What is OLYMPIC VIEW CARE's CMS rating?

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

How many inspection deficiencies does OLYMPIC VIEW CARE have?

OLYMPIC VIEW CARE has 90 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at OLYMPIC VIEW CARE?

OLYMPIC VIEW CARE has a four-star staffing rating from CMS with 0.54 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 OLYMPIC VIEW CARE located?

OLYMPIC VIEW CARE is located in PORT ANGELES, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does OLYMPIC VIEW CARE have?

OLYMPIC VIEW CARE has 101 certified beds.

Who owns OLYMPIC VIEW CARE?

OLYMPIC VIEW CARE is a for profit - corporation facility and is part of the CALDERA CARE chain.

Is OLYMPIC VIEW CARE safe?

OLYMPIC VIEW CARE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at OLYMPIC VIEW CARE stick around?

OLYMPIC VIEW CARE has average staff turnover at 44%, which is typical for the nursing home industry.

Was OLYMPIC VIEW CARE ever fined?

Yes, OLYMPIC VIEW CARE has been fined $35,997 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is OLYMPIC VIEW CARE on any federal watch list?

No, OLYMPIC VIEW CARE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at OLYMPIC VIEW CARE?

Medicare inspectors have found 90 deficiencies at OLYMPIC VIEW CARE: 3 serious, 86 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting OLYMPIC VIEW CARE?

Families visiting OLYMPIC VIEW CARE should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does OLYMPIC VIEW CARE compare to other nursing homes?

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

OLYMPIC VIEW CARE | 20/100 (Grade F)

