated 05/23/2024, 06/27/2024, 07/25/2024 and 08/29/2024 showed the Resident Council had reported concerns with staff response to call lights and residents waiting too long on night shift for staff to answer their call lights. Review of the meeting minutes and grievances showed Staff A, Administrator, Staff B, Director of Nursing, and Staff HH, Director of Activities either had knowledge of or should have had knowledge of the Resident Council's concerns voiced in council meetings for four months. Review of the incident reporting logs for May - August 2024 showed the facility had not logged the Resident Council's concerns. In an interview on 11/12/2024 at 8:47 AM, Staff HH, Director of Activities, stated they had notified the administrator of the 05/23/2024 Resident Council concerns of the one hour night shift call light wait times. In an interview on 11/12/2024 at 9:01 AM, Staff A, Administrator, stated the facility had not logged or investigated the Resident Council's 05/23/2024 concern with night shift call lights. In an interview on 11/14/2024 at 10:33 AM, Staff HH, stated they knew Staff A, Administrator, had been aware of the Resident Council's concerns with call light issues and staffing from May to August because after every council meeting they personally gave them the Resident Council meeting minutes. Staff HH stated Staff B, Director of Nursing, had attended the July Resident Council meeting. Review of an incident investigation, dated 11/13/2024, showed the facility had conducted an investigation, but it was not thorough as there were no interviews or witness statements from Staff A, Administrator, Staff B, Director of Nursing, or Staff HH, Director of Activities, regarding their roles in the facility's non-response to four months of documented Resident Council concerns. The investigation was also not thorough, as there were no interviews or witness statements from the Resident Council President, [NAME] President, or any other Resident Council representatives that could have provided information about the council's concerns and what their concerns had been from May to August. The investigation did not include any documentation whether the facility had substantiated abuse/neglect. The investigation really was not focused at all, as the investigation indicated it addressed the past three months of Resident Council concerns, but the council meeting minutes and related grievances showed documented council concerns from May to August. The investigation did not indicate if the council's concerns had been verified and it did not include any documentation of corrective actions taken regarding the facility's failure to respond to documented council concerns. Refer to WAC 388-97-0640 (6)(a)

CONCERN (E)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, included thorough summaries of the Care Area Assessments (CAA), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 4 of 4 residents (Resident14, 43, 88 and 98) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs. Findings included . The RAI consists of three basic components: the Minimum Data Set (MDS - a resident assessment tool) assessment, the CAA process, and the RAI Utilization Guidelines (instructions for when and how to use the RAI that include instruction for completion of the RAI as well as structured frameworks for synthesizing the MDS and other clinical information). The CAA process was designed to assist the assessor to systematically interpret the information recorded on the MDS. Once a care area has been triggered, nursing home providers use current, evidence-based clinical resources to conduct an assessment of the potential problem and determine whether or not to care plan for it. The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident. <RESIDENT 88> Resident 88 admitted to the facility on [DATE] with diagnoses to include surgical amputation to their right 4th and 5th toes and subsequent infection requiring a wound vacuum, urine retention requiring a catheter. Review of the admission MDS assessment, dated 09/13/2024, showed the CAAs did not contain input from the resident on actual or potential problems or needs. The dehydration/fluid maintenance, urinary incontinence/indwelling catheter, nutrition and functional ability CAA's did not contain a comprehensive assessment of the resident's needs, strengths, goals, life history and preferences. <RESIDENT 98> Resident 98 admitted to the facility on [DATE] with diagnoses to include deep tissue injury to their right heel. Review of the admission MDS assessment, dated 10/21/2024, showed the CAAs did not contain input from the resident on actual or potential problems or needs. The nutritional status and pressure ulcer CAA's did not contain a comprehensive assessment of the resident's needs, strengths, goals, life history and preferences. <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and atrial fibrillation (an irregular heart rate). Review of the admission MDS assessment dated showed the CAAs did not contain input from the resident on actual or potential problems or needs. The nutritional status CAA did not contain a comprehensive assessment of the resident's needs, strengths, goals, life history or preferences. In a joint interview on 11/14/2024 at 12:36 PM with Staff A, Administrator and Staff B, Director of Nursing Services said the CAA's should be completed by MDS nurses. During the Quality Assurance Performance Improvement meeting on 11/15/2024 at 12:15 PM, Staff A, Administrator said they had not identified CAA's as an issue and there was no performance improvement plan in place for CAA's. Cross Reference to: CFR 483.21(a), (a)(1)(i)(ii), F655 - Baseline Care Plan CFR 483.21(b), (b)(1),(c)(3)(i - iv), F656 - Develop/implement Comprehensive Care Plan CFR 483.21(b),(b)(2)(i-iii), F657 - Care Plan Timing And Revision Refer to WAC 388-97-1000 (1)(a)(2)(q)(5)(a)

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 8 residents (Resident 24, 43, and 98) reviewed for comprehensive care planning. The failure to ensure the comprehensive care plan was person-centered to maintain or attain the residents highest practicable well-being placed the residents' at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Findings included . <RESIDENT 24> Resident 24 admitted to the facility on [DATE]. In an interview on 11/04/2024 at 10:17 AM, Resident 24 stated they had sciatica and pain in their right shoulder and the muscle was sore. The resident said they received Lidocaine patches and Gabapentin for pain. Review of the care plan showed Resident 24 was at risk for pain related to advanced age, recent hospitalizations and multiple cardiorespiratory conditions. The care plan did not include the resident's goals or nonpharmacological interventions for pain. <RESIDENT 98> Resident 98 admitted to the facility on [DATE] with diagnoses to include a right heel deep tissue injury. Review of Resident 98's care plan showed the resident was at risk for a pressure ulcer rather than had a pressure ulcer. The discharge care plan was canned with prompts to staff to put in the information. The care plan did not have the residents wishes or goals for the discharge present. <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), bipolar disorder and dementia. Reivew of Resident 43's care plan dated 10/24/2024 showed they were ar risk for complications due to dementia. The care plan did not contain comprehensive person centered information or measurable objectives with regard to Resident 43 and dementia care. In an interview on 11/14/2024 at 12:36 PM, Staff A, Administrator said care plans can be updated by the MDS nurses and unit managers. In an interview on 11/15/2024 at 12:30 PM, Staff A, Administrator said they were not aware of any care plan issues and there was no performance plan in place for care planning. This is a repeat deficency from 12/14/2023. WAC Reference: 388-97-1020(1)(2)

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to follow professional standards of practice for 4 of 29 residents (Resident 2, 5, 58, and 78) reviewed for medication administration. Failure to transcribe orders accurately upon admission and pre-signing medications in the Medication Administration Record (MAR) ahead of adminsitration placed residents at risk for medication errors and acute medical problems. Findings included . According to the facility policy titled: Medication Administration: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination and infection. Review Medication Administration Record (MAR) to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. Sign MAR after administered. <RESIDENT 78> Resident 78 was admitted to the facility initially on 09/20/2024 and then got re admitted to the facility on [DATE] after they were in the hospital from [DATE] to 10/17/2024. Diagnoses to include oropharyngeal dysphagia (a term that describes swallowing problems occurring in the mouth and/or throat) after gastrostomy tube (G tube - a feeding tube that is inserted through the skin and the stomach wall to provide nutrition and fluids directly to the stomach) placement. In an observation and interview on 11/05/2024 at 1:15 PM, Staff P, Licensed Practical Nurse (LPN) administered Baclofen 15 mg tablet to Resident 78 via G tube. MAR order stated: Baclofen Oral tablet 10 mg by mouth three times a day for Stiff Person Syndrome. According to Staff P, resident was originally able to take medications by mouth but after Resident's hospitalization, they came back with a G tube and all medications were now given via G tube. Staff P stated that the nurse that did the admission should have updated the orders. They stated that the order should state via G tube and not by mouth. Staff P stated that they would update the order. In a record review on 11/05/2024 at 2:45 PM, Resident 78's discharge summary from the hospital dated 10/17/2024 had orders via mouth but also stated nothing by mouth (NPO). According to resident's electronic chart under order summary report, diet is NPO, order dated 10/17/2024. Further review of the MAR showed the following medications were all ordered to be given by mouth: Acetaminophen 325 mg tablet, Cyanocobalamin tablet 500 mcg, Diazepam 5 mg tablet, Ergocalciferol Capsule 1.25 mg, Famotidine 20 mg tablet, Gabapentin capsule 100 mg, Ibuprofen 600 mg tablet, Meclizine HCl 25 mg tablet, Ondansetron 4 mg tablet, Polyethylene glycol powder 17 grams, Senna 8.6 mg tablet, Tizanidine HCl 4 mg tablet. In an interview on 11/14/2024 at 12:30 PM, Staff B, Registered Nurse/Director of Nursing Services, stated that when a resident goes to the hospital and comes back all orders were considered new orders and that they will talk to the nurse that did the admission orders for Resident 78 for not clarifying the orders. <RESIDENT 58> Resident 58 admitted on [DATE] with diagnoses to include type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). In an observation on 11/14/2024 at 5:20 PM, Staff XX, Agency LPN drew up Humalog insulin and administered the shot to Resident 58. In a record review and interview on 11/14/2024 at 5:25 PM Resident 58's MAR showed Humalog Insulin was administered at 4:19 PM on 11/14/2024. According to Staff XX they signed the MAR that the insulin was given at the time they checked Resident 58's blood sugar even though they have not given it at the time they signed the MAR. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] with diagnosis to include Type 2 Diabetes Mellitus. In an observation record review on 11/14/2024 at 5:34 PM, Resident 2's MAR showed that Humalog insulin was signed that it was given at 4:15 PM on 11/14/2024. Observed Staff XX drew up the Humalog insulin and administered it to Resident 2 at 5:34 PM. In an interview on 11/14/2024 at 5:38 PM, Staff XX stated that after checking the blood sugar they signed the insulin order even though they have not given Resident 2's insulin yet. Staff XX stated that they signed that it was given so that it will not show that they were late giving the insulin in resident's electronic chart. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnosis to include Type 2 Diabetes Mellitus. In a record review on 11/14/2024 at 5:39 PM, Resident 5's MAR showed that the Humalog insulin was administered at 3:56 PM on 11/14/2024. In an observation and interview on 11/14/2024 at 5:40 PM, Staff XX drew up Humalog insulin and administered the shot to Resident 2 at 5:40 PM. Staff XX stated that they signed that they administered the insulin ahead of time. They stated they just don't want the medications to show up late in the resident's electronic chart. They stated that this is not a safe practice. Staff XX denied that they had anymore medications that they signed ahead of time. Refer to WAC 388-97-1620 (2)(b)(i)(ii)

CONCERN (E)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and provide necessary treatment and services consistent with professional standards of practice for 3 of 4 residents (Resident 14, 43, and 98) reviewed for Pressure Ulcers. This failure placed the resident at risk for increased pressure ulcers, pain, discomfort and diminished quality of life. Findings included . Review of the facility policy dated 10/01/2021, titled Pressure Injury Prevention and Management, showed that the nursing staff will develop and maintain systems and processes to ensure that the facility provides care and services consistent with professional standards of practice to promote the healing of existing pressure ulcers and prevent development of additional pressure ulcers. <Resident 98> Resident 98 admitted on [DATE] with diagnoses to include a right heel deep tissue injury. Review of Resident 98's physician's orders showed the resident had a right heel pressure ulcer and nurses were to check daily and apply skin prep and offload. Review of Resident 98's care plan showed the resident was at risk of skin impairment rather than the resident had actual skin impairment. An intervention was listed for nurses to monitor dressing per orders to ensure it was intact and adhering. There was no mention of an air mattress or heel protectors. Review of Resident 98's [NAME] (a tool to inform nurses aides on how to provide care), showed the resident wore heel protectors. In interview on 11/05/2024 at 10:27 AM, Resident 98 said their air mattress kept breaking at 12:00 to 1:00 in the morning a couple of times a week. They said the compressor on the bed pump did not come on and then they are lying on the metal frame and when the bed is flat their sciatica kicks in. The resident said they felt bad for the staff because they do not have time to deal with her mattress at night and the pump beeps all night long. Resident 98 said multiple aides and nurses were aware and they had also called the receptionist and asked to be transferred to the maintenance extension where they left two messages about their malfunctioning bed. In an interview on 11/06/2024 at 2:31 PM, Staff J, Director of Maintenance said they had not heard a thing about Resident 98's mattress. Staff J said they reviewed the TELS log (platform for staff to report maintenance concerns) and there was no entry about the mattress. Review of the TELS report showed staff had requested with medium priority for maintenance to fix Resident 98's bed air pump that kept beeping loudly on 10/21/2024. Review of the TELS report showed staff had requested with medium priority for maintenance to fix Resident 98's bed and call light that were not working on 10/29/2024. In an interview on 11/07/2024 at 11:00 AM, Resident 98 said they developed a right heel pressure injury while at the hospital. Resident 98 said Staff P, Licensed Practical Nurse (LPN ) was great at checking their heel but if another nurse was on, they had to ask them to look at their heel. Staff P said they will tell the nurse, Hey you haven't checked my heel today, please check it I do not want to lose my leg. The resident said their heels were supposed to be elevated but aren't and they cannot put the pillows under them. In an interview and observation on 11/12/2024 at 9:29 AM, Staff AAA, Agency Registered Nurse (RN) assessed Resident 98's right heel which showed a 4 centimeter (CM) by 4 cm resolving blood blister with traces of Betadine at the wound edges. Resident 98 said the nurse last night was supposed to put betadine, cream and a dressing over it but didn't have time. The resident said the nurse who was supposed to relieve Staff P, LPN did not show up on time. In an interview on 11/13/2024 at 1:44 PM, Resident 98 had a new mattress in place on the firm setting. The resident said the nurses were concerned about their right heel as they were. Resident 98 said there was no dressing on it again. In an interview on 11/14/2024 at 1:00 PM, Staff A, Administrator said specialty beds and their settings should be on the care plan. No additional information provided. Surveyor: Bush, Kally L. <RESIDENT 14> Resident 14 admitted to the the facility on 08/08/2024 with diagnoses that included dependence on renal dialysis, fracture of the patella (kneecap), and heart disease. In an interview and observation on 11/05/2024 at 9:17 AM Resident 14 stated they had a sore on their backside and on their heels. Resident 14 stated they developed the sores while at the facility. Resident 14 was observed upright in their wheelchair, with slippers on their feet which were on the footrests. Observed two blue heel protectors sitting on top of a chair. Resident 14 stated the staff put them on sometimes for the sores on their heels. Observed Staff T, Registered Nurse, entered Resident 14's room, removed their slippers and replaced them with the heel protectors. In an observation on 11/05/2024 at 10:26 AM Resident 14 was observed to have a specialized mattress on their bed. In an interview on 11/14/2024 at 9:26 AM Resident 14 stated the sore on their backside was causing them a lot of pain. Review of Resident 14's progress notes at admission, dated 09/29/2024 at 5:12 PM, showed they readmitted to the facility with no skin issues. Review of Resident 14's skin assessment dated [DATE] showed they had an open area to right buttock. Review of Resident 14's progress notes dated 10/15/2024, showed they were initially seen by the wound specialist for sacrum and left and right heel pressure ulcers, 16 days after discovery. Review of Resident 14's Administration Record dated 10/16/2024 showed a physician order for them to wear foam boots to both their heels every shift. Review of Resident 14's Care Area Assessment (CAA-an assessment of a specific resident care or medical issue, to holistically analyze the plan of care) dated 09/11/2024 did contained a limited and canned description of their risk for developing a pressure ulcer and referred to the care plan in place. Review of Resident 14's care plan dated 09/05/2024 they had a potential for alteration in their skin integrity based on their declined mobility and bowel incontinence. Interventions included monitoring for nutritional status and following skin protocols. There was no information found on Resident 14's care plan about the development and treatment of their pressure ulcers, the use of foam boots, or use of a specialized mattress. In an interview on 11/06/2024 at 2:14 PM Staff T, RN, stated Resident 14 had pressure ulcers and required the use of foam boots and a specialized mattress. In an interview on 11/14/2024 at 9:41 AM Staff CCC, Regional RN stated there was not an incident report completed for Resident 14's development of pressure sores while in the facility and they would provide Staff B, Director of Nurses, with education about the process. <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and atrial fibrillation (an irregular heart rate). In an interview on 11/06/2024 at 8:56 AM Resident 43 stated they had a sore on their backside, not a big one, and the aides apply cream on it every time they change them. On 11/06/2024 at 8:50 AM observed Resident 43 laying in their bed, on their back with their head of bed elevated. Observed a specialty air mattress device attached to the foot board of the bed. The device was not making any noise, and all there were no visible lights on indicating power. On 11/06/2024 at 2:27 PM observed resident specialized mattress device machine attached to the foot of the bed, plugged into wall, was not firm to touch and the machine had no lights to indicate it was powered on. In a review of Resident 43's care plan dated 10/24/2024 showed they had an open area on admission and the interventions included a low air loss mattress with nursing to check every shift for security and function. In a review of Resident 43's November Medication Administration Record (MAR) 2024 showed no order or directive to nursing staff related the low air loss mattress. In an interview on 11/06/2024 at 2:30 PM Staff J, stated they don't really have anything to do with the functioning of the specialized mattresses other than a yearly check that is completed. Staff J stated if the mattresses don't work, they get new ones. Observed Staff J check Resident 43's specialized mattress device, there was no lights indicating the mattress was functioning, they pushed the power button and the device turned on. Staff J stated turned the specialized mattress off and stated they did not know why it was off so they would leave it off. Staff J, when asked for the user manual for the specialized mattress, deferred to the Internet, however provided a copy. Review of the specialized mattress, titled Joerns User-Service Manual P.O.R [NAME] Plus showed the power button was used to turn the power on and off. The manual showed there is a standby light that illuminates when the unit is initially plugged in, indicating power is available. Observed on 11/12/2024 at 8:21 AM Resident 43's specialized mattress device not running. Resident 43 was laying in bed, on their back, with their head of bed elevated. In an interview on 11/12/24 09:34 AM Staff L, RN-unit manager, stated they were not familiar with Resident 43's care and was recently assigned to them. Resident L, when asked about Resident 43's skin stated that a skin check was completed on 11/7/2024 and they were noted to have scattered bruising to abdomen and left arm. Staff L stated they did not know about Resident 43's use of a specialized mattress device and were not sure of the process for checking the function and maintenance. Staff L stated there would usually be an order for the device and the nurse would check the function of the device each shift. Staff L stated they were not aware Resident 43's specialized mattress was not turned on. This is a repeat deficiency from 12/14/2023. REFERENCE WAC 388-97-1060(3)(b)

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 46> Resident 46 admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a disease that ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 46> Resident 46 admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a disease that causes the breakdown of the protective covering of the nerves), severe protein-calorie malnutrition, stage 2 pressure area on right lateral foot. Resident was alert and able to make needs known. In an interview on 11/06/2024 at 12:42 PM, Staff FF, Registered Nurse (RN) stated, Resident 46 was alert and oriented but forgetful, and requires total assist with care. In an observation on 11/07/2024 at 10:15 AM Staff GG, NAC and Staff EE, NAC were providing incontinent care to Resident 46. Resident's legs were both bent in the knees, left leg more than the right leg. Requested Resident 46 to straighten their left leg. Resident was able to straighten it but cannot keep it straight and it goes back to being bent. In an interview on 11/07/2024 10:38, Staff GG, NAC stated that Resident 46 was not on a restorative nursing program (nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). Review of Resident 46's Care Plan on 11/07/2024 showed under Focus: At risk for loss of range of motion related to impaired mobility, weakness. Revised on 07/23/2023. Goal: Will exhibit no decline in ROM within confines of disease processes. Intervention: Encourage to assist resident to do active ROM (the range of movement that a person can achieve by contracting and relaxing muscles without assistance) exercises of bilateral lower extremities twice a day as resident tolerates (see exercise sheets in resident's room or in resident's chart). In an interview on 11/07/2024 at 10:45 AM, Staff X, Licensed Practical Nurse (LPN)/Unit Manager (UM), they stated that activity assistants who were NAC's does restorative program in the facility. Staff X stated Resident 46 is not on a restorative program. Requested Staff X to show me where staff document the ROM exercises for Resident 46 per care plan. Staff X looked in resident's electronic chart and stated they were not able to find any documentation and will work on it. In a record review on 11/08/2024 Resident 46's electronic chart did not show any physical therapy notes. No physical therapy notes given when requested from the physical therapy department. In an interview on 11/08/2024 at 10:39 AM, Staff RR, Therapy Department Manager, stated that the facility did not have restorative nursing program and hasn't for the thirteen years they worked there. The facility does the walking and exercise program from the Activity Department. Therapy Department assist in writing the walking program. Staff RR stated that the facility has a screening process, where if a resident has a change in their functional mobility, they get notified or if the nurse that does the Minimum Date Set (MDS and assessment tool) showed that a resident had a decrease in their mobility then they assess the resident. In an interview on 11/08/2024 at 11:07 AM, Staff GG, NAC was not able to find documentation for the ROM exercises for Resident 46. Staff GG was not able to show me the exercise instructions that was either posted on resident's wall or in resident's chart according to the care plan. In an interview on 11/12/2024 at 12:48 PM Staff FF, RN stated Resident 46's left lower extremity has some contractures and they try to put pillows under the resident's legs but resident kicks them off. Resident 46 also refuses to get out of bed when they offer. Staff FF does not think resident is on a restorative program. In an interview on 11/13/2024 at 9:57 AM, Resident 46 stated that they don't think they were doing exercises to their lower extremities. They stated they were interested in doing ROM exercises especially on their left leg. They were not sure when their left leg started to bend. In an interview on 11/13/2024 at 10:05 AM, informed Staff X, LPN/UM that the exercise instructions were not in Resident 46's wall or in resident's chart. They stated it was usually posted by the wall in resident's room. Staff X stated they were not aware that Resident 46's left lower extremity may be contracted. They stated that when a resident was at risk for developing a contracture, the NAC or the nurse notifies the Unit Manager. The Unit Manager will then get a doctor's order for Physical Therapy to evaluate resident and obtain recommendations to prevent contracture. Staff X stated that they will look at Resident 46 and follow up regarding possible contractures on their leg. In a joint interview on 11/14/2024 at 12:25 PM, Staff A, Administrator and Staff B, RN/Director of Nursing Services (DNS), Staff B stated that they don't have restorative program, but they have restorative tasks that the NAC does, and they come from the therapy department. Unit managers usually receive the recommendations from the therapy department, and they update the care plan, and the NAC does the exercises with the resident. Staff B was not able to provide me a copy of the NAC documentation regarding the ROM exercises for resident per their care plan. This is a repeat deficiency from 12/13/2023. Refer to WAC 388-97-1060 (3)(d) Based on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment and services for 4 of 4 residents (Residents 2, 41, 46, 88) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their level of functioning. This failure placed residents at risk of further decline in ROM, increased pain and loss of function. Findings included . Review of the undated facility policy titled: Restorative Nursing Services, showed that the residents would receive restorative nursing care as needed to help promote optimal safety and independence. <RESIDENT 2> Resident 2 admitted [DATE] and was a long term resident with diagnoses which included weakness and spinal stenosis. According to the Annual Minimum Data Set (MDS) assessment dated [DATE], the resident had impaired lower extremity range of motion on one side and required extensive or total assistance with mobility. Review of the care plan with revision dated 08/25/2023 showed the following restorative nursing program: Encourage and assist pt to do active ROM exercises of lower extremities and passive ROM exercises of bilateral upper extremities twice a day (see exercise sheets in pt room or in pt chart) Record review on 11/07/2024 showed no exercise instruction sheet was included in the record. In an interview on 11/04/2024 at 2:02 PM, Resident 2 stated they wanted more therapy or exercises and stated they wouldn't let them try to walk or sit on the side of the bed. Resident 2 stated they got no exercises at all anymore. In an interview and observation of the resident room on 11/07/2024 at 11:02 AM, no exercise sheet was found in the resident room, the resident stated there has never been one that they remember. Review of the resident record on 11/07/2024 showed no documentation that the program was being completed. In an interview on 11/14/2024 at 10:04 AM, Staff X, Resident Care Manager (RCM) stated Resident 2's Restorative program should be showing up in the tasks for the NACs to chart. Staff X stated when there was an update to their system the programs disappeared so they needed to go through one by one and look at all of the care plans because they should be in the task section. Staff X stated they did not have a structured restorative program in the building and the activity department was doing some exercises but other programs were supposed to be done by the nursing assistants and Resident 2 was one of those. <RESIDENT 88> Resident 88 admitted on [DATE] with diagnoses to include right foot ulcer and right 4th and 5th toe amputations, weakness and limitation of activities due to disability. Review of the admission nursing assessment showed the resident had range of motion impairment on one side. Review of the admission MDS on 09/13/2024 showed the resident had no range of motion impairment. Review of the care plan initiated on 08/27/2024, showed Resident 88's goal was to return to their prior level of function in which they were independent with ADL's and mobility. The care plan intervention was for a PT and OT evaluation and treatment. In an interview on 11/14/2024 at 1:40 PM, Resident 98 said they used to get Physcial Therapy (PT) and Occcupational (OT) until insurance cut them off. They said no one comes in to do exercises with them. They said they need therapy because their left leg was very weak and when they tried to stand Monday, their leg did not want to work. They said they would like to get therapy but not to be in an uncomfortable wheelchair to go down to the gym. They said they would like someone to come to their room and do exercises to get their strength up. In an interview on 11/14/2024 at 4:48 PM, Staff A, Administrator said they did not have a budget for restorative care but do now and will be hiring for the position. In an interview on 11/15/2024 at 8:27 AM, Staff B, Director of Nursing provided therapy discharge communication from 10/07/2024 from PT where the Director of Rehab had recommended Active ROM of lower extremities during ADL's for10 reps and 2 sets with rest breaks between sets. Staff B provided a new program dated 11/14/2024, 38 days after PT recommended the following Restorative Program: Range of Motion daily- Active - Lower range of motion-10 reps at 2 sets daily, Range of Motion daily- Active - Lower extremity. <RESIDENT 41> Resident 41 re-admitted to the facility on [DATE] with diagnoses to include hip fracture. According to the significant change MDS, dated [DATE], the resident had no cognitive impairment, used a wheelchair, had a hip fracture, did receive occupational and physical therapy, but no restorative nursing program. In an interview on 11/04/2024 at 12:53 PM, Resident 41 stated the facility didn't let them walk, and nobody had asked them to walk today. In an interview on 11/13/2024 at 9:31 AM, Staff RR, Director of Rehab (DOR), stated the facility had not had a restorative program in years. They stated they had trained Resident 41 on a home exercise program, but they didn't have any documentation of the home exercise program. In an interview on 11/13/2024 at 9:58 AM, Resident 41 stated they had not been trained on a home exercise program. Review of Physical Therapy Evaluation and Plan of Treatment notes, start of care date: 09/18/20-24, showed the patient's goal was they wanted to be able to walk again. Review of Physical Therapy Discharge Summary documentation, dated 09/30/2024, showed a discharge recommendation of 24 hour care. The documentation also indicated a restorative program had been established/trained for a restorative range of motion program and the patient was educated on a home exercise program to maintain joint mobility to assist with bed mobility. In a joint interview on 11/13/2024 at 10:01 AM, Staff RR, DOR, stated therapy would have provided a home exercise program, and they would have provided the resident with a copy of that program. Staff RR stated the exercises would have been generic. Staff BBB, Physical Therapist, stated they had given Resident 41 a paper printout of exercises, but they couldn't recall which exercises, and they didn't have documentation of that and they could not recall what date that was. Staff BBB stated they did not coordinate with nursing.

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 5> Resident 5 was admitted to the facility on [DATE]. According to the quarterly MDS assessment, dated 08/07/202...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 5> Resident 5 was admitted to the facility on [DATE]. According to the quarterly MDS assessment, dated 08/07/2024, Resident 5 had no cognitive impairment. In an interview on 11/04/2024 at 10:41 AM, Resident 5 stated last week their daughter asked for protein drinks, and they had not got them yet. Review of physician order, dated 10/01/2024, directed nurses to administer nutritional shake: no sugar added with meals at 08:00 AM, 12:00 PM and 05:00 PM and at bedtime for supplement. Review of a wound note, dated 09/12/2024, showed non sugar added nutritional shake on order for additional protein to aid weight and wound healing. Review of Resident 5's breakfast tray card at 11/07/2024 at 8:23 AM and 11/08/2024 at 8:31 AM, showed they were supposed to receive Glucerna (a brand of nutritional shake) with breakfast. In an observation and interview on 11/07/2024 at 8:23 AM and 11/08/2024 at 8:31 AM, there was no Glucerna/nutritional shake on Resident 5's breakfast tray, Resident 5 stated they did not receive it. Review of Resident 5's lunch tray card at 11/07/2024 at 12:14 PM, showed no documentation they were supposed to receive a nutritional shake. In an observation on 11/07/2024 at 12:14 PM, there was no nutritional shake on the tray. In an interview on 11/07/2024 at 12:20 PM, Resident 5 stated they did not get any nutritional shake today. Review of MAR, copy date 11/07/2024 at 14:39 PM, showed nurses had signed and documented Resident 5 had taken the nutritional shakes at 8:00 AM and 12:00 PM on 11/07/2024, and they documented with an X the percentage of shakes consumed. In an interview on 11/07/24 at 2:41 PM, Staff AA, RN, stated the kitchen supplied the nutritional shakes with the breakfast and lunch, so they just signed on the MAR as given. Staff AA stated they thought they saw the resident was drinking it but they were not sure. In an interview on 11/07/2024 at 3:00 PM, Staff G, Dietary Manager, stated the kitchen supplied nutritional shakes with meals if the kitchen received the order and the order said to go with meals. Asked why Resident 5 did not receive nutritional shake since the order said with meals. Staff G said they did not know this resident had this order. Staff G said the nurse was supposed to write a communication sheet and give it to the kitchen, but they did not receive this communication sheet and the order did not show in their system either. In an interview on 11/07/24 at 3:02 PM, Staff AA, stated nurses were supposed to document in the MAR how much percentage of the nutritional shake the resident took. Asked what the meaning of X meant on the MAR. They said it should not be a X, should be able to put numbers of percentage. They said they did not know the kitchen did not supply the nutritional shakes today. In an interview on 11/07/2024 at 3:34 PM, Staff G, stated they receive an order of providing Glucerna to Resident 5 with meals at breakfast and dinner. Review a dietary communication form, dated 11/05/2024, showed diet change Glucerna with breakfast and dinner. Review of MAR, cope date 11/07/2024 at 7:49 AM, showed Glucerna with breakfast and dinner two times a day with start date on 11/07/2024. There was no documentation of the order in the MAR from 11/05/2024 to 11/06/2024. In an interview on 11/08/2024 at 9:41 AM, Staff X, Licensed Practical Nurse (LPN)/Unit manager, stated they did not know if Resident 5 received Glucerna or not this morning and they stated the kitchen was supposed to provide it. In an observation and interview on 11/08/2024 at 10:10 AM, Staff BB, LPN, prepared and administered Resident 5's morning medications. There was no Glucerna prepared or administered. Staff BB said they just came at 10am and received report and just started medication pass. Review of Resident 5's MAR, dated 11/08/2024, showed Staff BB had signed and documented Resident 5 consumed 240 cc (cubic centimeters) Glucerna at 08:00AM. Refer to WAC 388-97-1060 (3)(h) <Resident 25> Resident 25 was admitted to the facility on [DATE] with a diagnosis of renal failure (One or both of your kidneys no longer function well on their own) and has dialysis (Treatment for people whose kidneys are failing) three times a week. The resident is post below-knee amputation (BKA) of the right leg (right lower leg amputation). A record review of the Care Plan initiated on 10/02/2024 stated that the resident was to have Nepro (specialized protein drink for persons with kidney disease) three times a day with meals. A review of the Nutrition assessment, dated 10/02/2024, stated that Nepro 120 ml were to be given with meals three times a day to promote wound healing. In a review of Resident 25's November 2024 MAR, showed they received dialysis on Tuesdays, Thursdays and Sundays and were prescribed Nepro with their meals 120 ml three times a day with their meals starting 10/03/2024. From 11/01/2024 through 11/12/2024 the November MAR showed Nepro was not given to Resident 25 at lunch, documented to be out of the facility (hospitalized ), for the following dates: Sunday 11/03/2024 Tuesday 11/05/2024 Thursday 11/07/2024 Sunday 11/10/2024 Tuesday 11/12/2024 The record review of October's 2024 MAR showed that the 12:00 PM Nepro was not given 12 of 29 days, which were days Resident 25 was at Dialysis. Review of the at-risk meeting for nutrition note, dated 10/31/2024, Resident 25 was reviewed and documented they had not been getting their sack lunch on dialysis days. In an interview on 11/12/2024 at 11:45 AM, Staff OO, Dietary Aide, stated they made Resident 25's lunch for dialysis. Staff AAA stated Resident 25 received a sack lunch which included a peanut butter and jelly sandwich on white bread, cranberry juice, graham crackers and applesauce. Staff AAA stated they pack the same food items for residents that go to dialysis with the exception of at times a string cheese is provided at times. In an interview on 11/12/2024 at 1:45 PM, Staff MM, stated they were aware of Resident 25's weight loss, had addressed their weight loss with the dialysis dietician, and reviewed/evaluated their weight at their at-risk meetings. Staff MM stated they were unaware of Resident 25 had not been receiving their Nepro at lunch on their dialysis days. In a joint interview on 11/14/2024 at 12:30 Staff L, RCM, and Staff U, RCM, revealed that an X on the MAR represents days that Resident 25 was not receiving Nepro and that those were all days that Resident 25 was at dialysis. Staff L and Staff U stated the facility was to provide a sack lunch on dialysis days and they were unsure why Resident 25 was not receiving the ordered Nepro. <RESIDENT 43> Resident 43 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (long term condition in which the body has trouble regulating blood sugar), chronic kidney disease, and atrial fibrillation (an irregular heart rate). Review of Resident 43's MDS dated [DATE] showed they were at risk for malnutrition and was on a therapeutic diet. Review of Resident 43's care plan dated 10/24/2024 showed they had dialysis on Mondays, Wednesdays and Fridays from 3:40 PM until 7:40 PM and was to take a packed lunch and/or snacks with them to dialysis and offered snacks upon their return. Resident 43's care plan also showed they were at risk for malnutrition related to their chronic diseases and were on a therapeutic diet of consistent carbohydrate (CCHO), renal and chopped meats and provide oral supplement per physician order, Prosource 30 milliliters (ml). Review of Resident 43's October and November 2024 MAR showed an order for daily weights for three days, then weekly for four weeks and then monthly every day shift on Mondays. Resident 43 was weighed on 10/18/2024, 10/19/2024 and 11/04/2024. Review of Resident 43's October 2024 MAR showed an order for Prosource No Carb Oral Liquid protein (supplement) 30 ml. The order reads mixed into beverage of choice for wound healing. **Do not allow rt [resident] to see product being added into beverages** started 10/18/2024 to be administered at 5:00PM daily. Resident 43 received Prosource at 5:00 PM daily per MAR documentation. In an interview on 11/12/2024 at 9:42 AM Staff L, Registered Nurse (RN)- Unit Manager, stated they did not know the process for meals for residents who received dialysis and residents should be get a sack lunch. Staff L stated residents can always get a snack when they return from dialysis. In an interview on 11/13/2024 at 2:24 PM Resident 43 stated they had not received a sack lunch since admission when they go to dialysis. Resident 43 stated returned from dialysis and ate their dinner left on their overbed table after it had been out for several hours and was cold. Based on observation, interview, and record review, the facility failed to ensure 8 of 9 residents (25, 41, 43, 54, 78, 84, 98, and 5), reviewed for nutrition, received adequate weight monitoring, timely evaluation of weights, and implementation of effective interventions, to maintain adequate nutrition. This failure placed the residents at risk for ongoing weight loss and poor nutrition and potential harm. Findings included . Review of hte facility policy , titled, Weight Guideline created 05/2023 directed staff to weigh residents upon admission and readmission, weekly for an additional three weeks, then monthly or as indicated by the physician. The staff were to obtain an admissin weight then the following day to ensure an accurate weight. The weights and vital sign exception report will be reviewed at the morning meeting daily. Review of the policy reviewed 05/25/2023 titled,Weight Assessment and Intervention showed the facility will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The policy showed significant unplanned weight loss was: * one month -5 % weight change is significant, greater than 5% is severe weight loss * three months-7.5 % weight change is significant, greater than 7.5% is severe weight loss *six months-10% weight change is significant, greater than 10% is severe weight loss Any weight change of 5 % or more, nursing will immediately inform the physician and dietary team. <RESIDENT 84> Resident 84 admitted on [DATE] with diagnoses to include severe protein-calorie malnutrition, anemia and diarrhea. Review of the 5-day Minimum Data Set (MDS-an assessment tool) assessment on 08/09/2024 showed the resident had no weight loss and weighed 122 pounds. Review of the care plan developed on 08/07/2024 showed the resident had a nutritional problem related to severe protein calorie malnutrition and staff would minimize complications. Interventions included provide diet as ordered, monitor meal intake, Registered Dietitian (RD) to evaluate and make diet change recommendations as needed and administer medications as ordered. Review of the clinical record showed the resident had the following weights since admission 08/06/2024: 121.8 pounds 08/19/2024: 123.4 pounds 09/02/2024: 118.4 pounds 11/12/2024: 102.5 pounds In an interview on 11/12/2024 at 9:40 AM, Resident 84 said the food was hot at lunch yesterday, but her two bowls of malt o meal cereal were cold this morning. The resident showed a laminated list of available snacks that was dropped off to them yesterday. The resident stated can you believe these were available all this time and I never knew about them. They said they never received bedtime snacks since admit. Resident 84 said they would have liked to talk to a dietician but hadn't seen one. The resident said they had a shower yesterday and their weight was down to 103 pounds. The resident said they usually weighed 130 pounds and that is what they would like to weigh. The resident said they barely weighed them here and now they are bony maroney The resident commented that until yesterday the staff hadn't weighed them since the beginning of September. Resident 84 said they have their son take them out for a burger and fries when they discharged later that day. The resident said they hoped they would gain weight at home where the food is hot. Review of a weight note on 11/12/2024 at 11:40 AM, showed the weight today showed a weight loss of 16 pounds in 60 days and resident 84 told them the weight loss was attributed to loose stools edema, and loss of appetite. In an interview on 11/12/2024 at 2:00 PM, Staff MM, RD said they could not speak to what has occurred before September first. Staff MM said Resident 84 did not trigger on the significant weight change report as there was not a current weight. Staff MM said they did notify the facility on 11/05/2024 and 11/11/2024, there were missing weights. Staff MM said they did not discuss Resident 84 in nutrition team as there were no weight obtained that would had shown the significant weight loss. In a joint interview on 11/19/2024 at 11:18 AM, Staff B, Director of Nursing acknowledged the lack of weight monitoring, and the weight loss was not identified until day of discharge. <RESIDENT 78> Resident 78 admitted on [DATE] with diagnoses to include adult failure to thrive, nausea with vomiting, anemia, gastro esophageal reflux disease (GERD) and hypokalemia (low potassium level) and required enteral feeding (nutrition through a tube surgically implanted). Review of the 5-day MDS assessment on 09/26/2024 showed the resident experienced coughing or choking during meals and when swallowing medications and complaints of pain when swallowing. The resident weighed 133 pounds and had no recent weight loss. Review of the admission MDS on 10/23/2024 showed the resident had no weight loss of 5 % or 10% or more in the last six months. The weight recorded was 118 pounds. Review of the care plan developed on 09/20/2024 showed Resident 78 was at risk for alteration in nutritional status related to adult failure to thrive, stiff man syndrome, breast cancer, nausea and vomiting, anemia, GERD, hypokalemia , anxiety and low BMI for population. The goal was for the resident to exhibit a gradual weight gain toward ideal body weight, tolerate tube feeding and show no signs of malnutrition or dehydration. Interventions included obtain and monitor labs, monitor meal intake, and medications and supplements as ordered and document consumption. Review of physician documentation at the hospital on [DATE] showed Resident 78 reported that for the past 2 to 3 days they had been unable to swallow anything including liquids, solids, and pills. The resident reported having to constantly spit out everything that comes into their mouth and reported that it was particularly worse with liquids. The resident denied pain with swallowing but felt unable to swallow. Resident reported while at the facility the speech therapist evaluated them and recommended, they go to the Emergency Department. The resident reported that their main concern was that they were hungry, and tired of not being able to eat and concerned that they will continue to grow weaker which would delay their upcoming planned breast surgery. Review of the care plan developed on 10/24/2024 showed Resident 78 was at risk for malnutrition related to their diagnoses of stiff man syndrome, dysphagia, vitamin B 12 deficiency, anemia, copper deficiency, adult failure to thrive, nausea with vomiting, GERD , hypokalemia, anxiety, history of weight loss, polypharmacy, altered labs, increased needs for healing and need for enteral nutrition. The care plan interventions showed the resident would maintain their weight status at an appropriate BMI for age without significant change and resident would maintain desirable hydration status. Nursing staff were directed to monitor and record weekly weights for four weeks then per facility protocol. Review of the nutrition/dietary note dated 10/31/2024 at 9:52 AM, showed Resident 78 was seen for triggering for undesirable significant weight loss of 9.6% of their body weight for one month. The RD noted that weight loss occurred outside of facility between 09/22/2024 until 10/17/2024. Review of the October Medication Administration Record (MAR) showed the resident did not get weighed on 10/28/2024. In an interview on 11/08/2024 at 11:16 AM, Staff P, Licensed Practical Nurse (LPN) said Resident 78 was on Jevity 1.2 calorie and it was changed to the 1.5 formula at 70 cubic centimeters (CC) an hour for 18 hours. Staff P said the resident reports they are thirsty. Staff P said a weight was missed. Staff P said the RD worked remotely and did not come to the facility. In an interview on 11/08/2024 at 1:10 PM, Resident 78 said they were losing weight and did not know why they leave them off the tube feeding so many hours. The resident said the nurse told them yesterday they would be hooked up for food at 5 PM. The resident said they told the nurse they were hungry and did not want to get sick again. Resident 78 said their tube feeding did not get started until 6 PM Resident 78 said their weigh was down to 55 kilograms and it was too low. They said they are not weighed regularly. In a joint interview on 11/12/2024 at 1:45 PM, Staff MM, said they do not come to the facility to talk with the residents. Staff MM said they try to call the residents. Staff MM reported their first phone conversation was yesterday with Resident 78. Staff MM said they review the medical records to obtain her information. Staff MM said the dietary manager would be unable to address Resident 78's enteral nutrition needs. Staff MM said they notified the facility of missed weights for Resident 78 on 11/05/2024 and 11/11/2024. Staff NN, Registered Dietitian Supervisor said residents were to be weighed on admission, weekly for four weeks then monthly. They said they notify the Administrator, Director of Nursing, unit managers and food services when there are missing weights. In a joint interview on 11/19/2024 at 11:18 AM, Staff B, acknowledged the lack of weight monitoring for Resident 78. Staff B said they had not been looking at missed weights. Staff A, Administrator said Staff MM and NN have not attended their Quality Assurance Performance Improvement meetings. Staff A said they will be looking for an in house RD as the current contract is not working. <RESIDENT 54> Resident 54 admitted to the facility on [DATE]. According to the admission MDS assessment, dated 07/17/2024, the resident had no cognitive impairment. Review of Resident 54's weight history showed weights to include: 07/11/2024 no documented weight found (day of admit) 07/14/2024 - 182.0 lbs. 08/08/2024 - 157.2 lbs. This was significant weight loss of 13.6% in less than 30 days. There was no documented re-weight found in the electronic health record. 08/16/2024 - 154.2 lbs. 11/07/2024 - 150.4 lbs. Review of a hospital Discharge summary, dated [DATE], showed Resident 54's weight was 186 lbs. 11 ounces on discharge from the hospital. Review of a nursing progress note, dated 10/09/2024, showed staff documented the resident had no significant weight changes. Review of a nutrition/dietary note, dated 08/27/2024, showed the resident's weight loss was categorized as unplanned/undesired, and the 07/14/2024 weight may be an outlier. The note indicated the dietitian was unable to communicate with the resident as they were not available. In an interview on 11/12/2024 at 11:41 AM, Resident 54 stated they knew they had weight loss because of the way they feel and the way their clothes fit, and they thought their weight loss was due to not having as much access to food and food machines for snacks. The resident stated believe me I will eat it if you give it to me. In an interview on 11/12/2024 at 12:38 PM, Staff X, LPN/Resident Care Manager (RCM), stated facility weight policy was that residents were supposed to be weighed on the day of admission, then daily for three more days so they are weighed the first four days while in the facility, then weekly for four weeks, then monthly. Staff X stated for questionable weights there should be a re-weight and notification of the dietitian. Staff X stated Resident 54 should have had a re-weight on 08/08/2024, but they didn't and they didn't know why because the resident had resided on a different floor in the facility at that time. Staff X was unable to provide any information whether the resident's physician or the dietitian had been notified of the resident's significant weight loss. Staff X stated there should have been a progress note that notifications were done regarding the resident's significant weight loss. Staff X stated the resident had not been care planned for weight loss until 08/27/2024. In a phone interview on 11/12/2024 at 1:44 PM, Staff NN, stated they were not monitoring Resident 54's weight when it changed significantly from 182.0 lbs. to 157.2 lbs., they said to check with nursing regarding that as the dietitians were not monitoring the resident then. Staff NN stated they didn't review the resident for significant weight loss until 08/27/2024. Staff NN was unable to provide any information about missing weights for the resident. Review of the Facility Assessment, reviewed date 10/01/2024 by the QAPI (Quality Assessment and Performance Improvement) Committee, showed the facility had a full-time Registered Dietician who monitored weights and overall nutritional well-being of residents, and the unit managers, Director of Nursing Services, and the dietitian met weekly to discuss residents' nutritional status. The Facility Assessment also indicated the dietitian attended daily clinical meetings and QAPI meetings. In an interview on 11/14/2024 at 8:13 AM, Staff A, stated the facility dietitian didn't attend all daily clinical meetings, that they only came about once a week, and they had not attended at least the last two QAPI meetings they knew for sure. <RESIDENT 41> Resident 41 admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. According to a significant change MDS, dated [DATE], the resident had no cognitive impairment, they had malnutrition, and they had no weight loss of 10% or more in the last six months) Review of Resident 41's weight history showed weights to include: 04/05/2024 (day of admission, no documented weight) 04/06/2024 no weight documented (day two of admit) 04/07/2024 no weight documented (day three of admit) 04/08/2024 - 200.4 lbs. (this was the first weight taken this admission) 04/12/2024 - 203.0 lbs. 04/19/2024 - 187.8 lbs. (15.2 lbs weight loss in 5 days, significant weight loss of 6.3% in 2 weeks) 09/18/2024 - 171.6 lbs. (day of admit) 09/19/2024 - no weight documented (day two of admit) 09/20/2024 - no weight documented (day three of admit) 09/21/2024 - no weight documented (day four of admit) Next weight was 10/07/2024 - 182.6 lbs. (no re-weights found) 10/14/2024 - 157.2 lbs. (Significant weight loss of 13.8% in 1 week) 10/15/2024 - 158.6 lbs. 10/18/2024 - 159.9 lbs. (Significant weight loss of 14.9% in 6 months (since 04/19/2024) In an interview on 11/04/2024 at 12:31 PM, Resident 41 stated the facility food was terrible, and it was undercooked, and they didn't get what they ordered. In an interview on 11/13/2024 at 10:38 AM, Staff X, LPN/RCM, was unable to provide any information about lack of weights for three days after their admission on [DATE]. Staff X stated there should have been a re-weight when the resident experienced a 16 lb. weight loss from 04/12/2024 to 04/19/2024. Staff X was unable to provide any information about the 25.4 lb. weight loss from 10/07/2024 - 10/14/2024 (13.9% significant weight loss in one week). Staff X stated the resident had been refusing weights, when asked for documentation of that, Staff X stated they were unable to find any documentation. Staff X stated they thought the scales on the first floor and the second floor did not weight the same. Review of Resident 41's September 2024 MAR showed an order dated 09/19/2024 for daily weights for three days, and a licensed nurse had signed off they had done the daily weights on 09/19/2024, 09/20/2024, and 09/21/2024. Comparison of this documentation with documented weights showed no documentation these weights had ever been done. In an interview on 11/13/2024 at 2:28 PM, Staff X, was unable to provide any information regarding the licensed nurse signing off they did daily weights on 09/19/2024, 09/20/2024 and 09/21/2024.

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In an interview on 11/15/2024 at 10:15 AM, Resident 43 stated that the time the staff answers their call light depends on how many people were working. When there's enough staff, wait time was usually 10-20 minutes and when they don't have enough staff, wait time will take half an hour or longer. Resident 43 stated that there was a time when 1 nursing assistant had to do 11 showers in a day. In an interview on 11/15/2024 at 10:20 AM, Resident 2 stated that nighttime is the worse time for staff to answer their call light, it takes 2 hours. Resident stated after 9 pm was when it was hard to find someone to help them. In an interview on 11/15/2024 at 10:25 AM, Resident 5 stated that it takes half an hour to an hour wait for someone to answer their call light. Resident stated that it also depends on who were the staff that were working. Resident thinks the norm for staff to answer call lights should be within 15-20 minutes. In an interview on 11/15/2024 at 10:30 AM, Resident 46 stated that they wait between 20-25 minutes for a staff to answer their call light and it was longer wait in the late afternoon. Resident stated the facility does not have enough staff to help the residents. <RESIDENT 15> In an observation and interview on 11/05/2024 at 1:25 PM, Resident 15 was observed sitting in their wheelchair with their right stump on the elevating leg rest. Resident 15 stated, It takes too d**n long to get your call light answered. An hour or two usually. The day before yesterday, the aide left me on the bedside commode for 45 minutes after lunch time. The aide told me to put my call light on when I was done. I did but waited and waited for 45 minutes. My butt was killing me. It hurts to be sitting on that (commode) and trying to stay up right. I was so mad. I told my nurse about it. Resident 15 stated their sitting balance was not good. Review of a 30-day Staffing Pattern worksheet, dated 11/05/2024, showed the facility did not have registered nursing staff on duty on night shift on 11 of 30 days reviewed. In an interview on 11/14/2024 at 8:13 AM, Staff A, Administrator, stated they were actively recruiting nursing staff. And Staff A stated the facility had not assessed the impact the lack of night shift registered nursing staff had on resident care and resident needs. Refer to WAC 388-97-1080 (1) Based on observation, interview and record review, the facility failed to provide sufficient numbers of adequately supervised nursing staff to provide care and services for 5 of 9 residents (Residents 5, 2, 43, 36, 15) and 1 of 1 organized resident groups (Resident Council) reviewed for nursing staffing and nursing care and services. Failures to ensure sufficient nursing staff and nursing staff supervision resulted in delays in nursing staff response to resident call lights, failures in administering nutritional supplements as ordered by physicians, missed bathing, cold food and not-accurate medical records. Findings included . <RESIDENT COUNCIL> In a group interview with Resident Council representatives on 11/07/2024 at 10:00 AM, Resident 50 stated overnight call light response times were sometimes slower than they should be, and they thought it was due to a shortage of staff. Resident 50 stated the facility was short of staff when it came time to pass out meal trays. Resident 50 stated it took staff only five minutes to bring their meal tray carts to the unit, then the cart sits in the halls and they wait for staff to bring them their food and it can get cold. Resident 50 said they have to grin and bear it when they get cold foods and staff don't have an answer to get it warm, they stated you could request alternate foods but to find staff to get it is limited. Resident 19 stated they had missed a lot of showers because staff don't come and get them and tell them it was shower days, Resident 50 said it was because they were short of staff, Resident 55 stated they too had missed showers because staff don't come and tell them, and that sometimes residents need to be transferred to a shower chair and they don't have two staff to do that. Resident 50 stated they can have late medications when agency staff was working and every now and then they were really late. Resident 55 stated they had a lot of agency staff. Review of Resident Council meeting minutes and related Resident Council grievances, dated 05/23/2024, 06/27/2024, 07/25/2024 and 08/29/2024 showed the Resident Council had reported concerns with long call light staff response times of up to an hour. In an interview on 11/13/2024 at 9:15 AM, Resident 50, Resident Council representative, stated staffing and call light issues were their biggest problem and they had never been resolved. Resident 50 verbalized specific concerns about night shift and on weekends when there were more agency (temporary) staff. Resident 50 stated they had a concern about residents not receiving necessary toileting care and services. Resident 50 stated they had reported their concerns to administration, but their concerns had never been resolved. In an interview on 11/12/2024 at 9:01 AM, Staff A, Administrator, stated they didn't do anything to investigate the resident council's staffing concerns. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnoses to include hemiplegia/hemiparesis (weakness/paralysis on one side of the body, and a need for assistance with personal cares. According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 08/07/2024, the resident had no cognitive impairment. The MDS indicated they required substantial/maximal assistance with toileting, bathing and lower body dressing, and they were frequently incontinent of bowel and bladder. In an interview on 11/04/2024 at 10:51 AM, Resident 5 stated if they said anything to the nursing assistants, they just argued with them. The resident stated many times they had to wait an hour for their call light to be answered and they've had to wait 45 minutes to be cleaned up after a bowel movement. Resident 5 stated their bed baths were inadequate because the staff used the same water with soap to wash and rinse them and wash their hair which caused them to feel itchy. The resident stated they wanted to bathe three times a week, but they only got bed baths twice a week. In an interview on 11/05/2024 at 11:27 AM, Collateral Contact 4 (CC4), Resident 5's family member, stated they just wanted Resident 5 to have care, but staff don't come when they were supposed to and one night Resident 5 had to call 911 because they weren't getting care. CC4 stated one night a gentleman came into the resident's room and removed their briefs and didn't come back, and the resident was left with no briefs, and they just wanted Resident 5 to be treated with dignity. CC4 stated the resident was missing 20 shirts. In an interview on 11/15/2024 at 9:42 AM, Resident 5 stated one night staffing was so bad they had to wait six hours, they needed a nursing assistant as they were wet and needed to be changed and they waited from midnite to 6:00 AM, so they called 911. They stated weekend staffing they have a lot of agency staff and call light staff response times can range from ½ hour to one hour. Resident 5 stated yesterday they got the wrong food at noon, they stated they looked on the tray card and staff had delivered them a tray for a resident from across the hall. The resident stated they had a lot of stress over bathing, that staff would wash them and rinse them with the same water. The resident stated they had missed bathing a couple times because they refused because they were so tired, but that since they had refused they had to wait a week without a bath, and evidently if you miss your bath you are out of luck as they did not come back and offer again. The resident stated you miss your bath if you can't do it on their schedule. The resident also stated they had issues with getting their Glucerna (nutritional shakes) and their daughter had to bring in some protein drinks because they couldn't get them here. The resident stated the staffing is better now, but it has been real bad, and the care changed once you (survey team) came out here, it changed because we didn't have to wait so long once you came, the wait changed. Resident 5 stated sometimes they would use their napkin box to bang it on the table because they would not answer my call light. Review of a physician assistant progress note, dated 05/14/2024, showed the patient reported their clothes were missing, they were informed that there was a shortage of staff which likely caused a delay in receiving their clothes from laundry. Patient thinks that staffing in the facility should be addressed because they were not happy with some of the staff or agency staff that come and works with them. Facility administration is aware of patient's concerns and working to improve staffing and patient's satisfaction. Review of a social services progress note, dated 09/20/2024, showed the resident had notified them that care staff did not bring supplies with them when they gave them care, and they said the care staff come in and change them, and realize they don't have the supplies and leave them there naked and don't return for a long time. Review of a care conference note, dated 06/14/2024, showed the resident had issues with not receiving their bed baths, and staff documented they showed them their bathing schedule and it showed their bed baths were being done. Review of an alert note, dated 11/03/2024, showed no bath/shower for five days. Review of Resident 5's bathing documentation for 30 days, print date 11/13/2024, showed they were care planned to bathe twice weekly, on Wednesday and Saturday evening shifts, and they preferred bed baths. The documentation showed they had been bathed five times in 30 days, and they had three documented refusals. Review of the progress notes on the dates of the three refusals showed no documentation staff had documented why the resident refused to bathe, and there was no documentation the resident had been offered to bathe at another time. In an interview on 11/13/2024 at 2:18 PM, Staff X, Licensed Practical Nurse/Resident Care Manager, stated they didn't know about the resident's bathing refusals, and they thought the resident should have been re-offered to bathe the next day, they looked in the electronic health record and stated they could find no documentation they were re-offered to bathe after refusals. Review of Resident 5's breakfast tray card on 11/07/2024 showed the resident was to have Glucerna on their tray. In an observation on 11/07/2024 at 8:23 AM, there was no Glucerna on the resident's breakfast tray. In an interview on 11/07/2024 at 12:30 PM, Resident 5 stated last night was the first time they ever got their nutritional shake. Review of Resident 5's Medication Administration Records (MARS), from 11/01/2024 - 11/07/2024 showed an order dated 10/01/2024 for a Nutritional Shake: no sugar added with meals for supplement and it had a box for the nurse to document the percentage of the shake consumed, but that box always had an x instead of a percentage actually consumed. In an interview on 11/07/2024 at 2:41 PM, Staff AA, Registered Nurse (RN), stated the kitchen usually supplied the nutritional shakes with breakfast and lunch, so they just signed off on the MARs. Staff AA stated they thought they saw the resident drinking a nutritional shake, but now they were not sure. In an interview on 11/07/2024 at 3:00 PM, Staff G, Dietary Manager, stated the kitchen supplied nutritional shakes with meals if they received the order and it said to go with meals. Staff G stated they did not know the resident had an order for a nutritional shake with meals because they never received a communication sheet from nursing staff. Staff G stated their system never showed an order for the nutritional shake. In an interview on 11/07/2024 at 3:02 PM, Staff AA, RN, was asked about their documentation of an x on the MARS for amount of nutritional shake consumed, they stated it shouldn't be an x, that it should have been a number percentage.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent (%), there were 29 opportunities for error observed and resulted in 68.97% medication error rate. Failure to administer the right dose of medication for 1 of 8 residents (Resident 43), failure to administer medication by the correct route for 1 of 8 residents (Resident 78), and failure to administer medications at the right time for 7 of 8 residents (Resident 2, 5, 34, 43, 58, 75, 78) placed residents at risk for adverse side effects, medical complications and diminished quality of life. Findings included . According to the facility policy titled Medication Administration: Medications administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician in accordance with professional standards of practice. Review Medication Administration Record (MAR) to identify medication to be administered. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. Administer within 60 minutes prior or after scheduled time unless otherwise ordered by physician. Sign MAR after administered. In an observation and record review, on 11/05/2024 at 9:00AM, Staff P, Licensed Practical Nurse (LPN) administered medications: Tylenol 1000 milligram (mg), Gabapentin 800 mg (nerve pain medicine), and 1 unit of Humalog insulin to Resident 75. Review of the MAR for Resident 75 showed those medications were supposed to be given at 7:00 AM. The time medications were given were outside the time parameter per facility policy. In a record review on 11/05/2024 at 9:07 AM, Resident 43's MAR showed 8:00 AM medications were not given. These medications were: Multivitamin with minerals 1 tablet, Eliquis 2.5 mg (blood thinner medicine), Vitamin C 500 mg, Calcium Carbonate Antacid (Tums) 1177 mg chewable tablet and Arnuity Ellipta Inhalation Aerosol powder (inhaler for asthma), one puff. In an observation and interview on 11/05/2024 at 9:20 AM, Staff N, Agency Registered Nurse (RN) prepared the 8:00 AM medications and administered it to Resident 43. When asked about the Calcium Carbonate Antacid dose, Staff N stated that they gave resident the 750 mg chewable tablet. Staff N will contact the provider to clarify the order. In an interview on11/05/2024 at 1:50 PM, Staff N stated that they were expected to pass medications within one hour before or one hour after the time that's in the MAR. They stated that when they think they will be late on passing medications, they prioritize the medications that were important such as blood pressure medications and insulin. Staff N stated that they can ask the unit manager for assistance as well. In an observation and record review on 11/05/2024 at 9:45 AM, Resident 4 received their medications, given by Staff XX, Agency LPN. According to the MAR, Pro Source (supplement) 30 milli liter, Lidocaine patch and Tylenol extra strength 1000 mg were all due at 7:30 AM. In an observation and record review on 11/05/2024 at 10:00 AM, Resident 34 received her medications, given by Staff XX. According to the MAR, Artificial Tears, one drop to both eye, Aspirin Enteric Coated 81 mg, Metoprolol Extended Release 25 mg (blood pressure medicine), Senna 8.6 mg (stool softener), Multivitamin 1 tab were all due at 8:00 AM. In an interview on 11/05/2024 at 10:05, Staff XX, stated that they were expected to give medications within one hour prior or one hour after the time in the MAR. They stated that even if the medications were late that they'd rather give it then not give the medications at all. They stated that the unit manager may probably be able to help with giving medications when they were running late but did not ask for assistance. In an observation on 11/05/2024 at 1:15 PM, Staff P, LPN, administered Baclofen (muscle relaxant medicine) 15 mg tablet to Resident 78 via gastrostomy tube (G tube - a feeding tube that is inserted through the skin and the stomach wall to provide nutrition and fluids directly to the stomach). Review of MAR and doctors order showed Baclofen 15 mg, give 1 and a half tablet (10 mg tablets) by mouth at the same time another doctor's order stated nothing by mouth. Staff P stated that whoever was the staff that admitted the resident should have updated the orders and should be per G tube and not by mouth. Staff P stated that they will clarify and update the order. In an interview on 11/07/2024 at 10:48 AM, Staff X, LPN/Unit Manager (UM) stated that per facility policy, the timing of Medication Administration is one hour before or one hour after the time in the MAR if the medication was administered past the time that was considered as medication error. They stated that it was an expectation that the staff notifies the UM if they were running late on their Medication Administration so they can assist. In an interview on 11/07/2024 at 2:05 PM, Staff L, RN/UM stated that medications should be passed one hour before and one hour after the time in the MAR. They stated that if the medications were over an hour late, the Director of Nursing Services (DNS), monitors them and the DNS was the one that follows up. In a joint interview on 11/08/2024 at 12:34 PM with Staff A, Administrator and Staff B, RN/DNS, Staff B stated that medications should be given one hour before or one hour after the time in the MAR unless there was an unforeseen event, then they notify the provider and the nurse will prioritize on what medications to give first such as blood pressure medications and insulin. Staff B stated that they print out the medication error report in the morning and discuss it in the morning meetings and then they give it to the Staff Development Manager and the Staff Development Manager will talk to the nurse. If the nurse was a multiple offender, then they discipline them. When asked about supervision for the nurses, Staff B stated that the Unit Managers should be doing their rounds and assisting the nurses. Staff B stated that they did not count late medications as medication errors. Late medication administration was not in their QAPI. When asked what the plan of correction was when they were cited with medication error on their last survey, Staff A stated that they did audits and follow up. Staff B stated that the late medications that were given today will be logged as medication errors. In an observation on 11/14/2024 at 5:20 PM, Staff XX drew up Humalog insulin and administered the shot to Resident 58. In a record review and interview on 11/14/2024 at 5:25 PM Resident 58's MAR showed Humalog Insulin was administered at 4:19 PM on 11/14/2024. According to Staff XX, they signed the MAR that the insulin was given at the time they checked Resident 58's blood sugar even though they have not given it at the time they signed the MAR. In an observation and record review on 11/14/2024 at 5:34 PM, Resident 2's MAR showed that Humalog insulin was signed that it was given at 4:15 PM on 11/14/2024. Observed Staff XX drew up the Humalog insulin and administered it to Resident 2 at 5:34 PM. In an interview on 11/14/2024 at 5:38 PM, Staff XX stated that after checking the blood sugar they signed the insulin order even though they have not given Resident 2's insulin yet. Staff XX stated that they signed that it was given so that it will not show that they were late giving the insulin in resident's electronic chart. In a record review on 11/14/2024 at 5:39 PM, Resident 5's MAR showed that the Humalog insulin was administered at 3:56 PM on 11/14/2024. In an observation and interview on 11/14/2024 at 5:40 PM, Staff XX drew up Humalog insulin and administered the shot to Resident 2 at 5:40 PM. Staff XX, stated that they signed that they administered the insulin ahead of time. They stated they just don't want the medications to show up late in the resident's electronic chart. They stated that this is not a safe practice. Staff XX denied that they had anymore medications that they signed ahead of time. This is a repeat citation from SOD 12/14/2023 Refer to WAC 388-97-1060 (3)(k)(ii)

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 78> Resident 78 admitted on [DATE] with diagnoses to include stiff person syndrome. In an observation and inter...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 78> Resident 78 admitted on [DATE] with diagnoses to include stiff person syndrome. In an observation and interview on 11/05/2024 at 12:28 PM, Resident 78 said their nurse (Staff N, Agency RN) this morning did not know how to give their medications through their feeding tube. Resident 78 said they had to walk them through the steps to do it. The resident said they told them to crush the meds, and how to use the syringe. Resident 78 commented maybe they did not learn that at their school. Review of the enteral feeding competency demonstrated by Staff N, Agency RN on 11/13/2024, showed that Staff N failed to follow enhanced precautions protocol, tap water was used instead of sterile or purified water, and date and label the formula. There was no competency of medication administration via tube. In an interview on 11/06/2024 at 8:43 AM, Resident 78 was resting in bed and said they had missed medications on three different days, including the day before yesterday. Resident 78 said they talked to Staff O, Licensed Practical Nurse (LPN) about it and they said they passed it onto day shift to give those medications. Resident 78 said they then asked the day shift nurse that followed Staff O, and they said that was not true, Staff O was supposed to administer them. Review of the September, October and November MARS showed the resident was to receive Gabapentin 100 MG at bedtime. Baclofen 10 MG three times a day and Diazepam 5 MG before breakfast and at bedtime. Review of the MARS showed the following for Gabapentin: - 09/24/2024 scheduled 8:00 AM, administered 9:30 AM -09/25/2024 scheduled 8:00 AM, administered 9:43 AM -09/27/2024 scheduled 8:00 AM, administered 10:23 AM -10/18/2024 scheduled 8:00 AM, administered 12:02 PM -11/05/2024: Scheduled 8:00 PM, administered 10:35 PM Review of the MARS showed the following for Diazepam: -09/24/2024 scheduled 7:00 AM, administered 9:32 AM -10/18/2024 scheduled 7:00 AM, administered 12:02 PM -10/29/2024 scheduled 1:00 PM, administered 2:51 PM -11/05/2024: Scheduled 9:00 PM, administered 10:35 PM -09/24/2024 scheduled 7:00 AM, administered 9:36 AM -09/27/2024 scheduled 7:00 AM, administered 10:23 AM -10/18/2024 scheduled 7:00 AM, administered 12:02 PM -10/19/2024 scheduled 7:00 AM, administered 9:25 AM -10/20/2024 scheduled 7:00 AM, administered 10:13 AM -10/23/2024 scheduled 7:00 AM, administered 10:20 AM -10/30/2024 scheduled 7:00 AM, administered 09:03 AM -10/31/2024 scheduled 7:00 AM, administered 8:53 AM -11/01/2024 scheduled 7:00 AM, administered 9:48 AM -11/02/2024 scheduled 7:00 AM, administered 9:11 AM -11/03/2024 scheduled 7:00 AM, administered 9:42 AM -11/04/2024 scheduled 7:00 AM, administered 8:52 AM -11/05/2024 scheduled 7:00 AM, administered 10:14 AM -11/06/2024 scheduled 7:00 AM, administered 8:28 AM Review of the MARS showed the following for Lidocaine patches: -10/18/2024 scheduled 8:00 AM, administered 12:02 PM -10/19/2024 scheduled 8:00 AM, administered 10:27 AM -10/20/2024 scheduled 8:00 AM, administered 10:14 AM <RESIDENT 98> Resident 98 admitted on [DATE] with diagnoses to include diabetes requiring insulin. In an interview on 11/06/24 at 9:03 AM, Resident 98 said they get their medications helter skelter and there is no normal time. The resident said they still hasn't gotten their nasal spray today. The resident said last night the nurse refused to mix Triamcinolone with the powder for her bottom although two different nurses have used it on them. The resident said this one refused and said there was no order for it. Review of the MARS showed the following for insulin Lispro three times a day: -10/16/2024 scheduled 7:00 AM, administered 8:44 AM, Blood Glucose (BG) check was 8:40 AM -11/01/2024 scheduled 7:00 AM, administered 8:40 AM, BG check was 7:13 AM -11/02/2024 scheduled 7:00 AM, administered 8:30 AM, BG check was 8:30 AM -11/02/2024 scheduled 11:00 AM, administered 12:45 PM BG check was 12:45 PM -11/02/2024 scheduled 4:00 PM, administered 5:10 PM -11/03/2024 scheduled 7:00 AM, administered 8:45 AM, BG check was 8:44 AM -11/03/2024 scheduled 11:00 AM, administered 12:41 PM BG check was 12:42 PM -11/03/2024 scheduled 4 PM, administered 5:59 PM, BG check same time -11/04/2024 scheduled 11:00 AM, administered 12:20 PM BG check was 12:20 PM -11/04/2024 scheduled 4 PM, administered 5:41 PM, BG check same time -11/05/2024 scheduled 7:00 AM, administered 8:39 AM BG check was 8:46 AM -11/05/2024 scheduled 11:00 AM, administered 12:50 PM BG check was 12:50 PM -11/05/2024 scheduled 4:00 PM, administered 6:36 PM, BG check same time -11/08/2024 scheduled 7:00 AM, administered 8:23 AM, BG same time -11/12/2024 scheduled 8:00 PM, administered 9:41 PM Review of the MARS showed the following for insulin Lispro sliding scale: -10/16/2024 scheduled 7:00 AM, administered 8:43 AM, BG check was 7:13 AM -11/01/2024 scheduled 7:00 AM, administered 8:40 AM, BG check was 8:40 AM -11/02/2024 scheduled 7:00 AM, administered 8:30 AM, BG check was 8:29 AM -11/02/2024 scheduled 11:00 AM, administered 12:45 PM BG check was 12:45 PM -11/03/2024 scheduled 7:00 AM, administered 8:44 AM, BG check was 8:44 AM -11/03/2024 scheduled 11:00 AM, administered 12:41 PM BG check was 12:42 PM -11/03/2024 scheduled 4:00 PM, administered 5:59 PM, BG check same time -11/04/2024 scheduled 7:00 AM, administered 9:51 AM BG check was 9:53 AM -11/04/2024 scheduled 11:00 AM, administered 12:20 PM BG check was 12:20 PM -11/04/2024 scheduled 4 PM, administered 5:41 PM, BG check same time -11/04/2024 scheduled 4 PM, administered 5:35 PM, BG check same time -11/05/2024 scheduled 7:00 AM, administered 8:39 AM BG check was 8:46 AM -11/05/2024 scheduled 11:00 AM, administered 12:50 PM BG check was 12:50 PM -11/05/2024 scheduled 8:00 PM, administered 9:22 PM, BG check same time -11/08/2024 scheduled 7:00 AM, administered 8:22 AM, BG same time <RESIDENT 453> Resident 453 admitted on [DATE] with diagnoses to include multiple cardiac conditions, requiring medication management. In an interview on 11/04/2024 at 10:02 AM, Resident 453 said they were waiting on their morning meds. The resident stated their med delivery was spotty, they are late a lot. I usually get them right after breakfast with their food. In an interview on 11/06/2024 at 8:53 AM, Resident 453 said Staff D, RN is the only nurse who gives them their medications on time. Review of the MARS showed the following for Spironolactone: -11/02/2024 scheduled 8:00 AM, Administered 9:34 AM -11/04/2024 scheduled 8:00 AM, Administered 10:58 AM -11/06/2024 scheduled 8:00 AM, Administered 9:57 AM Review of the MARS showed the following for Furosemide: -11/02/2024 scheduled 8:00 AM, Administered 9:33 AM -11/04/2024 scheduled 8:00 AM, Administered 10:59 AM -11/06/2024 scheduled 8:00 AM, Administered 9:57 AM <LATE INSULIN ADMINISTRATION> <RESIDENT 253> Resident 253 was admitted to the facility on [DATE] with diagnoses that included acute cystitis (a bladder infection that begins suddenly and usually caused by bacteria) and type 2 diabetes mellitus (DM-long term condition in which the body has trouble regulating blood sugar). In a review of the Medication Administration Audit Report dated 11/08/2024 showed Resident 253 had physician orders for Lantus Solostar Subcutaneous Solution Pen Injector 100 unit/ml (Insulin Glargine) to inject 25 unit subcutaneously (under the skin) two times a day to (DM) hold for blood glucose (BG) under 90 and miss a meal and follow hypoglycemic protocol if BG under 70. The medication was ordered to be administered at 8:00 AM and Resident 253 received Insulin Glargine at 10:09 AM. <RESIDENT 35> In a review of the Medication Administration Audit Report dated 11/08/2024 showed Resident 35 had a physician order for Humalog Solution on 100 unit/ml, to inject 8 units subcutaneously two times a day for diabetes hold for BG under 90 and to follow hypoglycemic protocol if BG under 70. The medication was ordered to be administered at 8:00 AM and Resident 35 received Humalog Solution at 9:43 AM. <RESIDENT 61> In a review of the Medication Administration Audit Report dated 11/08/2024 showed Resident 61 had a physician order for Insulin Lispro Injection Solution 100 unit/ml to inject 5 units subcutaneously with meals for DM hold for BG under 90. The medication was ordered to be administered at 8:00 AM and Resident 61 received their Insulin Lispro Injection at 9:58 AM. <RESIDENT 37> Resident 37 admitted to the facility on [DATE] with diagnoses that included bilateral below the knee amputations, DM, and high blood pressure. In a review of the Medication Administration Audit Report dated 11/08/2024 showed Resident 37 had a physician order for insulin Lispro Injection Solution 100 unit/ml and to inject as per sliding scale, subcutaneously before meals and at bedtime for DM hold if BS 90 or not eating and to follow hypoglycemic protocol for BG under 70. The medication was ordered to be administered before meals scheduled at 7:00 AM, Resident 37 received their Insulin Lispro at 8:59 AM. <RESIDENT 75> In a review of the Medication Administration Audit Report dated 11/08/2024 showed Resident 75 had a physician order for Humalog Solution 100 UNIT/ml (Insulin Lispro Human) to inject as per sliding scale subcutaneously before meals for diabetes and for BS 70 follow hypoglycemic protocol. The medication was ordered to be administered before meals at 7:00 AM, Resident 75 received their medication at 8:41 AM. <RESIDENT 77> In a review of the Medication Administration Audit Report dated 11/08/2024 showed Resident 77 had a physician order for insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) to inject as per sliding scale and 6 units subcutaneously before meals related to DM and to follow hypoglycemic protocol for BG under 70. The medication was ordered to be administered before meals at 7:00 AM, Resident 77 received their both medications 8:42 AM and 8:43 AM. In a joint interview on 11/08/2024 at 12:34 AM with Staff B, Director of Nursing Services, and Staff A, Administrator, stated they had two call outs this morning and were aware of the late insulin being provided to the residents. Staff B stated the provider was notified. Staff B stated their policy allows for medication administration an hour before or after the scheduled time. Staff B stated medication administration and late medications are being monitored daily in their clinical meeting. Staff B stated they are not completing mediation error reports or incident reports on late medications. <MEDICATION ERROR MANAGEMENT> Review of the facility incident reporting logs from May - October 2024 showed: May 2024: no logged medication errors June 2024: one logged medication error July 2024: three logged medication errors August 2024: no logged medication errors September 2024: one logged medication error October 2024: one logged medication error In an interview on 11/08/2024 at 12:33 PM, Staff B, Director of Nursing, was asked how many medication error reports they did a week, Staff B stated not many, what it comes down to I haven't been doing it, I need to try to make it more functional than we have been doing. In an interview on 11/14/2024 at 8:13 AM, Staff A, Administrator, stated they were not aware of any medication error trends. Staff A stated they were not aware that medication errors were not being reported and investigated as Staff B had not been reporting them. Staff A stated they didn't know if Staff B had been trained on facility medication management policy. Staff A stated they didn't know about any root cause analysis being done regarding the many medication errors that had occurred, they stated they hadn't known about all of the medication errors because the director of nursing had not been reporting them. In an joint interview on 11/15/2024 at 11:48 AM, Staff B, Director of Nursing stated they reviewed the late medication report at stand up meeting. Staff B said they talked with some nurses who reported they are documenting their medication administration at at end of shift. Staff B said that they pulled the late medication report this morning and were pleased the report went from 77 pages down to 13 pages. Staff B said they had been more focused on missed meds than the late meds. This is a repeat deficiency from 12/14/2023. Refer to WAC 388-97-1060 (3)(k)(iii) Based on observation, interview and record review, the facility failed to ensure 7 of 10 residents (Residents 5, 2, 58, 78, 24, 98, 453) remained free of significant medication errors when administering and documenting medication administration. The failure to administer medications within the required time frame of one hour before/after the scheduled time resulted in countless timing and/or documentation errors including breakfast and lunch insulin administrations given within minutes of each other. The facility's failed medication management practices placed residents at risk for adverse medication-related complications, diminished quality of life, and for having inadequate medical records being used to make medical decisions. Additional failed practice included lack of sorely needed nursing supervision and administrative oversight of medication management practices and systemic failures in reporting, documenting and investigating medication errors. Findings included . Review of the facility policy titled Medication Administration, undated, showed the medications were administered by licensed nurses or other legally authorized staff as ordered by the physician and in accordance with professional standards of practice. The policy indicated staff were to administer medications within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. The policy also indicated staff were to sign the medication administration record after medications were administered. Review of the facility policy titled Adverse Consequences and Medication Errors, undated, showed It was the policy of the interdisciplinary team to evaluate medication usage in order to prevent and detect adverse consequences and medication-related problems. Medication error was defined as the preparation or administration of drugs and biologicals which was not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing the service. Examples of medication errors included wrong time: and/or failure to follow manufacturer instructions and/or accepted professional standards. The policy indicated the interdisciplinary team reviewed residents' medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. The policy indicated facility staff monitored residents for possible medication-related adverse consequences, including mental status and level of consciousness, to include when residents had a clinically significant change in condition/status, and when medication errors occurred, and when they occurred the prescriber and staff rule out medications as a cause and document it in the resident's clinical record. The policy indicated the attending physician was notified promptly of any significant error or adverse consequence, and the resident/resident representative would be notified of any significant medication error or adverse consequence and actions taken to monitor and/or treat the resident's response to the error. The policy indicated the incident would be described in the resident's medical record and would be reported to the prescribing practitioner, director of nursing/designee, and the facility administrator, and the facility would alert staff of the need to monitor the resident. The policy indicated documentation would be done in the resident's clinical record to include a factual description of the error or adverse consequence, name of physician and time notified, physician's subsequent orders, and resident's condition for 24 to 72 hours or as directed. The policy indicated data regarding medication adverse consequences and errors (e.g. total number of incidents, number of incidents by category/type, trends) would be compiled and presented to the quality assurance and performance improvement committee on at least a quarterly basis. The policy indicated the director of nursing or designee would conduct a root cause analysis of medication administration errors to determine the source of errors, implement process improvement steps, and compare results over time to determine that system improvements were effective in reducing errors. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] and had diagnoses to include diabetes, depression, anxiety, and a communication deficit. According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 08/07/2024, the resident had no cognitive impairment. In an interview on 11/05/2024 at 11:27 AM, Collateral Contact 2 (CC2), family member of Resident 5, stated twice when they visited, Resident 5 had low blood sugar levels where their blood sugar dipped down to 60 (low blood sugar level) and they had to yell for nursing to come and staff told CC2 to give them yogurt while they went to get juice, and that staff told CC2 the resident needed to go to a different doctor than the facility doctor because they could not manage the resident's diabetes. CC2 also stated that facility staff had double-dosed Resident 5 on medications, and they gave the resident Xanax (Alprazolam) and Triazolam (sedative medications) at the same time and when they called the facility to speak to the resident they could not speak and they thought the resident was having a stroke. Review of Resident 5's Medication Administration Records showed: November 1 - 10, 2024: there were 32 insulin doses in 10 days where the resident did not receive their insulin doses within one hour of the scheduled time, resulting in 32 medication errors. On 11/07/2024, the resident was scheduled to receive Humalog insulin at 7:00 AM, the medication records indicated the resident did not receive that insulin until 10:25 AM, then they received their scheduled 11:00 AM dose at 12:07 PM. Review of the resident's progress notes showed no documentation the facility had contacted the resident's physician regarding their late insulin medication administration. October 2024: there were 62 insulin doses where the resident did not receive their insulin within one hour of the scheduled time, resulting in 62 medication errors. A few examples of late Humalog insulin administration included: -10/12/2024 7:00 AM dose, given at 10:03 AM (No physician notification found in the progress notes) -10/11/2024 7:00 AM dose, given at 10:52 AM (No physician notification found in the progress notes) -10/06/2024 11:00 AM dose, given at 1:30 PM (No physician notification found in the progress notes) September 2024: there were 84 insulin doses where the resident did not receive their insulin within one hour of the scheduled time, resulting in 84 medication errors. -09/27/2024 4:00 PM dose, given at 2:11 PM (progress note review showed no documentation why the dose was given almost two hours early, and there was no documentation a physician was notified) -09/17/2024 7:00 AM dose, given at 10:05 AM, then the 11:00 AM dose was given at 10:59 AM, only 54 minutes later (progress note review showed no documentation a physician had been notified) August 2024: there were 68 insulin doses where the resident did not receive their insulin with one hour of the scheduled time, resulting in 68 medication errors. July 2024: there were 53 insulin doses where the resident did not receive their insulin with one hour of the scheduled time, resulting in 53 medication errors. -07/20/2024 0700 dose, given at 11:33 AM, then two minutes later the 11:00 AM dose was given at 11:35 AM (progress notes review showed no documentation explaining this irregularity, and there was no documentation a physician was notified). June 2024: there were 79 insulin doses where the resident did not receive their insulin with one hour of the scheduled time, resulting in 79 medication errors. -06/16/2024 7:00 AM dose was given at 11:41 AM (almost 5 hours late), the 11:00 AM dose was given at 11:16 AM which was actually given before the 7:00 AM dose (progress note review showed there was no documentation explaining this irregularity). Both of these doses included scheduled prescribed dose of Humalog insulin and scheduled sliding scale Humalog insulin. -06/20/2024 7:00 AM dose was given at 11:33 AM (4 ½ hours late), then the 11:00 AM dose was given at 12:14 PM (progress note review showed no documentation explaining this irregularity). Review of a physician assistant progress note, dated 06/20/2024 at 00:00, showed the patient was seen today regarding report of taking additional doses of medication. Nursing and patient report they were given Triazolam (sedative medication) at bedtime twice on 06/16/24. Nursing reports patient was more sleepy than usual on that day, but patient was arousable. Nursing was instructed to continue monitoring patient. Patient was seen today to check on how they were feeling. They reported talking to their daughter on the phone that day and daughter told the patient they didn't seem like themselves. Patient takes Triazolam for sleep nightly. Patient recalls sleeping for more than they usually slept. Patient reports feeling fine today and back to their normal self. Review of the nursing progress notes for 06/16/2024 and 06/17/2024 showed there were no nursing progress notes explaining this situation or which nurse had reported this to the physician assistant. May 2024: there were 50 insulin doses where the resident did not receive their insulin with one hour of the scheduled time, resulting in 50 medication errors. April 2024 - December 2023 Review of medication administration records for those months showed there were over 200 medication errors found that were like the medication errors described for the months of May - November 2024. Review of Care Conference/Concern Follow up Call notes, dated 11/14/2024, showed there was a discussion regarding the resident's daughter's concerns about the resident's diabetes and what was causing the extreme fluctuations in blood sugar readings. The note indicated the physician and nurse manager (Staff X, LPN/RCM) agreed the cause was the resident's diet. The notes also indicated the resident's daughter's concern was the resident was not receiving the foods per their tray cards. The notes indicated the facility had discovered that tray cards were not matching what was being served on the tray. Review of an email interview, dated 11/18/2024, showed Staff B, Director of Nursing, reported finding discrepancies regarding Triazolam and Alprazolam (both sedative medications) being administered together on 07/15/2024, 07/31/2024, 08/23/2024, 09/06/2024 and 09/24/2024. The email indicated Staff B had opened an internal incident report and would be investigating as a medication error. Medication Administration observation: In an observation on 11/14/2024 at 5:40 PM, Staff XX, Agency LPN, was observed to administer the resident their insulin. Review of the insulin administration documentation on the November 2024 medication administration records showed Staff XX documented they administered the resident their insulin at 3:36 PM, which was over 2 hours earlier than they actually administered the insulin. In an interview on 11/14/2024 at 5:40 PM, Staff XX, Agency LPN stated that they signed that they administered the insulin ahead of time. They stated they just don't want the medications to show up late in the resident's electronic chart. They stated that this was not a safe practice. <RESIDENT 2> Medication Administration observation: In an observation on 11/14/2024 at 5:36 PM, Staff XX, Agency LPN, was observed to administer Resident 2 their insulin. Review of the insulin administration documentation on the November 2024 medication administration records showed Staff XX documented they administered the resident their insulin at 4:15 PM. In an interview on 11/14/2024 at 5:38 PM, Staff XX, Agency LPN stated that after checking the blood sugar they signed the insulin order even though they have not given Resident 2's insulin yet. Staff XX stated that they signed that it was given so that it will not show that they were late giving the insulin in resident's electronic chart. <RESIDENT 58> Medication Administration observation: In an observation on 11/14/2024 at 5:19 PM, Staff XX, Agency LPN, was observed to administer Resident 58 their insulin. Review of the insulin administration documentation on the November 2024 medication administration records showed Staff XX documented they administered the resident their insulin at 4:19 PM. In an interview on 11/14/2024 at 5:285 PM, Staff XX, Agency LPN stated they signed the MAR that the insulin was given at the time they checked Resident 58's blood sugar even though they have not given it at the time they signed the MAR.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <MEDICATION CARTS> In an observation on 11/05/2024 at 1:35 PM, the Yellow Medication Cart on the first floor had 4 expired...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <MEDICATION CARTS> In an observation on 11/05/2024 at 1:35 PM, the Yellow Medication Cart on the first floor had 4 expired bottles of medications. They were, Calcium 600 milligram (mg), Guaifenesin 400 mg, Cetirizine HCl 10 mg, the expiration date on the bottles were 09/2024, Acetaminophen with Aspirin and Caffeine, expiration date was 03/2024. The nurse stated they will dispose the expired medications. In an observation on 11/05/2024 at 1:50 PM, the [NAME] Medication Cart on the first floor had 1 expired medication - Calcium 600 mg with expiration date of 09/2024. Nurse stated they will dispose of the expired medication. In an observation on 11/05/2024 at 2:20 PM, the Pink Medication Cart on the second floor had 2 expired medications. They were, Cetirizine HCl 10 mg with expiration date of 09/2024 and Zinc 50 mg with expiration date of 10/2024. The nurse stated they will dispose the expired medications. In a joint interview on 11/14/2024 at 12:20 PM with Staff A, Administrator and Staff B, DNS, Staff B stated that the nurses working the medication carts were supposed to look at the dates prior to opening containers and dispose expired medications. Staff A stated that they went through all the medication carts and checked to make sure there were no more expired medications. This is a repeat deficiency from 12/14/2023. Refer to WAC 388-97-1300 (2) Based on observation, interview and record review, the facility failed to ensure medications were secured for 4 of 4 residents (Resident 47, 78, 453 and 454) observed with medications at bedside. Further, the facility failed to discard expired in three of four medication carts reviewed. This failure placed the residents at risk for receiving compromised or ineffective medications This failure placed the residents at risk for consuming medication in excessive dosage, medical complications, and diminished quality of life. Findings included . Review of the undated facility policy titled, Medication Storage showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdate, or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed. <RESIDENT 453> In an observation and interview on 11/04/2024 at 10:30 AM, Resident 453 was resting in bed with Normal Saline Spray in a clear cup, Artificial tears in a medication cup and Proair inhaler on their overbed table. Resident 453 said the medications were theirs and the staff know all about it In an observation on 11/05/2024 at 2:20 PM, the Normal Saline Spray in a clear cup at bedside, Artificial tears, Proair inhaler. In an interview and observation on 11/06/2024 at 8:53 AM, Resident 453 reported a couple days ago a nurse gave me two pills that were not my Xarelto. Resident 453 said they told the nurse These are not my Xarelto, I need my blood thinner. The nurse told me oh, we don't have yours, but these two are Xarelto and just a little over your dose. The Artificial tears, nasal spray and Proair remained on their overbed table. At 4:00 PM, Resident 453 was out of their room and the artificial tears, nasal spray and Proair inhaler were on their overbed table. In an observation on 11/07/2024 at 11:00 AM, the artificial tears, nasal spray and Proair inhaler were on their overbed table. <RESIDENT 47> In an observation and interview on 11/04/2024 at 2:21 PM, Resident 47 was up in their wheelchair with Timolol eye drops on their overbed table. The resident stated they were their eye drops. <RESIDENT 454> In an observation and interview on 11/04/2024 at 3:09 PM, A bottle of medicated Metholatum Gold Bond Powder were at bedside on their nightstand. <RESIDENT 78> In an observation and interview on 11/06/2024 at 8:43 AM, Resident 78 was resting in bed. There was an orange-colored bottle filled 1/4 full with a child safety cap on it to the right of their nightstand. There was no label on it. Resident 78 said it was their Lidocaine and they used it for the pain caused from their cancer treatment. Resident 78 said their son had brought the bottle to them from home. In an interview on 11/14/2024 at 12:43 PM, Staff B, Director of Nursing Services (DNS) said there was only one resident in the facility on self-medication program and it was not Resident 47, 78, 453 or 454. Staff B [NAME] the expectation was meds should be secured and not be left at bedside.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

<TEST TRAY> On 11/13/2024 at 12:44 PM was provided a test tray by the aide working on the first floor. The following meal was provided: mashed potatoes and gravy, thin chicken cutlet, boiled zuc...