Sept 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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to involve the resident's representative in the development of the res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to involve the resident's representative in the development of the resident's plan of care, inform the representative of changes in the plan of care and review the plan of care for 1 of 3 (Resident 1) residents reviewed. This failure placed residents at risk of lack of advocacy for their healthcare needs, preferences and medical history. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and diabetes (a condition where the body does not produce or use insulin effectively, leading to high blood sugar levels).Resident 1's Clinical admission Assessment, dated 08/05/2025, showed Resident 1 was chronically confused and had moderate cognitive impairment.Resident 1's Durable Power of Attorney for Health Care (DPOA-HC) dated 10/02/2023 and uploaded to Resident 1's electronic medical record (EMR) on 08/05/2025, showed Collateral Contact 1 (CC1) was Resident 1's chosen agent and was effective on the date the DPOA-HC was signed.On 09/09/2025 at 1:10 PM, CC1, said Resident 1 had been a diabetic for years and had been on insulin to manage their diabetes. CC1 said when Resident 1 was admitted to the facility Resident 1 had not been admitted with insulin orders but CC1 was not informed of that. CC1 said the facility discontinued many of Resident 1's medications for their bipolar disorder that had kept their condition stable without notifying CC1. CC1 said staff informed them the medications were discontinued due to Resident 1 having nausea and vomiting. CC1 said they had not been informed that any medications had been discontinued and were very concerned because CC1's diabetes and bipolar disorder had been stabilized with those medications. CC1 said they were working with an assisted living facility for Resident 1 to move to after their stay at the facility. CC1 said the assisted living facility could not accept Resident 1 due to unstable blood sugar levels. CC1 said they had never seen Resident 1's care plan and had requested to view it, a list of Resident 1's medications, including when medications had been started and stopped and the blood sugar readings. CC1 said they were not contacted until the end of August by the medical provider but had still not received the plan of care and/or the answers to the specific questions regarding the medications even after repeated requests. CC1 said the staff had not made an effort to collaborate with CC1 regarding the plan of care.Resident 1's progress notes, dated 08/06/2025, showed Resident 1 continued with nausea and vomiting, up throughout the night with emesis (vomit) brown liquid and the medical provider notified.Resident 1's progress note, dated 08/07/2025, showed an IV (a catheter used to administer medications and/or liquids into a vein) was inserted and Sodium Chloride (solution used to rehydrate) was running per the orders.Resident 1's medical provider notes, dated 08/07/2025, showed Resident 1's dementia was advanced, and they were oriented to self and place but had marked short term memory loss. The note showed since arrival at the facility, Resident 1 had nausea and vomiting, somnolence (sleepiness), and poor intake. The note showed the nausea, vomiting, and somnolence was possible due to medication or metabolic cause and the plan was to order labs and start IV fluids for 48 hours for hydration. The noted showed staff were to discontinue medications to include medications for diabetes and bipolar disorder.Resident 1's EMR (electronic medical record) showed no notification to CC 1 regarding the medications being discontinued, lab orders and/or the IV hydration.Resident 1's medical provider notes, dated 08-29-2025, showed a care conference was held with the resident and CC1. The note showed the staff discussed multiple issues regarding Resident 1's admission, medication management and progress.On 09/17/2025 at 1:12 PM, CC2, resident advocate, said they had attended Resident 1's care conference on 08/29/2025 and the facility staff were unable to answer all CC1's questions. CC2 said it was very frustrating.Review of an email from CC1 to facility staff, dated 09/04/2025, showed CC1 addressed concerns to the team that was taking care of Resident 1 to include: the plan for Resident 1 due to their insurance ending, an assessment of Resident 1's current condition, Resident 1's medication list, a final report from PT [physical therapy], OT [occupational therapy] and ST [speech therapy]. The email showed that CC1 did not know Resident 1's plan of care and it was not discussed in the care meeting.Review of an email from facility staff, dated 09/04/2025, showed facility staff responded to CC1's questions but wrote that CC1 should let them know if they still had concerns.Review of an email from CC1 to facility staff, dated 09/05/2025, showed CC1 had questions that were not addressed in the 09/04/2025 email from facility staff and had asked for a care plan and had not received it. CC1 wrote it was a deep concern to them. CC1 requested information about a swallowing issue from the evening prior. Facility staff responded to the email on 09/05/2025 and said they would schedule a care conference to address the rest of the questions.Review of an email from CC1 to facility staff, dated 09/10/2025, showed CC1 was following up regarding the care conference, they had not heard from the staff.Review of an email from CC1 to facility staff, dated 09/11/2025, showed CC1 had asked for a care meeting to answer CC1's questions and had not heard back. The email showed CC1 had questions regarding medication status, therapy and discharge, and the email showed CC1 was upset at the lack of response to their questions and requests.On 09/17/2025 at 2:33 PM, Staff A, Resident Care Manager and licensed practical nurse, said they had been Resident 1's care manager since admission on [DATE]. Staff A said they had a care conference on 09/16/2025 with CC1 and that was the first time they had spoken to them. Staff A said it was the responsibility of the license nurses on the floor to notify residents' representatives of changes in a resident's care.On 09/17/2025 at 4:00 PM, Staff B, Director of Nursing, said they expected when residents had a change in condition and/or changes to the plan of care the DPOA-HC should be notified. Staff B said CC1 should have been notified of Resident 1's clinical change of condition, medications changes and plan of care. When asked if CC1 should have been sent Resident 1's plan of care, Staff B said yes, they should have had that information. On 09/17/2025 at 5:33 PM, Staff C, Administrator, said they understood why CC1 was frustrated, and they should have been involved in Resident 1's care since admission to include the plan of care and changes to their medications.WAC Reference 388-97-1000(1)(a),1020 (2)(f)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain and monitor laboratory tests timely per physician orders for ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain and monitor laboratory tests timely per physician orders for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of clinical complications, unstable medical conditions and delayed recovery. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and diabetes (a condition where the body does not produce or use insulin effectively, leading to high blood sugar levels).Resident 1's medical provider notes, dated 08/07/2025, showed since arrival at the facility, Resident 1 had nausea and vomiting, somnolence (sleepiness), and poor intake. The note showed the nausea, vomiting, and somnolence was possible due to medication or metabolic cause and the plan was to order labs and start IV fluids (liquids administered through a catheter in the vein) for 48 hours for hydration. The note showed the plan was to order laboratory tests. Resident 1's physician orders, dated 08/07/2025, showed an order to draw a CMP (test to monitor electrolyte balance), CBC (blood test that measures the number and types of cells in the blood), TSH (blood test to monitor thyroid function), Hgb A1C (lab related to diabetes) and a valproic acid level (anti-seizure medication - checking for level of medication in blood).Resident 1's provider notes, dated 08/19/2025, showed labs still pending and Depakote was held pending labs.Review of Resident 1's laboratory results, dated 08/25/2025, showed results for CMP, CBC, and TSH.Review of Resident 1's laboratory results, dated 09/04/2025, showed results for a valproic level.Review of Resident 1's electronic medical record (EMR) showed no result for the Hgb A1C.On 09/17/2025 at 2:33 PM, Staff A, Resident Care Manager and Licensed Practical Nurse, reviewed Resident 1's EMAR and contacted the facility laboratory to obtain all lab results from Resident 1. Staff A could not locate a Hgb A1C lab result and verified the CMP, CBC and TSH were not collected until 08/25/25 and the valproic acid level was completed on 09/04/2025.On 09/17/2025 at 4:00 PM, Staff B, Director of Nursing, said when medical providers order labs to be drawn they expect them to be completed timely.WAC Reference 388-97-1620(2)(b)(i)

Aug 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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation, interview and record review, the facility failed to ensure the resident or resident representatives' righ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation, interview and record review, the facility failed to ensure the resident or resident representatives' right to make healthcare choices was upheld. Specifically, the facility did not provide the resident's representative with adequate information or involvement in decision making related to care and treatment for 1 of 3 residents (Resident 1). This failure placed residents and their representatives at risk of not being able to make informed decision regarding care and services.Findings included.A Resident Rights Policy, undated, given to all residents and or resident's representatives on admit, stated, You have the right to be informed of, and participate in, your treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option you prefer.Resident 1 admitted to the facility on [DATE] and had a history of skin cancer. The quarterly MDS, dated [DATE], showed Resident 1 had severe cognitive impairment and was dependent on staff for all activities of daily living. Review of the Treatment Administration Record for July 2025 showed Resident 1 was receiving wound care for a cancerous lesion to their forehead, two times a day. Review of a wound care progress note, dated 07/28/2025, documented the wound had excessive drainage and was very painful for the resident. During interview on 08/01/2025 at 10:45 AM, Staff C, Licensed Practical Nurse (LPN) said they were called into Resident 1's room around 5:00 AM on 07/30/2025 as maggots had been discovered in the wound. Staff C said they reported it to the oncoming nurses but did not notify the family.Review of a progress note, dated 07/31/2025 at 8:21 AM, showed moving organisms were present in the wound during a dressing change. The note showed a supervisor and a charge nurse were notified but did not make note that family was notified.Review of a Social Services progress note, dated 07/31/2025 at 9:28 AM, showed the facility provider had spoken with the family in regard to moving Resident 1 to a private room but did not mention any discussion about the maggot infestation. During interview on 08/01/2025 at 1:15 PM, Staff D, Physician Assistant -Certified, Travel Agency, said they provided the best treatment they could for the infestation. When asked why Resident 1 was not sent to the hospital, Staff D said they were told by facility staff that the family did not want hospitalization. When asked if they had spoken to the family, Staff D stated, No, because I thought [Staff B, Director of Nursing (DNS)] had.On 08/01/2025 at 3:12 PM, Staff B, DNS, said they did not notify the family. When asked if the family should have been notified so that they could have made an informed decision about treatment including possible hospitalization, Staff B stated, Yes, everyone has that right, but I thought the nurse that found the maggots talked to them.Reference WAC 388-97-0300(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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents and staff rela...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents and staff related to shower rooms, utility rooms, and equipment storage rooms. This failure placed residents and staff at risk for injury, cross contamination (process by which bacteria or other microorganisms are transferred from one subject or object to another), and a decreased quality of life. Findings included.During an observation on 08/12/2025 at 1:15 PM, the shower room on the [NAME] wing was observed. The floor was littered with garbage (used gloves, paper towels, wipes). There were several personal hygiene items (body wash, shampoo, lotions) open and scattered around the room. The toilet had a brown ring inside of it with a piece of toilet paper hanging down. The drain for the shower was not covered. The exhaust fan in the ceiling was not covered and had wires hanging down.During an observation on 08/12/2025 at 1:30 PM, resident room [ROOM NUMBER] was observed. The door was open. There were several pieces of equipment being stored (beds, wheelchairs, air mattresses, mechanical lift devices). An air mattress was observed on the floor where dirt and dead insects were seen. Two garbage containers were noted by the door with lids ajar. Inside were bags of used incontinence products. There was a laundry container that had bags of dirty clothes. During an observation on 08/12/2025 at 1:40 PM, the soiled utility room on the East wing was observed. There was garbage on the floor (oxygen masks and gloves). Isolation carts filled with clean gloves, gowns, and masks were observed. The hopper (a type of sink used for waste disposal, such as feces) was empty of water with dark brown rings on the inside.During an observation on 08/12/2025 at 1:50 PM, the shower room on the North wing was observed. There was an uncovered outlet with visible wires. During an interview on 08/12/2025 at 2:00 PM, Staff E, Housekeeping Supervisor, said the garbage and soiled linen containers should not be in room [ROOM NUMBER]. Staff E said the bins should be in a soiled utility room, but the nursing aides moved them out of the shower room due to not having enough space. When asked if the equipment in room [ROOM NUMBER] was clean or dirty, Staff E said they didn't know. During an interview on 08/12/2025 at 2:10 PM, Staff A, Administrator, observed the [NAME] and North shower rooms, the dirty utility room on the East wing, and room [ROOM NUMBER]. They said these rooms were not in safe or sanitary conditions. Staff A said garbage and soiled linen containers should be stored in a dirty utility room. They said isolation carts with clean supplies should not be stored in the dirty utility room. Refer to F552Reference WAC 388-97-3220(1).