Read full inspector narrative →

<TEST TRAY> On 11/13/2024 at 12:44 PM was provided a test tray by the aide working on the first floor. The following meal was provided: mashed potatoes and gravy, thin chicken cutlet, boiled zucchini and an uncovered fruit cocktail cup from a can. Each component of the meal had the temperature taken and was within standards. The mashed potatoes and gravy consisted of good flavor and texture. The chicken cutlet was thin, dry, and tough to chew with minimal flavor. The zucchini were mushy and disintegrated into mush when picked up by a fork. The fruit cocktail was not consumed as it was delivered after being walked down a hall uncovered. The meal was not palatable. This is a repeat deficiency from 12/14/2023. Reference: WAC 388-97-1100(1)(2) Based on observation, interview and record review, the facility failed to ensure foods were served in a timely manner and were palatable for 6 of 7 residents (Resident 75, 81, 84, 95, 98 and 454) and 1 of 1 organized resident groups (Resident Council) who were interviewed about the food palatability and temperatures. Failure to meet these requirements could negatively impact the residents' nutritional status, appetite, and meal acceptance. Findings included . <RESIDENT INTERVIEWS> <RESIDENT 84> In an interview on 11/04/2024 at 11:27 AM, Resident 84 said they hate cooked spinach and they serve it to them. Resident 84 said the food could be served hotter. In an interview on 11/05/2024 at 8:41 AM, Resident 84 said they forgot my coffee. The resident said they just don't like spinach and they write in a lot of stuff on their tray card. Resident 84 said they must hate me in the kitchen. They do a lot of canned fruit. Lots of fruit cocktail, mostly canned. I would like fresh berries. Food is lukewarm at best. Maybe those carts are not insulated well. Food needs to be hotter. In an interview on 11/08/2024 at 10:14 AM , Resident 84 said their peas and carrots were not warm last night. Resident 84 showed a picture on their phone with their order for this morning which was 2 bowls of oatmeal and they had crossed off eggs and toast. The resident said they received the eggs, toast and only one bowl of cereal, Resident 84 said why did they not even look at these preferences or maybe they cannot read. <RESIDENT 98> In an interview on 11/04/2024 at 11:53 AM, Resident 98 stated the food services there were questionable. They said they worked in the food services for 30 years. The resident said they serve us cold pork chops. They said they have learned to go get their meals in the dining room so the food was palatable. The resident said they do not use spices here and they cook with a lot of salt, Resident 98 said their breakfast this morning was a piece of toast and a hash brown square and canned orange juice which was all carbs and they are diabetic. They said last week they had rice and pasta alfredo in the same meal. The resident said some of the aides will go get them a hot meal because they know they do not like cold food. In an interview on 11/07/2024 at 11:00 AM, Resident 98 said today they got a sausage that was cold and pork should be hot and safe. They said this morning they got a heavily iced cinnamon roll, cereal and a piece of toast. The resident said they needed to talk to the dietician but had not seen one since they admitted . Resident 98 said the heavy carb diet was not good for their diabetes. They said their fiend who is a Registered Dietician came to visit them there, looked at their food and said what are they trying to kill you? Resident 98 said they has been asking to talk with the dietician but since admit. <RESIDENT 95> In an interview on 11/04/2024 at 1:33 PM, Resident 95 said they had concerns about the food. Resident 95 said the food was served cold. They said the menu today said frosted cake but there was no frosting. The resident said the food is nothing to write home about. <RESIDENT 75> In an interview on 11/04/2024 at 1:59 PM, Resident 75 said the food needs to be hotter. They said yesterday their breakfast was served cold. Resident 75 stated they absolutely hate mushy vegetables, and all the vegetables were way overcooked. In a follow up interview on 11/12/2024 at 3:17 PM, Resident 75 said the food had been better since we talked and their breakfast was hot today. <RESIDENT 454> In an interview on 11/04/2024 Resident 454 was frowning and said the food is terrible, there is no flavor. Resident 454 said the food is not good so their family brings them food. <RESIDENT COUNCIL> In a group interview with resident council representatives on 11/07/2024 at 10;00 AM, Resident 50 stated staff do not warm their food when they eat in their rooms, and the food frequently came cold to their rooms and they had no way to get it warmed up, and the french fries were served ice cold. Resident 50 stated cold food was an ongoing issue and if you want to eat food and it's cold, you just have to eat it. Resident 50 stated they had talked to the kitchen staff every month and tell them they get cold food, but nothing happens. Resident 55 stated it took five minutes to bring the cart up from the kitchen, then the cart sits in the halls and they wait for staff to bring their their food and it got cold. Resident 50 stated when they came back from dialysis their food was sitting in their room cold, and what were they to do, they tell staff they have cold food and they don't do anything about it, and they just have to grin and bear it with their cold food because they don't have an answer to get it warm. In an interview on 11/07/2024 at 11:14 AM, Staff HH, Director of Activities/Staff that facilitates Resident Council Meetings, was asked about the resident council concerns of cold food, they stated the company don't let them have a microwave. In an interview on 11/08/2024 at 12:33 PM, Staff B, Director of Nursing, stated if residents had cold food they should tell staff.

CONCERN (E)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure residents' menus and individual food plans met the nutritional needs and preferences of 5 of 9 residents (Residents 2, 19, 50, 5, 81) and 1 of 1 organized resident groups (Resident Council) reviewed for food services. The failure to ensure residents received foods that met their nutritional needs, and their individual preferences placed residents at risk for weight loss, dissatisfaction with their food and diminished quality of life. Findings included . <RESIDENT COUNCIL> In a group interview with Resident Council representatives on 11/07/2024 at 10:00 AM, Resident 50 stated they can't always get alternative foods if they don't like the food they get, they stated they know there were alternatives, but to find staff to get them was limited. Resident 19 stated there was a lot of not getting foods they had requested as they were not following their menu. Resident 50 stated the tray cards (documentation for each meal what the resident had requested and what they were to receive for each meal) didn't usually match what foods they got, and they thought staff didn't enter their foods right from the menus onto their tray cards. Review of a Resident Council Grievance, dated 05/23/2024, showed there was a slips issue (tray cards), and residents not getting what they ordered, and an issue with missing foods. Review of documentation included with the grievance, undated, showed the facility had changed their menu system where activities was now assisting with the menus, and they hoped that solved the timeliness of the kitchen getting back the completed menus. The documentation stated to ask residents for an update at the June Resident Council meeting. Review of Resident Council meeting minutes, dated 06/27/2024, showed a dietary concern there were missing items on trays and the foods they received were not what they ordered from the menus. In an interview on 11/14/2024 at 8:13 AM, Staff A, Administrator, was asked how the facility had resolved the resident council's food concerns from the 06/27/2024 resident council meeting, they were unable to provide any information. <RESIDENT 5> In an interview on 11/04/2024 at 10:41 AM, Resident 5 stated the food was terrible and they didn't bring the right food to match the menu. Review of a physician assistant progress note, dated 05/14/2024, showed the resident complained of not receiving foods they chose from the menu. Review of a social services progress note, dated 09/20/2024, showed the resident stated they had not been receiving the correct food on their trays. Review of physician order, dated 10/01/2024, directed nurses to administer nutritional shake: no sugar added with meals at 08:00 AM, 12:00 PM and 05:00 PM and at bedtime for supplement. Review of Resident 5's breakfast tray card at 11/07/2024 at 8:23 AM and 11/08/2024 at 8:31 AM, showed they were supposed to receive Glucerna (a brand of nutritional shake) with breakfast. In an observation and interview on 11/07/2024 at 8:23 AM, there was no Glucerna/nutritional shake on Resident 5's breakfast tray, Resident 5 stated they did not receive it. In an interview on 11/07/2024 at 3:00 PM, Staff G, Dietary Manager, stated the kitchen supplied nutritional shakes with meals if the kitchen received the order and the order said to go with meals. Asked why Resident 5 did not receive nutritional shake since the order said with meals, Staff G said they did not know this resident had this order. Staff G said the nurse was supposed to write a communication sheet and give it to the kitchen, but they did not receive this communication sheet, and the order did not show in their system either. Review of care conference/concern follow-up call notes, dated 11/14/2024, reviewed there were concerns the daily food the nursing home had provided the resident was not the food requested on the tray cards. An example discussed was on 10/31/2024 when family visited during lunch, their tray card showed they were to receive mashed potatoes with gravy, cottage cheese, diet ice cream and peanut butter and jelly and whole wheat bread, but what they received was a slice of cheese pizza, a cup of chocolate ice cream, apple sauce and a glass of cranberry juice. The facility documented in the care conference notes they had discovered that tray cards were not matching what was being served on the tray and they were going to implement an audit to compare the menu and tray card. In an interview on 11/15/2024 at 9:42 AM, Resident 5 stated last week they started receiving Glucerna (nutritional drink), and they weren't getting any before that, and their daughter had to bring some in because they couldn't get them here. They stated when they started receiving their Glucerna, it wasn't open and they couldn't open it, so they would have to call staff and there wouldn't be anyone, they thought staff should come and check on them during meals to see if everything was ok. Resident 5 stated there was a lot of food issues because there was food on the menu, but it was not on their trays so they would have to call someone to go get the food. <RESIDENT 81> In an interview on 11/06/2024 at 1:17 PM, Resident 81 stated they had a salad for lunch, but they needed another dressing, and the nursing assistant said they would get another one, but they never came back, so they just sent their lunch tray back. In an interview/observation on 11/07/2024 at 8:13 AM, Resident 81 stated their French fries/steak fries from last night were cold, and their macaroni salad was warm so they didn't eat it as they didn't want to take a chance getting sick. Resident 81 stated their banana with breakfast was quite brown and it's kind of rotten, and they didn't eat their yogurt, the yogurt was observe sitting by the sink with the lid to their plate warmer. Review of their breakfast tray card showed they were supposed to get sausage links, the resident said they did not receive them. The tray card said they disliked bacon, the resident stated that was not true because they did like bacon, but it was rare that they got it. In an observation/interview on 11/07/2024 at 12:37 PM, observed Resident 81's lunch tray, it had a cheeseburger, onion, and tomato, soup, something that looked like cornbread, and yogurt, the resident stated they were not going to eat the cheeseburger, onion and they didn't order them. They stated the bowl of soup was not very warm and they thought it had chicken in it, so they were not going to eat it, and they stated they were not going to eat the corn bread because they were not sure what it was, and they were not going to eat the yogurt, that they always got yogurt and they always sent it back. Review of Resident 81's Medication Administration Records, from 11/01/2024 - 11/14/2024, showed an order for probiotic yogurt with meals for supplement, dated 07/23/2024, staff had been documenting a y for yes that the resident ate it. In an interview on 11/13/2024 at 3:23 PM, Staff G, Dietary Manager, stated Resident 81 like their bananas green. Regarding the yogurt, Staff G stated the resident said they wanted yogurt when they assessed them. Regarding the cheeseburger, the resident got a cheeseburger because they didn't like chicken. Staff G stated all of this tells me I need to go talk to the resident. In an interview on 11/15/2024 at 10:50 AM, Resident 81 was interviewed about the yogurt, they stated I don't eat yogurt, I've never eaten yogurt, I always send it back and I think they give it to someone else, I already showed you I sent it back, I don't know why they would document I ate yogurt, that's a lie, I just don't eat it and they know that. <RESIDENT 2> In an interview and observation on 11/04/2024 at 1:55 PM, Resident 2 stated they get the same foods days in a row and not what the menu says. Resident 2 stated the menu today stated it was supposed to be stir fry and they got chicken thighs (observation of the tray still in the resident room on the overbed table showed the remnants of the meal with small chicken fragments.) Resident 2 stated there was supposed to be alternates but you don't get the alternate that you choose, they don't follow the requests or the cards. New people bought the place and ever since the food is lousy. We used to get snacks but now it is like pulling teeth or they will say there is nothing. I get low blood sugar and they don't get me the right snacks. They will bring potato chips and say that is all there is. Record Review of the posted menu for 11/04/2024 lunch showed pork stir fry. <TRAY LINE OBSERVATION> On 11/12/2024 at from 11:20 AM until 12:00 PM observed the lunch meal tray line. During this time Staff HH, cook plated food after reviewing a diet slip passed to them on a shelf above the steam table above eye level. Observed Staff HH stand on their tips of their shoes to read the diet slip. During the tray line, observed Staff HH, make five errors in plating the food from preferences to diet texture which were identified by the dietary aide. The errors were identified by the dietary aide and the meal replated with the correct preferences and diet. Refer to WAC 388-97-1120 (3)(a), -1140 (6), -1180 (1)

CONCERN (E)

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

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Reference: (WAC) 388-97-1120 (1) Based on observation, interview and record review, the facility failed to consistently offer and/or provide a nutritional snack when ordered or requested for 4 of 6 (Resident 2, 24, 84, and 50) residents reviewed for dining preferences. This failure to provide nutritional snacks at non-traditional times and meet resident choices placed residents at risk for inadequate nutrition. Findings included . <BEDTIME SNACKS> <RESIDENT 2> In an interview and observation on 11/04/2024 at 1:55 PM, Resident 2 stated. We used to get snacks but now it is like pulling teeth or they will say there is nothing. I get low blood sugar and they don't get me the right snacks, I need protein. They will bring potato chips and say that is all there is. <RESIDENT COUNCIL> In an interview with resident council representatives on 11/07/2024 at 10:00 AM, Resident 50, Resident Council Representative, stated they used to get snacks at bedtime, but not anymore. Resident 50 stated when they returned from dialysis every Monday, Wednesday and Friday evening, their dinner meal would be sitting in their room cold and staff tell them there is no way to heat it up for them or get them an alternate meal because the kitchen is closed. <RESIDENT 24> Resident 24 admitted on [DATE]. In an interview on 11/14/2024 at 9:44 AM, Resident 24 said they were so happy with the new snack offering card and they ordered a yogurt and two puddings last night. Resident 24 said they like to have something sweet around 10 at night and they were happy they can now get bedtime snacks. <RESIDENT 84> Resident 84 admitted on [DATE] with diagnoses to include severe protein calorie malnutrition. In an interview on 11/12/2024 at 9:40 AM, Resident 84 showed a laminated list of available snacks that was dropped off to them yesterday. The resident stated can you believe these were available all this time and I never knew about them. In a joint interview on 11/15/2024 at 11:32 AM with Staff A, Administrator and Staff B, Director of Nursing they were informed of the resident council concerns with lack of snacks at bedtime. Resident 24 and 84 stated they had not received any bedtime snacks since admit until this week. Staff A and B were informed of the dialysis sack lunches that contained inadequate nutrition. No additional information was provided.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 5 of 5 residents (Resident 6, 14, 46, 54, and 81) observed during cares. Failure to wear personal protective equipment (PPE) prior to entering a precaution room(first floor) and failure to do hand hygiene between glove changes during wound care and peri care placed residents and staff at risk for potential infections. Findings included . Review of an undated facility policy titled Hand Hygiene, all staff are responsible for following hand hygiene procedures: when hands move from a contaminated-body site to clean body site during resident care and before and after wearing gloves. Review of facility policy titled, Infection Control Program, stated the facility has an infection control program and committee that addresses the surveillance, prevention and control of disease and infection that was consistant with the guidelines from the Center for Disease and Control (CDC) .the facility will develop and implement isolation precaution protocols for control of infectious or communicable disease in accordance with current CDC guidelines and recommendations. <RESIDENT 46> Resident 46 admitted to the facility on [DATE]. Diagnoses included a pressure ulcer (bed sore) on the right Lateral foot. In an observation on 11/07/2024 at 11:01 AM, Staff AA, Registered Nurse (RN), applied gloves prior to performing wound care. Staff AA removed the old dressing and cleansed the right lateral foot wound of Resident 46. With the same gloves, applied Medi honey (ointment used to treat wounds) using a cotton applicator and then covered the wound with a bandage. Staff AA did not change gloves or do hand hygiene after removal of the old dressing, prior to applying ointment and a new dressing to the wound. <RESIDENT 6> Resident 6 admitted to the facility on [DATE] and readmitted on [DATE]. In an observation on 11/13/2024 at 9:25 AM, Staff Y, Certified Nursing Assistant (CNA) and Staff GG, CNA both were wearing gloves. Staff Y provided peri care (washing the genitals and anal area) to Resident 6 while Staff GG was assisting in turning the resident. Once peri care was done, Staff Y removed their gloves and put on new gloves. Staff GG did not perform hand hygiene prior to putting on new gloves. In an observation on 11/13/2024 at 9:36 AM, Staff Z, RN, applied gloves prior to wound care. Staff Z removed the dressing and packing strip from Resident 6's wound on their left leg. Staff Z cleansed the wound and then took their gloves off and put on new gloves. Staff Z did not perform hand hygiene prior to putting on new gloves. In an interview on 11/13/2024 at 9:47 AM, Staff Z stated the steps in doing a dressing change and as they recited the steps, they then realized that they forgot to wash hands prior to putting on clean gloves. They stated they missed that step when they were doing the wound care for Resident 6. In an interview on 11/13/2024 at 9:55 AM, Staff Y stated the steps on how to change resident's brief and while explaining the steps they realized that they forgot to clean their hands after they took their gloves off and prior to putting on clean gloves during care of Resident 6. They stated that they will not forget that step again the next time they provide peri care/brief change to residents. In an interview on 11/13/2024 at 10:11 AM, Staff X, Licensed Practical Nurse (LPN)/Unit Manager, stated that the infection prevention (IP) nurse does random audits and teaching to staff regarding hand hygiene. In an interview on 11/13/2024 at 2:15 PM, Staff V, LPN/IP nurse, stated that staff received infection prevention training upon hire and during all-staff meetings which were held every month. They stated that they do random audits and spot checks to staff while walking in the hallways. Staff V reported if they see incorrect practice, they educate the staff on the spot. Staff V reported agency staff received education on infection prevention from their company but if they happen to be working during staff meetings then they also attend the meeting and receive education from the facility. In an observation and interview on 11/06/2024 at 12:53 PM, Staff E, CNA was observed passing lunch trays in the hallway. room [ROOM NUMBER] had a contact isolation sign outside the door that advised all that enter to wear PPE including a gown and gloves prior to entering the room. Staff E was observed to approach the door to room [ROOM NUMBER] with a lunch tray, knocked on the door and entered the room. Staff E was not wearing any PPE when they entered the room. Staff E exited the room a couple minutes later. Staff E stated that the sign on the door stated that they only had to wear a gown and glove if they were helping the resident with their wound care. In an observation and interview on 11/06/2024 at 12:57, Staff QQ, Maintenance assistant, was observed to enter room [ROOM NUMBER]. Staff QQ did not wear any PPE when they entered the room. Staff QQ exited the room after a couple minutes. Staff QQ stated that the sign on the door stated they only had to wear PPE if they were going to have contact with the resident, and that they did not so they did not have to wear PPE. In an interview on 11/07/2024 at 1:28 PM, Staff V stated the expectation for residents on contact precautions was that staff were educated that before they enter the room their must be a barrier between them and the resident prior to entering the room. Staff V was informed of observations that were made during the survey process, Staff V stated that was not how they had educated the staff and was not what they expected. <RESIDENT 253> Resident 253 was admitted to the facility on [DATE] with admitting diagnosis to include Acute Cystitis (infection of the bladder) and on contact precaution due to Extended-spectrum beta-lactamase (ESBL- is an enzyme produced by some bacteria that makes them resistant to many antibiotics) in urine. In an observation and interview on 11/06/2024 at 9:35 AM, observed Staff D, RN, going into Resident 253's room with no PPE. Observed a sign on the outside of resident's room showing contact precaution. On the sign it stated to wash hands, don gown and gloves prior to entering room. After Staff D came out of the room, this writer asked why they did not wear PPE prior to entering the room, and what was the reason why resident was on contact precaution. They stated that the contact precaution sign was not there before, and that the infection was from a small scab in Resident 253's arm. In a record review on 11/06/2024 at 2:19 PM Resident 253's electronic chart showed that resident was on contact precaution due to ESBL in their urine. In an interview on 11/07/2024 at 2:08 PM, with Staff L, RN/UM and Staff U, LPN/UM, Staff L stated that during morning meetings they were notified if new admits were on precautions, then they relayed it to the staff. The Infection Preventionist nurse also updates the staff on which residents were on precaution. Per Staff L, staff should follow what is posted on resident's door prior to entering residents' rooms and if they need clarifications to ask the managers prior to entering the room. In an interview on 11/13/2024 at 2:15 PM with Staff V stated that any precautions for residents were shown on resident's profile and [NAME] (lists care needs for residents) in their electronic chart. They stated that it was an expectation for all staff to check resident's profile and/or [NAME] prior to providing care to residents. I asked about what was observed by Staff D did and Staff V stated that Staff D talked to them about it and that they made a mistake of going in the room without PPE. Staff V stated they re- educated Staff D. Refer to WAC 388-97-1320 (1)(a)(c) <RESIDENT 14> During an observation of wound care on 11/14/2024 at 3:31 PM, Staff T, RN, provided care to a wound on Resident 14's sacrum (lower part of spine, just above the buttocks). Staff T applied a gown and gloves before entering resident's room. Resident 14 was laying on their back in bed and had heel protector boots on and feet were on top of a pillow. Staff T removed the pillow from underneath Resident 14's feet and then removed the heel protectors and socks. Staff T applied skin prep (substance that leaves protective covering over skin) over both of residents feet and toes and then applied a vitamin enriched ointment. Staff T removed thier gloves but had another pair on underneath. Staff T reached into the box of gloves and pulled out more gloves and applied them over the top of the gloves they were wearing. Staff T did not do hand hygiene. Staff T assisted resident to roll onto their side in bed. Staff T pulled down on Resident 14's incontinent brief, exposing the buttocks. After touching the incontinent brief, Staff T used their contaminated gloved hands to open the bathroom door, went into the bathroom, and also opened the nightstand at the bedside and removed a container of disposable washcloths, placing them on the bed. Staff T removed the old dressing to Resident 14's sacrum. Staff T used disposable washcloths to clean the resident's buttocks. Staff T then picked up the garbage can with their gloved hands and placed it at the bedside and disposed of the disposable washcloths. Staff T then touched the package of disposable washcloths, removed more, and continued to clean the resident's buttocks. Staff T did not remove gloves or do hand hygiene. After cleansing Resident 14's buttocks, Staff T applied a protective ointment over the buttocks. Staff T then used his contaminated gloved finger to apply an ointment onto the resident's sacral wound. Staff T removed a pair of gloves, but still had a pair of gloves on underneath. Staff T did not do hand hygiene. Staff T applied a new dressing to Resident 14's wound, reapplied the incontinent brief and assisted resident with repositioning. Staff T removed all gloves but did not do hand hygiene. Staff T reached his contaminated hands into the box of gloves and applied new gloves. Staff T provided Resident 14 with their overbed table and call light, removed their gloves and washed their hands. During an interview on 11/14/2024 at 4:07 PM, Staff T stated that hand hygiene was to be performed before and after going into a resident room. When asked if there were any other times hand hygiene should be done, Staff T replied they do hand hygiene per common sense. Staff T was questioned about when hand hygiene should be done during wound care and they stated after cleansing the wound, after wound care, and at the end. When Staff T was questioned about double gloving and how was hand hygiene done if already wearing gloves, they stated they used two pairs of gloves for their protection because they were concerned about the integrity of the gloves, but they understood what surveyor was asking and that they were always learning. During an interview on 11/14/2024 at 5:36 PM, Staff V stated gloves and hand hygiene should be done when going in or out of a room, when handling garbage, prior to starting wound care, after removing the old dressing and when done with wound care. Staff V stated if staff touched the garbage can with their gloved hand, they should remove gloves and perform hand hygiene. <TRANSMISSION BASED PRECAUTIONS> During an observation on 11/14/2024 at 4:45 PM, Staff VV and Staff WW, CNAs, were observed pushing the hoyer lift (machine that lifts resident from one surface to another) into a room with an Enhanced Barrier Precaution (EBP) Sign at the doorway. The staff were wearing gloves but were not wearing gowns. Resident 25 could be seen sitting in their wheelchair from the doorway. Review of the EBP sign at the doorway showed that staff should wear gown and gloves when doing high contact resident care activities such as transfers. After a few minutes, Staff WW exited the room with the hoyer lift. Resident 25 was lying in bed and Staff VV was seen assisting them to reposition in bed and provided them them with the overbed table. Staff VV was observed wearing gloves but did not have a gown on. During an interview on 11/14/2024 at 4:54 PM, Staff VV was asked about the EBP sign at the doorway to Resident 25's room. Staff VV stated the sign was for Resident 25. Staff VV reported they had just transferred Resident 25 from the wheelchair to bed and they did not use gowns as they had not touched any wounds. Reviewed the EBP sign with Staff VV and they reported that the sign showed staff were to wear gowns with resident transfers. During an interview on 11/14/2024 at 5:36 PM, Staff stated staff were to use gown and gloves when providing resident transfers if resident required EBP.

CONCERN (E)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure call lights were consistently operational and functioning appropriately on 2 of 2 floors, including 6 residents (Residents 24, 50, 53, 78, 98,and 454 ) and potentially any of the residents who used a call light throughout the facility. The failed practice placed residents at risk of not having their needs met and psychosocial harm. Findings included . <RESIDENT 50> Review of the resident record showed the resident made an allegation on 10/27/2024 that a nursing assistant had not responded to their call light for over an hour. The nursing assistant denied that the call light was on and was alleged by the resident to be rude. Review of the facility incident investigation showed that the resident was not interviewed regarding the incident until 10/31/2024 and it was determined that the resident's call light was, in fact, not functioning. Review of the facility audit documentation following the incident showed that the facility was conducting audits of call light response, but there were no audits related to call light function. <RESIDENT 98> In an interview on11/05/2024 at 10:27 AM, Resident 98 said their call light was not working and the Director of Nursing said that is why there was a delay in my care. The resident said their call light was broken from day of admit until last week. Resident 98 asked the maintenance man to check their call light and it wouldn't come on the first two times. <RESIDENT 24> In an interview on 11/04/2024 at 10:10 AM, Resident 24 reported their call light was not working and staff seemed unaware. <RESIDENT 454> In an interview on 11/04/2024 at 3:00 PM, Resident 454 said they had a few issues here when they first admitted . The resident sated they put their call light on and no one came, so they called their wife who drove down to the facility. They said staff were unaware the call light was not working and they did not know how the system worked but they kept pressing the button and no one came. <RESIDENT 53> In an observation on 11/05/2024 at 12:10 PM, Resident 53 was observed calling out they needed help. The resident's call light was activated, but the light did not come on outside their room door. <RESIDENT 78> In an interview on 11/05/2024 at 12:21 PM, Resident 78 said their call light works but sometimes it is not in reach. One night there was only one nurse and two aides and it was too hard for them to answer their light. Resident 78 said, last week, they heard their neighbor yelling out Help, Help all night. No one came to help them. They resident said they wanted to get out of bed and go help them. They timed the yelling and there was a straight hour and 20 minutes of someone yelling help, help. <MAINTENANCE LOG (TELS) 09/01/2024 to 11/06/2024> Review of the TELS log showed 18 call light issues logged work orders for maintenance; * call light critical priority Resident Room-218 09/19/2024 * call light not working all the time medium priority 218 A 09/13/2024 * call light on and will not turn off medium priority 215 A 10/18/2024 * call light button missing from cord medium priority 226 A 10/15/2024 * call light not working medium priority 235 10/18/2024 * call light not working medium priority 230 10/19/2024 * call light not working medium priority 230-A 10/21/2024 * call light needs to be fixed medium priority 230-A 10/21/2024 * call light not working medium priority 128-A 10/23/2024 * call light not signaling and turning off automatically medium 128-A 10/23/2024 * bathroom light out medium priority 205 10/25/2024 * call light not working medium priority 131-A 10/29/2024 * call light not working medium priority 215-B 10/30/2024 * call light not working medium priority 134 10/30/2024 * Bathroom call light needs bulb. medium priority 203-B 10/31/2024 BR call light hard to hear from * light is not working medium priority 133 11/01/2024 * call light not working medium priority 102-B 11/05/2024 * call light outside room [ROOM NUMBER] needs replacement ASAP medium priority 232 11/05/2024 In an interview on 11/14/2024 at 10:16 AM, Staff J, Director of Maintenance said they fix call lights whenever there is a problem. They said they just did an audit the other day and the call lights were all working 100%. Staff J said there were not new call lights available to staff because the issues were electrical maintenace needed to fix them. At 11/14/2024 at 10:28 AM, Staff J showed the call light was audit completed on 11/12/2024 and the audit was done monthly. Refer to WAC 388-97-2280

CONCERN (E)

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

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure that facility staff were educated on all required topics that were identified on the facility assessment for 5 of 5 sampled staff (Staff DD, CC, EE, K, X) reviewed for education and training. Failure to ensure staff received required trainings placed residents at risk of not receiving competent care, unmet care needs, and a diminished quality of life. Findings included . Review of the facility assessment, review date 07/29/2024, showed the identified trainings to be provided to staff on hire and annually included: • Culture change/person-centered care. • Special needs of residents. • Identification of resident changes in condition. • QAPI (Quality Assurance Process Improvement) • Emergency Preparedness. • Dementia <STAFF DD> Review of Staff DD, Nursing Assistant Certified's (NAC) education log for the past year showed they had not received education on Culture change/person-centered care, Special needs of residents, Identification of resident changes in condition, QAPI, or Emergency preparedness. <Staff CC> Review of Staff CC, NAC's education log for the past year showed they had not received education on Culture change/person-centered care, Special needs of residents, Identification of resident changes in condition, or Emergency preparedness <Staff EE> Review of Staff EE NAC's orientation and education log since they were hired on 05/28/2024, showed they had not received education on Culture change/person-centered care, Special needs of residents, or Identification of resident changes in condition. <Staff K> Review of Staff K, Occupational Therapist's (OT) orientation and education log since they were hired on 06/11/2024, showed they had not received education on Culture change/person-centered care, Special needs of residents, Identification of resident changes in condition, or Dementia. <Staff X> Review of Staff X, Licensed Practical Nurse's education log for the past year showed they had not received education on Culture change/person-centered care, Special needs of residents, or Identification of resident changes in condition. During an interview on 11/14/2024 at 4:17 PM, Staff V, Registered Nurse/ Staff Development Coordinator, reported that they did not have records to show the sampled staff had received the missing education. During an interview on 11/14/2024 at 5:42 PM, Staff V stated they were not aware of what education was required per the facility assessment and they used the list of required educations that had been provided by the corporate office. During an interview on 11/15/2024 at 8:31 AM, Staff A, administrator, reported that they had just found out that the list of education per the facility assessment did not match the list of education on the in-service training policy. Staff A stated they would have to review both documents and make changes. Refer to WAC 388-97-1680 (2)(b)(ii)

CONCERN (F)

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

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to administer services effectively and efficiently to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. The facility failed to ensure all allegations had a complete and thorough investigation and failed to maintain systems to prevent repeat citations throughout the last year. In addition, the facility failed to recognize and/or correct repeated concerns that had been documented on the Resident Council meeting minutes for long call light wait times. The administrator should have been aware of these issues and did not put corrective action into place to sustain these systems. These failures placed residents at risk for the potential for continued abuse, unmet care needs and decreased quality of life. Findings included . Review of a facility policy, titled, Administrator, dated 10/01/2021, showed the administrator was responsible for the day-to-day functions of the facility and they were responsible for implementing operational policies to remain in compliance with current laws and regulations. Review of the facility's last annual recertification Statement of Deficiencies (SOD), dated 12/14/2023, showed the facility had repeat deficiencies cited regarding Resident rights (F550), grievances (F585), investigate/prevent/correct alleged violations (610), activities of daily living (ADL) provision for dependent residents (F677), Quality of care (F684), treatment/services to heal and/or prevent pressure ulcers (686), increase/prevent decrease in range of motion/mobility (F688), respiratory care (F695), dialysis (F698), sufficient nursing staff (F725), pharmacy services, procedures, records (F755), free of medication error rate of 5% or more (F759), free of significant medication errors (F760), and infection control procedures (F880). The administration failed to implement an Abuse Prohibition policy which included prevention, identification, and resident protection. Reporting of abuse violations was noted on a SOD dated 06/07/2024. These failures placed residents at risk for continued abuse, caused a delay in investigation and failed to ensure residents were protected. Refer to F607- Develop/Implement Abuse/Neglect, etc. Policies The Administration failed to ensure that allegations of abuse had a thorough investigation, and corrective actions put into place. Failure to conduct a thorough investigation to identify root cause and all contributing factors placed residents at risk for unidentified abuse or neglect. Refer to 610-Investigate/Prevent/Correct Alleged Violations During an interview on 11/15/2024 at 8:31 AM, Staff A, Administrator, reported the Director of Nursing Services completed the investigations for abuse allegations, but they were responsible to review them after completion. <Resident Council Minutes> Review of the resident council meeting minutes, dated 05/23/2024, showed it took a long time (an hour), for call lights to be answered on the night shift. Review of a grievance form dated 05/23/2024, showed the resident council had reported a concern with long call light wait times but the Action taken to Address Concern section was blank. Review of the resident council meeting minutes, dated 06/27/2024, showed call lights were taking too long to be answered. Review of the resident council meeting minutes, dated 07/25/2024, showed long call light waiting times. Review of the resident council meeting minutes, dated 08/29/2024, showed long call light waiting times on the night shift. Review of the resident council meeting minutes, dated 09/26/2024, showed that Staff X, Licensed Practical Nurse/Resident Care Manager talked to the resident council about waiting for call lights. During an interview on 11/14/2024 at 1:08 PM, Staff A stated they received the Resident Council Minutes monthly to review. Refer to WAC 388-97-1620 (1)

CONCERN (F)

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

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the governing body failed to provide adequate active and engaged oversight and monitoring of the facility's appointed Administrator. The governing body failed to ensure the Administrator had clinical systems in place and that were followed related to Abuse/Neglect, Resident Rights, Grievances, Pressure Ulcers, Infection Control and Prevention, Social Services, Nutrition, Care Planning, Accidents and Supervision, Transfer and Discharge, Staffing, Medication Safety, Range of Motion program, and Infection Control Practices, failed to identify and correct their own identified deficiencies to ensure sustainability with compliance for state/federal regulations and previous deficiencies. The governing body also failed to ensure the Administrator had sufficient staff to meet the needs of the residents, i.e., personal care/grooming, restorative care, and an effective call light system. These failures placed residents at risk for less-than-optimal care and services for residents. The governing body's failure to provide oversight and support to enuse all policies and procedures were being followed and ensure the facility had an effectively functioning QA&A program that consistently self-identified deficient practices, placed residents at risk for injury and abuse and unmet needs that could negatively impact their physical function, psychosocial wellbeing, quality of life and quality of care. Findings included . Review of the facility's last annual recertification Statement of Deficiencies (SOD), dated 12/14/2023, showed the facility had repeat deficiencies cited regarding Resident rights (F550), grievances (F585), investigate/prevent/correct alleged violations (610), activities of daily living (ADL) provision for dependent residents (F677), Quality of care (F684) also cited 06/07/2024, treatment/services to heal and/or prevent pressure ulcers (686), increase/prevent decrease in range of motion/mobility (F688), respiratory care (F695), dialysis (F698), sufficient nursing staff (F725), pharmacy services, procedures, records (F755), free of medication error rate of 5% or more (F759), free of significant medication errors (F760), and infection control procedures (F880). The governing body failed to implement an Abuse Prohibition policy which included screening, prevention, identification, and resident protection. Reporting of abuse violations was noted on a SOD dated 06/07/2024. These failures placed residents at risk for continued abuse, caused a delay in investigation and failed to ensure residents were protected. Refer to F607- Develop/Implement Abuse/Neglect, etc. Policies In an interview on 11/14/2024 at 10:50 AM, Staff CCC, Regional Director of Clinical Services (RDCO) said they had been with the company for a month and a half and had visited the facility twice before survey started. Staff CCC said the company was down another RDCO position so they had more facilities than the four they were assigned to. Staff CCC, said Staff EEE was hired about a month ago. Review of the facility document dated 01/03/2024 titled, Governing Body-[NAME], showed the governing body was responsible for establishing and implementing policies regarding management and operation of the facility, appointing the Administrator who is licensed by the state, responsible for management of the facility, and reports to and is accountable to the Governing Body and the QAPI program. The Governing Body will have a process in place by which the administrator reports to the Governing Body, the method of communication between the Administrator and Governing Body and how the Governing Body responds back to the Administrator. Review of the facility assessment last reviewed on 07/01/2024, showed Staff A, Administrator had signed off on the review. There were no signatures or review from the Governing Body. Review of the past six months of QAPI minutes showed the Governing Body was not in attendance. In an interview on 11/15/2024 at 11:06 AM, Staff A, Administrator said the facility assessment was developed primarily by them. Staff A said the Governing Body consisted of Staff FFF, Chief Nursing Operator (CNO) and Staff GGG,Chief Operating Officer (COO), Staff EEE, Regional Director of Operations (RDO) and Staff CCC, RDCO. Staff A said Staff EEE and Staff CCC did not participate in QAPI. Staff A said Staff FFF and GGG had not attended any QAPI meetings. Staff A said they had seen Staff FFF once at the facility in the last 15 months and they had never met Staff GGG. Staff A said the Governing Body did not communicate with them and they did not send any direct reports to them. Staff A said they had no documentation of any Governing Body meetings. In an interview on 11/15/2024 at 11:07 AM, Staff B, Director of Nursing said they send abuse allegations and weekly skin reports to Staff CCC. In an interview on 11/15/2024 at 11:07 AM, Staff A, Administrator stated they conducted the Quality Assurance Performance Improvement (QAPI) meetings monthly. The Administrator stated they do not any current Performance Improvement Projects (PIP) other than the dining room. The Administrator acknowledged past deficiencies had been reviewed during QAPI and the facility failed to document their review. Staff A said they follow their own past written plans of corrections to ensure on-going compliance until compliance is met. Staff A acknowledged there were 11 repeated citations from the prior re-certification survey eleven months ago. The Governing body failed to ensure repeat citations were corrected and sustained. Refer to F 835, Administration Reference: WAC 388-97-1620 (2)(c)

Aug 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff had the skills and competencies to perform an ordered procedure on 1 of 1 sampled resident (Resident 1) reviewed for care of a chest tube (tubing that inserted into lining of lung to drain fluids). This failure placed the resident at risk of excess fluid collecting around the lung which could compromise breathing and respiratory function. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include heart failure, respiratory failure and malignant breast cancer. During a phone interview on 07/18/2024 at 8:24 AM, Collateral Contact 1 (CC1), Emergency Medical Staff (EMS), reported they had responded to a 911 call at the facility on 07/07/2024 at approximately 1:30 PM. CC1 stated Resident 1 had called 911 as they were having difficulty breathing. CC1 reported that Resident 1 was short of breath upon their arrival to the facility. CC1 stated the attending nurse had told them that Resident 1 had a tube that could drain the fluid around their lungs, but they were going to leave it for oncoming staff to do. Review of the fire departments patient care record for Resident 1, dated 07/07/2024, showed EMS arrived at the facility at 1:35 PM. The record showed that the nurse reported they were uncomfortable draining the chest tube and the next shift was more comfortable draining the chest tube. Review of the July 2022 Medication Administration Record (MAR) showed an order for the Pleurx (chest tube) to be drained every 48 hours ordered on 06/22/2022. On 07/02/2024, the order was modified for the chest tube to be drained daily, scheduled for 8:00 AM. The MAR showed the chest tube was not documented as being drained on 07/07/2024. Review of an EMAR (electronic medication administration record) progress note dated 07/07/2024 at 2:02 PM, showed Resident 1 had shortness of breath and had gone to the emergency room. During an interview on 08/02/2024 at 1:13 PM, Staff A, Director of Nursing Services/ Registered Nurse, reviewed Resident 1's medical record and stated the chest tube was not documented as being drained on 07/07/2024. Staff A stated there was no documentation of why the procedure was not done at 8:00 AM when it was scheduled, nor was there documentation the provider was notified of the procedure not being completed. Refer to WAC 388-97-1060 (3)(j)

Jan 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to conduct safe and orderly discharges for 2 of 3 sampled residents (Residents 3 and 4) reviewed for discharges. The failure: 1) to provide necessary post-discharge instructions regarding wound treatments, 2) to coordinate for and/or provide necessary post-discharge medications, 3) to provide discharge instructions to a resident's representative for a cognitively impaired resident, 4) to provide information regarding a resident's post-discharge follow-up physician appointment, 5) to document medications prescriptions provided to residents, 6) to follow the discharge plan for the time of day for a resident to be discharged , and 7) to document medications/quantities of medications sent with a resident on discharge placed residents at risk for unmet care needs and for Resident 3 it resulted in missed medications after discharge. Findings included . Review of the facility policy titled, Discharge Planning, dated 10/01/2021, showed: -When a resident's discharge was anticipated, a discharge summary and post-discharge plan would be developed to assist the resident to adjust to his/her new living environment. - The discharge plan would involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. - All relevant resident information must be incorporated into the discharge plan to facilitate its implementation. - The post-discharge plan of care would be developed with participation of the resident, and with the resident's consent, the resident representative. - The post-discharge plan of care would indicate any arrangements that have been made for the resident's follow up care. <RESIDENT 3> Resident 3 admitted to the facility on [DATE] and was discharged on 12/26/2023. The resident had diagnoses to include surgical repair of a hip fracture, psychotic (a disorders are characterized by a loss of touch with reality characterized by altered thinking, perceptions, and behavior and mood (your general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function) disorders, and severe dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 12/01/2023, the resident had severe dementia and had a surgical wound that required surgical wound care. In a phone interview on 12/27/2023 at 2:30 PM, Collateral Contact 1 (CC1), staff member at another entity, stated Resident 3's discharge from the nursing home was very poorly put together. CC1 stated when the resident discharged from the nursing home and admitted to their new facility, they were not given discharge instructions regarding their surgical wound care, the discharge instructions received did not include a date/time for the follow-up physician appointment, and the resident missed medications after discharge. Resident 3 did not receive necessary medications after discharge, the nursing home did not coordinate to ensure the resident had their medications when needed, so they missed medications until they could obtain them from the pharmacy the day after their discharge. CC1 stated they had asked the resident's representative if they had any information regarding a follow-up physician appointment, but they did not. Review of Resident 3's facility Resident discharge instructions, dated [DATE], showed under Post Discharge Appointments/Follow-up Visits, staff were supposed to document the appointment date, time, purpose, location, and phone number and who the appointment was with, there was a name and phone number of a physician, but no date/time/purpose were provided. The Resident Discharge Instructions had a place to document Post Discharge Wound Care or Procedures, that was left blank. The Resident Discharge Instructions indicated all remaining medications and signed scripts (medication prescription forms) were sent with the resident at the time of discharge, but it did not indicate which medications or how many were sent with the resident, and it did not indicate which scripts for which medications, were sent with the resident. In an interview on 01/03/2024 at 2:05 PM, Staff B, Registered Nurse (RN)/Director of Nursing Services (DNS), stated they usually provided the date/time of follow-up physician appointments in the discharge paperwork, and they didn't know why that information was not included. Staff B stated they usually used a discharge medication slip for medications sent with residents on discharge, but stated they didn't use one for Resident 3's discharge. Staff B was unable to provide any information why the nursing home did not provide wound care instructions with this discharge. <RESIDENT 4> Resident 4 admitted to the facility on [DATE] and was discharged on 12/22/2023. Resident 4 had diagnoses to include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). According to the admission MDS assessment, dated 12/14/2023, the resident had severe cognitive impairment. In a phone interview on 01/04/2024 at 11:05 AM, CC2, a family member of Resident 4, stated they had previously coordinated for Resident 4 to be discharged at 1:00 PM, but the facility had started discharging the resident at 11:00 AM. CC2 stated a friend was there visiting Resident 4 and when they realized staff were giving discharge instructions to the resident, they called CC2 who went to the nursing home right away. CC2 stated when they arrived staff basically just handed them a pamphlet of papers and said they had already given the discharge instructions to the resident. CC2 stated they asked the nurse if they knew the resident had severe dementia and didn't understand anything told to them, and the nurse stated they were fully aware of that. CC2 stated they had clarified the discharge time because they had to take time off from work to pick up Resident 4 from the facility. CC2 stated staff made a follow-up doctor appointment for the resident, but staff didn't coordinate that with them, but they should have because they were the resident's transportation to their appointments, CC2 stated they had to cancel the appointment made by facility staff. CC2 stated staff had made a follow-up doctor appointment with the wrong physician. Review of Resident 4's progress notes showed a progress note, dated 12/22/2023 at 1:58 PM, that documented Discharge instructions provided to patient. In an interview on 01/04/2024 at 11:05 AM, Staff B stated they were working on educating their staff in implementing their discharge planning processes. Staff B stated they shouldn't be giving discharge instructions to cognitively impaired residents, they were unable to provide any other information. Staff B was asked about Resident 4's 11:00 AM discharge, they stated they could find no reasons in the resident's clinical record why they had started the discharge early. Staff B stated they needed to educate their nurses. In an interview on 01/04/2024 at 11:25 AM, Staff A, Administrator, stated they were facing challenges getting all their agency nurses (temporary nurses) educated on the implementation of facility policies. Cross Reference: CFR 483-21 (c )(2) - F661 Discharge Summary Refer to WAC 388-97- 0120(3)(a) .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the discharge summary was completed that included a recapitulation (overview) of the residents' stay, a final summary of the resident's status, a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) and a post-discharge plan of care for 3 of 3 sampled residents (Residents 1, 3 and 4) reviewed for discharge planning. This failure put the residents at risk of complications and delayed treatment of medical conditions by not having the necessary information to ensure continuity of care when discharged to the community. Findings included . Review of the facility policy titled, Discharge Planning, dated 10/01/2021, showed when the facility anticipated discharge, the facility would prepare a discharge summary and a post-discharge plan that included, but was not limited to a recapitulation of the resident's diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. The policy also stated the discharge summary would include a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). <RESIDENT 1> Resident 1 admitted to the facility on [DATE] and was discharged on 12/24/2023. In a review of Resident 1's clinical record on 01/04/2024, no discharge summary could be found. <RESIDENT 3> Resident 3 admitted to the facility on [DATE] and was discharged on 12/26/2023. In a review of Resident 3's clinical record on 01/04/2024, no discharge summary could be found. <RESIDENT 4> Resident 4 admitted to the facility on [DATE] and was discharged on 12/22/2023. In a review of Resident 3's clinical record on 01/04/2024, no discharge summary could be found. In an interview on 01/04/2024 at 11:05 AM, Staff B, Registered Nurse/Director of Nursing Services, stated they could find no discharge summaries for the Resident 1, 3 and 4. Staff B stated they did have a form for discharge summaries in their electronic health record, but they weren't using it, but they would be. Staff B stated they would be educating their staff on completing discharge summaries. Cross reference: CFR 483.15(c )(7) - F624 Preparation for Safe Orderly Transfer Discharge Refer to WAC 388-97-0080 (7)(a-c) .