Aug 2025 2 deficiencies 1 Harm

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

Incontinence Care (Tag F0690)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation, interview, and record review, the facility failed to provide the appropriate care and services for 2 of 3...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation, interview, and record review, the facility failed to provide the appropriate care and services for 2 of 3 residents (Resident 1 and Resident 2) reviewed for indwelling catheter (a flexible tube inserted into the bladder to drain urine) care and maintenance. Resident 1 experienced harm when their indwelling suprapubic urinary catheter was not changed monthly as ordered and required hospitalization due to catheter related complications. This failure placed residents with indwelling catheters at risk of medical complications. Findings included.An Indwelling Catheter Policy, revised 12/2024, stated indwelling catheters need, Orders to include type of catheter (size and balloon size), diagnosis, and catheter change orders to include change complete catheter system prn, blockage, leakage, encrustation, catheter care every shift and change catheter bag as needed.<Resident 1>Resident 1 admitted to the facility on [DATE] with a diagnosis of obstructive uropathy (a urinary tract disorder that occurs when the urine flow is blocked) and had an indwelling urethral catheter. The quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was cognitively intact and needed minimal assistance with activities of daily living (ADL's). Review of the electronic medical record (EMR) showed Resident 1 had the indwelling urethral catheter removed and a suprapubic (small opening in the lower abdomen through which a catheter is inserted directly into the bladder) catheter placed on 07/25/2024. Orders documented to follow up in four to six weeks for catheter change. Resident 1 was seen at a clinic on 08/24/2025 where the suprapubic catheter was changed and was sent with orders following that visit said to change out the catheter monthly. Review of the care plan, dated 07/26/2024, showed to document the size and type of catheter to change the catheter per physician order. Review of the Treatment Administration Record (TAR) from July of 2024 to June of 2025 did not have an order to change the catheter.Review of the EMR showed the suprapubic catheter was changed out by the facility Physician Assistant-Certified (PA-C) on 10/02/2024 and 11/12/2024. Review of a Resident Choice of Medication, Treatment and/or Dietary Restriction form, dated 11/12/2024, was signed by the PA-C and Resident 1. The form addressed the following risks of not changing the catheter out monthly: urinary tract infection, catheter blockage, bladder spasms, skin breakdown, bladder stones, and/or kidney failure. o Review of progress notes, dated 12/19/2024, 02/01/2025, and 03/10/2025, showed Resident 1 refused the catheter change. No further documentation was provided regarding possible alternatives or the increase in risks. There was no documentation about catheter changes or refusals for January 2024, April 2024, May 2024, or June of 2024. Facility records showed the catheter had not been changed since 11/12/2024 through 06/24/2025 (224 days) when the resident was sent to the hospital. Review of progress notes showed Resident 1 was sent to the hospital on [DATE] due to not having urine output in the collection bag attached to the suprapubic catheter. Review of hospital documentation, showed Resident 1 had significant cellulitis (infection of the skin) along the inside of both legs and groin area from leaking urine. The emergency department attempted to remove the suprapubic catheter, but it was too painful due to calcifications (buildup of calcium salts which harden) that were formed inside the bladder. Resident 1 was admitted to the hospital for surgical removal of the suprapubic catheter and intravenous (in the vein) medications for cellulitis and a urinary tract infection. On 07/29/2025 at 3:40PM, Staff C, Registered Nurse (RN), said they were aware of Resident 1's skin issues but didn't realize how bad they were until the wound nurse notified them on 05/16/2025 and they went to assess. Staff C said there was a strong urine odor. Resident 1 was sent to the hospital and was diagnosed with dermatitis (skin inflammation), was prescribed cream, and was sent back the same day. Staff C said they thought the dermatitis was caused by Resident 1 emptying his urine bag and having some dribble down the legs. When asked if the nursing team had discussed the catheter being changed out, Staff C said they did not. When asked if the skin conditions could have been caused by the catheter becoming obstructed and leaking, they said yes. Staff C said they thought the PA-C