Dec 2023 32 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 74> Resident 74 was admitted to the facility on [DATE] with diagnoses to include severe protein calorie malnutri...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 74> Resident 74 was admitted to the facility on [DATE] with diagnoses to include severe protein calorie malnutrition (weight loss from not enough protein and calorie intake), adult failure to thrive (weight loss, poor appetite, nutrition, and inactivity), muscle wasting and atrophy (decrease in the size of the muscle), and anorexia (an eating disorder characterized by an abnormally low body weight). Review of Resident 74's admission MDS assessment, dated 10/25/2023, showed Resident 74 was frequently incontinent of bowel and bladder, and there was no documented no PU's present upon admission to the facility. Review of the hospital Discharge summary, dated [DATE], showed Resident 74 admitted to the hospital with a coccyx wound, directions to the nursing home to follow standard nursing protocols for wound care to the coccyx wound, and a supplement twice daily to assist with wound healing. Review of Resident 74's facility admission orders, dated 10/19/2023, did not show wound care orders to the coccyx or a supplement, that were identified on the hospital discharge orders. Review of Resident 74's admission Evaluation assessment, dated 10/19/2023, showed the resident had no skin issues. Review of Resident 74's Braden Scale for Predicting Pressure Ulcer Risk (a standardized, evidence-based tool to identify resident's risk for developing PU's), dated 10/19/2023, showed a score of 17, indicated the resident was at risk for developing a PU. Review of the skin at risk care plan, dated 10/19/2023, showed Resident 74 was at risk for skin breakdown. Interventions included education to the resident and caregiver on the importance of repositioning and nutrition. Review of the activities of daily living care plan, dated 10/19/2023, showed Resident 74 required one-person limited assistance for bed mobility and transfers, and one-person extensive assistance for toileting. Review of a provider note, dated 10/20/2023 at 8:23 PM, showed Resident 74 had an unstageable coccyx wound and was being seen by the in house wound care team. Review of a nursing progress note, dated 10/21/2023 at 1:59 PM, showed Resident 74 had blanchable (when there is a red ulcer that is pressed down and released, the redness goes away and then comes back) redness to their sacrum (bottom) and the nursing staff applied barrier cream. Review of a physician order dated, 10/22/2023, showed barrier cream applied every shift to blanchable redness to Resident 74's sacral (bottom) area. Review of a nursing progress note, dated 10/25/2023 at 9:36 PM, showed Resident 74 had an open area to their coccyx with a dressing in place. Review of Resident 74's TAR, dated 10/19/2023 through 10/25/2023, showed no wound care orders to the resident's unstageable coccyx wound. Review of a physician order, dated 10/26/2023, showed a referral to contracted wound consultant company to evaluate and treat Resident 74's wound if indicated. Review of the faxed referral to the contracted wound consultant company, dated 10/26/2023, showed Resident 74 had a wound to their coccyx and the acquired date was 10/25/2023 ?. Review of a physician order, dated 10/26/2023, showed an order for Resident 74 to have a low air loss mattress, a supplement daily, and wound care treatment daily was implemented. Review of a focus care plan interventions of an actual unstageable PU to Resident 74's coccyx, dated 10/27/2023, included to assess and document the coccyx wound, treatment per the physician orders, monitor nutrition, and monitor and report changes in the coccyx wound to the physician. Review of Resident 74's Braden Scale Risk assessment, dated 10/26/2023, showed a score of 13 which indicated the resident was at moderate risk for developing PU's. Review of Resident 74's weekly wound evaluation, dated 10/27/2023, showed the resident had a 1.5 centimeter (cm) by 1.0 cm unstageable skin tear to their coccyx (tailbone). Review of nursing note dated 10/31/2023 at 12:18 PM, Staff W, Registered Nurse (RN)/Unit Manager, documented Resident 74's was seen by the contracted wound care company evaluated Resident 74's coccyx. A new coccyx wound care order was implemented. Review of Resident 74's Braden Scale Risk assessment, dated 11/02/2023, showed a score of 12, indicating the resident was at high risk for PU development. Review of a risk review progress note, dated 11/02/2023 at 5:56 PM (eleven days after the wound was identified), Staff B documented Resident 74 had an unstageable coccyx wound which was identified on 10/21/2023 as blanchable redness to the resident's coccyx. Staff B documented through a review the resident was noted to have an unstageable coccyx wound when admitted to the facility. Review of a nursing progress noted dated 11/06/2023 at 7:30 AM, Staff W documented Resident 74 was evaluated and treated by Collateral Contact 5 (CC5), Advanced Registered Nurse Practitioner, from the wound care company. Review of a late entry nursing note, dated 11/07/2023 at 12:37 PM, Staff W, documented Resident 74's wound base had slough versus fibrinous (a protein found in plasma) tissue, no changes to wound care. Review of a late entry progress note, dated 11/14/2023, Staff W documented Resident 74's coccyx PU measured 1.6 cm by 0.5 cm by 0.1 cm. The wound base had slough versus fibrinous tissue and re-staged the PU to a Stage III. Review of a nursing progress noted, dated 11/20/2023 at 9:01 PM and 11/27/2023 at 10:59 AM, Staff W documented the resident was evaluated and treated by CC5, no changes to wound care. In an interview on 12/07/2023 at 11:03 AM, Resident 74 stated they had a wound on their bottom. Resident 74 stated the facility found the wound and have been providing treatments. observed lying on right side in bed. The resident stated they ensure they do not lie on their back, so the wound does not worsen. In an interview on 12/08/2023 at 9:30 AM, Staff HH, Nursing Assistant Certified (NAC), stated the resident had sore by her tailbone but was not sure if it was still there. Staff HH stated the resident was able to turn and reposition herself. In an observation and interview on 12/11/2023 at 7:45 AM, Resident 74's wound was observed with CC5, stated the coccyx wound was closed and blanchable. In an interview on 12/12/2023 02:26 PM, Staff B, stated the admission Braden was incorrect, and the resident was more at risk than the assessment showed. Staff B stated had the assessment, dated 10/19/2023, been accurate, the facility would have initiated more preventative measures. Staff B stated the resident had a PU prior to admission but had no treatment orders from the hospital. When asked about expectation for a new admission who is at risk for developing skin issues, Staff B, stated Resident 74 should have had an accurate skin assessment and an air mattress and other preventable measures should have been initiated. Staff B stated once the wound was identified the resident was referred to wound care company. Staff B stated the investigation did not show the PU was clinically unavoidable. This is a repeat deficiency from the Statements of Deficiencies, dated 06/10/2022 and 12/23/2022. Reference: (WAC) 388-97-1060 (3)(b) Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcer (PU) (bedsore)/pressure injury (PI), (localized damage to the skin and underlying soft tissue usually over a bony prominence) for 2 of 2 sampled residents (Resident 28 and 74) reviewed for PU's. The facility did not consistently complete comprehensive and accurate assessments, develop/update and implement person centered care plans to address the residents' risk factors for developing and deteriorating PUs, or monitor to ensure the implementation of care plan interventions. Residents 28 experienced harm when they were admitted without a PU and developed an unstageable (is a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough, nonviable tissue, or eschar, dead tissue, obscures the wound bed) PU on their heel and placed all residents at risk for developing PUs/PIs and a decreased quality of life. Findings included . Review of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facility's, revised 02/02/2023, showed: -An avoidable PU is defined as a PU that developed in the facility and the facility failed to do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident's needs, goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. -A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. - A Stage III PU is a full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough (nonviable tissue) and/or eschar (dead of devitalized tissue) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity (body fat) can develop deep wounds. Undermining (destruction of tissue or ulceration extending under the skin edges) and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) may occur. <RESIDENT 28> Resident 28 was admitted to the facility on [DATE] with diagnoses that included a right periprosthetic knee fracture (a fracture above or around a total knee replacement) with an external fixation device in place (a metal frame with pins or wires inserted in bones to hold them together while healing,) Diabetes Mellitus (alteration in how the body uses sugar), neuropathy (numbness and pain from nerve damage) in their legs and feet, and Parkinson's disease (a disorder of the central nervous system that affects movement). Review of Resident 28's admission Minimum Data Set (MDS- an assessment tool) assessment, dated 09/19/2023, showed the resident was cognitively intact, received extensive assistance of two staff members with bed mobility, required extensive two-person assistance with a mechanical lift for transfers, identified at risk for developing PU's, and currently had no PU's present. The Care Area Assessment (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned), dated 09/26/2023, showed the resident was at risk for developing PU's related to right knee fracture and required extensive assistance of two staff for bed mobility, and did not walk. Review of Resident 28's Care Plan focus/problem Alteration in Skin Integrity, dated 09/13/2023, showed Resident 28 was at risk for PU development related to (but not limited to) their right periprosthetic knee fracture with pain, and weakness. Interventions included to monitor nutrition and reposition the resident in bed with a draw sheet. Updated interventions, dated 9/26/2023, included use of a pressure reducing mattress and floating the resident's heels while in bed. Review of Resident 28's weekly skin observation assessment tools, dated 09/14/2023 to 10/05/2023, showed no new skin conditions or documentation of a current PU/PI. There was no weekly skin assessment tool found for 10/12/2023. Review of Resident 28's weekly skin observation assessment, dated 10/17/2023, showed the resident had a PU on the resident's left heel measured 4 centimeters (cm) by 2.8 cm. The wound was unstageable due to the presence of eschar. Review of a physician order, dated 10/17/2023, showed to ensure offloading (a way to redistribute pressure) device was placed to both of Resident 28's heels, a specific treatment to the left heel wound on Monday, Wednesday, and Friday and a referral to a contracted wound consultant company. Review of the facility incident investigation, dated 10/23/2023, showed Resident 28 had a left heel wound that was found on 10/16/2023 (date identified on the investigation). Review of Resident 28's Treatment Administration Record (TAR), initiated 10/29/2023, showed the nurse was to document every shift to ensure pressure offloading boots were in place to both heels. Review of the contracted wound consultant company initial assessment, dated 10/23/2023, showed Resident 28's left heel wound measured 5 cm by 3 cm and was covered with slough. Review of the contracted wound consultant company weekly assessment, dated 10/30/2023, showed Resident 28's left heel wound measured 4.5 cm by 3 cm in size and was covered with slough. Review of the contracted wound consultant company weekly assessment, dated 11/20/2023, showed Resident 28's left heel wound measured 4.5 by 3 cm with depth of 0.2 cm following debridement (removal of slough) of the wound. Records showed PU was a Stage 3 after the debridement. Review of the contracted wound consultant company weekly assessments from 11/20/2023 through 12/11/2023 showed no change in left heel wound size. During an interview on 12/07/2023 at 08:59 AM with Resident 28, stated they developed a sore on their left heel about a month ago from rubbing their heel on the bed when repositioning self while in bed. In an observation and interview on 12/11/2023 at 08:20 AM, Resident 28's left heel wound was observed with an adhesive bordered dressing in place. CC5 stated had just completed wound care and found left foot wound healing had stalled and would make recommendations for further diagnostic measures to promote wound healing. During a joint review of the incident investigation and interview on 12/13/2023 at 11:40 AM, with Staff A, Administrator, and Staff B, Director of Nursing Services, Staff B stated Resident 28's left heel PU was not present on admission and developed at the facility. Staff B stated the incident report did not show the PU was unavoidable. Staff B stated they did not offer use of offloading boot to Resident 28's left foot until after wound was found.

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for 3 of 5 residents (Residents 3, 1, and 61) reviewed for resident rights. The facility failed to ensure staff interacted with residents in a dignified manner which placed residents at potential risk to experience emotional distress, humiliation, embarrassment, and a diminished quality of life. Findings included . The Cambridge English Dictionary, dated April 28, 1995, defines Dignity as The quality of a person that makes him/her deserving of respect, sometimes shown in behavior or appearance. According to Washington State Long-Term Care Ombudsman Program website 12/15/2023, People who live in long-term care facilities are more vulnerable than people who live independently. In 1987, the U. S. Congress recognized this fact and passed The Nursing Home Reform Act that gave nursing home residents additional legal protections, including a set of Resident Rights. Resident rights include the right to a dignified existence and to be treated with consideration, respect, and dignity, recognizing each resident's individuality. Quality of life is to be maintained or improved. Residents have the right to request, refuse and or discontinue treatment. <RESIDENT 3> Resident 3 admitted on [DATE] with diagnoses to include aftercare following abdominal surgery and weakness. The resident was alert and oriented with no cognitive impairment and required extensive assistance for bed mobility. Review of an abuse allegation investigation for Resident 3, dated 11/08/2023 at 6:45 AM, showed the resident was given incontinent care from Staff N, Nursing Assistant Certified (NAC), who asked the resident to participate in the task. Resident 3 got upset and started to cry. The resident reported the NAC was lazy and had asked them to do something that they were not capable of doing. The facility had ruled out abuse. Review of a statement included with the investigation from Staff O, Licensed Practical Nurse, on 11/08/2023 at 2:05 PM, showed at approximately 6:45 AM, they heard raised voices and what sounded like crying coming from room [ROOM NUMBER]. Staff O went into the room and observed Resident 3 crying, Staff N was in the room briefly and left. The resident began to sob and said (Staff N) would not turn them when they hurt and said they were too busy. Staff O repositioned the resident. The resident was crying while talking and said Staff N was angry at me, I don't think they like me, I told them I was hurting. Staff O medicated the resident for pain and told Staff N they were not to provide care for Resident 3 anymore. Review of the statement from Staff N, dated 11/08/2023, showed they provided care and asked Resident 3 to help with getting pulled up in bed. The resident told Staff N, No. Staff N then told the resident they believed they could do it, the resident got mad and started to cry and talk at the same time. Staff N wrote they could not understand the resident clearly and tried to calm them down and left to get them ice water. Staff N returned and Resident 3 told Staff N, they were being mean to them. Staff N added the resident was still crying when they returned. In an interview on 12/13/2023 at 2:14 PM, Staff B, Director of Nursing Services, stated Staff N told them they were encouraging Resident 3 to participate with care. Staff B said Staff N's last day of employment was on 11/17/2023. In an interview on 12/14/2023 at 8:24 AM, Resident 3 was observed resting in bed with a bathrobe draped over them. Resident 3 stated they were upset because they left to an appointment yesterday and had asked staff to change their bedding as it was soiled and when they returned no one cleaned the room or changed the bedding. Resident 3 stated they waited an hour to have their call light answered all the time. Resident 3 said, I cry, I cry. I have to lay in urine for hours and then my skin burns and itches, it is very painful. The resident said staff do not treat them with kindness. The resident said there was an aide last month (regarding the incident on 11/08/2023 with Staff N) who made them upset, and they cried and cried. The resident said they were hurting and asked the aide to turn them, but the aide wouldn't turn them because they said they were too busy. The resident said it made them very upset and they told their nurse who had to give them pain pills for it. The resident said they did not like how they were treated. <RESIDENT 61> Resident 61 admitted to the facility on [DATE] with diagnoses to include end stage renal failure requiring dialysis. Review of the Significant Change of Condition Minimum Data Set (MDS - an assessment tool) assessment, dated 11/13/2023, showed Resident 61 had no cognitive impairment, was able to make their needs known, and required moderate assistance with transfers. The resident was not able to walk related to medical and safety concerns. Review of an abuse allegation investigation, dated 11/20/2023 at 6:10 PM, showed Resident 61 reported a care issue on 11/15/2023 that mostly every night, call lights took up to an hour to be answered during night shift, a night shift staff member (Staff E, NAC) berated and argued with them regarding their care. The resident requested another aide to care for them. Review of a written statement, undated, showed Staff E provided care for Resident 61 on 11/14/2023 and gave them ice chips twice. Staff E said the resident asked for more ice chips and the nurse told Staff E, to not give the resident anymore ice chips related to them being on a fluid restriction. Staff E then told the resident they could not have ice chips and instead brought them graham crackers. Review of a statement, dated 11/15/2023, showed Staff A, Administrator, interviewed Resident 61 and said every night the resident and Staff E go at it. Resident 61 stated Staff E had an issue with the heat in their room, would get upset and say, I can't work in here. I can't deal with the heat in here. The resident said Staff E would then keep their door open, which they do not like, but they tried to appease Staff E, and they turned the heat off. The resident said when they put the call light button on, Staff E would get upset, entered their room, and would say, It's too hot in here, what is it now? The resident said Staff E did not help them right away even though the task took a minute. The resident said Staff E told them they would be back, and it took them a while to return. Resident 61 stated Staff E made them feel like they were inconveniencing them, and Staff E should talk to them like they were a customer. In an interview on 12/06/2023 at 9:14 AM, Resident 61 was observed sitting on side of their bed in a hospital gown. The resident said yesterday, Staff D, NAC, snapped at them and made them feel like an inconvenience. The resident said they had reported this to staff already. In an interview on 12/06/2023 at 2:21 PM, Resident 61 was asked if they felt staff treated them with respect and dignity. The resident said No, I do not like [Staff E] the aide. The resident said they told the Administrator they did not want this aide to care for them anymore. The resident said Staff E complains my room is too hot and tells me they can't work in here and argues with me on any requests I have. The resident said there was another aide (Staff D) that said they could not do things for you, because it would hurt Staff D's back. The resident said Staff D gave them a shower yesterday and told them to walk to the bench, but (Staff D) knew they could not do it. The resident said they told Staff D they needed help to lift their legs, but Staff D said you can do it. The resident said they had swelling, and their legs hurt. The resident said Staff D argued with everything they asked for. The resident stated they told management and management was supposed to talk with that aide, but they did not know if they did. The resident said there was also another shower incident that really got them mad. The resident said they were in the shower chair and had a bowel movement (BM) and [Staff D] took the bucket out in front of me and let water run in it. The resident told Staff D they didn't want to see the BM mixed with water go down the drain and Staff D replied, I don't either. In a joint interview on 12/13/2023 at 2:13 PM, Staff A and Staff B stated they were unaware of Staff D telling a resident they could not do things related to back pain. <RESIDENT 1> Resident admitted on [DATE] with diagnosis of sepsis (blood infection), kidney and cardiac disease. The resident was alert and oriented and able to make their needs known. In an interview on 12/06/2023 at 10:01 AM, Resident 1 was asked if they were treated with respect and dignity. The resident stated there was a male aide (name provided) on day shift that was not a good fit for this place at all which the resident had reported to the next shift. Resident 1 stated the aide was on their phone in the room while providing care then they left in the middle of their care. The resident said when the staff member returned, they asked them why they had just left them. The resident said the aide responded they were trying to pick up shifts for the next day. The resident said they were not even treated as a person. The resident said they were not a complainer, and they did not want that aide back. Resident 1 said no one had ever talked to them about the incident. Review of the incident report log and grievance log for 10/13/2023 through 12/13/2023, showed no investigation involving Resident 1 and a staff member. In an interview on 12/08/2023 at 10:27 AM, Resident 1 was in bed reading and commented they had a new aide today, not their usual aide Staff D who could be rude and abrupt but knew how to care for them. In a joint interview on 12/13/2023 at 2:15 PM, Staff A and Staff B said they were unaware of any male aide by the name Resident 1 identified or of Resident 1's concerns but they would look into it. This is a repeat citation from SOD dated 12/23/2022. Refer to WAC 388-97-0180)(2) .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information and/or resources to residents to assist with the development of an Advanced Directive (AD) for 2 of 4 sampled residents (Residents 59 and 61) reviewed for AD. This failure denied residents the opportunity to appoint someone to make choices regarding finances and/or healthcare decisions if the residents became unable to make their own decisions. Findings included . Review of a facility policy, titled, Advanced Directives, revised date 10/13/2022, showed the resident would be provided written information concerning the right to formulate an AD. <RESIDENT 59> Resident 59 admitted to the facility on [DATE]. Review of Resident 59's electronic medical record (EMR) on 12/07/2023 at 11:15 AM, showed no record of an AD. <RESIDENT 61> Resident 61 initially admitted to the facility on [DATE]. Review of Resident 61's EMR on 12/08/2023 at 8:34 AM, showed no record of an AD. During an interview on 12/08/2023 at 8:39 AM, Staff A, Administrator, reported the facility went over AD when the admission packet was completed. During an interview and record review on 12/08/2023 at 10:15 AM, Staff A reviewed the admission paperwork for Resident 59 and Resident 61. Both residents' AD page was blank. Staff A was not able to report why the pages were blank. During an interview on 10/08/2023 at 10:20 AM, Staff U, admission Director, reported they asked new residents if they had an AD, but did not provide information or resources if one was not already in place. This is a repeat citation from Statement of Deficiencies, dated 06/10/2022. Refer to WAC 388-97-0280 (1),(3)(c) .

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain documentation regarding a grievance for 1 of 2 residents (Resident 49) reviewed for grievances. This failed practice placed the resident at risk for not having their grievance resolved and for diminished quality of life. Findings included . <RESIDENT 49> The resident admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment (an assessment tool), dated 12/05/2023, the resident had no cognitive impairment. In an interview on 12/12/2023 at 2:08 PM, Resident 49 stated they were missing a shirt, a pair of pajama bottoms, and their hearing aids. Review of the facility grievance log, dated October 2023, showed there was a grievance from Resident 49 regarding missing property. In an interview on 12/13/2023 at 2:06 PM, Staff A, Administrator, was unable to provide the investigation of the resident's grievance and stated they had lost the paperwork regarding Resident 49's grievance. Refer to WAC 388-97-0460 (2) .

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to implement their Abuse policy by not ensuring reference checks were conducted prior to hire for 2 of 5 employees (Staff J and T) reviewed for reference checks. These failures placed residents at risk for abuse, neglect, or mistreatment by staff. Findings included . Review of a facility policy titled, Abuse, revised date 10/20/2022, showed the facility would screen potential employees for a history of abuse, neglect, or mistreating residents by obtaining employment references. <STAFF J> Staff J was hired on 03/01/2023 as a Nursing Assistant Registered. Review of Staff J's employee file showed there were no professional or personal reference checks completed. <STAFF T> Staff T was hired on 04/01/2023 as a housekeeping aide. Review of Staff T's employee file showed there were no professional or personal reference checks completed. During an interview on 12/12/2023 at 10:43 AM, Staff P, Human Resource Manager, stated they were unable to find any reference checks in Staff J or Staff T's employee files. This is a repeat citation from SOD(s) dated 06/10/2022; 12/23/2022 Refer to WAC 388-97-0640(1)(2)(a) .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately assess 2 of 5 sampled residents (Residents 19 and 59) reviewed for Minimum Data Set (MDS - a required assessment used to identify resident's care needs) accuracy. Failure to ensure accurate assessments regarding dental/oral status and behavioral health indicators placed residents at risk for unidentified and/or unmet care needs, and inaccurate or incomplete care plans. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11 v6, dated October 2023, steps for assessment of Oral/Dental Status included: . Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining <RESIDENT 59> Resident 59 was admitted to the facility on [DATE] with diagnoses to include a history of stroke with right sided weakness. Review of Resident 59's admission MDS assessment, dated 10/24/2023, showed no dental concerns, No Obvious or likely cavity or broken natural teeth. During a joint observation and interview on 12/11/2023 at 11:55 AM with Resident 59 and Collateral Contact 4 (CC4), the resident's family member, they stated the resident had lifelong problems with their teeth. Resident 59 was observed with a broken right upper tooth with jagged edges and gums that receded from the bottom front teeth. There were observed black areas on the bottom teeth along the gum line. CC4 stated the condition of Resident 59's teeth was not new. During a joint record review and interview on 12/11/2023 at 2:31 PM, Staff KK, Licensed Practical Nurse (LPN)/MDS Nurse Coordinator, stated they had completed the MDS section regarding oral/dental status on the admission MDS, dated [DATE]. Staff KK stated they did not do a physical oral assessment and completed that section from information found on the admission nursing evaluationevaluation. <RESIDENT 19> Resident 19 admitted on [DATE] with diagnoses which included bipolar disorder (a serious mental illness characterized by extreme mood swings) and paranoid personality disorder (a sustained pattern of behavior characterized by paranoia, mistrust and suspiciousness of others). Review of Resident 19's documentation survey (v2) report (a report used to show specific coding regarding resident care), dated 11-01-223 to 12/11/2023, in the medical record, showed responses coded as RR (resident refused) daily for assistance with activities of daily living such as personal hygiene, grooming, weights and assessments. The medical record showed Resident 19 displayed behaviors such as yelling and cursing at staff. Review of Resident 19's Quarterly MDS assessment, dated 11/15/2023, showed the MDS incorrectly marked the resident as having rejections of care only one to three days in the reference period. The MDS incorrectly coded the resident as having 0 verbal behaviors directed at others. This resulted in three additional questions being skipped which identified whether those behaviors placed the resident at risk for illness or injury and interfered with the resident's care or participation in activities or social interaction. In an interview on 12/11/23 at 12:07 PM, Staff V, LPN/Resident Care Manager, stated Resident 19 refused care every day, refused weights, and cursed and yelled at others. Staff V stated, we attempt and (they) will say no. In an interview on 12/11/23 at 12:12 PM, Staff G, Social Services Director, stated they completed the mood and behavior sections of the MDS. Staff G stated, when I attempt to do the interview, (they) will refuse to respond to me and tell me to get out of the room. I will have to look but it should show that they have those behaviors. Refer to WAC 388-97-1000 (2)(f)(k) .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a comprehensive care plan for 2 of 2 residents (Residents 1 and 61) in the areas of pacemaker and dialysis. This failure placed residents who had a pacemaker and were on dialysis at risk for unmet care needs. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include heart disease and an irregular heart rhythm with a cardiac pacemaker (a small device that helps the electrical events of the heart). Review of Resident 1's care plan, dated 10/27/2023, showed their pacemaker was not included on the care plan. In an interview on 12/13/2023 at 12:10 PM, Resident 1 said they have had their pacemaker for three years now and the battery was supposed to last ten years. Review of the resident's clinical record revealed there was no record of pacemaker information, or a pacemaker check being completed or scheduled. <RESIDENT 61> Resident 61 admitted [DATE] with a diagnosis to include end stage renal failure with dependance on kidney dialysis (process for removing toxins and excess fluid from the blood). In an interview on 12/06/2023 at 2:29 PM, Resident 61 said they had been on dialysis since December 2019 and pointed to their right arm for the access site. They stated they went to dialysis on Tuesday, Thursday, and Saturday evenings. Review of Resident 61's dialysis care plan directed staff to encourage the resident to go to dialysis three times weekly but did not include which kidney center, days, or times. The care plan directed staff to listen or feel the AV fistula (surgical connection of artery and vein used for access during dialysis) to assure adequate blood flow per protocols but did not state what the protocol was. Staff were not to draw blood or take blood pressures on the arm with the graft but did not state which arm should be avoided. Review of the [NAME] (tool to direct nurse's aides on how to care for residents) did not include any mention of dialysis, avoiding blood pressures on Resident 61's right arm. In an interview on 12/13/2023 at 1:43 PM Staff C, Registered Nurse/Unit Manager, said the nurses all have a piece in the care planning process. Staff C said they had an admission nurse who started the care plan on admit. Staff C said they were unaware Resident 1's care plan did not include a pacemaker or that Resident 61's dialysis care plan was incomplete and lacking necessary components. In a joint interview on 12/13/2023 at 2:24 PM, Staff B, Director of Nursing Services, said the admission nurse completed the initial or baseline care plan, then the unit manager was responsible for changes. Staff B said Resident 1's care plan should address the type of pacemaker, battery etc., and Resident 61's dialysis access care. Reference: (WAC) 388-97-1020 (1)(2)(a)(3) .

CONCERN (D)

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

Deficiency F0678 (Tag F0678)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on a resident's request to change their code status (level of intervention a resident wishes to have started if their heart or breathing stops) for 1 of 1 resident (Resident 85) reviewed for Cardiopulmonary Resuscitation (CPR - staff performing chest compressions and providing breaths to mimic heartbeat and breathing). This failure placed residents at risk to have CPR initiated when they had requested to change their status to No CPR. Findings included . Review of the facility's undated policy, titled, Cardiopulmonary Resuscitation, showed a resident's code status would be reviewed periodically, with care plan review or any time the resident requests to change their decision. Resident 85 admitted to the facility on [DATE]. Review of the Portable Orders for Life-Sustaining Treatment (POLST) form, a form designated a resident's code status and other treatment options, showed Resident 85 requested to have Full Treatment including CPR initiated if their heart or breathing stopped. Review of a social service progress note, dated [DATE] at 4:02 PM, showed a meeting was held with Resident 85, Staff F, Social Service Worker, and nursing. The note did not specify which nursing staff attended. The meeting progress note showed Resident 85's code status was reviewed, and the resident no longer wanted to have CPR initiated. Review of the medical record showed no updated POLST form nor any further progress notes to show Resident 85's request had been followed up. Review of a progress note on [DATE] at 5:15 AM, showed Resident 85 was found unresponsive and was without a pulse or respirations. The progress note showed CPR was initiated. During an interview on [DATE] at 9:38 AM, Staff F reported Resident 85 did request to change their code status at the meeting on [DATE]. Staff F stated they didn't update the POLST with the resident as it was not a social service issue. Staff F reported they did not report to another staff member that Resident 85 wanted to change their code status. WAC Reference 388-97-0280 (3)(c)(i), (d)(i)(ii) .

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment/services for 1 of 1 residents (Resident 11) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their level of functioning. This failure placed residents at risk of further decline in ROM, increased pain and loss of function. Findings included . Review of the facility policy (undated) titled: Range of Motion Exercises, stated that Range of Motion exercises would be provided by qualified nursing staff. The policy stated documentation should include the time spent on the exercise, how the resident tolerated the exercise, problems or compiaints and if the resident refused. <RESIDENT 11> Resident 11 admitted [DATE] with diagnoses which included Bipolar Disorder (a mood disorder), other psychotic disorder, dementia, and contracture (permanent shortening of a muscle) of the left hand. Review of the resident's care plan showed: RESTORATIVES: ROM: Encourage and assist patient with passive ROM for upper and lower extremeties twice a day (see exercise sheets in patient's room or in patient's chart.) Soft splint to L (left) hand. SKIN/WOUND: Left hand- apply carrot hand splint, remove for ROM and hygiene, showers and daily to cleanse the hand. In observations on: 12/06/23 at 09:11 AM, The resident's left hand observed clenched and contracted. No soft splint or carrot was in place. 12/07/23 at 02:14 PM, The resident was in bed with the carrot in their right hand holding on to it. (ordered for the Left hand) No soft splint was in place. 12/08/23 at 09:49 AM, Carrot was on the overbed table. A soft splint was observed in the resident's bedside table top drawer. 12/11/23 at 04:50 AM, The resident was in bed with blankets covering their left arm, the carrot was observed in their right hand and the soft splint was still observed in the bedside drawer. 12/12/23 at 01:00 PM, The resident was in their bed, the soft splint was in the bedside table drawer, carrot sitting on the overbed table. The resident says hello and was unable to state if they wore their splint or carrot. There were no observations of the soft splint or carrot in place to the resident's left hand at any time during the survey, or any observations of staff performing Range of Motion Services or hand care. In an observation and interview on 12/12/23 at 01:06 PM, Staff CC, Certified Nursing Assistant (CNA), stated Resident 11 used to have something for their hand so much contraction. Staff CC Stated they had not seen it for a while, and maybe the nurses did that. Staff CC stated they thought Resident 11 was supposed to have exercises every day but wasn't sure. Staff CC stated they had not tried to do exercises with Resident 11 for a while. Staff CC went to the computer and viewed the CNA task list, which showed that there were no exercises for the resident. When Staff CC was asked to view the care plan which does show the splint, the carrot and the ROM, Staff CC looked confused and stated I don't know, Staff CC motioned to follow her, walked to Resident 11's room and looked for an exercise sheet which was not found. Staff CC stated that it was difficult to work with Resident 11's hand, and started to reach toward the resident who yelled aaaaah, no, bring me a pain pill! Staff CC reassured Resident 11 and stated, this is what I mean, it hurts (them) to try to do the exercises so (they) were always refusing. In an interview on12/13/23 at 10:02 AM, Staff B, Director of Nursing Services, stated the facility did not have a structured Restorative program. The nurses were responsible for splints and the floor staff were responsible to do ROM as part of care. Staff B stated that Resident 11's care plan was not updated to reflect that the soft splint was discontinued because it irritated their skin. There should still be ROM being attempted and the resident's task list had not been created for the resident's ROM program so it was not showing up for the CNAs to complete or chart. There were orders for the resident to be pre-medicated. The resident should still have the carrot to the left hand, but will remove it and place it on the bedside table themself. This is a repeat citation from SOD dated 06/10/2022. Reference (WAC) 388-97-1060 (3)(d)

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses to include end stage renal disease and depende...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses to include end stage renal disease and dependence on renal dialysis. Review of Resident 47's Medication Administration record (MAR) and Treatment Administration Record (TAR) for October 2023 through 12/12/2023, showed no pre or post dialysis assessment, dialysis pressure dressing instructions, assessment of the arteriovenous (AV) fistula, or nephrologist information. Review of the Resident 47's clinic record on 12/12/2023, showed there were no Dialysis Communication Forms present. In an interview on 12/12/2023 at 9:06 AM, Staff OO, Licensed Practical Nurse (LPN), Supervisor, stated they were unable to find contact information for Resident 47's Nephrologist. Staff OO stated they would contact the facility provider or kidney center if needed, and stated, there have been no concerns with the resident. In an interview on 12/12/2023 at 9:12 AM, Staff V, LPN, Unit Manager, was unable to provide information for the resident's Nephrologist. When asked if nursing was exptected to document regarding Resident 47's fistula, bruit and thrill, and dialysis dressing, Staff V stated nurses documented on the MAR. Staff V stated there were no orders on the MAR for documentation of assessment of Resident 47's fistula, dialysis dressing, or what concerns to report and who to report them to. In an interview on 12/12/2023 at 2:45 PM, Staff B, Director of Nursing Services, stated the expectation was for nurses to monitor the fistula, prepare dialysis paperwork, and remove the dialysis dressing per orders for residents on dialysis. When asked where the nurses would document, Staff B stated there should be a physician order and nurses would document in the TAR. Staff B confirmed there was no information for the Nephrologist in Resident 47's medical record. During an interview on 12/13/2023 at 8:43 AM, Staff A, Administrator, stated they could not locate Dialysis Communication Forms. During an interview on 12/13/2023 at 9:48 AM, Staff B confirmed the facility was not completing dialysis communication forms. Reference: WAC 388-97-1900(1)(6)(a-c) Based on interview and record review, the facility failed to ensure two of two residents (47 and 61) reviewed for dialysis, received consistent ongoing communication and collaboration with the dialysis center. The facility further failed to document before and after-dialysis assessments of resident's condition, which placed the residents at risk for unmet care needs and dialysis related complications. Findings included . Review of the facility's policy titled, Hemodialysis Access Care, undated, showed that facility was committed to following current Centers for Medicare and Medicaid (CMS) guidelines, and clinical standards of practice providing care for residents with End Stage Renal Disease receiving hemodialysis at an outpatient dialysis facility. Nursing staff will care for, prevent infection and maintain patency (preventing clots) to the AVF (arteriovenous fistula), provide care immediately following dialysis treatment, and monitor and document the dialysis site type, patency, observing for signs of infection or bleeding and document the condition of the dressing and interventions completed every shift. <RESIDENT 61> Resident 61 admitted on [DATE] with diagnoses to include heart failure, malnutrition and End Stage Renal disease, with dependence on kidney dialysis (the process of removing waste and excess water from the blood). Review of Resident 61s significant change Minimum Data Set assessment dated [DATE], showed that the resident received dialysis treatment and was able to make their needs known. Review of the physician's order dated 11/08/2023, showed Resident 61 was prescribed dialysis treatment at the dialysis center every Tuesday, Thursday, and Saturday. The nurses were directed to remove the dialysis pressure dressing to the right upper extremity after dialysis and only reapply if bleeding was present, Review of Resident 61's physician's order dated 11/08/2023 showed the resident was a dialysis patient and was to attend dialysis at the (kidney center and location) on Tuesdays, Thursdays and Saturdays at 5:00 PM for hemodialysis. Review of Resident 61's clinical record including the assessment tab and Treatment Administration Records (TARs) from 10/17/2023 through 12/09/2023, showed no pre-dialysis assessment documented. Review of the dialysis care plan interventions dated 10/17/2023 showed the care plan did not include communication directives between the kidney center and the facility. The care plan did not include the dialysis center, times, how often to assess the AV fistula or type and location of the fistula. The care plan did not address the residents daily fluid restriction. Review of Resident 61's clinical record shower there were no Dialysis Communication Forms present from admission on [DATE] until 12/09/2023. During an interview on 12/13/2023 at 8:43 AM, Staff A, Administrator stated that they could not locate Dialysis Communication Forms for Resident's 47 or 61. At 8:51 AM, Staff B, Director of Nursing (DNS) brought in a 2-page fax from the kidney center that contained lab results but no pre or post assessment communication forms. At 9:39 AM, Staff B said the nurse's had not been doing a pre or post assessment on the dialysis residents. Staff B said they were inputting orders, and the nurses will do a pre and post dialysis assessment on those residents. In an interview on 12/13/2023 at 1:48 PM, Staff C, RN Unit Manager said the expectation was there was to be communication on the dialysis residents between the kidney center and the facilty. Staff C was informed the care plan was lacking the dialysis site, nephrologist information, who was responsible for what interventions and communication as well as the fluid restriction. In a follow up interview on 12/13/2023 at 2:39 PM, Staff B, DNS stated the facility currently had four dialysis residents and they had been unaware of these dialysis issues.

CONCERN (D)

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

Deficiency F0728 (Tag F0728)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure staff with a Nursing Assistant Registered (NAR) license completed a Nursing Assistant Certified (NAC) class and passed the state license exam within four months of hire for 1 of 2 NAR's (Staff J) reviewed for staff licenses. This failure placed residents at risk to receive care from unlicensed staff. Findings included . Record review of the facility staff list showed Staff J was hired on 03/01/2023 as a Nurse Aide Trainee. Review of the daily staff assignment sheets from 12/01- 12/07/2023, showed that Staff E worked from 6 AM - 2 PM on 12/01/2023, 12/04/2023, 12/05/2023, and 12/06/2023. During an interview on 12/12/2023 at 10:43 AM, Staff P, Human Resource Manager, stated Staff J had a current NAR license, but had not yet taken the state test to become a NAC. Staff P confirmed Staff J's hire date of 03/01/2023 and that they had been working as a NAR until 12/07/2023. WAC Reference: (WAC) 388-97-1660 (2)(b), (3)(a)(i) .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, and administering of all drugs) to meet the needs of each resident for two of two residents (40 and 147). Failure to ensure timely receipt and administration of ordered medications placed Residents 40 and 147 at risk for discomfort, pain and a decline in their physical health. Findings included . <RESIDENT 40> Resident 40 admitted [DATE] with diagnoses to include low back pain, left and right foot pain and chronic pain. Review of the physician's orders directed nursing staff to administer Suboxone film sublingually (under the tongue) every eight hours as needed for opioid dependance. Suboxone was a controlled drug (scheduled 3 substance that required facility to keep under double lock and account for each shift change). Review of a progress note dated 12/05/2023 at 5:17 PM, showed Resident 40 requested a dose of Suboxone in the morning and the medication was unavailable. Resident 40 informed the Registered Nurse (RN) they had one dose of Suboxone in their personal items. The Suboxone dose was verified, and the physician was called for permission to administer the dose from the resident's personal supply. In an interview on 12/12/2023 at 10:35 AM, Staff M, RN said they had to call the pharmacy as medications were out for residents. Staff M said it happened from time to time and they had a Cubex (device that holds emergency medications) they could access. In an interview on12/13/2023 at 1:51 PM, Staff C, RN/Unit Manager, said being out of medications did happen and they would call the doctor and pharmacy. Staff C said they did have a Cubex for emergency doses but that it was hit or miss on if the medication was there. In an interview on 12/13/2023 at 2:54 PM, Staff B, the Director of Nursing Services (DNS) stated the Suboxone was not in the Cubex. Staff A, Administrator and Staff B said they had not heard there were issues with meds not being reordered timely. The expectation would be the nurses call and get the medication satellited or call the physician and see if another medication could be given. No additional information was given. <RESIDENT 147> The resident admitted to the facility on [DATE] with diagnoses to include chronic pain and long-term use of opiate analgesics (potent opioid pain medications). According to the admission Minimum Data Set assessment (an assessment tool), dated 12/06/2023, the resident had no cognitive impairment and they had frequent pain that affected their sleep. In an interview on 12/06/2023 at 2:51 PM, Resident 147 stated they had an issue with pain when they admitted to the nursing home because it took several days for the facility to obtain their pain medication. Review of the hospital Discharge summary, dated [DATE], showed Resident 147 admitted to the nursing home with an order for Oxycodone (a potent opioid pain medication). Review of Resident 147's November and December 2023 Medication Administration Records showed the resident did not receive their first dose of Oxycodone until 12/04/2023. In an interview on 12/08/2023 at 2:19 PM, Staff C, Registered Nurse/Resident Care Manager, stated the resident did admit to the facility with an order for Oxycodone, but they did not come with a hard prescription (paper copy written on a prescription pad), so there was a delay. Staff C stated without a hard prescription, they couldn't even administer the resident Oxycodone from their emergency kit. Staff C stated when the resident admitted without a hard prescription from the hospital, the nurse should have reached out right then to obtain a hard copy prescription. This is a repeat citation from SOD dated 12/23/2022. Refer to WAC 388-97-1300 (1)(a)(b)(i)(ii) .