was changing it. When asked if changing a suprapubic catheter was within the scope of an RN, they said yes. On 07/29/2025 at 4:25PM, Staff B, Director of Nursing (DNS), said they were not aware that the catheter had not been replaced for several months. Staff B said they thought the PA-C was completing that task. When asked if the facility had a policy for suprapubic catheters, Staff B said they did not. When asked if changing a suprapubic catheter was within the scope of an RN, they responded, yes. On 07/29/2025 at 5:06PM, Resident 1 had returned from the clinic after having their catheter changed. Resident 1 said they had been under the impression that the catheter needed to be changed every 6 months or so. When asked if they had understood the severe complications that could happen if the catheter was not changed out monthly, Resident 1 said they did not. They said if they had, they would never have refused. <Resident 2>Resident 2 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairment and was dependent on staff for all ADLs. Review of the care plan, dated 05/16/2025, showed Resident 2 had a urethral foley catheter in place. The care plan interventions and tasks did not include when the catheter needed to be replaced. Review of the TAR showed an order for the catheter to be changed every month with a start date of 02/06/2024. The TAR showed the catheter was not changed for the month of May 2025. On 07/29/2025 at 4:40PM, Staff B, DNS, said all catheter care and maintenance should be on the care plan. They said orders should be obtained for changing out a catheter on admit or as soon as a catheter is placed. Reference WAC 388-97-1060(3)(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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on interview and record review, the facility failed to report and investigate an incident of potential neglect for 1 of 1...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on interview and record review, the facility failed to report and investigate an incident of potential neglect for 1 of 1 resident (Resident 1) reviewed for hospitalization related to a preventable complication of a suprapubic catheter. This failure limited the opportunity for the facility to identify and correct system failures that contributed to the residents' decline.Findings included.Resident 1 admitted to the facility on [DATE] with a diagnosis of Obstructive Uropathy (a urinary tract disorder that occurs when the urine flow is blocked) and had an indwelling urethral (the tube that carries urine from the bladder out of the body) catheter (a tube inserted into the bladder to drain urine). The quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was cognitively intact and needed minimal assistance with activities of daily living (ADL's). On 07/25/2024, the urethral catheter was replaced with a suprapubic (small hole in the lower abdomen leading to the bladder) catheter. Resident 1 was admitted to the hospital on [DATE] due to an obstructed (blocked) suprapubic catheter. Review of the hospital documentation showed calcifications (build up of calcium salts that harden) had grown around the insertion site in the bladder. The balloon (fluid filled end of the catheter that holds it inside of the bladder) of the catheter was hardened and difficult to remove. Resident 1 had to undergo surgical and intravenous (in the vein) medication interventions for removal of the catheter and for cellulitis (skin infection), caused by leaking urine, to the groin area and down both legs. Review of facility records showed the catheter had not been changed since 11/12/2024. Review of clinical orders, dated 08/28/2024, showed the catheter should have been changed monthly. On 07/07/2025 at 2:35PM, Staff B, Director of Nursing (DNS) was asked about the investigation into the hospitalization for Resident 1. They said they had not completed one. When asked if they were aware the hospital had requested documentation regarding the last time the suprapubic catheter had been changed, they said they were not. On 07/29/2025 at 1043 AM, Staff D, Admissions Coordinator, said they had called and emailed Staff B on 06/24/2025 about receiving the records request from the hospital. Staff D said they were told by Staff B that the catheter was being changed by an outside clinic and did not have the records. On 07/29/2025 at 4:50PM, Staff B, DNS was asked if they had been contacted by Staff D, Admissions Coordinator on 06/24/2025 about the request for the records. Staff B said they didn't remember. On 07/29/2025 at 5:00PM, Staff A, Administrator, said the catheter complication and subsequent hospitalization should have been investigated. They said the incident should have been reported to the appropriate agencies. Reference WAC 388-97-1640(5)(a)

May 2025 21 deficiencies

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to immediately notify the physician and resident representative of ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to immediately notify the physician and resident representative of significant changes in physical condition, for 2 of 5 residents (Resident 15 & 28) reviewed for nutrition. This failure placed residents at risk for a delay in medical/nutritional treatment and not having their representatives involved in the health care decision making process for timely care and services. Findings included . 1) Resident 15 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/09/2025, documented Resident 15 was severely cognitively impaired. The electronic health record (EHR) documented Resident 15's weight as 100.1 pounds (lbs) on 03/03/2024, the last documented weight in the weights/vitals tabs. On 05/07/2025, the resident weighed 85.8 lbs which was a -14.29 % loss in twelve months. A Nutritional Assessment, dated 03/07/2025, documented Resident 15 weighed 111.6 lbs on 09/21/2024. This weight was not documented under the weights/vitals tab. On 05/07/2025, the resident weighed 85.8 lbs which was a -23.12 % loss since 09/21/2024. On 05/08/2025 at 9:24 AM, Resident 15's Durable Power of Attorney (DPOA, legal decision marker) said they had noticed Resident 15 had been losing weight because the residents arms and legs were thin. When informed of Resident 15's current weight loss, Resident 15's DPOA confirmed no one from the facility had notified them of the significant weight loss. Resident 15's DPOA said he was concerned Resident 15 had lost that much weight. On 05/09/2025 at 8:22 AM, Staff C, Resident Care Manager (RCM), said when a resident had lost weight the DPOA, provider and Registered Dietitian (RD) should have been notified, even if the weight loss was expected. Staff C reviewed the EHR and confirmed neither the DPOA, provider or RD had been notified of the weight loss. On 05/09/2025 at 9:20AM, Staff B, Director of Nursing Services (DNS), said when a resident was losing weight, the nutritional team had a weekly meeting to discuss weights, quality of care, and quality of life interventions. Staff B said the provider, DPOA, and RD needed to be notified when a resident lost weight. Staff B reviewed Resident 15's EHR and confirmed there was no notification to the DPOA, RD or provider of the 05/07/2024 significant weight loss. 2) Resident 28 was admitted to the facility on [DATE] with a diagnosis of dementia. The Quarterly MDS, dated [DATE], showed Resident 28 was rarely understood or rarely understands. On 05/05/2025 at 2:04 PM, Resident 28's family member reported they were concerned Resident 28 was losing weight, they could see the weight loss on Resident 28's shoulders, and that Resident 28 had a high level of activity/moved around a lot. Review of the facility's weight binder, on 05/08/2025, showed Resident 28 had a weight obtained sometime in May 2025, at 156.2 lbs. There was no specific date listed for the weight. Using 05/08/2025, as the best approximation of the date the weight was obtained, review of weights showed the following: 1 month: On 04/06/2025, the resident weighed 166.6 lbs. On 05/08/2025, the resident weighed 156.2 pounds which was a -6.24 % Loss. 3 month: On 02/04/2025, the resident weighed 169.4 lbs. On 05/08/2025, the resident weighed 156.2 pounds which was a -7.79 % Loss. During an interview on 05/12/2025 at 1:59 PM, Staff C, RCM, said weights should be put into the EHR right away. Staff C reviewed the EHR and confirmed Resident 28's May 2025 weight was not yet put in the EHR. When asked if the weight not being inputted into the EHR meant the power of attorney had not been notified yet, Staff C agreed and said and they would make sure this would happen. During an interview on 05/13/2025 at 10:43 AM, Staff B, DNS, when asked how they met the requirement for notification of changes when staff were not inputting weights into the EHR right away, said the weight binder was just to make it easier for the certified nursing assistants to document, but the expectation was that nursing would put the numbers into the EHR on the same shift. Regarding Resident 28's weight not being inputted into the EHR right away, Staff B said it was now in the EHR and triggered as a significant weight change, and they would have expected weights to have been put in the EHR on the same shift and notifications made to the provider. Reference WAC 388-97-0320 .