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 27> Resident 27 re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome. During a r...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 27> Resident 27 re-admitted to the facility on [DATE] with diagnoses including chronic pain syndrome. During a review of Resident 27's physician orders on 12/08/2023 at 9:08 AM showed the resident received pain medication as needed (PRN) for pain management. During a review of Resident 27's MAR dated 11/07/2023 through 11/30/2023, showed the resident used PRN pain medication 11 times. During an interview on 12/14/2023 at 10:09 AM, Staff V, Licensed Practical Nurse, Unit Manager confirmed non-pharmacological interventions should be attempted prior to administration of pain medication. Staff V confirmed Resident 27 did not have orders for non-pharmacological pain interventions. During an interview on 12/14/2023 at 10:16 AM, Staff B, Director of Nursing Services, confirmed non-pharmacological interventions should be attempted prior to administering as needed pain medication. Refer to WAC 388-97-1060 (3)(k)(i) Based on interview and record review, the facility failed to ensure 2 of 5 residents (138, 27) remained free of unnecessary drugs. The failure to monitor for adverse side effects of medications and to provide non-pharmacological pain interventions placed the residents at risk for medication-related complications and for receiving unnecessary pain medication. Findings included . <RESIDENT 138> The resident admitted to the facility on [DATE] with diagnoses to include a stroke. Review of Resident 138's November and December 2023 Medication Administration Records/Treatment Administration Records (MARS/TARS) showed the resident was being treated with apixaban (an anticoagulant medication used to thin the blood to treat blood clots and to prevent/treat strokes). Review of the MARS/TARS showed no documentation the resident was being monitored for adverse side effects of the apixaban. In an interview on 12/08/2023 at 2:26 PM, Staff C, Registered Nurse/Resident Care Manager, stated they should have been monitoring the resident for side effects of the treatment with apixaban.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely and accurate Medicare notices to 3 of 4 sampled residents (Residents 290, 61 and 289) reviewed for required liability notices. This failure placed residents or their representatives at risk for not being informed of their appeal rights prior to the end of their health plan company (managed Medicare insurance) ended and not being fully informed of the cost of continued services after skilled services ended. Findings included . Review of a facility policy titled, Medicare Liability Notice, dated 10/01/2021, showed the facility will provide written notice when Medicare coverage was determined to be ending. The Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) must be provided to the resident no later than the last covered (Medicare) day. <RESIDENT 290> Resident 290 admitted to the facility on [DATE] under their private Medicare health plan. During an interview on 11/08/2023 at 12:02 PM, Collateral Contact 1 (CC1), Resident 290's family member, stated they had been given the wrong phone number to appeal the Notice of Medicare Non-Coverage (NOMNC, form letter that shows insurance will no longer cover services). CC1 stated they had not received a copy of the NOMNC letter, the information had just been provided during a phone conversation with the facility. Review of the NOMNC, dated 10/10/2023, showed Resident 290's stay at the facility would not be covered after 10/12/2023. The NOMNC had information notifying the resident they could appeal the decision by contacting their private Medicare health plan company. The NOMNC showed the information had been provided to CC1 via phone. The NOMNC showed the phone number provided to CC1 was the phone number to the traditional Medicare insurance company and not to Resident 290's private Medicare insurance company. During an interview on 12/11/2023 at 9:42 AM, Staff F, Social Service worker, stated the phone number provided to CC1 was the phone number to the traditional Medicare company and did not realize there was a different number to provide for private Medicare health plans. <RESIDENT 61> Resident 61 admitted to the facility under skilled Medicare services. Review of Resident 61's NOMNC letter, dated 11/27/2023, showed skilled services would end 11/29/2023. Review of the SNFABN showed the estimated costs of care if Resident 61 remained in the facility after 11/29/2023. It was dated as being provided to Resident 61 on 12/06/2023. During an interview on 12/08/2023 at 2:52 PM, Staff Q, Business Office Manager, stated Resident 61 received their SNFABN after their last skilled day as it was mistakenly missed. <RESIDENT 289> Resident 289 admitted to the facility under skilled Medicare services. Review of Resident 289's NOMNC letter, dated 09/12/2023, showed skilled services would end 09/12/2023. Review of the SNFABN showed the estimated costs of care if Resident 289 remained in the facility. It was dated as being provided to Resident 289 on 09/15/2023. During an interview on 12/08/2023 at 2:52 PM, Staff Q confirmed the SNFABN was provided to Resident 289 after their last skilled day. Refer to WAC 388-97-0300 (1)(e),(6)(a) .

CONCERN (E)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 74> Resident 74 admitted to the facility on [DATE] with diagnoses including severe protein calorie malnutrition ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 74> Resident 74 admitted to the facility on [DATE] with diagnoses including severe protein calorie malnutrition (weight loss from not enough protein and calorie intake), adult failure to thrive (weight loss, poor appetite and nutrition and inactivity), and muscle wasting. Review of admission MDS assessment, dated 10/25/2023, showed Resident 74 did not have a pressure ulcer (PU) when they admitted to the facility. Review of Resident 74's weekly skin observation and weekly wound evaluation, dated 10/27/2023, showed the resident had a skin tear to their coccyx. Review of the facility incident investigation, dated 10/27/2023, showed Resident 74 had an open area to the coccyx measuring 1.5 centimeters (cm) by 1.0 cm. The injury type was documented as unstageable (unable to see the base of the wound to determine the stage). Review of a facility incident investigation showed the investigation was incomplete and did not contain staff statements or a summary of the conclusion of the investigation that ruled out abuse and/or neglect. During an interview on 12/12/2023 at 2:26 PM, when asked about the investigation, Staff B stated they had completed the investigation. Staff B stated during the investigation they were aware Resident 74 had a PU at the hospital and did not investigate further to rule out Resident 74 did not develop the PU after admission to the facility. Reference WAC 388-97-0640 (6)(a) <RESIDENT 59> Resident 59 was admitted to the facility on [DATE] with diagnoses to include history of a stroke with right sided weakness and cardiac disease. Review of admission MDS assessment, dated 10/24/2023, showed the resident experienced urinary and bowel incontinence and was dependent on staff for mobility and toileting. During an interview on 12/07/2023 at 11:33 AM, Collateral Contact 4 (CC4), Resident 59's family member, stated on 11/24/2023 at noon time, Staff GG, NAC, declined to assist the resident with incontinent care when they requested assistance. CC4 stated the resident had been incontinent of their bowels. CC4 stated Staff GG told them they had already assisted the resident and don't tell me how to do my job. CC4 stated the resident did not get assistance with incontinent care until after 2:00 PM, two and a half hours later, when evening shift staff arrived. On 12/13/2023, the allegation of neglect incident report, which occurred on 11/24/2023 was reviewed. There was a statement from Staff G indicating the allegation did not occur, there were no interviews from other staff on duty, or interviews with other residents who Staff G had provided care. The investigation did not rule out abuse and/or neglect. During joint interview on 12/13/2023 at 11:47 AM with Staff A and Staff B they stated the investigation was not complete. There was no summary to show if abuse or neglect were ruled out or a date indicated the investigation was complete. <RESIDENT 3> Resident 3 admitted on [DATE] with diagnoses to include aftercare following abdominal surgery and weakness. The resident was alert and oriented with no cognitive impairment and required extensive assistance for bed mobility. Review of an abuse allegation investigation, dated 11/08/2023 at 6:45 AM, showed Resident 3 was provided incontinence care from Staff N, NAC, who asked the resident to participate in the task. Resident 3 got upset and started to cry. The resident reported the NAC was lazy and had asked them to do something they were not capable of doing. The incident report showed the care plan was updated to have a second staff present when providing care to the resident. Review of a statement included with the investigation, dated 11/08/2023 at 2:05 PM, Staff O, Licensed Practical Nurse (LPN) documented at approximately 6:45 AM, they heard raised voices and what sounded like crying coming from room [ROOM NUMBER]. Staff O went into the room and observed Resident 3 to be crying. The resident began to sob and said Staff N would not turn them when they hurt and said they were too busy. Staff O repositioned the resident. The resident was crying while talking and said Staff N was angry at me, I don't think they like me, I told them I was hurting. Staff O told Staff N they were not to provide care for the resident anymore. Review of a statement, dated 11/08/2023, showed Staff N provided care and asked Resident 3 to help with getting pulled up in bed. The resident told Staff N, No. Staff N then told the resident they believed they could do it and the resident got mad and started to cry and talk at the same time. Staff N wrote they could not understand the resident clearly and tried to calm them down and left to get them ice water. Staff N returned and the resident told Staff N, they were being mean to them. Staff N added the resident was still crying when they returned. In an interview on 12/13/2023 at 2:14 PM, Staff B said Staff N told them they were encouraging Resident 3 to participate with care. Staff B said Staff N, last day of work was 11/17/2023. Staff B said they would add customer service to their staff orientation. In an interview on 12/14/2023 at 8:24 AM, Resident 3 said staff did not treat them with kindness, last month an aide made them upset, and they cried and cried. The resident said they were hurting and asked the aide to turn them, but the aide wouldn't turn them because they said they were too busy. Review of the facility incident report investigation failed to include interviews of other residents and staff about any unidentified concerns with Staff N. There was no summary to show the allegation was thoroughly investigated. In a joint interview on 12/13/2023 at 2:30 PM, Staff A stated the incident report investigation was not thorough. Staff B said they were unsure when Staff N last worked. At 4:00 PM, Staff B said Staff N had not worked again since 11/17/2023. Based on interview and record review, the facility failed to conduct thorough investigations for 4 of 5 residents (Residents 143, 3, 59, and 74) whose investigations were reviewed. The failure to conduct thorough investigations placed residents at risk for repeat incidents, unmet care needs, and for frustration with unresolved care issues. Findings included . Review of the facility's policy titled Abuse, dated 10/20/2022, showed: -The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. -Other residents who may have potentially been affected or at risk will be identified and a plan of care will be developed or revised as appropriate to ensure their safety. -Designated staff will immediately review and investigate all allegations or observations of abuse. If the alleged violation is verified appropriate corrective action must be taken. <RESIDENT 143> Resident 143 admitted to the facility on [DATE] with diagnoses to include anxiety, a left humerus fracture, an infection with Clostridium Difficile (a bacteria that causes diarrhea), colitis (inflammation of the colon), and enterocolitis (inflammation that occurs throughout the intestines). According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 12/05/2023, the resident had no cognitive impairment, and they were frequently incontinent of bowel and bladder. The resident requested to be discharged to the hospital on [DATE] due to unmet toileting care needs. Review of an incident investigation, dated 12/04/2023, showed Resident 143 alleged staff had upset them on multiple occasions with the verbal comments they made, staff were unable to accommodate the frequency of the resident's bowel movements, and monitoring indicated they had bowel movements every 20 - 30 minutes. The investigation indicated the resident stated they could not hold their chronic loose stools and had accidents daily. The investigation included documentation from Staff B, Director of Nursing Services (DNS), they had monitored the resident's call light and it had come on multiple times, to include four times within an hour with the resident requesting a bed pan to have a bowel movement. The investigation did identify the staff involved or any witness statements. The investigation did not rule out abuse and/or neglect. The investigation included a progress note done by Staff B, DNS, that indicated the resident's concerns were validated and addressed, and that staff were unable to accommodate the frequency of the resident's bowel movements, the note recommendation elaborated the provider was aware of the request for further interventions and they had been requested to evaluate the resident for a rectal tube (a tube that is inserted in the rectum as part of a fecal management system for patients experiencing fecal incontinence and excessive bowel movements) to preserve their skin integrity. The investigation was noted to have no information about follow-up to the request the resident be evaluated for a rectal tube. In an interview on 12/06/2023 at 1:26 PM, Resident 143 stated they had to have a bowel movement in their briefs because staff didn't come for 45 minutes when they had called staff for help to use the bedpan (a container to collect urine or feces for a person who is confined to bed and unable to use a toilet or bedside commode. A bedside commode is a portable toilet for someone who can't make it to the toilet but is able to get out of bed), it is shaped to fit under a person lying or sitting in bed), and when staff came they asked them why they didn't hold it, and they told the staff you can only hold it for so long and then it comes out. The resident stated it was almost always 20 - 30 minutes before staff would come when they used their call light, and that staff told them to expect a 20 minute wait when they used their call light. The resident stated they had no large bowel, so when they had to have a bowel movement, they almost always had to end up going in their diaper, and that wasn't good for their skin or emotionally. The resident stated they had to use their diaper for peeing and pooping because they couldn't get timely help because staff didn't respond timely to their call light. The resident stated staff had told them to urinate in their briefs and that they would clean them up after. The resident stated they had used a toilet at home, but they couldn't walk now, so they preferred to use a bedpan. In a phone interview on 12/11/2023 at 8:06 AM, Resident 143 stated they called the police to take them to the hospital (on 12/09/2023) because they had sat in their own feces for an hour and 50 minutes, and they couldn't control their bowels. They stated the bowel movement was drying to their skin, and they felt staff were very rough, so they were afraid. They stated they talked to the head of nursing who they said told them they couldn't help them. They stated they would not be returning to that nursing home. The resident stated Staff LL asked them the week prior why they bowel movement in their briefs and that Staff LL was rough with them when cleaning off feces that had dried on them. In an interview on 12/11/2023 at 8:29 AM, Staff A, Administrator, and Staff B were jointly interviewed. Staff B stated they offered the resident to go to the hospital because the resident said they weren't getting the care they needed, and the resident had chronic diarrhea and needed lots of care. In an interview on 12/11/2023 at 9:37 AM, Staff B was asked about the lack of documentation in the investigation regarding the allegations about Staff LL, they stated they had reached out to Staff LL for information, but they did not get a response back. Staff B stated they should have been more aggressive in getting information from Staff LL. Review of the care plan, print date 12/11/2023, showed staff were to check the resident every two hours and assist with toileting as needed and to provide a bedpan/bedside commode. In an interview on 12/13/2023 at 8:51 AM, Staff A was asked about the lack of response from the resident's provider regarding their request they evaluate the resident for a rectal tube, they were unable to provide any information. In an interview on 12/13/2023 at 9:02 AM, Staff B was asked about the investigation (dated 12/04/2023) that did not include documentation other residents had been asked about concerns with lack of toileting cares, they stated they thought that had been included.

CONCERN (E)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 27> Resident 27 admitted on [DATE], with diagnoses which included depression and anxiety. The resident re-admitt...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 27> Resident 27 admitted on [DATE], with diagnoses which included depression and anxiety. The resident re-admitted on [DATE] with additional diagnosis of post-traumatic stress disorder (PTSD - is a mental health condition that develops following a traumatic event). Review of Resident 27's Level 1 PASRR, dated 08/16/2019, showed no serious mental health indicators in the past two years. Review of Resident 27's Level 1 PASRR, dated 10/07/2019, showed no serious mental health indicators in the past two years. Review of Resident 27's Level 1 PASRR, dated 04/04/2022, showed no serious mental health indicators in the past two years. The PASRR showed it was printed from the resident's hospital record on 12/11/2023 at 12:13PM. Review of Resident 27's Level 1 PASRR, dated 10/19/2022, showed no serious mental health indicators in the past two years. The PASARR showed it was printed from the resident's hospital record on 12/11/2023 at 12:12PM. During an interview on 12/13/23 at 10:33 AM, Staff G stated social services and admissions reviewed PASRR's upon admission. Staff G stated the facility was in the process of reviewing all PASRR's because they had identified some were inaccurate. Staff G stated Resident 27 had diagnoses of anxiety and depression since 08/16/2019, and diagnosis of PTSD dated 10/19/2022. Staff G stated the resident had been on antidepressant medication since 08/16/2019, Resident 27's PASRR's were incorrect and had not been updated Reference: (WAC) 388-97-1915 (1)(2)(a-c) <RESIDENT 28> Resident 28 was admitted to the facility on [DATE] with current diagnoses of generalized anxiety and depression. Review of Resident 28's PASRR, dated 09/12/2023, showed the resident had no indicators of mental illnesses within the previous two years. Review of Resident 28's current physician orders, showed they had received an antianxiety and antidepressant medications for anxiety and depression since admission. During a joint record review and interview on 12/13/2023 at 8:04 AM, Staff F, Social Service worker, stated Resident 28 received treatment for their current diagnoses of anxiety and depression and the PASRR was incorrect and needed to be updated. <RESIDENT 11> Resident 11 admitted [DATE] with diagnoses which included bipolar disorder (a mood disorder), other psychotic disorder, Dementia, and contracture (permanent shortening of a muscle) of the left hand. Review of Resident 11's Level 1 PASRR, last updated in 2018, showed mood disorder was checked as a mental illness indicator category but psychotic disorder was omitted. The following question asked whether the resident had exhibited serious functional limitations in the past six months related to serious mental illness and was checked no. The resident was not referred for Level 2 PASRR assessment. Review of Resident 11's record showed the resident exhibited behaviors such as refusals of care, positioning, refusal to come out of their room and refusal to accept care of their contracted hand or to wear their ordered hand splint. These refusals occurred almost daily, placed the resident at risk for decline in condition and impacted their participation in cares and activities. The documentation showed the resident was demonstrating behaviors which constituted a serious functional limitation. <RESIDENT 19> Resident 19 admitted on [DATE] with diagnoses which included Bipolar and paranoid personality disorder (a sustained pattern of behavior characterized by paranoia, mistrust, and suspiciousness of others). Review of Resident 19's Level 1 PASRR, last updated 2018, showed mood disorder and personality disorder was marked. The question whether the resident had exhibited serious functional limitations in the past six months related to serious mental illness was checked no, and the resident was not referred for a Level 2 PASRR assessment. Review of Resident 19's survey report (v2) documentation, dated 11/01/2023 to 12/11/2023, showed the resident had refused staff assistance with activities of daily living such as personal hygiene, grooming, weights, and assessments. Review of Resident 19's medical record, showed they displayed behaviors such as yelling and cursing at staff. These refusals occurred daily, placed the resident at risk for decline in condition and impacted the resident's participation in cares and activities. The documentation showed the resident was demonstrating behaviors which constituted serious functional limitations. In an interview on 12/11/23 at 12:12 PM, Staff G, Social Services Director, stated they checked new admissions to make sure they had a pre-admission PASRR and that it was correct. Staff G stated residents were reviewed quarterly and did not know if Residents 11 or 19 had been due for a quarterly review yet since they came to work at the facility adding, but I know they have had those behaviors for as long as I have been here, which was stated to have been a year (at least three quarterly assessments would have occurred). Staff G stated the resident's behaviors exhibited had not been identified as mental illness indicators causing serious functional limitations and requiring Level 2 PASRR referral. Staff G stated the facility had recently contracted with an additional mental health provider, but this did not replace the requirement to refer to a Level 2 PASRR when residents met the criteria to determine if the resident was entitled to additional services. Based on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 5 of 7 sampled residents (40, 11, 19, 28 and 27) reviewed for unnecessary medications. Incomplete or inaccurate PASRR's placed residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability. Findings included . <RESIDENT 40> Resident 40 admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder. Resident 40 admitted to the facility on an anti-depressant medication. A Level 1 PASRR (a screening to determine if a resident may have a SMI/ID related condition and if positive a Level II PASRR is required), was not located in the clinical records on 12/06/2023 with no evidence it was completed pre-admission. In an interview on 12/08/2023 at 10:38 AM, Staff B, Director of Nursing Services, stated they could not locate a PASARR for Resident 40. At 11:00 AM. Staff B said they were still trying to locate the assessment. At 12:34 PM, Staff B brought in Resident 40's level 1 PASARR with a fax date at the top that read 12/08/2023 at 12:14 PM from (transferring hospital). Staff B said they were aware the PASARR was to be present on admission from the hospital. In an interview on 12/13/2023 at 1:43 PM, Staff C, Registered Nurse (RN)/Unit Manager, stated social services was responsible for looking at the PASRR's. In an interview on 12/13/2023 at 2:22 PM, Staff A, Administrator, stated they were unaware of the PASRR's process not being correct.

CONCERN (E)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 85> Resident 85 admitted to the facility on [DATE]. Review of the clinical record from 11/11/2023-11/13/2023, sh...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 85> Resident 85 admitted to the facility on [DATE]. Review of the clinical record from 11/11/2023-11/13/2023, showed no documentation a written summary of the baseline care plan had been provided to Resident 85 within 48 hours of admission. Review of the clinical record showed Resident 85 had a meeting with social services and nursing on 11/14/2023. The note did not show the resident was provided a copy of their care plan or they received a list of medications. During an interview on 12/11/2023 at 9:38 AM, Staff F, Social Services, stated the facility did a meet and greet at 72 hours post admission. Staff F stated they did not provide a copy of the care plan or medication list to the residents at the meeting. Refer to WAC 388-97-1020 (3) Based on interview and record review, the facility failed to provide 3 of 3 residents (Residents 143, 147, and 85) and/or their representatives with a written summary of their baseline care plans (minimum healthcare information necessary to properly care for a new resident). This failure resulted in residents not being informed of their initial plan for delivery of care and services. Findings included . <RESIDENT 143> The resident admitted to the facility on [DATE]. According to their admission Minimum Data Set (MDS - an assessment tool,) assessment, dated 12/05/2023, they had no cognitive impairment. In an interview on 12/06/2023 at 1:32 PM, Resident 143 stated they had not been provided with a written summary of their baseline care plan, and they did not know which medications they were receiving or what the medications were for. Review of Resident 143's clinical record on 12/11/2023 showed no documentation the resident or their representative had been provided with a written summary of their baseline care plan. In an interview on 12/11/2023 at 11:52 AM, Staff C, Registered Nurse/Resident Care Manager, stated they could find no documentation Resident 143 had been provided written care planning or medication information. <RESIDENT 147> The resident admitted to the facility on [DATE]. According to their admission MDS assessment, dated 12/06/2023, they had no cognitive impairment. In an interview on 12/06/2023 at 2:37 PM, Resident 147 stated they had concerns with pain management, lack of bathing, and they had not received a written summary of their baseline care plan. In an interview on 12/08/2023 at 2:19 PM, Staff C was unable to provide any documentation they had provided Resident 147 with written information regarding their baseline care plan or their medications .

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide assistance with activities of daily living (ADLs) for 3 of 3 sampled residents (Residents 59, 28, and 49) reviewed for ADL's. The facility failed to provide the necessary assistance with grooming (oral care) and assist with hearing needs placed residents at risk for unmet care needs and diminished quality of life. Findings included . <RESIDENT 59> Resident 59 admitted to the facility on [DATE] with diagnoses to include history of a stroke with right sided weakness, difficulty with swallowing and cardiac disease. Review of Resident 59's admission Minimum Data Set (MD - an assessment tool used to identify a resident's care needs), dated 10/24/2023, showed the resident required substantial/maximum assistance with mobility and oral hygiene. Review of Resident 59's care plan showed the resident required substantial assistance with personal hygiene and oral care. During an interview on 12/07/2023 at 11:34 AM, Collateral Contact 4, Resident 59's family member, stated they were concerned the resident's teeth were not being brushed. During an interview on 12/11/2023 at 11:29 AM, Staff MM, Nursing Assistant Certified, stated they had not offered Resident 59 assistance with their oral care. During an observation on 12/11/2023 at 11:55 AM, there was food debris on the front of Resident 59's bottom teeth and their toothbrush was observed dry in a dry basin on their nightstand. <RESIDENT 28> Resident 28 was admitted to the facility on [DATE] with diagnoses that included right leg fracture and Parkinson's disease (a disorder of the central nervous system that affects movement.) Review of Resident 28's most recent MDS assessment, dated 10/30/2023, showed the resident was cognitively intact, dependent on staff for transfers in and out of bed and required set-up assistance with oral hygiene. Review of Resident 28's care plan showed the resident had their own teeth and needed set-up with oral care in the morning and evening and as needed. In an interview on 12/07/2023 at 8:21 AM, Resident 28 stated it had been a couple of days since they had their teeth brushed, and stated some aides offered assistance and others did not consistently. In an interview on 12/11/2023 at 8:45 AM, Resident 28 stated they had not been offered assistance or set-up to brush their teeth this morning. Resident 28 stated they were unable to get out of bed independently to get to sink to brush their teeth, needed at least someone to bring them a cup of water, basin and their toothbrush in order for them to be able to complete their oral care in bed, if they were not getting out of bed. In an interview and observation on 12/11/2023 at 10:10 AM, Resident 28 stated they had still not received any assistance with oral care. The resident's toothbrush was observed dry in dry basin on the nightstand where the resident was unable to reach. In an interview on 12/11/2023 at 11:29 AM, Staff MM stated they had not offered Resident 28 assistance with oral care. In an interview on 12/11/2023 at 11:43 AM, Staff V, Licensed Practical Nurse/Resident Care Manager, stated the expectation for routine care included to offer assistance with oral care twice a day, at least every morning and evening and more often if the resident requested. <RESIDENT 49> Resident 49 admitted to the facility on [DATE]. According to the quarterly MDS assessment, dated 12/05/2023, the resident had no cognitive impairment. Review of Resident 49's care plan, print date 12/07/2023, showed staff were to assist the resident with putting on their hearing aids and cleaning their hearing aids as needed. In an interview on 12/12/2023 at 2:13 PM, Resident 49 stated they hadn't worn their hearing aids for about a year. They stated they didn't even know if their hearing aids worked because they needed to be cleaned and they couldn't do that themselves. They stated they hadn't even seen their hearing aids for about a year. In an observation on 12/12/2023 at 2:47 PM, Resident 49's hearing aids were observed with Staff V, they were soiled with yellowish/brown matter on them. Refer to WAC 388-97-1060 (2)(c )(3)(a) .

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include heart disease, generalized swelling, ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include heart disease, generalized swelling, swelling of both lower limbs, recent weight loss and chronic kidney disease. Review of the physician's orders, showed Resident 1 was to be weighed daily every evening shift beginning 11/09/2023 for congestive heart monitoring. The resident was to receive Isosorbide Dinitrate three times a day for high blood pressure and Doxazosin Mesylate one time a day, and nurses were directed to hold the dose for SBP < 110. Review of the 11/01/2023 to 12/13/2023 MAR's, showed blood pressures were documented once a day rather than prior to each Isosorbide dose. Review of the clinical records showed Resident 1 was not weighed on 11/09/2023, 11/14/2023, 11/22/2023, 11/24/2023, 11/25/2023, 11/26/2023, 11/30/2023, 12/09/2023 and 12/11/2023. In an interview on 12/13/2023 at 12:10 PM, Resident 1 said they were not weighed everyday as they were supposed to be. The resident said they did not refuse to be weighed. <RESIDENT 3> Resident 3 admitted on [DATE] with diagnoses to include high blood pressure and diabetes. Review of the physician's orders showed Resident 3 received Enalapril Maleate daily and the nurses were to hold if SBP was below 110. The orders directed nurses to notify the physician for blood glucose (BG) levels over 349 mg/dl. Review of the November 2023 MAR's, showed Enalapril Maleate was administered to Resident 3, when it should have been held on 11/02/2023 for a blood pressure (BP) of 104/62, 11/24/2023 for a BP of 109/74, and 11/26/2023 a BP of 99/65. Review of Resident 3's 12/01/203 to 12/11/2023 MAR's, showed Enalapril Maleate was administered when it should have been held on the following date on 12/02/2023 for a BP of 107/78. Review of Resident 3's 11/01/2023 to 12/11/2023 MAR's, directed the nurse to notify the pysician if the resident's BG was over 349 mg/dl. On 11/29/2023 at 8:00 PM the BG was 432. In December 2023 the physician should have been notified nine times on 12/03/2023 at 4:00 PM the BG was 358, 12/05/2023 at 4:00 PM the BG was 385, 12/06/2023 at 4:00 PM the BG was 572, 12/07/2023 at 7:00 AM the BG was 578, at 11:00 AM the BG was 487, at 4:00 PM the BG was 476, 12/08/2023 at 7:00 AM the BG was 385, 12/10/2023 at 4:00 PM the BG was 405, and on 12/11/2023 at 7:00 AM the BG was 387. <RESIDENT 40> Resident 40 admitted on [DATE] with diagnoses to include both low and high blood pressure and heart disease. Review of the physicians orders directed staff to administer Metoprolol Tartrate one time a day for hypertension and hold for SBP below 110 or a heart rate (HR) below 60. Review of the November 2023 MARs showed Metoprolol Tartrate was administered when it should have been held on the following dates: - 11/15/2023, the BP was 98/58. - 11/18/2023, the BP was 107/62. - 11/19/2023, the BP was 102/46. - 11/20/2023, the BP was 109/57. - 11/29/2023, the BP was 102/77. Review of the December 2023 MARs showed Enalapril Maleate was administered when it should have been held on the following dates: - 12/02/2023, the BP was 100/56. - 12/07/2023, the BP was 106/52. - 12/08/2023, the BP was 100/46. - 12/10/2023, the BP was 95/45. <RESIDENT 61> Resident 61 admitted on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm) and heart disease. Review of the physician's orders directed staff to administer Carvedilol two times a day for atrial fibrillation and hold for SBP below 110 or HR below 60. Review of the October 2023 MARs showed Carvedilol was administered when it should have been held on the following dates: 10/19/2023 109/65 10/25/2023 109/64 Review of the November 2023 MARs showed Carvedilol was administered when it should have been held on the following dates: 11/03/2023 108/52 11/26/2023 108/64 Review of the December 2023 MARs showed Carvedilol was administered when it should have been held on the following date: 12/06/2023: 108/60 In an interview on 12/13/2023 at 1:45 PM, Staff C said they looked for missed or late medications every morning but did not look at parameters. Staff C said daily weights should have been take for Resident 1. In an interview on 12/13/2023 at 2:27 PM, Staff B, Director of Nursing Services ,said meds should be held as indicated and vital signs should be taken prior to giving cardiac meds. Staff B said they were unaware of this issue and would audit this now. This is a repeat citation from SOD dated 11/03/2023. Reference (WAC) 388-97-1060 (1) Based on interview and record review, the facility failed to provide care and services according to professional standards of practice for 6 of 10 residents (Residents 138, 143, 1, 3, 40, and 61) reviewed. The failure to perform resident weights as ordered, to push fluids as ordered, and to hold medications when indicated per physician ordered parameters placed residents at risk for unidentified weight loss/gain, dehydration, and for medication-related complications, and for not reaching their highest practicable well-being. Findings included . Review of the facility provider standard orders revised 03/31/2023 directed staff to hold cardiac medications if the systolic blood pressure (top blood pressure value) was less than 100. <RESIDENT 138> Resident 138 admitted to the facility on [DATE]. On 12/08/2023, a review of Resident 138's weight documentation showed they had been weighed only one time, on 12/04/2023. Review of Resident 138's November 2023 Medication Administration Records/Treatment Administration Records (MARS/TARS), showed an order dated 11/28/2023 for daily weights for three days. A nurse had placed their initials on the MARS/TARS the weights were done on 11/29/2023 and 11/30/2023. Review of Resident 138's December 2023 MARS/TARS, showed an order dated 12/04/2023 for daily weights for three days, a nurse had placed their initials on only one day, 12/04/2023, the daily weight was done. In an interview on 12/08/2023 at 2:26 PM, Staff C, Registered Nurse/Resident Care Manager, stated they had missed those weights, and they should have been done as ordered. <RESIDENT 143> Resident 143 admitted to the facility on [DATE]. On 12/11/2023, a review of Resident 143's weight documentation showed they had been weighed only twice, on 11/30/2023 and 12/04/2023. Review of Resident 143's November 2023 MARS/TARS showed an order, dated 11/29/2023 for daily weights for three days. Review of Resident 143's December 2023 MARS/TARS showed an order, dated 12/04/2023, for daily weights for three days. Review of an order, dated 12/06/2023, showed a physician's order, dated 12/06/2023, to push an extra 500 cc (cubic centimeters) of fluids, on the 1st and 2nd shifts. No documentation could be found in the clinical record that this order was ever implemented. In an interview on 12/11/2023 at 11:52 AM, Staff C was unable to provide any information about the lack of daily weights that had been ordered. Staff C stated the order to push fluids did not get implemented because it was entered incorrectly into the electronic health record, so it did not show up on the MARS/TARS for staff to know to implement it.

CONCERN (E) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a physician's order with a prescribed oxygen (O2) flow rate (the amount of supplemental oxygen flowing over a certain length of time), indication for use was completed, and failure to ensure O2 tubing was regularly changed and dated for 1 of 3 sampled residents (Resident 27). Additionally, the facility failed to provide routine cleaning for a C-Pap (continuous positive airway pressure device used for breathing issues during sleep) and Bi-Pap (Bi Level Positive Airway Pressure) machine for 3 of 3 sampled residents (Residents 5, 27, and 49) reviewed for respiratory care. This failure placed residents at risk for respiratory distress, respiratory infection, and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, undated, stated the faciltiy would verify that there was a physician's order for this procedure. Review of the facility policy titled, CPAP/BiPAP Guidance, undated, stated masks, nasal pillows, and tubing were cleaned daily by placing them in warm, soapy water and soaking/agitating them for 5 minutes .rinse with warm water and allow to air dry between uses. <RESIDENT 5 > Resident 5 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea (OSA), [a sleep disorder that caused pauses in breathing and/or shallow breathing during sleep]. During an interview and observation on 12/07/2023 at 9:00 AM, Resident 5 stated that they had a C-Pap, but nobody cleaned the mask. Resident 5's mask was observed to be soiled with a dried brown crusty substance. A review of Resident 5's Medication and Treatment Administration Records dated November 2023 showed no orders for cleaning of the C-Pap mask. A review of Resident 5's Medication and Treatment Administration Records dated 12/01/2023 through 12/08/2023 showed no orders for cleaning of the C-Pap mask. During an interview on 12/08/2023 at 1:52 PM, Staff V, Licensed Practical Nurse (LPN/Unit Manager confirmed there were no orders for Resident 5's C-Pap mask to be cleaned. During an observation and interview on 12/08/2023 at 1:53 PM, Staff V confirmed Resident 5's C-Pap mask had debris on the inside of the mask and was not clean. During an interview on 12/08/2023 at 2:51 PM Staff B, Director of Nursing Services (DNS), stated the expectation for residents who use a C-Pap or Bi-Pap would be for the mask to be cleaned daily and as needed. Staff B sated Resident 5 had no orders for the C-Pap mask to be cleaned. <RESIDENT 27> Resident 27 re-admitted to the facility on [DATE] with diagnoses including sleep apnea. During an observation on 12/06/2023 at 10:27 AM, an O2 concentrator was observed next to Resident 27's right side of the bed and the O2 tubing was dated 09/04/2023. During an observation on 12/06/2023 at 2:11 PM, Resident 27's O2 tubing was dated 09/04/2023. During an observation on 12/07/2023 at 9:11 AM, Resident 27 was observed to receive oxygen by nasal canula (a thin tube inserted into a person's nose to give oxygen). The O2 tubing was dated 09/04/2023. During an observation on 12/07/2023 at 10:40 AM, Residnet 27's O2 tubing was dated 09/04/2023. During an observation on 12/07/2023 at 2:30 PM, Resident 27's O2 tubing was dated 09/04/2023. During an observation on 12/08/23 at 8:58 AM, Resident 27's O2 tubing was dated 09/04/2023. A review of Resident 27's MAR and TAR, dated November 2023 showed no orders for O2 use, changing of O2 tubing, or cleaning of Bi-Pap mask. A review of Resident 27's MAR and TAR dated 12/01/2023 through 12/08/2023 showed no orders for O2 use, changing of O2 tubing, or cleaning of Bi-Pap mask. During an interview and observation on 12/08/2023 at 1:42 PM, Staff V, stated Resident 27 used Oxygen (O2) at night and there were no physician's orders for O2 use or changing of O2 tubing. Staff V stated O2 tubing should be changed weekly. Staff V stated confirmed the O2 tubing was dated 09/04/2023. Staff V stated the Bi-Pap mask should be cleaned daily and stated there were no orders for cleaning the mask. During an interview on 12/08/2023 at 2:51 PM, Staff B stated the expectation was for residents to have a physician's order for O2 use and to change and date O2 tubing weekly. Staff B stated the expectation for resident's who use a C-Pap or Bi-Pap would for the mask to be cleaned daily and as needed. Staff B stated Resident 27 had no orders for the Bi-Pap mask to be cleaned. <RESIDENT 49> The resident admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment (an assessment tool), dated 12/05/2023, the resident had no cognitive impairment. In an interview on 12/07/2023 at 2:23 PM, Resident 49 stated their BIPAP machine (a machine that helps a person to breathe if they are not getting enough oxygen or can't get rid of carbon dioxide) was not getting cleaned anymore since October when they got a new one. The resident stated they didn't think their BIPAP machine was clean because no one was cleaning it anymore. In an interview on 12/07/2023 at 2:35 PM, Staff DD, Licensed Practical Nurse, stated there used to be an order for Resident 49's BIPAP machine to be cleaned weekly, but that order got discontinued. Staff DD looked in the electronic health record and showed the surveyor the order got discontinued on 06/08/2022. Staff DD stated they cleaned the resident's breathing equipment on Fridays when they worked, but they didn't document they performed that cleaning. Staff DD stated they didn't work the next Friday, so they didn't know who would clean the resident's breathing equipment. Review of an order audit report, discontinued date of 06/08/2022, showed there had previously been an order for breathing equipment mask and tubing to be cleaned weekly, but there was no documentation of any order for cleaning the actual BIPAP machine. In an interview on 12/08/2023 at 2:26 PM, Staff C, Registered Nurse/Resident Care Manager, stated they didn't currently have a process for ensuring Resident 49's breathing equipment was cleaned routinely, but they would be addressing that issue. In a phone interview on 12/11/2023 at 9:55 AM, Collateral Contact 3, stated the main issue was that the BIPAP machine had never been cleaned and when they had observed it recently, the machine had to be replaced because the water chamber was slimy with mold, and they had to change the hose, the headgear which was grimy, the nasal mask was soiled, and the filter was not in good condition. This is a repeat citation from SOD dated 06/10/2022. Refer to WAC 388-97-1060 (3)(j)(vi) .

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure Licensed Nurses and Nursing Assistants Certified (NAC) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 3 of 4 staff (Staff K, L and M) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1). Staff K Nurse's Aide Certified (NAC),was hired 10/04/2023. Staff K's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. 2) Staff L, Licensed Practical Nurse (LPN) was hired 05/27/2020. Staff L's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. 3). Staff M, Registered Nurse (RN) agency nurse's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. In an interview on 12/06/2023 at 9:55 AM, Resident 45 said the staff were not totally trained, were not culturally aware and a couple staff were abrupt. Resident 45 said they didn't think the staff got orientation but this was their home. In an interview on 12/06/2023 at 11:05 AM, Resident 138 stated the nursing assistants needed more training and did not know how to use equipment. The resident stated some staff do not understand their culture. In an interview on 12/13/2023 at 2:06 PM, Staff A, Administrator, stated they had identified competencies were not completed annually and an action plan would be going into place. Refer to WAC 388-97-1080 (1), -1090 (1), -1680 (2)(a)(b)(i-ii)(c) .

CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for three of four employees (D, E, and GG) files reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of these NACs and the quality of care provided to residents. Findings included . Staff D was hired on 10/09/2014. Review of Staff D's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff D. In an interview on 12/12/2023 at 2:20 PM, Staff D said they had not had a performance evaluation this year. Staff E was hired on 07/11/2005. Review of Staff E's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff E. Staff GG was hired on 03/04/1993. Review of Staff GG's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff GG. In a joint interview on 12/13/2023 at 2:41 PM, Staff B, Director of Nursing Services said Staff R, Licensed Practical Nurse was responsible for completing the performance evaluation for NAC's and they were responsible for the nurses. Staff A, Administrator stated the evaluations need to be completed on the month of hire date annually. Staff A said they had identified these were late but had not gotten to them yet. Refer to WAC 388-97-1680 (2) (a-c) .

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 11> Review of Resident 11's record showed the resident had orders for Depakote (used as a mood stabilizer), and ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 11> Review of Resident 11's record showed the resident had orders for Depakote (used as a mood stabilizer), and Namenda (a medication used to treat dementia). The resident was unable to make decisions and had a legally appointed guardian. Review of Resident 11's record showed the facility used a written consent for use of psychotropic medication form for each psychoactive medication, which was provided to the resident's guardian in order to provide the guardian with information regarding the risks and benefits of each medication prior to consenting for the medication to be administered to the resident. Review of the consent form for Depakote dated 08/09/2018, showed no documentation of the expected benefit of taking the medication. Review of the consent form for Namenda dated 01/31/2018, showed no documentation of the expected length of treatment, and there was no name or signature of the staff member who provided the education to the guardian. Review of Resident 11's record showed the psychotropic medication consents for both Depakote and Namenda incorrectly identified the medications as antipsychotic medications, which then listed the side effects of antipsychotic medications rather than the correct side effects for each medication, which were not the same. <RESIDENT 36> Review of Resident 36's record showed the resident had orders for Duloxetine (an antidepressant). The resident was their own responsible party and made their own legal decisions. Review of the record showed the consent for psychotropic medication form was presented to the resident with no specific condition, expected benefit of treatment or expected length of treatment provided. In an interview on 12/13/2023 at 10:02 AM, Staff B, DNS, stated that psychotropic medication consents were done as part of the admission process and the Unit Coordinators were responsible to do updates and changes. The DNS reviewed the consents for Residents 11 and 36 and stated they were inaccurate and needed to be corrected. Reference WAC 388-97-1060 (3)(k)(i)(4) <RESIDENT 40> Resident 40 admitted [DATE] with diagnoses to include major depressive disorder. Resident 40 had no cognitive impairment. A review of the physician's orders included orders for Duloxetine (an anti-depressant medication) once daily for depression and Mirtazapine (an anti-depressant medication) once a day at bedtime for appetite. Review of the consents for Duloxetine and Mirtazapine showed they were anti-depressants for depression. The clinical indications for use and expected benefits from these medications were left blank. The possible side effects or adverse effects from the medication were not selected. The consents were not signed by a staff member who provided the information to Resident 40. Review of the side effect monitoring in the Medication Administration Record (MAR) was for an antipsychotic medication, instead of an anti-depressant. In an interview on 12/13/2023 at 1:53 PM, Staff C, RN/RCM, was made aware of the concern related to the incomplete consents and incorrect monitoring for Resident 40's psychotropic medications. Staff C said the admission nurse should make sure consents and adverse side effect monitoring were monitored. Staff C said they review consents in the morning meeting to see if they were there, but did not make sure they were accurate. In an interview on 12/13/2023 at 2:30 PM, Staff B, Director of Nursing Services (DNS), stated they were auditing the clinical records to ensure the consents were obtained and did not open the consents up to verify accuracy. Based on interview and record review, the facility failed to ensure 4 of 5 residents (138, 40, 11, 36) were free of unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). The failure to monitor residents for adverse side effects and appropriate target behaviors (any behavior that has been chosen or targeted for change) and to provide/obtain informed consent for treatment with psychotropic drugs placed residents at risk for receiving unnecessary psychotropic drugs and for not being fully informed of the risks/benefits/alternatives of treatment with psychotropic drugs. Findings included . <RESIDENT 138> The resident admitted to the facility on [DATE] with diagnoses to include depression and insomnia. Review of Resident 138's December 2023 Medication Administration Records/Treatment Administration Records (MARS/TARS) showed: - the resident was being treated with bupropion (an antidepressant medication). Additional review of the MARS/TARS showed no documentation the resident was being monitored for target behaviors or for potential adverse side effects of the medication. -the resident was being treated with Melatonin (a hormone medication) and trazodone (an antidepressant medication) for insomnia. Additional review of the MARS/TARS showed no documentation the resident was being monitored for sleep. Review of Informed Consent For Use of Psychotropic Medication forms for bupropion and Trazodone, both dated 11/27/2023, showed they were incomplete as they did not include information about which diagnosed conditions were being treated, they included no information about the clinical indications for the use of the medications, they included no information about the benefits expected from the medications, and they did not include the name of the staff providing the information to the resident and obtaining the resident's consent, and they did not include the name of the prescribing provider. In an interview on 12/08/2023 at 2:26 PM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM), stated: -they had not yet implemented adverse side effects monitoring for the treatment with trazodone, -there should have been a sleep monitoring process put into place, -they should have already started monitoring the resident for target behaviors and adverse side effects for the treatment with bupropion, -and they stated the informed consents they had obtained were incomplete.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to timely administer 19 of 28 medications for 3 of 5 residents (47, 69, and 78) observed during medication pass audit resulted in a medication error rate of 67.86%. The failure to administer medications on time placed residents at risk for side effects and/or altered medication effectiveness. Findings included . Review of the facility's policy and procedure titled, Medication Administration General Guidelines dated 2007, showed medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. <RESIDENT 47> During a medication administration observation on 12/11/2023 at 8:26 AM, Staff V, LPN (Licensed Practical Nurse), prepared and administered to Resident 47: - Novolog insulin (a medication that helps to control blood sugars) injection and - Midodrine (a medication that treats low blood pressure) tablet . Review of Resident 47's December 2023 MAR (Medication Administration Record) and physician's orders, these two medications were scheduled to be given at 7:00 AM and ordered to be given before meals. Observation of Resident 47's breakfast tray present at bedside at time of administration of medications showed plates and cups empty and the resident stated they had eaten their breakfast. <RESIDENT 69> During a medication administration observation on 12/11/2023 at 9:33 AM, Staff M, Registered Nurse (RN), prepared and administered to Resident 69: - Propranolol (a medication to treat high blood pressure) tablets, - Carbamazepine (a medication to treat seizures) tablet, - Amlodipine (a medication to treat high blood pressure) tablet, - Aspirin tablet, - Fluoxetine (an antidepressant) capsule, - Folic acid (a supplement to treat a Vitamin B deficiency) tablet, - Calcium with Vitamin D (supplement) tablet, and - Dilantin (a medication to treat seizures) suspension. - Levetiracetam (a medication to treat seizures) tablet - was not available at time of medication pass. Review of Resident 69's December 2023 MAR, showed these nine medications were scheduled to be given at 8:00 AM. <RESIDENT 78> During a medication administration observation on 12/11/2023 at 9:16 AM, Staff M, RN, prepared and administered to Resident 78: - Acetaminophen/Tylenol tablets, - Aspirin tablet, - Finasteride (a medication to treat urinary retention) tablet, - Losartan (a medication to treat high blood pressure) tablet, - Famotidine (a medication to treat acid reflux) tablet, - Primidone (a medication to treat hand tremors) tablet, - Senna (a medication to treat constipation) tablet, and - Miralax (a medication to treat constipation.) Review of Resident 78's December 2023 MAR, showed these eight medications were scheduled to be given at 8:00 AM. During an interview on 12/13/2023 at 12:16 PM, Staff B, Director of Nursing, stated expectations were that medications wee to be given within the one hour parameter before and after the scheduled time. Reference WAC: 388-97-1060 (3)(k)(ii)

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 28> The resident admitted to the facility on [DATE] with diagnoses to include diabetes. Review of Resident's 12...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <RESIDENT 28> The resident admitted to the facility on [DATE] with diagnoses to include diabetes. Review of Resident's 12/01/2023 - 12-09-2023 MAR, showed Resident 28 received Lantus insulin and was scheduled to be administered at 8:00 AM and 8:00 PM. The resident received their scheduled insulin late eight times: - The 12/01/2023 8:00 AM dose, was administered at 10:22 AM. - The 12/01/2023 8:00 PM dose, was administered at 10:18 PM. - The 12/04/2023 8:00 AM dose, was administered at 11:23 AM. - The 12/05/2023 8:00 AM dose, was administered at 10:10 AM. - The 12/07/2023 8:00 PM dose, was administered at 10:08 PM. - The 12/05/2023 8:00 AM dose, was administered at 11:53 AM. - The 12/09/2023 8:00 AM dose, was administered at 10:23 AM. - The 12/10/2023 8:00 AM dose, was administered at 10:12 AM. Review of the resident's December MAR showed the resident received Humalog insulin and was scheduled to be administered at 8:00 AM, 12:00 PM and 6:00 PM. -12/01/2023 8 AM dose was administered at10:23 AM -12/02/2023 6 PM dose was administered at 8:30 PM -12/04/2023 8 AM dose was administered at 10:40 AM -12/04/2023 6 PM dose was administered at 8:53 PM -12/05/2023 8 AM dose was administered at 10:10 AM -12/08/2023 8 AM dose was administered at 11:43 PM -12/08/2023 6 PM dose was administered at 8:21 PM -12/10/2023 8 AM dose was administered at 10:11 AM -12/10/2023 6 PM dose was administered at 9:04 PM. <RESIDENT 144> Resident 144 admitted to the facility on [DATE] with a diagnosis of diabetes. Review of Resident 144's MAR, dated 12/05/2023- 12/11/2023, showed an order for NPH insulin (insulin that takes effect slowly) one time a day, and to hold the dose if BG was less than 90 or the resident was not eating. The medication administration time was scheduled for 6:00 AM. The MAR was blank for the doses on 12/07/2023, 12/09/2023, and 12/10/2023. During an interview and record review on 12/11/2023 at 1:31 PM, Staff B reviewed Resident 144's December MAR. Staff B stated there were blanks on the MAR for the NPH insulin on 12/07/2023, 12/09/2023, and 12/10/2023. Staff B stated the EMR showed the medication was not administered and they could not find any information as to why it was not administered. Staff B stated the medication was timed for 6:00 AM and breakfast did not come until 8:30 AM, so the nurse would not know if the resident was going to eat or not at that time. <RESIDENT 238> Review of Resident 238's physician's orders, showed the resident had a change in their glargine insulin on 12/02/2023. Review of the previous insulin order was glargine 100 units/mL (milliliter), inject 20 units one time per day at 7:00 AM, and to hold the insulin for a BG below 90 or if the resident was not eating. On 12/02/2023, the insulin order was changed to Insulin glargine 100units/mL, inject 16 units one time per day at 8:00 AM, and to hold for a BG below 90 or if the resident was not eating. Review of Resident 238's administration documentation included the BG reading each AM. In an observation and interview on 12/11/2023 at 11:06 AM, there was no documentation Resident 238 received their morning insulin for the day (3 hours late). The resident was observed to be out of their room. Staff Z stated today was their first time working with Resident 238. Staff Z stated I still need to check [Resident 238] sugar but I do not even see a place to chart it. I know it is late. I still owe [Resident 238] some meds and insulin, I have to find (them). Review of Resident 238's Medication Administration Record (MAR), dated 12/03/2023 - 12/11/2023, showed since the change in the insulin dose on 12/02/2023, there were no recorded BG's in their record. The insulin dose was signed as administered each AM with no documentation to show that the BG was not below 90. In an interview on 12/13/2023 at 10:36 AM, Staff B reviewed Resident 238's record and confirmed there were no documented BG's in over a week for the resident and stated they had seen there was a gap in the documentation for the resident's BG. I did just see that, there was a gap, the order was apparently not set up correctly in the EMR (electronic medical record). Based on observation, interview and record review, the facility failed to administer medications timely for 5 of 6 residents (3, 238, 144, 28, 151) reviewed for medication timeliness. The failure to administer medications timely resulted in these residents having multiple significant medication errors and placed them at risk for medication-related complications and for diminished quality of life. Findings included . Review of the facility's undated policy titled Medication Administration, showed medications were to be administered within 60 minutes of the scheduled time, except before or after meal orders, which are to be administered based on mealtimes. <RESIDENT 3> Review of Resident 3's Medication Administration audit records, dated 12/01/2023 through 12/13/2023, showed Piperacillin intravenous (IV) antibiotic was scheduled to be administered at 7:00 AM, 3:00 PM, and 11:00 PM. Piperacillin was administered late on: -The 12/01/2023 11:00 PM does, was administered on 12/02/2023 at 12:44 AM. -The 12/02/2023 11:00 PM dose, was administered on 12/03/2023 at 12:38 AM. -The 12/03/2023 11:00 PM dose, was administered on 12/04/2023 at 3:16 AM. -The 12/07/2023 11:00 PM dose, was administered on 12/08/2023 at 12:39 AM. -The 12/08/2023 11:00 PM dose, was administered on 12/09/2023 at 1:16 AM. -The 12/09/2023 3:00 PM dose, was administered on 12/09/2023 at 7:38 PM. -The 12/09/2023 11:00 PM dose, was administered on 12/10/2023 at 12:39 AM. -The 12/10/2023 11:00 PM dose, was administered on 12/11/2023 at 1:59 AM. -The 12/11/2023 11:00 PM dose was, administered on 12/12/2023 at 1:34 AM. Review of Resident 3's Medication Administration audit records, dated 12/01/2023 through 12/13/2023, showed the resident received Humalog (a fast-acting injectable insulin) insulin for blood glucose (BG) over 180. The Humalog was administered late on: - The 12/01/2023 7:00 AM dose, was administered at 8:34 AM. - The 12/04/2023 7:00 AM dose, was administered at 8:42 AM. - The 12/09/2023 11:00 AM dose, was administered at 12:48 PM. - The 12/10/2023 11:00 AM dose, was administered at 1:03 PM. - The 12/11/2023 11:00 AM dose, was administered at 1:18 PM. - The 12/14/2023 7:00 AM dose, was administered at 8:58 AM Resident 3 had orders to receive heparin (medication to prevent blood clot formation) injections every 12 hours (at 8:00 AM and 8:00 PM) for clotting prevention. The heparin was administered late on: - The 11/01/2023 8:00 AM dose, was administered at 11:10 AM. - The 11/04/2023 8:00 AM dose, was administered at 11:18 AM then 8:00 PM dose was administered 9:49 PM. - The 11/07/2023 8:00 PM dose, was administered at 10:03 PM. - The 11/09/2023 8:00 PM dose was, administered at 9:22 PM. - The 11/13/2023 8:00 AM dose was, administered at 10:35 AM. - The 11/25/2023 8:00 PM, dose was, administered at 10:49 PM. - The 11/27/2023 8:00 PM dose was, administered at 9:38 PM. - The 11/29/2023 8:00 AM dose was, administered at 12:10 PM. - The 12/03/2023 8:00 PM dose was, administered at 10:08 PM. In an interview on 12/12/2023 at 9:43 AM, Staff Z, Licensed Practical Nurse (LPN), stated yesterday, a resident had fallen, which put them behind, and their medications were not passed within the one-hour window. Staff Z said they spent a great deal of time helping the aides out as they were so short. In an interview on 12/13/2023 at 11:39 PM, Staff C, Registered Nurse (RN)/Unit Manager, said an agency nurse called off at the last minute this morning (on 12/13/2023), so they were on the cart and medications were administered a couple hours late. In an interview on 12/13/2023 at 1:55 PM, Staff C said they had audited for late and missed medications. Staff C said they were aware the medications were late when they reviewed the report. In a joint interview on 12/13/2023 at 3:01 PM, Staff A, Administrator, and Staff B, Director of Nursing Services, were asked about resident medications being administered late to multiple residents on both floors, including insulin, pain medications, blood thinners, antibiotics, and heparin. Staff B said the nurses have a one-hour window to get their medications passed. Staff B said they had been auditing for missed medications but not late medications. <RESIDENT 151> Resident 151 admitted to the facility on [DATE] with diagnoses to include diabetes. Review of Resident 151's December 2023 MAR, showed late medications had been administered to include: - Humalog insulin scheduled for 6:00 AM, was given on 12/01/2023 at 9:55 AM. - Humalog insulin scheduled for 7:30 AM, was given on 12/02/2023 at 8:37 AM. - Humalog insulin scheduled for 7:30 AM, was given on 12/03/2023 at 10:14 AM. - Humalog insulin scheduled for 11:00 AM, was given on 12/03/2023 at 1:05 PM. - Humalog insulin scheduled for 12:00 PM, was given on 12/10/2023 at 1:07 PM. In an interview on 12/12/2023 at 8:25 AM, Staff C stated those doses of late medications were all medication errors. Staff C stated those insulin doses should have been administered within 20 minutes or so from their scheduled times. Refer to WAC 388-97-1060 (3)(k)(iii) .

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor the medication refrigerator temperatures and ensure medications were stored in the medication room refrigerator under proper temperature controls in 2 of 2 (first floor and second floor) medication refrigerators observed. This failure placed residents at risk for receiving compromised or ineffective vaccines and medications with unknown potency. Additionally, the facility failed to ensure medications were secured for two of two residents (19, 61) observed with medications at bedside. This failure placed the residents at risk for consuming medication in excessive dosage, medical complications, and diminished quality of life. Findings included . <MEDICATION ROOMS> During an observation on 12/07/2023 at 2:28 PM, the second floor medication refrigerator contained 29 Insulin pens, 11 Insulin vials,16 multi-dose Fluzone Influenza Vaccines 5 ML (milliliters), 2 multi-dose Tubersol (a prescription solution to test for Tuberculosis)[potentially serious infectious disease that mainly affect the lungs] vials. During a review on 12/07/2023 at 2:28 PM the second floor medication room refrigerator temperature log, dated November 2023, showed 16 missing readings with six out of range temperatures for the AM shift and seven missing readings with five out of range for the PM shift. During a review on 12/07/2023 at 2:28 PM, the second floor medication room refrigerator temperature log, dated 12/01/2023, through 12/07/2023, showed seven missing readings for the AM shift and six missing readings with one out of range for the PM shift. During an interview on 12/07/2023 at 2:39 PM, Staff V, Licensed Practical Nurse/Unit Manager, confirmed refrigerator temperatures were not consistently documented and resident medications, Tubersol and Influenza vaccines were stored in the refrigerator. Staff V stated refrigerator temperatures should be completed by the night shift nurse. During an observation and interview on 12/07/2023 at 2:50 PM, the medication refrigerator on the first floor contained one multi-dose Fluzone Influenza Vaccines, four multi-dose Tuberculin vials, four bottles of liquid Vancomycin (medication to treat infection) ,seven bags containing Daptomycin (medication to treat infection), 22 insulin pens, two insulin vials, and one vial of Ativan (treatment for anxiety) in a lock box. Staff NN, Registered Nurse, confirmed vaccinations and resident medications were stored in the refrigerator. Staff HH stated that the night shift nurse is responsible for documenting refrigerator temperatures. During a review on 12/07/2023 at 2:50 PM the first floor medication room refrigerator temperature log, dated November 2023, showed 30 missing readings for the AM shift and 14 missing readings with seven out of range for the PM shift. During a review on 12/07/2023 at 2:50 PM, the first floor medication room refrigerator temperature log, dated 12/01/2023, through 12/07/2023, showed no documentation. During a joint interview on 10/26/2023 at 1:51 PM, with Staff B, Director of Nursing Services, and Staff JJ, Registered Nurse/Administrator, Company Support Staff, Staff B stated all temperature logs should be completed daily by the night shift nurses. Staff JJ confirmed temperature logs should be completed twice daily when containing vaccinations. Staff B confirmed nurse managers should be reviewing documentation weekly for completion. Staff B confirmed nurses may not know the process for out of range temperatures and did not provide documentation of staff education. Staff JJ confirmed the vaccinations and medications may be compromised. <RESIDENT 19> In an observation on 12/06/2023 at 8:54 AM, Resident 19 was self administering medications from a plastic medication cup. No nurse was present. The resident took two white pills and a red gel cap from the medication cup. The resident became angry at being asked questions and refused to answer. In an interview on 12/06/2023 at 9:00 AM, Staff DD, LPN, stated they were not sure if the resident had an assessment and stated the resident would tell you to get out. Review of Resident 19's medical record showed no documentation that the resident had been assessed as being safe to self-administer medications or to have medications left at the bedside. In an interview on 12/13/2023 at 1:58 PM, Staff C, RN Unit Manager said they facility did not have any residents who can have their medications at bedside. Staff C said medications should not be left at bedside with residents. Staff C said this was another issue with agency staff. In an interview on 12/13/2023 at 3:02 PM, Staff B, Director of Nursing Services said the expectation was meds should not be left at bedside. - Refer to WAC 388-97-1300 (2) . <MEDICATIONS AT BEDSIDE> <RESIDENT 61> Resident 61 admitted on [DATE] with diagnoses to include end stage renal disease, heart failure and glaucoma. The resident had no cognitive impairment. In an interview and observation on 12/08/2023 at 10:33 AM, Resident 61 was up in their wheelchair in their room with their breakfast tray still present. On the tray was a clear medication cup with 3 white, one red and one tan pill in it. There were also two white pills (one round and one oblong) on the breakfast tray sticking out from their plate. Resident 61 said the nurses always leave their pills so they can take them as they eat but they had not taken them yet today. In an interview on 12/08/2023 at 10:34 AM, Staff M, Registered Nurse (RN), confirmed they were the nurse for Resident 61. Staff M was asked if the resident had been assessed to have their medications at bedside at which time, Staff M went to Resident 61's room. In an observation and interview on 12/08/2023 at 10:43 AM, Resident 61 was sitting on the side of their bed watching a video on her phone. The resident said the pills were gone as Staff M, had just been in there and said they needed to watch me take my pills. In a follow up interview on 12/08/2023 at 3:01 PM, Staff M stated they went back to Resident 61 and asked them why they had tricked them. Staff M stated they had watched the resident take the medications and they must have pocketed them. Staff M said they never would have left the medications with them had they known there was a pocketing history. Staff M said medications were not to be left at the bedside.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <HOUSEKEEPING> During an observation on 12/06/2023 at 9:00 AM, Staff T, housekeeping aide, was observed cleaning room [ROO...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <HOUSEKEEPING> During an observation on 12/06/2023 at 9:00 AM, Staff T, housekeeping aide, was observed cleaning room [ROOM NUMBER]. Staff T was observed using a cleaning cloth to clean the sink area in the room and in the bathroom while wearing gloves. Staff T also had a storage caddy in the room containing spray bottles. Staff T came to the housekeeping cart and disposed of cleaning cloths in a plastic sack, used their contaminated gloved hand to open the cart and place the storage caddy inside the cart and then picked up the mop. Staff T mopped the bathroom in room [ROOM NUMBER], then removed the mop head and placed it in a plastic bag. Staff T removed their gloves, did not do hand hygiene, and then opened the roll top door on the housekeeping cart to obtain new gloves. After applying new gloves, Staff T removed the garbage from within the room and discarded it in the housekeeping cart. They then removed their gloves, but did not do hand hygiene. Staff T moved the housekeeping cart out of the doorway with contaminated hands to grab the vacuum cleaner. Staff T then proceeded to vacuum the carpet inside room [ROOM NUMBER] without gloves being worn. After vacuuming, Staff T did not do hand hygiene. When completed with room [ROOM NUMBER], Staff T moved their housekeeping cart and vacuum cleaner to the doorway of the room next door. A resident was propelling their wheelchair toward Staff T. Staff T then pushed the resident in their wheelchair down the hall with their contaminated hands. During an interview on 12/06/2023 at 9:08 AM, Staff T reported that they change their gloves twice while cleaning a room, once when they start and then also after cleaning the bathroom. Staff confirmed they did not use hand sanitizer when removing gloves or before touching the resident. During an interview on 12/12/2023 at 9:31 AM, Staff R stated housekeeping staff should change gloves and do hand hygiene before opening the housekeeping cart, when completed with a room and before moving the housekeeping cart, and before touching a resident. This is a repeat citation from SOD dated 05/11/2023. Refer to WAC 388-97-1320 (1)(a) Based on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines (IPC) and standards of practice for 1 of 2 units (2nd floor) reviewed for IPC procedures. The facility failed to follow processes to prevent cross contamination during meal delivery in resident halls and to follow standards of practice related to hand hygiene and disinfection of multi-use equipment. These failures placed residents at risk for food borne illness and/or other infectious diseases. Findings included . <Meal Delivery> In an interview on 12/06/2023 at 9:06 AM, Resident 9 stated the facility changed the way they were delivering the beverages during meals. Resident 9 stated the beverages used to be on the trays and now they come in and ask you what you want, then they go down the hall to get it and carry it back uncovered. I don't feel like that is a very hygienic practice, I don't know what gets in there. In an observation of the lunch meal delivery on 12/06/2023 beginning at 11:44 AM, Staff BB, Nursing Assistant- Registered (NAR), was observed to deliver meals on the 2nd floor. There was a large metal cart with the meal trays and a separate beverage cart which contained pitchers of beverages, coffee carafes, coffee mugs and drink glasses. There were no lids observed on the beverage cart. Staff BB stated there was supposed to be someone to help with beverages but there was nobody today. Staff BB was observed to push the meal cart along through the hall as they delivered the trays, but the beverage cart remained at the end of the first hall, Staff BB stated, I will have to go back later and get them all drinks. At 12:12 PM, Staff BB stated, no, there are no lids, which makes no sense, I think that is unsanitary, what if someone sneezes. In an observation on 12/06/2023 at 12:15 PM, Resident 34 was observed in the hallway with their hands on the middle shelf of the beverage cart. There were no staff nearby. Staff BB stated (Resident 34), please don't touch that. Resident 34 replied, I just got coffee, but I put it back, I don't like it (pointed to a partial cup of coffee sitting on the middle shelf next to the clean mugs). Staff BB removed the cup from the beverage cart and stated, see why I am worried about this? In an interview on 12/12/2023 9:35 AM, Staff II, Dietary Services Manager, stated the delivery of the beverages on a separate cart was a new process, and foods and beverages should be covered. They had not been aware that there were no lids stocked on the beverage carts and stated the cart should not be unattended, staff are to assist the residents to get their beverages. <Disinfection of equipment> In an observation and interview on 12/06/2023 at 10:38 AM, Staff AA, Nursing Assistant Certified, was observed exiting a resident's room pushing a Hoyer lift, pushing it directly into another resident room without stopping to disinfect the lift. When questioned, Staff AA stated they were supposed to wipe down the lifts after each use and stated they were supposed to use a yellow wipe to do this. Staff AA stated she had not disinfected the lift because they could not find any wipes and needed to find some. In a continued observation, Staff AA was observed to look in the doors of nearby rooms on their way to the nurse's station, where they looked behind the counter and shook their head, then went to the utility room on the 2nd floor where they opened the lower cabinet (it was empty), pointed and stated, they should be there. When asked what they would do in this situation, Staff AA stated they could squirt some hand sanitizer on a towel, then shook their head and said, no, I really should go find a wipe. In an interview on 12/07/2023 at 2:23 PM, Staff BB, NAR, stated they run out of the disinfectant wipes, and have to go all the way to the basement supply to get them. When Staff BB was asked how this affected them disinfecting the items in the halls such as the Hoyer lifts and vital sign equipment, Staff BB shook their head no and said, we don't do it. In an observation on 12/08/2023 at 10:23 AM, Staff HH, NAC was observed to exit a resident room pushing a vital sign pole and left it at the end of a hallway without disinfecting it. The vital sign pole included a wire basket where disinfectant wipe tubs are typically seen, and one was not present in the basket. In an interview on 12/12/2023 at 2:52 PM, Staff R, Infection Preventionist, stated they were responsible for education regarding environmental cleaning and other infection control education and audits in the facility. Staff R stated they conducted audits and observations of staff practices and stated they would re-educate staff on the process for disinfection of equipment and was unaware of an issue with supplies and had not been aware of staff failing to disinfect equipment on the nursing units. In an interview on 12/13/2023 at 10:02 AM with Staff B, Director of Nursing Services, they stated that there were no more yellow wipes since the new ownership change and stated the appropriate wipes were the purple top Sani cloth disinfectant wipes and there should be ample supply available at the nurse's stations, on the infection control carts, in the supply room and in the wire baskets on the vital sign poles. Staff B was made aware of observations, staff reports and observations of lack of available supply and observations of staff failing to disinfect equipment.

CONCERN (E)

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

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review and interview, the facility failed to develop, implement and maintain an in-service training program for 3 of 4 Nursing Assistant's (D, E and GG) reviewed for the required 12 hours of nurse aide training per year. The failure to ensure Nursing Assistants Certified (NACs) received 12 hour per year in-service training placed residents at risk for potential unmet care needs. Findings included . Review of Staff D, E, and GG's employee file showed each NAC did not have documented evidence of 12 hours of in-servicing. Review of the in-service records showed the facility failed to document how long the in-service lasted or the time it started. In an interview on 12/13/2023 at 3:08 PM, Staff A, Administrator, stated they were aware the 12 hours were not completed for the NAC's and they planned to pull the NAC's from the floor to get their education completed. Refer to WAC 388-97-1680 (2)(a-c) .

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to provide sufficient qualified staff to provide care and services for 20 of 48 sampled residents (Residents 1, 7, 9, 10, 21, 30, 36, 37, 45, 48, 49, 59, 60, 61, 74, 77, 78, 120, 138, and 143), 3 of 4 family members (Residents 59, 138, and 141), and 2 of 2 anonymous complaints that had concerns related to staffing on 2 of 2 floors (Floor 1 and 2). Failure to timely respond to resident call lights and to provide adequate nursing supervision and oversight to the Nursing Assistants resulted in residents with diminished quality of life and unmet needs including having toileting accidents and soiling themselves when staff did not respond to their call lights timely and they were unable to hold it any longer. Findings included . <FACILITY ASSESSMENT> Review of the facility's assessment, dated 09/07/2023, showed the average daily census was 74 and the facility averaged two admits and two discharges daily. The assessment showed 75% of residents needed assistance with their activities of daily living (ADL's - bed mobility, transfers, walking, toileting, dressing, bathing, personal care and eating). The assessment showed the first-floor staffing was primarily agency staff nurses and NACs. The second floor had in-house facility staff for nurses. The facility goal was to decrease agency usage, which was calculated at 38% of facility staff. <admission CENSUS> Review of the facility's last 30 days of admission data on 12/06/2023, showed the facility admitted 22 residents. <RESIDENT INTERVIEWS> RESIDENT 9 In an interview on 12/06/2023 at 9:18 AM, Resident 9 stated the facility was short staffed and staff were so rushed. Resident 9 said about a month ago they were waiting an hour and a half. The resident said the other night they woke up, but they were told they had to wait for the day shift to get changed, so they stayed wet. The resident reported they then had an itching problem, a skin problem. RESIDENT 7 In an interview on 12/06/2023 at 9:45 AM, Resident 7 said the facility did not have enough staff and there was a staffing shortage. The resident reported call lights took up to 50 minutes, and if it was for pain medication, it took longer for the aide to get the nurse. RESIDENT 45 In an interview on 12/06/2023 at 9:55 AM, Resident 45 stated there was not enough staff. The resident said they got sores and frequent UTIs (urinary tract infections). They said they wore a diaper so there had been times it took 45 minutes or an hour to get help. Resident 45 said during the day, call lights were pretty good maybe a maybe they waited at the longest 30-minutes, but that was rare. The resident said on evening shift and night shift, the staff didn't come in and do rounds. RESIDENT 1 In an interview on 12/06/2023 at 9:58 AM, Resident 1 said call lights could be answered in five to 30 minutes but in the middle of the night they waited an hour to get help. Resident 1 said the nurses did not come very fast, you wait to get the aide, then wait longer to get the nurse. The aides told them they did not have enough help. Staffing was just a problem. RESIDENT 78 In an interview on 12/06/2023 at 10:34 AM, Resident 78 stated the facility needed more staff as they waited up to 45 minutes to have their call light answered. The resident said the staff worked hard but the facility needed to hire more of them. The resident commented, the lack of staff must come down to money. RESIDENT 138 In an interview on 12/06/2023 at 11:05 AM, Resident 138 stated it could take an hour plus to get their call light answered. They stated a typical call light response time was 30 minutes or more. The resident stated Staff B, Director of Nursing Services (DNS), told them the call lights were to be answered within seven minutes. Resident 138 reported staff had left them on the bedpan for over an hour early into the dayshift. Resident 138 said if staff did not answer their call light, they called their family member who would drive to the facility from home to answer their call light. The resident reported their family member had to come to the facility five times to respond to the call light since their admission on [DATE]. The resident reported they expressed their staffing concerns at the care conference last week. In an interview on 12/06/2023 at 11:05 AM, Collateral Contact 6, Resident 138' family member, stated they had to come in from home on five occasions to answer Resident 138's call light, or because they were upset and didn't want to be alone. RESIDENT 120 In an interview on 12/06/2023 at 11:53 AM, Resident 120 said call light response times can be up to 45 minutes. RESIDENT 77 In an interview on 12/06/2023 at 11:56 AM, Resident 77 stated their concern was staffing and it took 45 minutes for their call light to be answered on day shift. Resident 77 stated the staff would apologize and tell them, they were short-staffed related to call ins. RESIDENT 143 In an interview on 12/06/2023 at 1:26 PM, Resident 143 stated they had to have a bowel movement in their (incontinent) briefs because staff didn't come for 45 minutes when use the call light to request a bedpan. Resident 143 said the staff member asked them why they didn't hold it and they told staff You can only hold it for so long, and then it comes out. Resident 143 said call lights were a problem and it was almost always 20 to 30 minutes before anyone came. The resident stated when they had a bowel movement, it almost always had to end up going in their diaper, which they stated wasn't good for their skin, or emotionally. Resident 143 said they have been told to pee in their diaper because the diaper was super absorbent, and then they would come and change them, but they preferred to use the bedpan. In a phone interview on 12/11/2023 at 8:06 AM, Resident 143 was in the hospital and stated they had to call the police to take them to the hospital as they had sat in their own feces for an hour and 50 minutes, and they had to yell for help to come as they felt ignored. The resident stated they couldn't control their bowels, so they always had some drizzle of diarrhea, and they needed a lot of care as they leaked stool, and they felt staff were ignoring their call light. Review of a progress note dated 12/09/2023 at 4:08 PM, showed Resident 143 called the local police department related to their dissatisfaction with call light wait times. The note showed the residents call light was on frequently this shift. The Director of Nursing Services (DNS) was notified that Resident 143 had called police due to their dissatisfaction with call light wait time. The DNS suggested offering to send the patient back to the hospital since we were not meeting their care needs at the facility. The resident was offered to be sent back to hospital since their care needs were not being met to their satisfaction in the facility. The resident was agreeable, and happy to return to hospital. RESIDENT 60 In an interview on 12/06/2023 at 2:11 PM, Resident 60 stated call light wait times were long and it could be very long with up to an hour wait. RESIDENT 61 In an interview on 12/06/2023 at 2:31 PM, Resident 61 stated staffing on night shift was horrible and their call light was on for at least 45 minutes. The resident said they called the facility phone with their cell phone when staff did not answer their light, but staff did not always answer the facility phone. Resident 61 said one nurse told them they did not have enough staff. The resident said Staff E, NAC, worked on night shift but would not always come answer their light. The resident commented they did not want Staff E in there but there were two staff on the floor on night shift. In an interview on 12/08/2023 at 10:33 AM, Resident 61 said they were tired as they got back to the facility at about 4:00 AM from the emergency room. Resident 61 stated they immediately put their call light on, and it took an hour to get help. The resident said when Staff E came in they called them on it and asked Staff E if they had noticed their call light had been going off for an hour, but Staff E would not respond to them. RESIDENT 36 In an interview on 12/07/2023 at 9:22 AM, Resident 36 stated the facility needed more staff mostly at night and on PM shift. Resident 36 said they were impatient, so they yell. RESIDENT 49 In an interview on 12/07/2023 at 10:53 AM, Resident 49 said call light response times took over an hour to be answered and was worse at night. RESIDENT 74 In an interview on 12/07/2023 at 11:08 AM, Resident 74 stated call light response times took a while, sometimes 30 minutes. RESIDENT 59 In an interview on 12/07/2023 at 11:54 AM, Resident 59 stated they waited up to an hour for help in the morning. In an interview and observation on 12/07/2023 at 2:54 PM, Collateral Contact (CC) 4, Resident 59's family member, said the call light had been on since 2:00 PM and it was still not answered. <FAMILY INTERVIEWS> In an observation/witnessed conversation using a phone translator on 12/13/2023 at 9:42 AM, CC2, Resident 141's family member, told Staff C, Registered Nurse (RN)/Unit Manager (UM), their loved one was not getting showers. Staff C told them the resident was to receive showers on Tuesdays and Fridays. Resident 141's family member said that did not assure them at all and they had to make sure the resident got cleaned. <ANONYMOUS CONCERNS> Review of an anonymous complaint (AC-1), received on 11/20/2023, stated they had been working at the facility and were concerned with the staffing since the new company took over. AC-1 stated there were only two nurses that work on the second floor. One nurse was assigned to 27 residents and one nurse had 29 residents and staff did not feel that was safe. Review of an AC-2 received on 12/01/2023, stated there were too many residents to care for with the number of nurses and someone is going to get hurt there. AC-2 name was not included to maintain anonymity. <RESIDENT COUNCIL MEETING> During a resident council meeting with the surveyor on 12/07/2023 at 10:37 AM, residents were asked about staffing in the facility: - Resident 21 stated there used to be a lot more staff but staff left when new management took over and they saw a new face every day. - Resident 10 stated staff levels were cut with new ownership. - Resident 37 stated last week their call light was on for 45 minutes on night shift and when staff responded they told then they couldn't help them because they had 20 residents to care for. Resident 37 said they then had to wait another 45 minutes for care. The resident stated they went a month without a shower, so they complained and got a bed bath. -Resident 30 reported they had not received their morning medications yet. -Resident 48 stated they had concerns about showers and needed to talk to someone. <STAFF INTERVIEWS> In an interview on 12/11/2023 at 4:45 AM, Staff Y, Licensed Practical Nurse (LPN), stated they were the only nurse downstairs first floor and there was one nurse on the second floor for a total census of 89 residents in the building. Staff Y said they calculated it, and they got five minutes with each resident per shift. Staff Y said they could not meet the needs of the residents and asked this surveyor; how can you take care of all these residents when there was one of you? Staff Y said they had been working at the facility for months and there was always two aides and one nurse on the first floor and second floor. Staff Y said an extra NAC showed up from agency last night, so they kept them. Staff Y said there had been physician orders sitting at the desk for days, not processed until they just did them. Staff Y said if a doctor writes an order, you have to process it. With so many agency nurses here, unfortunately a lot of new orders get missed. Staff Y said they tried their best for the residents because it may be them someday. Staff Y pointed to an orange sign that showed Nurses please check completed folder for new orders and process them. In an interview on 12/11/2023 at 6:51 AM, Staff FF, RN, stated they do not know who was assigned to the other medication cart and had not arrived yet. Staff FF said they were short-staffed, and they were just there to help. Staff FF stated, They aren't here yet, they (facility staff) will have to figure it out. In an interview on 12/11/2023 at 9:18 AM, Staff H, Scheduler, said they were unaware of how many open nursing positions they had as there were staff out on vacation. Staff H said they would say they currently needed six nurses and three NAC's. Staff H said when the census jumps, they move staff around. Staff H said they have a staffing meeting every morning with Staff A, Administrator, and Staff B, DNS. They stated it has always been one nurse on each floor on night shift. Staff H said the aides on the floor were responsible for showers and restorative programs as well. In an interview on 12/13/2023 at 1:49 PM, Staff C said there was a quality-of-care issue with agency staff, and they did not always show up. Staff C said there had been turnover with the new company and they lost many long-term nurses and aides. In a joint interview on 12/13/2023 at 2:40 PM, Staff A and Staff B were informed there were numerous complaints from residents about call light response times taking 45 minutes to one hour. Staff A said they were working with a recruiter, offering sign on bonuses, referral bonuses, and had increased staff wages. Staff A stated they were aware staffing was an issue and had been working on it in their Quality Assurance Performance Improvement (QAPI) meeting. Refer to WAC 388-97-1080 (1)

CONCERN (F)

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure their facility assessment (a required document that comprehensively assessed levels and types of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff accurately reflected the risks and resources necessary for the facility's infection prevention and control program. This failure placed the facility at risk for lack of ability to manage day to day infection control and prevention and to respond appropriately in the event of an infectious disease outbreak in the facility. Findings included . Review of the facility assessment, revised 09/07/2023, showed the following: The facility was licensed for 113 beds. Review of the Facility Assessment section titled, Resident Population, showed the facility provided care to residents with infectious diseases and who were on contact, droplet, airborne and enhanced barrier precautions. The facility provided care to residents at risk for infection such as residents with wounds, urinary catheters, intravenous catheters, tubes and drains. The assessment stated the facility employed a certified infection prevention nurse. Review of the Facility Assessment section titled: Infectious Disease Overview, showed: Infectious Disease staff screening methods stated only that, staff were educated regarding signs and symptoms of COVID. Resident Screening stated only, residents are screened. PPE section stated only, PPE available. Staff Education stated only, Staff are educated upon hire, annually and as needed. Cleaning and sanitation stated only, daily, weekly, monthly schedules, utilize ecolab chemicals. The assessment lacked a thorough review of the facility infection prevention program needs for the facility. In an interview on 12/13/2023 at 2:06 PM, Staff A, Administrator, stated they had not been aware of the Facility Assessment lacking thorough information. Refer to: F - 0880 - 483.80(a)(1)(2)(4)(e)(f) - Infection Prevention & Control There was no reference WAC associated with this F-tag .

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to maintain an effective system to obtain and use information from staff, residents, and resident representatives to identify problem areas within the facility through a Quality Assurance and Performance Improvement (QAPI) program. This failed practice placed residents at risk of receiving lower quality services and for a diminished quality of life. Findings included . Review of the facility's undated policy titled Quality Assurance Performance Improvement Committee, showed their policy was the facility would maintain systems and processes to ensure that the quality assurance/performance improvement program identified and addressed issues and/or risks and they would implement corrective action plans as necessary. Review of the facility's QAPI program meeting minutes showed the facility only had documentation of four monthly meetings, 09/07/2023, 09/29/2023, 10/23/2023, and 11/30/2023. In an interview on 12/13/2023 at 8:47 AM, Staff A, Administrator, stated they could only provide four months of QAPI minutes as they couldn't find any documentation from meetings that may have been held before that. In an interview on 12/13/2023 at 2:06 PM, Staff A and Staff B, Director of Nursing Services, were jointly interviewed about the facility's QAPI program, Staff A stated the facility had not identified and/or addressed failed practice in multiple care areas to include care related to federal tag citations in F582, F645, F655, F684, F695, F725, F726, F730, F758, F760, and F947. Refer to: Fed - F - 582 Medicaid Medicare Coverage Liability Notice Fed - F - 645 Pasarr Screening for Md & Id Fed - F - 655 Baseline Care Plan Fed - F - 684 Quality of Care Fed - F - 695 Respiratory Tracheostomy Care and Suctioning Fed - F - 725 Sufficient Nursing Staff Fed - F - 726 Competent Nursing Staff Fed - F - 730 Nurse Aide Perform Review - 12 Hour/year In-service Fed - F - 758 Free from Unnecessary Psychotropic Medication Use Fed - F - 760 Residents are Free of Significant Med Errors Fed - F - 947 Required In-Service Training for Nurse Aides Refer to WAC 388-97-1760 (1)(2) .

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure nurse staffing information postings were current, accurate, and posted in prominent locations. These failures placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information. Findings included . In an observation on 12/06/2023 at 8:08 AM, the first-floor unit staff posting was for 12/05/2023. There was no census on it. In an observation on 12/07/2023 at 8:01 AM, the staff posting did not reflect changes in the census or staffing. In an observation on 12/08/2023 at 8:37 AM, the staff posting did not reflect changes in the census or staffing. In an observation on 12/11/2023 at 4:32 AM, the staff posting was for 12/09/2023 and did not reflect changes in the census or staffing. In an interview on 12/11/2023 at 9:18 AM, Staff H, Scheduler, stated they were responsible for the staffing posting and they updated the weekend's postings when they come back on Mondays. Staff H said they were not revised on the weekends, but they could ask the staff to revise them for changes. In an observation on 12/12/2023 at 8:08 AM, the staff posting was for 12/11/2023 did not reflect changes in the census or staffing. In an observation on 12/13/2023 at 11:39 AM, the staff posting did not reflect changes in the census or staffing. In an observation on 12/14/2023 at 8:08 AM, the staff posting was for 12/13/2023 and did not reflect the changes in staffing. In an interview on 12/13/2023 at 2:53 PM, Staff A, Administrator, said the expectation was the staff postings were revised with census and staffing changes each shift. Staff A said they were unaware these were being placed for the weekend and they were not being revised. Reference: No associated WAC reference. .

Nov 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow standards of practice for completing physician orders upon admission and medication administration for 1 of 1 residents (Resident1) reviewed for medication orders. Failure to transcribe orders accurately upon admission, failure to document when new orders were obtained and why, and failure to administer medications per orders placed residents at risk of exacerbation of acute medical problems. Findings included . Resident 1 admitted to the facility on [DATE] with diagnosis of diabetes (abnormal processing of sugar in the body), stroke, spinal stenosis (narrowing of spinal canal which causes pressure and pain on spinal cord), and low back pain. Review of the hospital Discharge summary, dated [DATE], showed Resident 1's medication orders were included: metformin (diabetic medication) 500 milligram (mg) once daily and to increase to 500mg twice a day on 10/07/2023, acetaminophen (pain medication) 650mg three times a day for pain, and levetiracetam (seizure medication) 500mg twice a day until 10/22/2023, then decrease dose to 500mg once daily until 10/27/2023 and then stop medication. Review of Resident 1's order summary report, dated 10/03/2023 (admission orders) showed no order to increase the metformin dose on 10/07/2023 or an order for the acetaminophen 650mg three times a day. There was an order for enoxaparin sodium (blood thinner) 40mg once daily. Review of Resident 1's admission note, dated 10/03/2023 at 4:00 PM, showed no documentation as to why the acetaminophen and the dosage increase for the metformin was not included in the admission orders. The note did not show documentation as to why the order for enoxaparin was obtained and which provider had given the order. Review of Resident 1/s October 2023 Medication Administration Records (MAR) showed that the metformin remained at once daily dosing, and not increased to twice daily, throughout the month. The order for levetiracetam 500mg once daily, scheduled at 8:00 AM, from 10/23-10/27/2023 showed the medication was not given on 10/23/2023, 10/25/2023, 10/26/2023 and 10/27/2023. The MAR showed a documentation code of '9' which indicated to see progress notes. Review of the progress notes from 10/23/2023-10/27/2023 showed no documentation as to why Resident 1 did not receive the levetiracetam per physician orders. On 10/27/2023 at 12:50 PM, there was a note that showed the levetiracetam had not been delivered from pharmacy. There were no notes that showed that the pharmacy had been contacted to supply the medication or if the provider had been notified the resident did not receive the medication until after resident had missed 4 doses of medication. During an interview on 11/03/2023 at 12:41 PM, Staff B, Registered Nurse (RN)/Resident Care Manager, stated the admission orders were obtained from the hospital discharge summary. Staff B stated the admission nurse should call the provider and confirm the orders, and if the provider wanted to make changes to the admission orders, that should be documented in the admission note. During an interview on 11/03/2023 at 3:45 PM, Staff A, RN/Director of Nursing Services, reviewed Resident 1's admission orders and the hospital discharge summary. Staff A confirmed the admission orders did not include acetaminophen, or the dosage increase of metformin. Staff A was unable to explain why the enoxaparin had been ordered. Staff A stated the admission nurse should have documented all communication with the provider and documented if they changed or added any orders. Staff A stated if a medication was not available at the time it was scheduled, the medication nurse should contact the pharmacy about the delivery of the medication, then report to the provider and see if they wanted to provide any additional orders. Refer to WAC 388-97-1620 (2)(b)(i)(ii)

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate management of diabetes for 1 of 1 residents (Resident 1) reviewed for diabetes management. Failure to educate resident and/or resident representative on diabetes management such as diet, monitoring blood glucose (BG), use of glucometer (device to test blood glucose), and side effects of diabetes medications placed residents at risk of complications. Findings included . Review of a facility policy titled, Diabetes Management-Nursing Care of the Older Adult, dated 10/01/2021, showed the resident/resident representative be educated on diabetic management to include medications, dietary restrictions, and identification of hyperglycemia (elevated BG level)/hypoglycemia (low BG level). Resident 1 admitted to the facility on [DATE]. Review of the hospital Discharge summary, dated [DATE], showed resident had a new diagnosis of diabetes that was diagnosed during the hospital stay and was started on metformin (diabetic medication). During an interview on 10/31/2023 at 10:21 AM, Collateral Contact 1 (CC1), Resident 1's family member, reported they had not received any education on diabetes care or diet. CC1 stated Resident 1 had been having diarrhea. Review of common side effects of metformin on drugs.com, last updated [DATE], listed diarrhea as a common side effect. Review of Resident 1's diet orders showed the resident had no diet restrictions upon admission on [DATE]. Resident 1's diet order was changed to consistent carbohydrate (diabetic diet) on 10/07/2023 by the dietician. There were no progress notes to show the resident, or their representative had been educated on diabetic diet restrictions. Review of Resident 1's care plan, initiated on 10/04/2023, showed a focus area the resident wanted to discharge home. Review of the interventions showed an entry, dated 10/14/2023, the facility was to provide education to the resident and family on their diet, treatments, and medications. Review of the nutrition care area assessment (CAA, an assessment of a specific area), dated 10/16/2023, showed that Resident 1 was diabetic. The resident/family input section of the CAA was blank. There was no documentation the resident or family had received education on dietary restrictions. Review of the progress notes dated 10/03/2023 thru 11/01/2023, showed no documentation education had been provided to Resident 1 or their representative. There were no notes addressing Resident 1's diarrhea or that it could be related to the initiation of metformin. Review of a social service progress note on 10/05/2023, showed Resident 1's discharge plan was to go home with family. During an interview on 11/03/2023 at 12:26 PM, Staff C, Social Services, stated they do not review resident records to determine education needs of the resident and left that up to therapy and nursing staff. During an interview on 11/03/2023 at 12:41 PM, Staff B, Registered Nurse/Resident Care Manager, stated the floor nurses should be educating residents on diabetes management, but they would have to be told what education was needed. Staff B stated they were not aware if diabetic education had been provided to Resident 1 or their family. During an interview on 11/03/2023 at 3:45 PM, Staff A, Director of Nursing Services, reported they did not know if education had been provided to Resident 1 or their family on regarding resident's diet, BG monitoring, or medications. No further information was received. Refer to WAC 388-97-1060 (1)

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to assess a resident's pressure injury/ulcer (bed sore) risks and identify skin conditions completely and accurately for 1 of 1 resident (Resident 1) reviewed for pressure injuries (PI). The failure to accurately identify, document, investigate, and obtain any history of previous PI's placed the resident at risk for unidentified wounds, a delay in treatment, and/or inappropriate clinical decisions being made based on inaccurate data. Findings included . Review of a facility's undated policy titled, Pressure Injury Prevention and Management, showed that documentation of the pressure ulcer/injury included a description of the wound, type of tissue, and measurements of length, width, and depth. A care plan will be developed to address the resident's risk for development of a pressure injury and to promote healing if the resident had a pressure injury. Resident 1 admitted to the facility from a hospital setting on 04/17/2023. Review of Resident 1's Admit -Screener Assessment (admission assessment), dated 04/17/2023, showed the only skin conditions on admission were bruising and psoriasis (rash) areas. Review of the admission Minimum Data Set assessment (assessment to identify specific care needs), dated 04/24/2023, showed Resident 1 did not have any PI's or Macerated Associated Skin Damage (MASD-inflammation of skin caused by moisture). Review of Resident 1's Pressure Ulcer/Injury Care Area Assessment CAA), dated 04/28/2023, showed the resident had intact skin on admit and was at risk of PI due to impaired mobility. The assessment did not show that Resident 1 currently had a PI, nor did it document an assessment of the wound, identify root cause of the wound, or any history of previous wounds. Review of the hospital records, labeled clinical notes.pdf and found under the misc [miscellaneous] tab in the facility's electronic medical record, showed Resident 1 was assessed by a wound ostomy nurse (specialized in wound care) on 04/10/2023. The note showed Resident 1 had a wound on their sacrum and there was MASD to their coccyx, sacrum, and buttock. Review of a skin eval only assessment, dated 04/27/2023, showed Resident 1 had a wound to their coccyx (tailbone) that measured 2 cm (centimeter) in length and 0.2 cm in width. The depth of the wound was not documented and there was no description of the wound. Review of a consulting wound clinic note, dated 05/01/2023, showed Resident 1 had a PI on their coccyx that was present on admission to the facility and the wound had been present for six weeks. The wound measured 0.7 cm in length by 0.5 cm in width and 0.2 cm in depth. Review of a skin eval only assessment, dated 05/03/2023, showed Resident 1 had a wound to their coccyx that measured 2 cm in length and 0.2 cm in width. The depth of the wound was not documented and there was no description of the wound. Review of Resident 1's care plan, print date 06/20/2023, showed no focus areas or interventions to address the pressure injury or to prevent any further pressure injuries from occurring. During an interview on 06/20/2023 at 1:52 PM, Staff A, Interim Director of Nursing Services, was asked about Resident 1's wound and if an investigation had been completed to determine the root cause and rule out neglect. Staff A stated the facility did not do an investigation because Resident 1 had the wound when they admitted to the facility and the nurse completing the admission assessment did not document correctly. Staff A was asked about the variances in the wound measurements from 04/27/2023 through 05/03/2023, Staff A stated the measurements from 05/03/2023 appeared to have been copied and pasted from the 04/27/2023 note and was not sure if those measurements were accurate. During an interview on 06/23/2023 at 11:10 AM, Staff A stated that the PI CAA should have had Resident 1's current skin issues and risk factors documented. Staff A stated the PI should have been added to the care plan. WAC reference 388-97-1620 (b)(ii) .