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to comprehensively assess for the use of bed rails/mobility bars, the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to comprehensively assess for the use of bed rails/mobility bars, the use of a bed against the wall, and a wander guard for 4 of 4 sample residents (Residents 19, 20, 3 and 24) reviewed for physical restraints. This failure placed residents at risk of potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . <Wander Guard> 1) Resident 19 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 04/21/2025, documented Resident 19 was moderately cognitively impaired and had a wander/elopement alarm used daily. A review of Resident 19's Electronic Health Record (EHR) showed an order dated 03/04/2025 for a wander guard placement due to elopement risk related to psychosis (a condition where a person experiences a significant loss of contact with reality, often marked by hallucinations, delusions, and disordered thinking). On 05/09/2025 at 9:29 AM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM), said a resident should have an order for the wander guard and a safety evaluation and it should be care planned. Staff C said, I am not seeing a safety evaluation and ideally there should be one. On 05/12/2025 at 11:30 AM, Staff B, Director of Nursing (DNS), said she did not see an elopement and safe device evaluation and it should have been completed. <Bed Against the Wall> 2) Resident 20 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 20 was cognitively intact. A review of Resident 20's EHR showed an order dated 02/17/2025 for Safety device: Bed against wall and a document titled Safety Device Data Collection, Evaluation, and Information dated 02/17/2025 said it provided information to the resident and power of attorney (POA) and was signed by the DNS. On 05/13/2025 at 11:05 AM, Staff B, DNS, said she could not find a Physical Therapy (PT) evaluation or documentation of less restrictive options tried first in the EHR before Resident 20's bed was placed against the wall. Staff B said her expectation was for a PT evaluation to be completed and interventions be documented and attempted before the bed was placed against the wall. <Loose mobility bars> 3) Resident 3 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 3 was severely cognitively impaired. Record review showed a physician's order, dated 01/06/2023, for two bed mobility bars for safe mobility. On 05/06/2025 at 8:44 AM, Resident 3's right and left mobility bars were assessed for stability and found to be loose, the bars moved forward towards the bed mattress as well as side to side. On 05/09/2025 at 9:50 AM, Staff J, Certified Nursing Assistant, when asked if Resident 3 used their mobility bars, said, yes they did when prompted and sometimes on their own. When asked if the mobility bars were supposed to be loose, Staff J physically moved the right mobility bar and said, I'm not sure why it is moving so much, it seems loose and I will put it in the maintenance log, it should have a little give but not like that. When Staff J checked the left mobility bar, she said, It moves forward a little, it seems better than the other one. Staff J said I think they should be solid, they shouldn't move. On 05/09/2025 at 11:47 AM, Staff C, RN/RCM, said mobility bars should be stationery and solid, if they move around a resident could get hurt. On 05/09/2025 at 11:52 AM, Staff C went to Resident 3's room and physically moved the left mobility bar. When asked if it was loose, Staff C said Yes, maintenance puts these on, that is concerning. Staff C then moved the right mobility bar, moved it and said, Oh, that is not good. Staff C said the right mobility was loose, and she would make sure it got fixed. When asked about the potential risks of loose rails, Staff C said, falls and injuries. When asked if entrapment was also a risk, Staff C said Yes, it seems extreme, but they could get trapped and die. On 05/12/2025 at 9:41 AM, Staff C, said Resident 3's loose bed rails did not meet her expectations and if staff noted a bed rail was loose it should have been fixed as soon as possible. <Lack of comprehensive assessment for bed mobility bars> On 05/12/2025 at 9:41 AM, Staff C, RCM, when asked if documentation of an assessment (evaluates for safety or entrapment concerns) for bed mobility bars had been done for Resident 3, Staff C said it would be found in the EHR under Progress Notes, that to her knowledge there was not a specific form the facility used to document the assessment, and she could not locate an assessment in progress notes for Resident 3. Staff C said she thought the therapy department completed assessment. On 05/12/2025 at 1:05 PM, Staff K, Physical Therapy Assistant/Therapy Director, when asked who completed the evaluations/assessments for safety equipment like bed rails or beds against the wall, Staff K said therapists make recommendations but the evaluation/assessment come from nursing. It was up to the nursing staff to do the evaluation. Staff K said after therapy makes a recommendation, a communication note goes into the EHR to nursing and it was up to nursing to follow up and do the final assessment for safety. On 05/12/2025 at 1:08 PM, when told the Therapy Director said they make recommendations and it is up to nursing to do the assessment and asked to provide documentation that Resident 3 was assessed prior to bed rails being applied, Staff C, RCM said, ideally the nurse would do an assessment, but she had thought therapy did it. Staff C said she would have to get back to me. No further documentation was received. On 05/13/2025 at 2:58 PM, Staff C was asked for documentation that less restrictive alternatives were attempted for Resident 3 prior to putting on the mobility bars, Staff C said she could not see anything in the EHR. <Lack of assessment, orders, or care plan for bed against the wall> 4) Resident 24 admitted to the facility 03/06/2020. The Quarterly MDS, dated [DATE], documented Resident 24 was rarely/never understood, rarely/never understood others and was severely impaired in making decisions of daily life. On 05/06/2025 at 8:18 AM, Resident 24's bed was observed to be pressed against a fall mattress, which was between the bed and the wall. On 05/08/2025 at 9:18 AM, Resident 24's bed was observed against the wall, with no fall mattress in between the bed and the wall. On 05/12/2025 at 12:31 PM, when asked what elements needed to be in place before a bed was put against the wall, staff S said a safety device evaluation, orders, it should be added to the care plan, and a consent obtained. When asked if there was an assessment done for Resident 24's bed against the wall, Staff C said therapy would have done the assessment. When asked if there was an order for the bed against the wall, Staff C said she could not locate an order. When asked if there was a care plan for Resident 24's bed against the wall, Staff C said she could not see it, and it should be there. On 05/12/2025 1:05 PM, Staff K, said nursing would do the assessment for a bed being placed against the wall. On 05/12/2025 at 1:08 PM, Staff C was asked to provide documentation that an assessment had been completed for Resident 24's bed being placed against the wall. No further documentation was provided. On 05/13/2025 at 2:58 PM, when asked to provide documentation of a less restrictive alternative had been attempted prior to putting Resident 24's bed against the wall, Staff C said she did not see anything in the EHR. On 05/13/2025 at 1:26 PM, when asked who in the facility was responsible for assessing the risks for each resident with devices or interventions, such as risk of entrapment, Staff B, DNS, said the process started with rehabilitation (therapy), and then goes to the RCM's. Staff B said before the device or safety intervention were implemented the RCM would document any interventions that were tried before the safety device was put into place.When asked where assessments were documented, Staff B said along with interventions that were attempted, her expectation was that any initial interventions and assessment would be documented under progress notes or an evaluation prior to device or safety intervention being implemented. Reference WAC 388-97-0620(1) .