May 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to honor bathing preferences for 2 of 3 residents (Resident 1 and 2) reviewed for bathing. The failure to honor the resident's bathing choice related to the lack of frequency and type of bathing placed residents at risk for poor hygiene, diminished dignity, and quality of life. Findings included . Review of the undated facility policy titled, Shower/Tub Bath, showed the facility would offer residents at least two full baths or showers per week and to the extent possible resident preference for type and frequency of baths would be taken into consideration and honored. If the resident refused the shower/tub, the reason(s) why and interventions taken were to be documented. <Resident 1> In an interview on 05/10/2023 at 10:00 AM, Resident 1 stated they had not had a shower in six weeks. The resident stated there were not enough aids (Nursing Assistants). Resident 1 stated they needed two staff to be transferred into a shower chair and staff did not have time. They stated staff would wash them up in bed but they stated they were not able to get their hair properly washed. Resident 1 stated one aid had helped them to wash their hair in a sink about a week ago. Resident 1 stated this was primarily an issue during the evening and this was when their shower was scheduled. Record review showed Resident 1 was scheduled for a shower twice per week in the evening. Review of the bathing documentation for the past 30 days showed no actual bathing task completed. On 05/03/2023 an entry stated, hair only. <Resident 2> In an interview on 05/11/2023 at 11:08AM, Resident 2 stated their showers were scheduled in the evening and they frequently refused their showers because they did not want to go to sleep with wet hair. Resident 2 stated the staff had asked them why they refused and stated they had expressed that they would prefer showers in the daytime but were told their shower was in the evening. They stated they have only been doing spit baths and would not refuse showers if they were offered during the day but stated they had not been made aware there was a choice. Review of the bathing documentation for Resident 2, showed they were scheduled for showers twice a week in the evening and showed the resident had one shower documented in the past 30 days with the remaining entries stating, resident refused. There was no follow up documentation regarding the reason for refusal or interventions taken. In an interview on 05/11/2023 at 10:15 AM, Staff A, Administrator, stated that the standard was to have two showers per week on either dayshift or evening shift. The shower day and time was set up by room number but if a resident had a different preference such as the time of day, they could change it. Staff A stated residents were asked regarding preferences on admission but was not able to state if this was documented anywhere. In an interview on 05/11/2023 at 1:50 PM, Staff E, Nursing Assistant, stated that resident showers were in their daily assignment book and when logged in to the electronic medical record, the showers for that shift were documented daily. Staff E stated that if a resident refused a shower, they were supposed to chart that the resident refused and tell the nurse. In an interview on 05/11/2023 at 2:00 PM, Staff D, Nursing Assistant Registered, stated they typically had two baths to do each evening but if staff called in sick, they might have three each. Staff D stated they frequently offered bed baths rather than showers to residents because it was easier. Staff D stated that often residents were in bed and rather than getting them up and taking them to the shower room they felt it was easier to offer them a bed bath. If residents refused showers, Staff D stated they would offer a bed bath but did not know how to chart regarding the reason someone refused a shower. Staff D stated they did not have a good way to wash residents' hair in bed stating they were only aware of shampoo caps but had not used them. Staff C, Nursing Unit Manager, added that if they were not able to give a shower, they were supposed to offer a bed bath. Reference (WAC) 388-97-0900(1)(3) .

CONCERN (E) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to identify and report a norovirus outbreak (a very contagious virus that causes nausea, vomiting and diarrhea), which was a communicable disease outbreak to the State Agency (SA) or Department of Health (DOH) for several days after symptoms presented in multiple residents and staff. This failure placed residents and staff at risk for being exposed to norovirus, including nausea, vomiting, and diarrhea, possible dehydration, and minimal to serious harm. Findings included . Review of the Guidelines for Nursing Homes, 6th Edition (AKA the purple book), appendix D, showed facilities were required to report communicable disease outbreaks to the SA hotline, the local health department (DOH) jurisdiction, and the state reporting log. Review of the SA intake showed that Staff A, Administrator, reported the communicable disease outbreak on 04/28/2023, which was 7 days past the first symptoms reported on 04/21/2023. Review of an email communication dated 04/28/2023 at 2:11 PM, from Collateral Contact 1 (CC1), county department of health infection preventionist, to Staff A showed that they provided guidance and advised Staff A to report the illnesses to their licensor (the SA). Review of the Gastroenteritis case log forms, initiated on 04/28/2023, provided by Staff A, showed that 43 residents and 11 staff experienced norovirus symptoms. In an interview on 05/10/2023 at 12:45 PM, Staff B, Interim Director of Nursing Services (DNS), stated they had been not working at the facility when symptoms presented on 04/21/2023 and was re-hired to start on 04/26/2023. Staff B stated that the facility had not reported the outbreak to the SA or DOH. Staff B stated that Staff A had been in contact with the SA and the DOH. In an interview on 05/11/2023 at 09:55 AM, CC1 stated Staff A had emailed them related to the outbreak on 04/28/2023. CC1 stated that they were notified that a couple of residents at the facility had symptoms starting on 04/25/2023, and/or 04/26/2023, and stated they were not notified that the first symptoms were on 04/21/2023. Reference WAC: 388-97-0640(5)(a) .

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to initiate an effective infection control program on 2 of 2 floors during a communicable disease outbreak to prevent the transmission, control and/or prevent infections in the facility. These failures placed residents at risk for transmissible diseases, unmet care needs, unmet medical needs, distress, and a diminished quality of life. Findings included . Review of the facility policy titled, Norovirus, undated, provided by the facility showed the definition of norovirus was a contagious virus that caused gastroenteritis (intestinal infection), with the most common symptoms being nausea, vomiting, diarrhea, and abdominal pain developing 12 to 48 hours after exposure. Norovirus spreads from infected individuals to others through contaminated foods, water, and surfaces. The policy also had specific procedures/guidance that showed that residents with suspected or confirmed norovirus would be placed on contact precautions for a minimum of 48 hours after resolution of symptoms. Review of the facility infection control log showed the facility was experiencing an outbreak of gastrointestinal illness with the first symptoms identified on 04/21/2023 and additional residents with symptoms on 04/24/2023 which met the definition of an outbreak. Review of the gastroenteritis case log initiated on 04/28/2023, showed 43 total residents and 11 total staff had symptoms of norovirus. In an interview on 05/10/2023 at 12:45 PM, Staff B, Interim Director of Nursing Services (DNS), stated they were not employed by the facility when symptoms of norovirus started on 04/21/2023, or when the number of residents reached outbreak status on 04/24/2023. Staff B stated that there were no contact or transmission-based precautions in place until they came and initiated interventions on 04/26/2023. In an interview on 05/11/2023 at 09:55 AM, Collateral Contact 1 (CC1) county department of health infection preventionist, stated they had not been notified of the outbreak until 04/28/2023 via email. CC1 replied with guidance was provided on 04/28/2023, which included attachments for contact precaution signage, transmission-based precaution signage, specifically enteric precautions signage, hand hygiene signage, and instructions to start a gastroenteritis case log to track infections. Review of the facility Quality Improvement and Performance Improvement (QAPI) Action Plan, titled, 04/28/2023 gastrointestinal signs and symptoms outbreak, provided by Staff A, Administrator, on 05/11/2023 showed that there was a missed opportunity to begin enteric contact precautions on 04/24/2023 and that staff did not recognize what constituted a norovirus outbreak and enteric/contact precautions were not initiated timely. Reference (WAC) 388-97-1320 (2)(a) .

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure a designated and qualified staff person was at the facility to serve as an Infection Preventionist (IP) at least part time. This failure placed the residents at risk for unmet infection control issues and lack of oversight of the facility's infection control practices. Findings included . In an interview on 05/10/2023 at 11:00 AM, Staff A, Administrator, stated the facility IP was out of the country on an extended vacation since the end of March. Staff B, Director of Nursing Services, was the current acting IP for the facility. The Administrator stated that Staff F, Unit Manager, was also qualified as IP and assisted with those duties. Review of the facility infection control log showed the facility was experiencing an outbreak of gastrointestinal illness with the first symptoms identified on 04/21/2023 and additional residents with symptoms on 04/24/2023 which met the definition of an outbreak. In an interview on 05/10/2023 at 12:45 PM, Staff B stated they were hired from a contract through a staffing agency and had only worked at the facility for a couple of weeks and then was gone. Staff B stated they just brought me back to work at the facility on 04/26/2023 and then they initiated interventions such as placing residents on transmission-based precautions, a tracking log and staff education. Staff B stated these interventions were not in place on 04/26/2023 when Staff B returned to employment at the facility. In an interview on 05/11/2023 at 10:15 AM, Staff A stated that while Staff B was not in the facility, they were available by phone and that Staff F was performing IP duties. In an interview on 05/11/2023 at 12:30 PM, Staff F stated they had only covered the IP role for a couple of weeks after the facility's IP had gone on vacation and stated they were not performing any IP duties or working part time in that role stating I made it clear that I was not doing that. Staff F clarified that since the middle of April and during the time period when the facility began experiencing an outbreak of gastrointestinal illness, they were not performing IP duties in the facility at least part time. In an interview on 05/11/2023 at 3:00 PM, the regulatory requirements for the facility IP were reviewed with Staff A, confirming that there had not been an IP present in the facility who had required qualifications, experience and performing IP duties at least part time, which may have contributed to the lack of identification and containment of an evolving gastrointestinal outbreak in the facility. No Associated WAC Reference .

Dec 2022 10 deficiencies 2 IJ (2 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Pharmacy Services (Tag F0755)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there was a system that provided pharmaceutical services (including procedures that effectively dealt with serious prescription discrepancies) that assured the accurate administration of all drugs and biologicals for four of five residents (4, 14, 1, 5) reviewed for safe and accurate medication practices. Resident 4 was harmed when they were administered 20x the intended dose of Oxycodone (a strong pain medication that affects mood/behavior and can be lethal in high doses) and had to be hospitalized . Several licensed nurses (LN), to include the only nurse manager, failed to verify the correct dose of the medication. LNs failed to correctly interpret physician orders and drug concentrations and failed to identify discrepancies in drug records. There was inaccurate documentation or missing documentation between the controlled substances records and the Medication Administration Records for the affected resident. Immediate Jeopardy (IJ) was called on 12/02/2022 at 2:35 PM, at F755 - Pharmacy Services/Procedures/Pharmacist/Records, when the facility was found to have inadequate pharmaceuticals procedures and record-keeping procedures in place and a resident had to be hospitalized when the facility administered the resident a single dose 20x the intended dose of Oxycodone (a potent opioid medication used for pain management). They removed the immediacy on 12/07/2022, by auditing medication records and educating licensed nurses on correct procedures for ordering and documenting medications, accounting for controlled substances, and ensuring licensed nurses were competent in performing medication dose calculations. Findings included . Review of the facility General Dose Preparation and Administration policy, dated August 2018, showed that, Prior to Medication Administration: Nursing Center staff should verify each time a medication is administered that it was the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident. The Nursing Center staff should confirm that the Medication Administration Record (MAR) reflects the most recent medication order. Nursing Center staff should document the administration of controlled substances in accordance with applicable law. Record review of the policy titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy, dated January 2022, showed when providing a written or verbal prescription to the pharmacy, the physician/prescriber should provide a verbal telephone order to the facility nurse or enter the order in the resident's electronic medical record. When submitting an E-prescription (electronic prescription) to the pharmacy, the physician/prescriber must also provide identical written or verbal chart orders to facility staff. Facility staff should immediately record the new orders in the resident's medical record and medication administration record. Upon receipt of medications from the pharmacy that have been electronically prescribed, facility staff should reconcile the medications received to the orders entered in the resident's medical record. Facility staff should notify the physician/prescriber of any identified discrepancies in electronically prescribed orders from the pharmacy and orders entered into the resident's medical record for resolution. RESIDENT 4 The resident admitted to the facility 11/18/2022 with diagnoses to include pancreatic cancer, secondary cancer to the liver, lungs and bile duct, abdominal pain, malnutrition, generalized weakness, and a need for assistance with personal care. In a phone interview on 12/01/2022 at 3:20 PM, Collateral Contact 1 (CC1), a family member of the resident, stated the nursing home had overdosed the resident on Oxycodone when staff gave them 200 milligrams (mg) instead of the 10-20 mg they were supposed to get. CC1 stated since the resident had terminal cancer and the overdose, they were probably never going to leave the hospital because their condition had deteriorated after the overdose. Review of Emergency Medical Service (EMS) records, dated 11/28/2022, showed when the medics arrived the resident had altered mental status and ineffective breathing. The medics administered Narcan (a lifesaving medication used to help reverse the effects of an opioid overdose), and the resident became responsive, and was transported to the hospital. The medics documentation showed their Primary Impression was Overdose - other opioids. Review of the resident's Skilled/Intermediate Nursing Facility Transfer Orders, dated 11/18/2022, showed the resident was ordered to receive Oxycodone 1mg/ml (milliliter) take 10 mls via J-tube (feeding tube) every 4 hours for abdominal pain (which equaled 10 mg per dose). Review of the resident's November 2022 Medication Administration Records (MARs) showed the admission order for Oxycodone that was to be scheduled, and not as needed, was transcribed and put on the MARs to be given every 4 hours, as needed. The order was transcribed and placed on the MARS to administer Oxycodone 100mg/5ml give 10ml via J-tube every 4 hours, which was a dose of 200mg. In an interview on 12/02/2022 at 4:01 PM, Staff K, Registered Nurse (RN)/Assistant Director of Nursing/Staff Development Coordinator/Infection Preventionist, stated when they had initially entered the resident's Oxycodone orders into the electronic health record, they may have clicked on the wrong line and may have pre-populated the wrong Oxycodone concentration. Review of an Order Audit Report for Oxycodone, dated 11/18/2022, showed Staff K, had initially entered the Oxycodone order into the electronic health record, then Staff CC, Agency Licensed Practical Nurse (LPN), confirmed the incorrect order, they confirmed Oxycodone Oral Concentrate 100mg/5ml give 10ml every 4 hours as needed, not the correct order from the hospital, which was for Oxycodone 1mg/ml take 10 mls scheduled every 4 hours. In a phone interview on 12/14/2022 at 10:10 AM, Staff CC, stated that a member of administration either Staff K, or the Director of Nursing, would enter admission orders into the electronic health record, then another nurse would confirm the admission orders with the prescriber and activate those orders. Staff CC stated the orders they confirmed were the paper orders, but they ended up being different than the ones entered into the electronic health record by a member of administration. In an interview on 12/02/2022 at 11:47 AM, the administrator stated Staff CC should have confirmed the orders the resident came with, not the orders staff had entered into the electronic health record. Review of an Order Audit Report for Oxycodone, dated 11/23/2022, showed Staff GG, Agency RN, revised the previous Oxycodone order, to change from every 4 hours as needed, to every 4 hours scheduled. In a phone interview on 12/14/2022 at 2:25 PM Staff G, Advanced Registered Nurse Practitioner, stated they gave Staff GG a verbal order to change the resident's as needed Oxycodone order to routine (11/23/2022). Review of the resident's orders on/about 11/23/2022, showed no documentation Staff GG had documented the verbal order from Staff G to change the resident's treatment with Oxycodone from as needed, to scheduled every 4 hours. In a phone interview on 12/13/2022 at 4:14 PM, Staff GG stated on 11/23/2022 they received a verbal order from Staff G to change the resident's order for Oxycodone from every 4 hours as needed, to every 4 hours scheduled. Staff GG stated there was no conversation at all about the medication concentration, that they kept everything the same except now it was a routine order, not as needed. Staff GG stated the facility policy was that verbal orders should be written down, then read back to the provider, which they didn't do, Staff GG stated it was their mistake. Review of a pharmacy bottle label dated 11/18/2022, showed the pharmacy supplied the nursing home with a 473 ml bottle of Oxycodone 5mg/5ml. In an observation and interview on 12/01/2022 at 11:21 AM, Staff GG, stated this was the bottle of Oxycodone the pharmacy initially supplied after the resident admitted to the facility. This was also the bottle the nurses used to administer the resident 50 doses of Oxycodone at 10 mg each, this was also what the nurses documented on the correlating controlled substances records, but these records did not contain all entries because multiple nurses failed to document on both the MARs and controlled substances records. Between 11/19/2022 - 11/28/2022, eight licensed nurses, including Staff Q, LPN, documented on the resident's MARs that they administered 200mg doses of Oxycodone on 50 occasions. In an interview on 12/06/2022 at 10:00 AM, Staff Q, LPN, stated they did not know they had documented on the resident's MARs they gave 200 mg doses, and then documented 10 mg doses on the controlled substances records. Staff Q stated they had not compared the orders on the MARs to the controlled substances records. Review of November 2022 MARS and controlled substances records showed three nurses on six occasions didn't document controlled substances on both the MARs and controlled substances records. In a phone interview on 12/12/2022 at 12:51 PM, when asked about the two doses of Oxycodone they had documented on the MARs, but not on the controlled substances records on 11/25/2022 at 4:00 PM and 9:00 PM, Staff FF, Agency LPN, stated they had not realized they forgot that. When asked if they realized the doses nurses had documented on the MARS at 200 mg was different than the 10mg doses they documented on the controlled substances records and was on the medication bottles, Staff FF stated they had not realized that, but thinking about it now, they thought that was where they all messed up. In an interview on 12/02/2022 at 11:47 AM, the Administrator stated that up until that last dose that sent the resident to the hospital, the staff had given the resident the right dose, except for their documentation in the MARs was not correct. Review of the resident's Oxycodone controlled substances records for November 2022, showed on 11/23/2022, the math regarding the on-hand quantity of Oxycodone was lacking, it went from 303 mls to 2903 mls, then 2803 mls, then 2703 mls. The last entry on the page showed an on-hand quantity of 173 mls, but then review of the next page showed staff started that page with 153 mls. Accountability and documentation of the resident's Oxycodone was inaccurate. In a phone interview on 12/12/2022 at 12:51 PM, when asked about the missing 20 mls of Oxycodone on 11/25/2022 when a new page was started on the controlled substances records, the new page started at a quantity of 153 mls, when the last page on the controlled substances records had 173 mls, Staff FF stated they hadn't been aware of that. Review of an incident investigation, dated 11/28/2022, showed Staff G, wrote a prescription dated 11/26/2022 for Oxycodone Oral Concentrate 100mg/5ml, give 10ml via J-tube every 4 hours for pain (this new prescription was for 200 mg doses). This order did not get filled by the pharmacy, but it did add to the confusion from the multiple orders. In a phone interview on 12/14/2022 at 2:25 PM, Staff G stated the problem was they had signed the Oxycodone order for 200 mg, but they had not read the whole thing. Staff G stated it was their mistake, that they should have caught that. Staff G stated they had given a copy of the order to a nurse, but they did not remember who they gave it to. Staff G stated the pharmacy did not fill that order for Oxycodone, that they thought an on-call provider had actually given the order for the Oxycodone that the resident had been overdosed on. Staff G stated the pharmacy had not contacted them for clarification regarding their 200 mg Oxycodone order. Review of a prescription, dated 11/27/2022, that the facility did not have in the resident's clinical record on 11/28/2022, showed Staff F, Physician's Assistant, wrote an order for Oxycodone Oral Concentrate 20mg/ml, take ½ ml every 4 hours (dose of 10mg). In a phone interview on 12/15/2022 at 1:00 PM, Staff F stated they didn't know which nursing home nurse called them for the order, but they assumed a nurse called for an Oxycodone refill and they gave them an order for the refill. Staff F stated they had been covering call duty and they got a call regarding a refill, and they had not treated that resident before. Staff F stated they gave an ePrescription that went directly to the pharmacy, and that no orders went back to the nursing home. Staff F stated No, when asked if they provided the nursing home with an identical written or verbal chart order to facility staff. Review of the resident's nursing home orders revealed no documentation of a verbal order from Staff F on/about 11/27/2022. Review of the resident's progress notes on/about 11/27/2022, showed no documentation a nurse had called Staff F for an Oxycodone refill. Review of an Oxycodone medication bottle/label showed the pharmacy did fill Staff F's Oxycodone order, dated 11/27/2022, it had 30 mls, or enough for 60 doses at 10mg/each. Review of a facility incident investigation, dated 11/28/2022, showed Staff FF questioned the situation with the new bottle of Oxycodone that indicated to give only 10mg (and not the 200mg that nurses had documented for 50 doses). Staff FF went to the Staff E, Director of Nursing (DON), who told them to contact the pharmacy for verification and for them to send additional doses since they only sent 30ml (enough for 3 doses at 10ml/dose). The investigation documentation indicated Staff FF did call the pharmacy and questioned as to why they only sent 30 mls if the order was to give 10 mls and asked why the order on the bottle was different from the order in the system. Staff FF stated the pharmacist/rep stated she was unsure but could send a larger supply on the night run. At 4:20 PM on 11/28/2022 Staff FF administered the resident a dose of Oxycodone at 200mg. At 5:00 PM the resident was found unresponsive and EMS was summoned who eventually gave the resident Narcan which was immediately effective, and the resident was then hospitalized . In a phone interview on 12/12/2022 at 12:51 PM, Staff FF stated the resident had been getting 200mg for over a week, so they questioned the new bottle that was labeled they were only to get 10mg, so they went to the DON because there was now only enough Oxycodone left for 3 doses and the resident was to get it every 4 hours. Staff FF stated the DON had not instructed them to clarify the order with the resident's physician/provider. Staff FF said when they called the pharmacy the pharmacist didn't raise any red flags, that they said that was strange, and that they had put them on hold to look into it, when they came back they said they would go ahead and send more and it would be on the night run. Staff FF said they told the pharmacy to be safe, to go ahead and fax them a copy of the signed order from the physician. Staff FF stated the pharmacy did fax the Oxycodone order from Staff G, ARNP, twice, because the first one didn't have the doctor's signature, so Staff FF called them again. Staff FF stated they were not sure who they talked to at the pharmacy, that it may not have been a pharmacist, but may have been just a pharmacist representative. Staff FF stated they did not document a progress note when they called the pharmacy. Review of email interview answers from Staff I, Consultant Pharmacist, dated 12/06/2022 showed: the pharmacy received a call from a nurse at 11/28/2022 at 4:09 PM. Nurse called insisting the dose was for Oxycodone 100mg/5ml: give 10ml or 200mg po q4h not 10mg po (by mouth) q4h. The pharmacy faxed clarification to the nursing home on [DATE] at 4:31 PM to clarify order pharmacy fax cover sheet message: Doctor, please clarify: 10ml dose would be 200mg per dose. Review of the controlled substances records for November 2022 showed the nurse gave the resident Oxycodone 200mg on 11/28/2022 at 4:20 PM. In a phone interview on 12/12/2022 at 12:51 PM, Staff FF stated they did receive the fax and it was the order from Staff G, ARNP, to give 200mg doses, which was the same amount nurses had documented they had been giving the resident all week. Staff FF stated that was all the verification they needed, so they gave the resident 200mg as ordered. Then 30 minutes later when they checked on the resident, they found the resident semi-unconscious, and was still breathing, but barely. The medics arrived and gave Narcan and took the resident to the hospital. In a phone interview on 12/12/2022 at 11:28 AM, Collateral Contact 1, family member of Resident 4, stated Resident 4 had passed away the day prior (12/11/2022). In an email communication on 12/15/2022, Staff H, Executive Director of the pharmacy supplier/pharmacist when asked if there was a pharmacy protocol for immediate person to person notification for provider prescriptions that were so irregular they could result in a resident receiving a lethal dose of a medication, they answered they held the order for 100mg/5ml with a 10ml dose every 4 hours, and they reached out to the prescriber and followed appropriate protocol and no additional outreach was needed. Staff H stated there was a failure by the facility to reconcile new admission orders entered into the electronic health record to hospital discharge orders by two separate nursing staff, and they had recommended training on this topic for the nursing staff. In an interview on 12/02/2022 at 11:47 AM, the Administrator was asked about the Director of Nursing's (DON) involvement in the matter, they stated they believed the DON was asked about the issue as they were leaving the building, and per the nurse, the DON had instructed the nurse to call the pharmacy, but the nurse should have contacted the provider. The Administrator stated if there was an issue with an order, or if they were questioning the order, they need to contact the provider. Similar findings were noted for Resident 14 who experienced nine medication errors about 10 days earlier, when facility staff failed to reconcile the admission orders with the hospital discharge orders. RESIDENT 14 The resident admitted to the facility 11/08/2022 with diagnoses to include coronary artery bypass and grafting (surgical revascularization of blood vessels in the heart), diabetes, history of a stroke, heart failure, kidney disease, gastroesophageal reflux (acid reflux), and high blood pressure. Review of an incident investigation, initiated 11/09/2022, and not signed it was reviewed by any facility staff, showed there were multiple medication errors that occurred when the facility and pharmacy failed to ensure the resident only received medications as ordered on admission. On 11/09/2022 and 11/10/2022, the resident received doses of medications that had been discontinued on the admission orders, they received the wrong dose of another medication, and they did not receive another medication that had been ordered. Review of Staff H's email interview answers, received 12/20/2022 showed the pharmacy had supplied the nursing home with five medications that had been discontinued. The pharmacy was asked to provide a copy of the physician/prescriber orders the pharmacy used to justify supplying the nursing home with the discontinued medications and none was provided. Review of the resident's progress notes showed a progress note by Staff I, Consultant Pharmacist, dated 11/17/2022, that they had done a Medication Regimen Review (MRR), and irregularities were noted, but the only irregularity identified by Staff I was that the provider needed to clarify the indications for use of the Metoclopramide (a medication used to treat acid reflux), none of the multiple medication errors were identified. Review of Staff H's email interview answers (the ones requested of the consultant pharmacist on 12/10/1022), received 12/15/2022 showed they were asked about only identifying one medication irregularity on the MRR done 11/17/2022, and not the other nine, and whether they had identified those medication errors, they answered the MRR was a review of current orders at the time of review, and it was not a retrospective review of past orders, they didn't answer the question whether the consultant pharmacist had identified the multiple medication errors, this question remains unanswered. Further review of the facility incident investigation, dated 11/09/2022, showed Staff CC, Agency LPN, failed to correctly confirm admission orders with the prescriber, and the errors occurred, which was the same failure that occurred with Resident 4. In a phone interview on 12/14/2022 at 10:10 AM, Staff CC stated that the nurse (Staff GG, Agency RN) that entered the wrong orders in the electronic health record entered the home medication orders, not the admission orders that came with the resident to the nursing home when they admitted to the facility. Staff CC stated they had missed a step when confirming the admission orders because they went out of order. When they confirmed the resident's paper admission orders, they were different than the ones that another nurse had already entered into the electronic health record which they stated were home orders, so the wrong orders got activated. Staff CC stated that they remembered that there were quite a bit of errors. In a phone interview on 12/16/2022 at 8:58 AM, Staff D, Medical Director, stated that they thought nine medication errors was significant. RESIDENT 1 The resident admitted to the facility 08/18/2020 and had diagnoses to include Parkinson's disease. Review of the November 2022 MARs showed the resident had an order for morphine (medication used to treat pain) for pain. Comparison of the documentation of medication administration on the MAR and the controlled substances records showed documentation irregularities as follows: According to the MAR the resident was administered morphine on 11/19/2022 at 12:00 PM, but there was no corresponding entry in the controlled substances records. Similar findings were noted for the dose administered 11/21/2022 at 12-midinght and another dose at 4:00 AM. In addition, a dose administered on 11/20/2022 at 8:00 AM, was not given within the facility's accepted guidelines of 1 hour before/after the scheduled dose. The controlled substances records showed it was given at 10:13 AM, then, per the controlled substances records, the next dose was given at 12:36 PM (2 hours and 23 minutes later), though the order was for it to be given every 4 hours. Review of documentation provided by the Administrator on 12/22/2022 regarding these morphine administration irregularities, showed these irregularities did in fact occur. RESIDENT 5 The resident admitted to the facility 09/22/2022 and had diagnoses to include nasopharyngeal cancer status-post chemoradiation (treatment for cancer) and chronic pain. Review of the resident's Lorazepam (controlled substance sedative medication being given to the resident for anxiety and nausea) documentation from 11/01/2022 - 12/04/2022, showed there were nine irregularities. The controlled substances records indicated one tablet of Lorazepam was administered on 11/02/2022 at 6:35 AM, but the dose was not documented on the MARs. Similar findings were noted on 11/06/2022 at 7:30 AM, 11/12/2022 at 12:00 PM, and 11/14/2022 at 8:00 AM. On 11/27/2022, controlled substances records indicated four doses administered, but the MARs indicated only three doses for that day. Review of the controlled substances records showed one tablet was administered on 11/19/2022 at 6:00 AM or 7:00 AM (the documentation time was illegible), and this dose was not documented on the MARs. A 11/27/2022 entry on the controlled substances record had no time listed, it was blank. The MARs did have a documented time of 11:38 PM. The controlled substances records indicated one tablet of Lorazepam was removed on 11/07/2022 at 6:50 AM, another entry reflected another tablet taken out at 6:00 AM. The 6:00 AM dose did not get documented on the MARs. Documentation regarding this dose was provided by the Administrator on 12/23/2022 showed the 11/07/2022 6:00 AM dose actually had an incorrect date documented; it should have been 11/08/2022. Similar findings were noted on 11/28/2022, where the MARs indicated dose given at 9:54 PM, but the date on the controlled substances records indicated 11/27/2022. Review of documentation provided by the Administrator on 12/23/2022 indicated these discrepancies did exist, and the Administrator provided the names of the nurses that failed to document controlled substances and medication administration properly. FACILITY PHARMACY/PHARMACEUTICALS RECORDS Review of Controlled Substances Record Book, for the 1st floor Schedule III [NAME] Book number 1, on 12/01/2022 at 1:00 PM showed from April 2022 - 12/01/2022, there were well over 100 shifts in that one controlled substances book where nurses that failed to document they conducted joint nurse controlled substances inventories as required. Review of the 1st floor controlled substances record book schedule II, yellow book, on 12/06/2022 at 7:30 AM, showed Staff L, RN, had not yet signed the book that they had conducted a joint controlled substances inventory that shift. In an interview at 7:30 AM, Staff L stated they forgot to sign the book. Review of the 2nd floor controlled substances record book schedule III, book III, on 12/07/2022 at 8:45 AM, showed no nurse had yet signed they did a joint controlled substances inventory with the other nurse who made a scribble mark for their Signature 1 that shift. Investigation revealed the staff member that had not yet signed was Staff R, LPN. The same issue was found with controlled substances record book II, Blue 2nd floor, schedule II, as Staff R also failed to sign that book that they had done a joint controlled substances inventory at the beginning of their shift that day. Review of the 2nd floor schedule III, Book number 8, green book, on 12/02/2022 at 8:10 AM, showed that Staff N, LPN, had already pre-signed the 3 PM-11 PM shift documentation that they had already conducted an evening shift joint nurse controlled substances inventory. Review of the consultant pharmacist's, Staff I, Physician Order Transcription Audit for active residents' irregularities, dated 12/05/2022, showed they identified 13 occasions where the narcotic order was not transcribed accurately in PCC (PointClickCare - electronic health record), 22 times the narcotic order in PCC did not match the controlled substances record, 21 times the PCC narcotic order did not match the medication card or the narcotic bottle. There were many notes that indicated follow-up was necessary. Review of Quality Improvement: Consultant Pharmacist Summary report for June 2022 showed: -Controlled substances documentation: 06/16/2022 pink cart 2nd floor - narcotic ledger entry not always cross match with MAR, 05/19/2022: green cart 2nd floor - a few ledger book pages not complete with missing Rx (prescription) number and missing full directions, 04/29/2022: green cart first floor - narcotic ledger book not cross matched with MARs, 03/17/2022: 2nd floor blue cart - missing Rx # on count sheet and please write out full directions (avoid using see MAR,) narcotic ledger entries not always cross matched with MAR. Routine and PRN (as needed) dose given less than 10 minutes after routine dose administered-please review with nursing to wait 4 hours before giving additional Oxycodone. 02/24/2022: 1st floor yellow cart and green carts - missing full directions, Rx number, two sets of signatures (nurse/POA or resident) when narcotics sent home. Narcotic ledger entries not cross-matched with MAR. The time signed out in MAR not always after signing out in ledger book. Observed times in MAR before signing out ledger book. Wasted narcotics need to be witnessed by a second nurse, on 02/13/2022 a residents Norco was wasted without a 2nd witness. Review of Quality Improvement: Consultant Pharmacist Summary report for July 2022 showed: -Controlled substances inventory was reconciled according to facility procedures: -03/17/2022: 2nd floor blue cart book - missing signatures on 2/17, 2/25, 2/12 on C2 book, and 3/3 on C3 book; [NAME] cart book -missing signatures on 3/10, 3/4 C2 book, and 3/15, 3/16, 3/5, 3/4, 3/3, 3/1 on C3 book, -02/24/2022: 1st floor yellow cart and green carts - missing set of signatures (yellow - missing 2/1, 2/2, 2/7, 2/11, 2/15; and green - missing 2/6, 2/11, 2/12, 2/20, -01/28/2022: 2nd floor green cart; missing set of signatures on 1/26, 1/25, 1/21, 1/15, 1/14, 1/13, 1/12, 1/10, 1/5, 1/3 - C2 book. -similar other findings as with June 2022 report. Review of Quality Improvement: Consultant Pharmacist Summary Reports for August, September, October, and November 2022 had similar findings as with June and July 2022. Reference: (WAC) 388-97-1300 (1)(b)(i, ii)(c )(i-iv)(3)(a)(4)(a)(i)(d) See related citations: F835 - Administration

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility was administered in a manner that used its resources effectively and efficiently so residents could attain or maintain their highest practicable physical, mental and psychosocial well-being and to ensure the facility maintained substantial compliance with state and federal regulations. The Administration failed to ensure there was active and engaged oversight and monitoring of systems related to Abuse/Neglect, Pressure Ulcers, Pharmacy Services, Hospice Services and Resident Records. These failures caused residents to have unmet care needs and caused harm to residents. Immediate Jeopardy (IJ) was called on [DATE] at 6:10 PM, at F835 - Administration, when the facility failed to ensure the nursing home was staffed and managed to address the significant clinical needs and quality of life and quality of care needs for residents. Residents had unmet needs in multiple care areas to include pressure injury/ulcer care/prevention, urinary catheterization, dressing changes, hospice care, pharmaceuticals processes, skilled nursing staff supervision/administration, inaccurate/incomplete/altered clinical records, and failures in investigating allegations of abuse. They removed the immediacy on [DATE] by establishing procedures for Director of Nursing coverage, updating hospice resident care plans and designating Facility hospice representatives, auditing narcotics medications and orders for accuracy, reviewing grievances and facility patient protection practices, reviewing the facility's operational systems, auditing residents with catheters and pressure ulcers, educating nurses and nursing assistants, and reviewing medication errors. Facility administration failed to ensure and provide administrative oversight and consistent nursing supervisory oversight of facility personnel, practices and policies regarding pharmaceuticals. The failure to provide oversight resulted in an Immediate Jeopardy (IJ) for CFR 483.45, F755 - Pharmacy Services/Procedures/Pharmacist/Records when the facility was found to have inadequate pharmaceuticals procedures and record-keeping procedures in place and a resident had to be hospitalized when the facility administered the resident a single dose 20x the intended doses of Oxycodone (a potent opioid medication used for pain management). Findings included . In an interview on [DATE] at 9:20 AM, the Administrator was asked who was in charge of the nursing department while the Director of Nursing (DON) was out of state, they answered they were, and they would get hold of Staff J, Agency Registered Nurse (RN)/Nurse Manager, or Staff K, RN/Staff Development Coordinator (SDC)/Infection Preventionist (IP) if necessary, as both staff were also assistant DONs. The Administrator did not ensure that a qualified nurse was in charge (overseeing) of the nursing department. In an interview on [DATE] at 11:38 AM, Staff K, RN/SDC/IP, stated there was no established facility procedures for how licensed nurses would know who to contact for urgent nursing matters after hours, but staff could call them. Staff K stated they did not know who was on-call after hours for nurses who needed a DON for urgent nursing matters while the DON was currently out of state. Staff K denied they were ever told they were a DON designee, that they were on-call for the facility, or they were ever told they had on-call duties at all. Staff K stated staff could call the Administrator if they needed to speak with a DON for urgent nursing matters. Staff K stated they also had another job working for an agency as a floor nurse, and just that weekend they worked Saturday and Sunday nights at another nursing home for the agency while the DON was out of state, and they had worked the past Tuesday night for an agency as well. Staff K stated they could ask the Administrator who was on-call the previous weekend. In an observation on [DATE] at 12:10 PM, Staff K was standing outside the Administrator's office and was observed to tell the Administrator the surveyor wanted to know who was the on-call for licensed nurses to contact over the weekend for nursing matters. The Administrator was overheard to tell Staff K to tell the surveyor that they had been on-call this past weekend. The Administrator was asked about their DON designee working at another facility while on-call for this facility, and while the facility was currently in a COVID outbreak, and while the facility residents were still in immediate jeopardy for inadequate pharmaceuticals procedures, the Administrator did not respond. Review of a Controlled Substances Record Book, for the 1st floor Schedule III [NAME] Book number 1, on [DATE] at 1:00 PM showed from [DATE] - [DATE], there were well over 100 shifts in that one controlled substances book where nurses had failed to document they conducted joint nurse controlled substances inventories as required at the beginning of each shift. Review of an incident investigation, dated [DATE], showed the facility had caused multiple medication errors for Resident 14 when staff failed to accurately confirm physician orders on admission. Facility nurses administered five medications that had been discontinued on the admission orders, and they didn't administer a medication that had been ordered, and they administered an incorrect dose of another medication. The investigation was not thorough, and it lacked witness statements from involved staff, there was no reporting done, and the incident was not logged on the incident reporting log, and the incident was not documented in the resident's clinical record. There was also no documented review of this incident, as no staff had signed they reviewed the incident investigation. The facility failed to monitor the staff/failed pharmaceuticals processes that had caused the multiple medication errors, and they failed to protect other residents from their staff and the failed facility processes. The same staff member that failed to accurately confirm the resident's medication orders on admit, then also failed to accurately confirm Resident 4's admission orders on [DATE], when that resident admitted to the facility. Review of an incident investigation, dated [DATE], showed Resident 4 was harmed when the facility administered them a dose of Oxycodone that was 20x the intended dose, and they had to be hospitalized and later expired. The same nurse that failed to properly process Resident 14's admission orders also failed to accurately confirm Resident 4's admission medication orders. The administration's failure to address Resident 14's medication errors and to monitor staff/processes to ensure the incident wasn't repeated resulted in harm to Resident 4. This investigation was also not thoroughly investigated, and it was also not reported as required. Review of an incident investigation, dated [DATE], showed Resident 2 had new skin issues on their feet. The investigation was incomplete as it lacked witness statements, it failed to document what the facility was going to do to correct the matter to ensure it did not happen again, and it lacked review by the Administrator and Medical Director. Review of an incident investigation, dated [DATE], showed Resident 2 had additional new skin issues on the back of their legs. The investigation was incomplete as it lacked witness statements, it failed to document what the facility was going to do to correct the matter and to ensure it did not happen again, and it lacked review by the Administrator and Medical Director. In a phone interview on [DATE] at 12:20 PM, Staff B, Regional Director of Operations Senior Care/Governing Body, stated the primary responsibility for reviewing incidents/investigations was with the Administrator, Director of Nursing, and the Medical Director. In an observation on [DATE] at 10:30 AM, Resident 2 was observed to have six skin injuries to include a sacral pressure injury, a pressure injury on the left posterior hip, a pressure injury on the lateral side of the left ankle, a pressure injury on the left heel, a pressure injury on the right heel, and a pressure injury on the posterior, midpoint aspect of the right lower leg. In observations and interview on [DATE] and [DATE], the resident was observed to not be repositioned, had no pressure relief interventions in place for their heels, and no Prevalon boots were being put on the resident. In interview, staff stated they didn't know if the resident had Prevalon boots or if they were care planned to wear them, staff stated they didn't know the resident because they had been moved to this new room recently. Review of Resident 2's census information showed the resident had moved to their new room on [DATE]. Review of an incident investigation, dated [DATE], showed Resident 1 had a new sore to their right heel. The investigation was not thorough, and it lacked review by the Administrator and Medical Director. Review of a Concern Form, dated [DATE], showed a hospice provider had reported to the DON that Resident 1's spouse was concerned the resident was always laying on their back, and that a urinary catheter had not been inserted as coordinated with staff, and a wound dressing change order had not been followed by staff. The facility failed to identify the allegation as potential abuse/neglect and investigated those allegations as a concern, or as a grievance. The concern/grievance did not get thoroughly investigated, reported properly, or logged properly. Review of Resident 1's Skilled Nursing Facility and Hospice Service Agreement, dated [DATE], and signed by the Administrator, did not get implemented, as the agreement called for the facility to designate a facility representative to coordinate care with hospice staff. Review of two other hospice resident's Skilled Nursing Facility and Hospice Service Agreements, Residents 2 (dated [DATE]) and 5 (dated [DATE]), both of which were signed by the administrator, did not get implemented either as the facility had failed to designate facility representatives to coordinate care with hospice staff. In an interview on [DATE] at 11:52 PM, Staff J, Agency RN/Nurse Manager, stated there were currently three residents in the facility (1, 2, 5) that were on hospice, and none of them had a designated Facility representative to coordinate hospice cares. RESIDENT 3 On [DATE], a review of the resident's [DATE] Treatment Administration Records (TARS), showed documentation starting on [DATE] for a treatment: Sacrum, one time a day every Mon, Wed, Fri for PI (pressure injury) NS (normal saline) cleanse, skin prep to periwound (around the wound) and allow to dry, protect with bordered foam dressing. There was documentation this was done on [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] a review of the resident's [DATE] TARs showed someone had changed the sacral treatment documentation retroactively back to [DATE] and all of the dates following to include [DATE], [DATE], [DATE], [DATE], and [DATE], they now reflected: Sacrum, one time a day every Mon, Wed, Fri for PI, NS cleanse, skin prep to periwound and allow to dry, Medi-honey to wound base, protect with bordered foam dressing. In an interview on [DATE] at 3:34 PM, Staff J stated that yesterday they called and got a verbal order to add Medi-honey, and they updated the previous order instead of cancelling it and entering a new one. Staff J was asked where they documented the verbal order, they stated they didn't specifically document the verbal order, that they went into the electronic health record and revised the previous order. Staff J was asked where they had documented the verbal order and the identity of the prescriber for that verbal order, they stated they hadn't documented that information. Joint review of the TARs showed that Staff J had retroactively changed the previous order to [DATE], Staff J was unable to provide any information about that. Joint review of the resident's progress notes from the day prior showed there was no documentation Staff J had called the provider to get the new order. The new order showed up in the electronic health record that it was given by Staff NN, Physician, but Staff J stated Staff OO, ARNP, gave that new verbal order. In a phone interview on [DATE] at 9:00 AM, Staff D, Medical Director, was unable to speak to how they had helped the facility with implementation of resident care policies or ensuring physicians/providers were knowledgeable and compliant with pharmacy prescribing policies. The Medical Director was also unable to state how they had reviewed incident investigations or how they had helped protect residents from staff that didn't follow facility policies and had committed the same medication errors with different residents. The Medical Director was also unable to state how they had provided medical direction to the facility regarding what types of incidents they wanted to be made aware of, except the medical director did state they had told the facility they wanted to be made aware of medical errors. Resident 14's medication errors were discussed with the Medical Director, the Medical Director stated they had not provided medical direction on that one. The Medical Director stated the facility had not notified them of the significant medication error for Resident 4 until four days after the resident was hospitalized . The Medical Director was not aware of the pharmacy policy for ePrescriptions that indicated prescribers were to also send identical hard copy or verbal orders back to the facility after they had submitted ePrescriptions directly to the pharmacy. Reference: (WAC) 388-97-1620 (1)(2)(b)(i, ii)(7)(b) See related citations: F607 - Develop/implement abuse/neglect Policies F684 - Quality of care F755 - Pharmacy services/procedures/pharmacist/ records

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of three residents (2, 1) reviewed for pressure injuries, received care planned interventions including applying pressure-relieving boots, offloading their heels, and repositioning, and staff failed to use careful and gentle resident-handling techniques, and to ensure uninterrrupted care and services after a room move, and to perform dressing changes as ordered and to insert a urinary catheter as ordered. Resident 2 was harmed when they experienced pressure injuries that didn't heal, and which resulted in them developing new pressure injuries, and Resident 1 was harmed when they developed a pressure injury and worsening of the pressure injury due to staff failing to implement their plan of care. Findings included . RESIDENT 2 The resident admitted to the facility on [DATE] and had diagnoses to include dementia, osteomyelitis (inflammation of bone caused by infection) of a sacrum (shield-shaped bony structure that is located at the base of the back and is connected to the pelvis) pressure injury, a Stage IV (Stage IV = full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) sacral pressure injury, uropathy (blockage in the urinary tract), a communication deficit, and aphasia (a disorder that affects how a person communicates). According to the quarterly Minimum Data Set assessment, dated 08/25/2022, the resident had no cognitive impairment, required 2-person assist with bed mobility and toileting, no transfers had occurred, and was totally dependent on staff for bathing. Review of Resident 2's wound healing progress notes, dated 10/03/2022, showed the resident had one wound, a Stage IV sacral pressure injury. Review of an incident investigation, dated 10/13/2022, showed Resident 2 had new pressure injuries on their feet, and that staff were using Prevalon (pressure-reducing boots) boots for pressure relief. Review of an incident investigation, dated 10/21/2022, showed Resident 2 had developed new skin issues on the back of their legs. Review of the resident's [NAME] (care directives for nursing assistants), copy date 11/28/2022, showed there were multiple interventions listed for encouraging and assisting the resident to reposition to offload pressure, and to apply the pressure-relieving boots. In an observation on 11/28/2022 at 10:30 AM, Resident 2 was observed to have six skin injuries to include a sacral pressure injury, a pressure injury on the left posterior hip, a pressure injury on the lateral side of the left ankle, a pressure injury on the left heel, a pressure injury on the right heel, and a pressure injury on the posterior, midpoint aspect of the right lower leg. In an observation on 11/28/2022 at 12:15 PM, the resident had no pressure-relieving boots on their feet. In an observation on 11/28/2022 at 1:42 PM, the resident was laying on their back in bed, their heels were directly on the bed, and they had no pressure-relieving boots on their feet. In an interview on 11/28/2022 at 2:05 PM, Staff U, Nursing Assistant, stated the resident didn't tolerate being positioned on their sides. Staff U stated they did not know if the resident had any pressure-relieving boots, and they didn't know if the resident was on any turning/repositioning program. In an observation on 11/29/2022 at 7:15 AM, the resident was observed laying on their back in bed, they had a pillow under their knees, their heels were directly on the bed, and they were not wearing pressure-relieving boots. The resident stated they needed help because their back hurt. In an interview on 11/29/2022 at 7:18 AM, Staff V, Nursing Assistant, stated they did not know if the resident had pressure-relieving boots because the resident had recently moved to their current room from another room and they didn't know them yet. Staff V looked in the resident's closet, and they pulled out a large blue padded pressure-relieving boot, they stated they would put it on the resident. Staff V was asked about the resident being positioned on their back; Staff V was unable to provide any information. In an observation on 11/29/2022 at 7:54 AM, the resident was still positioned on their back and was not wearing any pressure-relieving boots. In an observation/interview on 11/29/2022 at 7:58 AM, Staff V stated the resident rarely got out of bed because their bottom was sore. The resident stated they didn't get out of bed because of their back. The resident was asked if they were going to get out of bed that day, they stated they didn't know. In an observation on 11/29/2022 at 8:50 AM, Staff V and Staff W, Nursing Assistant, did incontinent cares for the resident, and they changed the resident's bed linen. After changing the resident's bed linen, Staff W was observed to give several strong yanks and pulls on the bottom sheet to straighten it out while the resident was on their back. Staff W was asked if they had any concerns of the resident's skin shearing, they did not provide any information. Staff V and Staff W put a pressure-relieving boot on the resident's right foot, then they started covering the resident with blankets. They were asked if the resident had a pressure-relieving boot for the left foot, they looked and found another pressure-relieving boot in a plastic bag that was in another large plastic bag and laying on the floor in the corner of the room, and they placed it on the resident's other foot. The staff were observed to turn the resident slightly to their left with a pillow behind their back. The staff stated they didn't know the resident because they were new to them because of the recent room change. In an observation on 11/29/2022 at 11:05 AM, the resident was observed to be still in bed and still laying on their left side, and they were still wearing the pressure-relieving boots. In an observation on 11/29/2022 at 1:45 PM, the resident was observed laying on their back in bed, and was still wearing the pressure-relieving boots. In an interview on 11/29/2022 at 1:59 PM, Staff J, Agency Registered Nurse (RN)/Nurse Manager, stated the resident had refused to wear the pressure-relieving boots in the past. Staff J was asked for documentation regarding the resident's refusal to wear their boots, Staff J looked in the computer and stated they couldn't find any. Staff J then stated the facility had recently run out of pressure-relieving boots. Staff J was asked how they ensured uninterrupted resident cares when residents had room moves, they were unable to provide any information. Review of the resident's census information showed they had moved to their current room on 11/22/2022, and they had previously been in a room down a different hall on the same floor. In an observation on 11/30/2022 at 7:40 AM, the resident was observed lying in bed on their right side and they were wearing their pressure-relieving boots. In an observation on 12/01/2022 at 9:05 AM, the resident observed in bed and wearing their pressure-relieving boots. RESIDENT 1 The resident admitted to the facility on [DATE] and had diagnoses to include dementia, history of a stroke, and Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors). According to the quarterly Minimum Data Set (MDS) assessment, dated 05/24/2022, the resident had moderate cognitive impairment, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers, had no unhealed pressure ulcers, and required 2-person assist with bed mobility, transfers and toilet use. Review of a Concern Form, dated 11/18/2022, showed Staff XX, Hospice RN Case Manager, made an allegation to the Director of Nursing (DON) that the facility had failed to follow the Hospice Plan of Care as coordinated with facility staff, regarding a urinary catheter had not been placed as coordinated, a wound dressing change order had not been followed, and that the resident's spouse had voiced concerns that when they visited, the resident was always laying on their back. Review of Hospice RN Visit Provider Notes, dated 11/14/2022, showed the resident had a decubitus ulcer (pressure injury) on their sacrum that the Facility nurse manager reported had happened over the weekend, Review of Hospice RN Case Manager visit notes, dated 11/18/2022, showed: Upon arrival, the patient did not have a urinary catheter inserted per the Plan of Care, so the Hospice RN Case Manager inserted it and they had a discussion with the DON (Director of Nursing) as to why the urinary catheter wasn't inserted on Monday (11/14/2022) when the Facility received orders and when the Facility Nurse Manager, Staff J, Agency RN/Nurse Manager, had stated their staff would insert the catheter. Upon arrival the patient was found on their back in bed, the pressure ulcer on the resident's sacrum had significantly increased in size, it had eschar (dead tissue that eventually sloughs off healthy skin after an injury) with drainage that was brownish in color and had a foul odor. The patient still had a Mepiplex bordered dressing in place (even though orders were changed to betadine and cover with ABD (a type of dressing). Review of a progress note, dated 11/21/2022, showed: the resident's wound to the sacrum measured approximately 5.5 x 4.6 centimeters with 100% eschar, and had no drainage. In a phone interview on 11/29/2022 at 12:05 PM, Staff XX, Hospice RN Case Manager, stated they had given the Facility Hospice orders for wound care, but they (Facility staff) did not want to follow them because they were concerned the resident would be wet from urine, so they got a Hospice order for a urinary catheter to be inserted, and they faxed it to the Facility, and even offered to come in and insert the urinary catheter, but they (Facility staff) stated all they needed was the order. Staff XX stated then when they returned to the Facility at the end of the week, the urinary catheter had not been inserted and the Facility had not notified Hospice that the catheter had not been inserted or that the Facility had not followed the Hospice wound care orders either. In a phone interview on 11/29/2022 at 1:15 PM, Staff XX stated they knew the order for dressing changes did not get implemented timely because when they came into the facility on [DATE] they saw a dirty foam dressing on the resident's bottom. Staff XX stated earlier that week they had talked to Staff J about the dressing change and catheter being inserted, and during the week had also talked to Staff R, Licensed Practical Nurse (LPN), who had told them they didn't have the correct size of catheter, and that Staff XX offered to bring one in. Staff XX stated had Hospice been notified the Facility did not obtain and insert the catheter, they could have brought the correct-sized catheter in. In an interview on 11/30/2022 at 11:29 AM, Staff R, LPN, stated the resident's wound was not getting better which is why the Hospice wanted a catheter. Review of the resident's Treatment Administration Records, for November 2022, showed an order: Non-stageable Pressure Ulcer to Sacrum: pain with betadine, allow to air dry, cover with ABD pad and secure with minimal tape every other day, Use skin protectant under tape and around the wound. If intact necrotic tissue sloughs (was removed) off or for any other changes, contact Hospice 24-hr nurse one time a day every other day for Sacrum wound. This order was signed off as done by Staff M, RN, on 11/15/2022 and 11/16/2022. In a phone interview on 11/30/2022 at 2:12 PM, Staff M, RN, stated they didn't want to use the ABD dressing because the resident was incontinent and it would get saturated and they didn't want it to get wet. Staff M stated they didn't want to put plastic tape on because they've seen people blister, so they didn't use the ABD dressing, they used an Optifoam dressing instead (on 11/15/2022 and 11/16/2022). In a phone interview on 11/30/2022 at 2:22 PM, Staff O, LPN, stated they had applied an Optifoam dressing on the resident that week because the other dressing had come off. Staff O stated they had not checked the current dressing order and didn't call Hospice for an order, they just covered the wound with a foam dressing. In a phone interview on 12/01/2022 at 9:20 AM, Staff XX, Hospice RN Case Manager, stated the Facility never called them back and they never implemented the dressing change orders and they never implemented the catheter orders, and they never contacted them that they never implemented the orders. Staff XX stated they didn't want to get anyone in trouble, but there needed to be better care. Staff XX stated the dressing that was on the resident when they returned to the facility had been very soiled and the wound was significantly worse, it was bigger, it was filthy with foul odors and it was very soiled, and it was not the dressing that was ordered. Reference: (WAC) 388-97-1060 (3)(b)

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility administration failed to honor residents' rights to have an open and functioning dining room where residents could eat and socialize in dining rooms on two of two floors. The failure to open the facility dining rooms placed residents at risk for isolation and diminished quality of life. Findings included . Review of the Patient Information Handbook, undated, showed: Food Service: Meals are served daily in the dining room at regular hours. Review of the admission Agreement between Patient and Center, undated, showed under General right that each resident has a right to: --be treated with consideration, respect and full recognition of his/her dignity, individuality and self-determination, --Encouragement, assistance, and promotion of the exercise of his/her rights as a resident and citizen, --receive care in a safe, clean, comfortable, and homelike environment. In an interview on 12/21/2022 at 7:45 AM, Resident 19, Resident Council President, stated the dining rooms weren't open and had not been since COVID started, and the residents really wanted them open. In an interview on 12/22/2022 at 8:00 AM, Resident 19 stated they had noticed yesterday through their room window that there were tablecloths and decorations down in the 1st floor dining room. They stated they had asked a staff member when the residents could go down for the celebration, but the staff member told them that celebration was a luncheon for staff. Resident 19 stated they told the staff member they should just change the name of the dining room to the staff dining room, as the residents did not get to use it and they have not been able to eat in the dining room since COVID started three years ago. In an interview on 12/23/2022 at 9:30 AM, the Administrator stated that opening the dining rooms was on their list to do for the new year. Reference: (WAC) 388-97-0180 (2)(3)(4)(a) .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to secure resident clinical information for two of two residents (17, 18) for whom facility medication nurses left the residents' medication information exposed on unattended computer screens for anyone walking by to see. This failed practice placed the residents' clinical information at risk for being exposed to others when the residents had a right to secure and confidential medical records. Findings included . Review of the facility Patient Information Handbook, undated, showed: Privacy - Your privacy is important to us and we are committed to protecting your medical information. Review of a blank admission Agreement between Patient and Center, undated, showed: General Rights: Each resident and legal representative had a right to personal privacy and confidentiality of his or her personal and clinical records. In an observation on 11/29/2022 at 7:20 AM, the computer on the medication cart by the nursing/social work/staff development office on the 2nd floor was on and had displayed Resident 17's medication information, no staff were near this computer. In an interview on 11/29/2022 at 7:20 AM, Staff Q, Licensed Practical Nurse (LPN), stated the resident's information should not have been visible and that the staff should have signed out of the computer before they left the medication cart. Staff Q stated it wasn't their medication cart. In an observation on 12/02/2022 at 7:00 AM, the 2nd floor green medication cart computer screen was on with Resident 18's medication information displayed for anyone walking by to see, no staff were in the vicinity. Staff J, Agency Registered Nurse/Nurse Manager, stated the nurse that was currently working that medication cart was Staff N, LPN. In an interview on 12/02/2022 at 7:07 AM, Staff N stated they didn't mean to leave the resident's information exposed, that they just stepped away for a bit. Reference: (WAC) 388-97-0360 (1) .

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure call lights were in reach for one of three residents (2) and that medications were not left unattended in the hallway. These failures placed residents at risk for medication-related incidents and for not being able to call staff for assistance when needed. Findings included . In an observation on 11/29/2022 at 7:10 AM there was a medicine cup with approximately six pills in it sitting on an infection control cart outside room [ROOM NUMBER], there were no staff or residents in sight. RESIDENT 2 In an observation/interview on 11/28/2022 at 8:55 AM, the resident's call light was observed attached to the bed up by the resident's right shoulder, the resident did not know if they knew how to use the call light. In an observation/interview on 11/29/2022 at 7:15 AM, the resident's call light was observed to be on the floor next to the resident's bed, the resident stated they didn't know where their call light was. In an observation/interview on 11/29/2022 at 8:23 AM, the resident's call light was observed to be clipped to the upper right side of the bed by the resident's right shoulder, the resident stated they couldn't reach their call light. In an observation/interview on 11/29/2022 at 8:50 AM, the resident stated they couldn't see or use their call light. In an observation on 12/01/2022 at 7:50 AM, the resident's call light was observed to be on the floor behind their bed. In an observation on 12/01/2022 at 8:10 AM, the resident's call light was observed to be clipped to the sheets by the resident's right shoulder. In an observation on 12/06/2022 at 8:45 AM, the resident's call light was clipped to the top of their bed behind their right shoulder, the resident was asked if they could reach their call light, they stated where is it? Review of the resident's care plan, print date 12/06/2022, showed: -have commonly used articles within easy reach, -impaired vision related to advancing age, history of a stroke, attempt to keep frequently used items within easy reach. Reference: (WAC) 388-97-1060 (3)(g)

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their Skilled Nursing Facility and Hospice Service agreements for three of three residents (1, 2, 5) reviewed for hospice care and services. The failure to: 1) designate in writing a Facility hospice representative for each resident to coordinate ongoing hospice care with the Hospice case manager, 2) document a coordinated hospice plan of care, 3) provide coordinated hospice care and services, and 4) to orient hospice providers to the skilled nursing facility, and their procedures, all resulted in unmet hospice care needs. Findings included . Definitions: Hospice care: a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. RESIDENT 1 The resident admitted to the facility on [DATE], and started hospice services 08/19/2022. Review of the Skilled Nursing Facility and Hospice Service Agreement, dated 08/19/2022, showed: The facility was to designate a member of the Facility Interdisciplinary Team to work with the Hospice representative: to coordinate care to the resident provided by the Facility and Hospice staff; who was responsible for collaborating with hospice representatives and coordinating Facility staff participation in the Hospice care planning process for those residents receiving these services. According to the service agreement the facility shall: ensure the Facility staff provided orientation to the policies and procedures of the Facility, and to Hospice staff providing care to Facility residents; abide by the Hospice's policies and procedures, patient care protocols and Plans of Care; immediately inform Hospice of any change in the condition of the Hospice Patient and to ensure quality of care for the patient and family. Review of a Concern Form, dated 11/18/2022, showed Staff XX, Hospice RN Case Manager, made an allegation to the Director of Nursing (DON) that the facility had failed to follow the Hospice Plan of Care as coordinated with facility staff, regarding a urinary catheter had not been placed as coordinated, a wound dressing change order had not been followed, and that the resident's spouse had voiced concerns that when they visited, the resident was always laying on their back. Review of Hospice RN Visit Provider Notes, dated 11/14/2022, showed: -the resident had a decubitus ulcer (pressure injury) on their sacrum that the Facility nurse manager reported had happened over the weekend, -care had been coordinated with the Facility nurse manager and explained the need for position changes every two hours with the use of pillows, and the resident was to be positioned off their bottom except during intake (oral) and after for 45 minutes, wound care orders and frequency, reportable signs and symptoms, agency 24-hours phone number use as needed, and plan for new wound care orders. -a phone call was made to the Facility after the Hospice RN Case Manager visit to confirm receipt of fax that went to 1st floor because the 2nd floor fax was not functioning. Review of Hospice RN Case Manager visit notes, dated 11/18/2022, showed: -Upon arrival, patient did not have urinary catheter inserted per the Plan of Care, so the Hospice RN Case Manager inserted it. -There was a discussion with the DON (Director of Nursing) as to why the urinary catheter wasn't inserted on Monday (11/14/2022) when the Facility received orders and when the Facility Nurse Manager, Staff J, Agency RN/Nurse Manager, had stated their staff would insert the catheter -Upon arrival the patient was found on their back in bed, the pressure ulcer on the resident's sacrum had significantly increased in size, it had eschar (dead tissue that eventually sloughs off healthy skin after an injury) with drainage that was brownish in color and had a foul odor. The patient still had a Mepiplex bordered dressing in place (even though orders were changed to betadine and cover with ABD (a type of dressing) and the Facility nurse manager confirmed receipt on Monday. -Reviewed orders that were faxed and received to keep patient off their bottom (back) except when during intake and for 45 minutes after intake to prevent aspiration, assisted Facility nurse in positioning patient on their left side with use of pillows. -Advised Facility nurse that since patient had a urinary catheter, they did not need to wear a diaper in bed. To use chux (pad to lay under patient) pad to allow more air to flow and change as indicated. Hospice RN Case Manager cleaned the patient and painted sacral wound with betadine, covered it with ABD (dressing) and small amount of tape. -Safety Risk: --Worsening pressure ulcer on sacrum. No urinary catheter inserted per orders. Mepiplex on bottom rather than betadine and ABD as ordered. Review of Hospice Nurse visit notes, dated 11/20/2022, showed: -Communication notes: When I arrived patient had a diaper on. Discussed with staff not wearing a diaper for skin hygiene and to promote healing. Facility staff helped with removing the diaper. The patient's wound was very malodorous (smelling very unpleasant). In a phone interview on 11/29/2022 at 12:05 PM, Staff XX, Hospice RN Case Manager, stated they had given the Facility Hospice orders for wound care, but they (Facility staff) did not want to follow them because they were concerned the resident would be wet from urine, so they got a Hospice order for a urinary catheter to be inserted, and they faxed it to the Facility, and even offered to come in and insert the urinary catheter, but they (Facility staff) stated all they needed was the order. Staff XX stated then when they returned to the Facility at the end of the week, the urinary catheter had not been inserted and the Facility had not notified Hospice that the catheter had not been inserted or that the Facility had not followed the Hospice wound care orders either. Staff XX stated at the end of the week they actually inserted the urinary catheter they thought the facility had inserted earlier in the week. In a phone interview on 11/29/2022 at 1:15 PM, Staff XX stated they knew the order for dressing changes did not get implemented timely because when they came into the facility on [DATE] they saw a dirty foam dressing on the resident's bottom. Staff XX stated earlier that week they had talked to Staff J about the dressing change and catheter being inserted, and during the week had also talked to Staff R, Licensed Practical Nurse (LPN), who had told them they didn't have the correct size of catheter, and that Staff XX offered to bring one in. Staff XX stated had Hospice been notified the Facility did not obtain and insert the catheter, they could have brought the correct-sized catheter in. In an interview on 11/29/2022 at 1:59 PM, Staff J, Agency Registered Nurse (RN)/Nurse Manager, stated there had been problems with the fax machine, and they were only receiving the first page of faxes, and there were concerns they were not receiving full fax transmissions. Staff J stated the DON didn't like the dressing change orders from Hospice, and wanted them to get changed, but then they decided to keep the order and add the catheter, but they continued to have problems with the fax machine. In an interview on 11/30/2022 at 11:29 AM, Staff R, LPN, stated they had called the Hospice regarding catheter orders that week, but they could not remember the details, and they had not documented the call in a progress note, and that they should have made some documentation of the call because when staff called Hospice or a provider they were supposed to document a progress note. In a phone interview on 12/01/2022 at 9:20 AM, Staff XX, Hospice RN Case Manager, stated the Facility never called them back and they never implemented the dressing change orders and they never implemented the catheter orders, and they never contacted them that they never implemented the orders. Staff XX stated they didn't want to get anyone in trouble, but there needed to be better care. Staff XX stated the dressing that was on the resident when they returned to the facility had been very soiled and the wound was significantly worse, it was bigger, it was filthy with foul odors and it was very soiled, and it was not the dressing that was ordered. Staff XX stated they did not feel there was good coordination from the Facility, that as a professional organization they should coordinate as necessary to ensure the resident received the best care. Staff XX stated, unfortunately, Hospice can't be there every day, but there is an expectation that a professional organization would follow orders or notify us if there was a reason they couldn't follow those orders, I understand things happen, but they need to let us know. In an interview on 12/01/2022 at 1:25 PM, the Administrator was asked the named of the Facility designated representative to coordinate with Hospice, they stated they had not designated a specific staff, that all of their nurses could call hospice. The Administrator stated the coordinated Hospice Plan of Care was in PointClickCare (electronic health record). The Administrator was asked the Facility process for making 24-hour contact with Hospice staff, they stated they were to use the Hospice 24-hour phone number. In a phone interview on 12/05/2022 at 8:18 AM, Staff XX stated they had not received any orientation from the facility, and they did not have access to the facility's electronic health record, and they were not familiar with that program. They stated they also did not have access to the Facility Plan of Care. Staff XX stated they had thought the 2nd floor fax machine was working, that they had not been notified it wasn't, then later found out that it wasn't working and had not been functioning right for weeks. Staff XX stated to their knowledge the Facility had never designated a Facility representative to coordinate with Hospice. Was asked about lack of Hospice documentation in the Facility clinical record regarding the coordinated Hospice Plan of Care, they stated the Facility did not ask for notes, they only asked for orders. In an interview on 12/06/2022 at 10:03 AM, the Administrator stated they had not provided Hospice staff any orientation to the Facility because they were not Facility staff, that the Hospice company would have to be the ones to offer any type of orientation for Hospice staff. Review of the resident's care plan, copy date 12/04/2022, showed: -for urinary incontinence, to still use absorbent briefs/pads, -nothing documented about Hospice Plan of Care to include positioning the resident off their back except during oral intake and for 45 minutes after. RESIDENT 2 The resident admitted to the facility on [DATE] and started Hospice 10/26/2022, and had diagnoses to include dementia, a sacral Stage IV pressure injury (Stage IV = full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), uropathy (blockage in the urine tract), and expressive/receptive aphasia (a disorder that affects how you communicate). The resident had a paid guardian. Review of the resident's clinical record showed they also had a Skilled Nursing Facility and Hospice Service Agreement, it was dated 10/24/2022. RESIDENT 5 The resident admitted to the facility on [DATE] and started Hospice 10/06/2022, and had diagnoses to include terminal cancer. Review of the resident's clinical record showed they also had a Skilled Nursing Facility and Hospice Service Agreement, it was dated 10/05/2022. In an interview on 12/07/2022 at 11:52 AM, Staff J stated there were currently three Hospice residents in the Facility, Residents 1, 2, and 5, but the facility had not designated a specific Facility representative to coordinate their Hospice Plans of Care. Reference: (WAC) 388-97-1060 (1) See related citations: F686 - Treatment/services to prevent/heal pressure ulcers F835 - Administration

CONCERN (D) 📢 Someone Reported This

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

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to have a functioning 2nd floor nursing station fax machine for the coordination of care for 57 of the facility's 79 residents that resided on the 2nd floor. This failure contributed to resident (1) having unmet care needs when Hospice Plan of Care documentation was sent to the Facility by fax, but not received and responded to timely by Facility nursing staff. Findings included . Review of Hospice RN (Registered Nurse) Visit Provider Notes regarding Resident 1, dated 11/14/2022, showed: - a phone call was made to the Facility after the Hospice RN Case Manager visit to confirm receipt of fax that went to 1st floor because the 2nd floor fax was not functioning. In an interview on 11/29/2022 at 1:59 PM, Staff J, Agency RN/Nurse Manager, stated they had been having problems with the fax machine, and they were only receiving the first page of faxes, and there was concerns they were not receiving full fax transmissions. In an interview and record review on 12/06/2022 at 8:55 AM, reviewed a sign on the 2nd floor fax/copier at the nursing station that indicated Not working use 1st floor copier. In an interview with Staff J stated the fax machine had not been working since October. Reference: (WAC) 388-97-2100 See related citation: F684 - Quality of care

CONCERN (E) 📢 Someone Reported This

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

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their written policy and procedures for abuse and neglect prevention, identification, resident protection, investigation, and reporting and response for four of four residents (14, 4, 2, 1) reviewed for incidents/allegations. There were failures in identifying and recognizing allegations of abuse, in reporting abuse and neglect, in protecting residents after incidents, and incomplete investigations. Findings included . Definitions: Allegation: a statement or a gesture made by someone that indicates that abuse, neglect, financial exploitation, or misappropriation of resident property may have occurred and required a thorough investigation. Neglect: means a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect means a pattern of conduct or inaction by a person or entity with a duty of care to provide the goods or services that maintain physical or mental health of a vulnerable adult, or that avoids or prevents physical or mental harm or pain to a vulnerable adult, and an act or omission that demonstrated a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health, welfare, or safety. Record review of the facility's policy titled Patient Protection, Abuse, Neglect, Mistreatment and Misappropriation Prevention, dated October 2021, showed: -Abuse includes all types of abuse, neglect, exploitation, mistreatment and misappropriation of patient property. -It was essential that center practices help prevent abuse, possible reoccurrence and respond actively to detect and prevent abuse. -Centers must adopt and operationalize an abuse prevention system that includes screening and training of employees, protection of patients, identification and investigation of all allegations of abuse, and reporting and responding to the appropriate individuals or agencies. -The facility must develop and implement written policies and procedures that: --prohibit and prevent abuse and neglect, --establish policies and procedures to investigate any such allegations. -In response to allegations of abuse and neglect, the facility must ensure that all alleged violations involving abuse or neglect were reported immediately but not later than two hours after the allegation was made. -Have evidence that all alleged violations were thoroughly investigated. -Prevent further potential abuse and neglect while the investigation was in progress. -The Administrator was responsible for the investigating, reporting and coordinating of the investigation process of any alleged or suspected abuse. -Centers can best support the detection and prevention of abuse by implementing a process that supports immediate reporting of suspected abuse. -The facility must establish a grievance policy to ensure the prompt resolution of all grievances. -The purpose of the investigation process was to reduce patient risk, mitigate harm, identify root cause and associated factors, and minimize the risk of occurrence. -Any allegation requires an investigation. -Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation. If the incident involves a center employee, the employee is suspended immediately after obtaining their statement, pending completion of the investigation. RESIDENT 14 The resident admitted to the facility 11/08/2022 with diagnoses to include coronary artery bypass and grafting (surgical revascularization of blood vessels in the heart), diabetes, history of a stroke, heart failure, kidney disease, gastroesophageal reflux (acid reflux), and high blood pressure. Review of an incident investigation, dated 11/09/2022, showed there were medication errors that occurred when the facility failed to ensure the resident only received medications as ordered on admission and that two staff had contributed to these medication errors, Staff CC, Agency Licensed Practical Nurse (LPN), failed to correctly confirm admission orders with the prescriber. The investigation indicated a second nurse was also involved in the medication errors, and they had failed to initially enter the correct medications in the electronic health record, then Staff CC confirmed their orders. That second nurse's name was not included in the incident investigation, their identity was later determined to be Staff GG, Agency Registered Nurse (RN). There were no witness statements in the incident investigation. The facility's investigation documentation showed their corrective action was to do a One-on-One In-service they did via a telephone call/verbal review with Staff CC regarding the proper procedures for confirming admission orders. The investigation did not indicate that any ongoing monitoring was going to be done to ensure Staff CC did not fail to properly confirm future orders for Resident 14 or other residents. The investigation did not indicate any reporting was done. The investigation showed there was a lack of protection measures put in place to prevent recurrence. The investigation did not include any corrective actions the facility had implemented regarding Staff GG's failure to enter the correct orders into the electronic health record, or how the facility was going to protect residents from Staff GG's failed practice. There was no documentation the facility had suspended either Staff CC or Staff GG, pending the completion of an investigation. There was no documented review of the investigation documented at all, to include none from the Administrator, the Director of Nursing, or the Medical Director. Review of the November 2022 incident reporting log showed the facility had not logged this incident on the reporting log, and there was no documentation the facility had reported the incident to the state survey agency responsible for investigating allegations of abuse. Review of Resident 14's November 2022 progress notes showed there was no documentation in the resident's clinical records that the incident had occurred. In a Teams interview on 12/12/2022 at 2:00 PM, Staff E, Director of Nursing (DON), stated the medication errors were not logged on the incident reporting log because they weren't significant. The DON stated the incident should have been documented in the resident's clinical record. The Administrator and DON were unable to state if they had identified any systemic failures during their investigation of this incident. The DON stated they had not logged the incident, but they would take it to their QAPI (Quality Assurance and Performance Improvement) this month (though the errors occurred 11/08/2022 and 11/09/2022). RESIDENT 4 The resident admitted to the facility on [DATE] with diagnoses to include pancreatic cancer, secondary cancer to the liver, lungs and bile duct, and abdominal pain. In a phone interview on 12/01/2022 at 3:20 PM, Collateral Contact 1 (CC1), a family member of the resident, stated the nursing home had overdosed the resident on Oxycodone when staff gave them 200 milligrams (mg) instead of the 10-20 mg they were supposed to get. CC1 stated since the resident had terminal cancer and the overdose, they were probably never going to leave the hospital because their condition had deteriorated after the overdose. Review of Emergency Medical Service (EMS) records, dated 11/28/2022, showed when the medics arrived the resident had altered mental status and ineffective breathing. The medics administered Narcan (a lifesaving medication used to help reverse the effects of an opioid overdose), and the resident became responsive, and was transported to the hospital. The medics documentation showed their Primary Impression was Overdose - other opioids. In a phone interview on 12/12/2022 at 11:28 AM, Collateral Contact 1, family member of Resident 4, stated Resident 4 had passed away the day prior (12/11/2022). Review of an incident investigation, dated 11/28/2022, showed that two nurses failed to accurately enter and confirm the admission medication orders. The same nurse that failed to accurately confirm Resident 14's admission medication orders, Staff CC, LPN, also failed to accurately confirm Resident 4's admission medication orders. Also, the first nurse that initially entered the medication orders into the electronic health record, Staff K, RN/Assistant Director of Nursing/Staff Development Coordinator/Infection Preventionist, entered them incorrectly into the electronic health record. There was no witness statement from Staff K included in the incident investigation, and there was no witness statement from the Director of Nursing who was also involved in the incident. There was no documentation in the incident investigation how the facility was going to monitor their pharmaceuticals systems to ensure staff followed facility policy for accurate medication order entry/verification, and there was no documentation the facility had suspended either Staff CC or Staff K pending the completion of an investigation. There was no documentation in the investigation that the facility had collaborated with the pharmacy or the Medical Director. There was no documentation the incident investigation had been reviewed by the Director of Nursing or the Medical Director, or any qualified clinical health care professionals, only the Administrator had signed they reviewed the investigation. There was also no documentation the facility had determined whether the prescribers of the resident's Oxycodone (Staff F, Physician Assistant or Staff G, Advanced Registered Nurse Practitioner) though Staff F had failed to follow pharmacy policy when they did the ePrescription, and Staff G had submitted a prescription for 20x the intended dose of Oxycodone. There were no witness statements from Staff F or Staff G. There was also no documentation the facility had identified that nurses had documented on the medication administration records that they had administered 50 doses at 200 mg of Oxycodone, though the order was for 10 mg. There was also no documentation the facility had collaborated with the pharmacy. RESIDENT 2 The resident admitted to the facility on [DATE] and had diagnoses to include osteomyelitis (inflammation of bone caused by infection) of a sacrum (shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) pressure injury, and a Stage IV (Stage IV = full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) sacral pressure injury. Review of Resident 2's wound healing progress notes, dated 10/03/2022, showed the resident had one wound, a Stage IV sacral pressure injury. Review of an incident investigation, dated 10/13/2022, showed Resident 2 had new pressure injuries on their feet, and that staff were using Prevalon (pressure-reducing boots) boots for pressure relief. The investigation was not thorough as it did not contain any documentation the facility had assessed the current plan of care to see if staff were following it. There was only one witness statement and it was by the nurse that found the new injuries, there were none from any nursing assistants or the nurse manager, who could have provided information on what interventions were currently in place, and whether they were being followed. There was no documented review by the Administrator or Medical Director. Review of an incident investigation, dated 10/21/2022, showed Resident 2 had developed new skin issues on the back of their legs. The investigation was not thorough, it did not include any information whether the current plan of care was being implemented by caregiver staff. There were no witness statements from the resident's nurse manager. In an observation on 11/28/2022 at 10:30 AM, Resident 2 was observed to have six skin injuries to include a sacral pressure injury, a pressure injury on the left posterior hip, a pressure injury on the lateral side of the left ankle, a pressure injury on the left heel, a pressure injury on the right heel, and a pressure injury on the posterior, midpoint aspect of the right lower leg. In a Teams meeting on 12/12/2022 at 2:00 PM, Resident 2's incident investigations were discussed with the Administrator, the Director of Nursing, and Governing Body members. The Director of Nursing stated they understood that things were missed. RESIDENT 1 The resident admitted to the facility on [DATE]. Review of a Concern Form, dated 11/18/2022, showed a hospice provider had made allegations a urinary catheter had not been inserted, a dressing change order had not been followed, and that the resident's spouse had voiced concerns that when they visited, the resident was always on their back. The facility investigated those allegations as a grievance/concern and their investigation was not thorough as it lacked witness statements by the complainant and the DON. The allegations did not get logged on the incident reporting log and there was no reporting to the State Survey agency that investigates allegations of abuse. Review of Staff XX's (Staff XX, Hospice RN Case Manager) Hospice Visit notes, dated 11/18/2022, showed upon their arrival, the urinary catheter had not been inserted per the plan of care, the dressing change orders did not get implemented as ordered, and that the resident's spouse had stated they had been there every day that week except one and each time found the patient on their back and they had to request staff to reposition them. The note indicated Staff XX was concerned about neglect and they were going to make a referral to the state agency responsible for investigating abuse, and that they notified the Director of Nursing of their concerns and that they were going to report their concerns. The note indicated the Director of Nursing was going to investigate. In a phone interview on 12/05/2022 at 8:18 AM, Staff XX stated they told the DON they were a mandated reporter and they were going to report their concerns. Reference: (WAC) 388-97-0640 (2)(a)(b)(5)(a)(6)(a)(b)(c )(7)(a) See related citations: F686 - Treatment and services to prevent and heal pressure ulcers F755 - Pharmacy services, procedures, pharmacist, records

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the Governing Body failed to provide adequate active and engaged oversight and monitoring of the facility's appointed Administrator, and they failed to ensure clear expectations were set around resident safety, quality, rights and respect. The Governing Body failed to ensure the Administrator had clinical systems and policies in place and that were followed related to Abuse/Neglect, Pressure Ulcers, Accidents, Pharmacy Services, Hospice Services, Medical Director, and that the Administrator ensured ongoing compliance with state/federal regulations. The Governing Body failed to ensure there was a professional nursing administration in place and that skilled nursing staff received professional supervision. The Governing Body failure to provide oversight and support to ensure all policies and procedures had been implemented and were being monitored placed all residents at risk for injury, abuse, decline in physical function, and diminished quality of life. Additional failed practice included the failure to ensure Quality Assurance and Performance Improvement (QAPI) programs were responsive and provided timely incident identification, reporting, investigation, analysis, documentation, and prevention of adverse events to Residents 1, 2, and 4. Immediate Jeopardy (IJ) was called on 12/02/2022 at 2:35 PM, at F755 - Pharmacy Services/Procedures/Pharmacist/Records, when the facility was found to have inadequate pharmaceuticals procedures and record-keeping procedures in place to ensure resident safety. IJ was also called on 12/08/2022 at 6:10 PM, at F835 - Administration, when the facility failed to ensure the nursing home was staffed and managed to address the significant clinical needs and quality of life and quality of care for residents. Multiple residents had unmet needs in multiple care areas. Findings included . Record review of the facility policy titled Quality Assurance and Performance Improvement, dated May 2022, showed: -the Governing Body was defined as the Assistant [NAME] President (Staff C), Regional Director of Operations (Staff B), and Staff A, Administrator of the facility. -the Governing Body was responsible for appointment of the Administrator who was legally responsible for establishing and implementing policies regarding the management and operation of the center. The Administrator reported to and was accountable to the Governing Body. -The center QAPI Committee reported to the center's Governing Body which was responsible and accountable for the QAPI program. In a Teams meeting on 12/12/2022 at 2:00 PM, Staff A, Staff B, and Staff C were unable to state how the facility had investigated and reviewed Resident 14's medication errors or how they had used their QAPI program to prevent future medication errors for other residents. Staff B and C were unable to state when the Governing Body had been made aware of Resident 14's medication errors. Staff E, Director of Nursing, was unable to state their involvement in Resident 14's multiple medication errors or the investigation process, or why the Administrator or Medical Director had not reviewed those errors/incident investigation. Staff E stated since Resident 14's medication errors weren't significant they had not yet taken those matters to QAPI, then Resident 4 had a similar medication error. The Governing Body members were unable to state if they had identified any systemic issues with their pharmaceuticals system when Resident 14 had their medication errors. Staff E stated they had not logged those medication errors on the incident reporting log. Staff A stated they had determined no staff had a serious disregard of the consequences, so they had not reported it according to the Purple Book (Washington State Nursing Home Guidelines for abuse prevention and protection, incident identification, investigation, and reporting). Staff A stated the facility Medical Director had not been notified of Resident 14's medication errors. The Governing Body members were unable state how the facility had protected other residents from similar medication errors as Resident 14's medication errors/incident. Staff E stated Resident 4 had an Oxycodone medication error (about 10 days after Resident 14) when the same nurse that failed to follow facility order entry/verification policies for Resident 14 also failed to properly confirm Resident 4's admission medication orders. The Governing Body was unable to state how the facility had implemented their resident protection policy for Resident 2 who had pressure injury skin incidents on 10/13/2022 and 10/21/2022, Staff E stated they understood information was missing from the incident investigations, and that only they had reviewed the incidents, and not the Administrator or Medical Director. Staff E was asked about lack of care planned care for Resident 2 after they moved rooms from one hallway to another, no information was provided. The Governing Body was asked how they had set clear standards for the Administrator regarding their expectations for how the facility was to be administered and policies implemented, Staff B stated those were the expectations for all of their facilities, and since the newest concerns had been brought to light, the Governing Body has been working tirelessly over the weekend to audit, correct and educate on findings. In a phone interview on 12/13/2022 at 12:04 PM, the Governing Body was asked how they ensured the facility had implemented their QAPI plan regarding preventing repeat incidents after incidents had occurred, Staff B stated if there was an open issue or timeline or an issue came to them, then they would discuss on the phone to address the issue. Staff B stated they were Governing Body for 13 facilities. Staff A stated that prior to recent events, the facility had identified no concerns with their hospice care. Staff A stated if there were any pharmacy reports to review, the Medical Director would review them. Reference: (WAC) 388-97-1620 (2)(c ) See related citations: F607 - Develop/implement abuse/neglect policies F684 - Quality of care F686 - Treatment and services to prevent/heal pressure ulcers F755 - Pharmacy services, procedures, pharmacist, records F835 - Administration

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), Special Focus Facility, 3 harm violation(s), $262,029 in fines, Payment denial on record. Review inspection reports carefully.
• 130 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $262,029 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

Email me this report

About This Facility

What is Alderwood Post Acute & Rehabilitation's CMS Rating?

CMS assigns ALDERWOOD POST ACUTE & REHABILITATION an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Alderwood Post Acute & Rehabilitation Staffed?

CMS rates ALDERWOOD POST ACUTE & REHABILITATION's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 70%, which is 24 percentage points above the Washington average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 77%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Alderwood Post Acute & Rehabilitation?

State health inspectors documented 130 deficiencies at ALDERWOOD POST ACUTE & REHABILITATION during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 124 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Alderwood Post Acute & Rehabilitation?

ALDERWOOD POST ACUTE & REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by HILL VALLEY HEALTHCARE, a chain that manages multiple nursing homes. With 113 certified beds and approximately 98 residents (about 87% occupancy), it is a mid-sized facility located in LYNNWOOD, Washington.

How Does Alderwood Post Acute & Rehabilitation Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, ALDERWOOD POST ACUTE & REHABILITATION's overall rating (2 stars) is below the state average of 3.2, staff turnover (70%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Alderwood Post Acute & Rehabilitation?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the facility's high staff turnover rate.

Is Alderwood Post Acute & Rehabilitation Safe?

Based on CMS inspection data, ALDERWOOD POST ACUTE & REHABILITATION has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Alderwood Post Acute & Rehabilitation Stick Around?

Staff turnover at ALDERWOOD POST ACUTE & REHABILITATION is high. At 70%, the facility is 24 percentage points above the Washington average of 46%. Registered Nurse turnover is particularly concerning at 77%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Alderwood Post Acute & Rehabilitation Ever Fined?

ALDERWOOD POST ACUTE & REHABILITATION has been fined $262,029 across 3 penalty actions. This is 7.3x the Washington average of $35,699. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Alderwood Post Acute & Rehabilitation on Any Federal Watch List?

ALDERWOOD POST ACUTE & REHABILITATION is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 113
Avg. Residents: 98
Occupancy: 87.0%
Ownership: For profit - Corporation
Chain: HILL VALLEY HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
High Turnover: -5
2 Immediate Jeopardy citations: -24
3 Actual Harm citations: -15
130 Deficiencies: -10
Fines ($262,029): -15
Abuse Finding: -15
Special Focus Facility: -20
Final Score: 0/100

Nearby Alternatives

REGENCY CARE CENTER AT MONROE 5-star BETHANY AT SILVER LAKE 5-star JOSEPHINE CARING COMMUNITY 5-star

View all in LYNNWOOD →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505319