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) asse...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected residents' mental health diagnoses for 2 of 5 sampled residents (Residents 62 & 48) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their mental health needs. Findings included . 1) Resident 62 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/24/2025, showed the resident had severe cognitive impairment, a diagnosis of depression, and demonstrated signs and symptoms of delirium (a serious change in mental abilities, resulting in confused thinking and a lack of awareness of someone's surroundings) including inattention and altered levels of consciousness. Resident 62 received both antipsychotic and antidepressant medication during the assessment period. A level 1 PASRR, dated 04/16/2025, assessed Resident 62 had no indicators of serious mental illness (SMI), and did not require a level 2 PASRR referral. Review of the electronic health record (EHR) showed Resident 62 had 04/21/2025 orders for the following: - aripiprazole (an antipsychotic) every morning for delirium related to acute cystitis (infection of the bladder). - duloxetine (an antidepressant) every morning for depression. - quetiapine (an antipsychotic) daily at bedtime for depression. On 05/12/2025 at 3:52 PM, Staff C, Resident Care Manager, said Resident 62's level 1 PASRR was inaccurately completed and needed to be updated. Staff C said Resident 62's diagnoses of depression and delirium/psychosis should have been identified and level 2 PASRR referral made. 2) Resident 48 was admitted to the facility 02/07/2024. The Significant Change MDS, dated [DATE], showed they rarely or never understood others, and were sometimes understood. Resident 48 had diagnoses of depression (mood disorder characterized by persistent feeling of sadness) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). The level 1 PASRR, completed 02/06/2024, did not show documentation of the diagnoses of depression or anxiety disorder. A level 2 PASRR assessment, dated 02/29/2024, which used the inaccurate level 1 PASRR assessment, that failed to identify the resident's underlying mental health diagnoses of depression and anxiety disorder, to invaliadate the level 2 PASRR referral. On 05/08/2025 at 3:21 PM, Staff A, Administrator, acknowledged Resident 48 had diagnosis of depression and anxiety. When reviewing with Staff A the level 1 from 02/06/2024 did not include the depression and anxiety diagnosis, and the Invalidation assessment was based on the level 1, Staff A was asked if the facility should have caught this and completed a new level 1 and referral for level 2. Staff A said, yes, we should have caught it, that was our error. Refer to F-605 Reference WAC 388-97-1915 (1)(2)(a-c) .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 32 residents (Residents 127 & 20). Facility staff's failure to administer medications in accordance with physician's orders, and to complete assessments and treatments as ordered placed residents at risk for ineffective treatment of disease processes, medication adverse side effects and other potential adverse health outcomes. Findings included . 1) Resident 127 admitted to the facility on [DATE] with orders for intravenous (IV) cefazolin (antibiotic) every eight hours at 8:00 AM, 4:00 PM and midnight. Review of Resident 127's admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of pneumonia (infection in lungs) and sepsis (infection in blood), and received IV antibiotics via Peripherally Inserted Central Catheter (PICC - long, flexible, thin tube inserted into a vein in your arm, usually the upper arm, and threaded up to a larger vein near your heart). Review of Resident 127's April and May 2025 Medication Administration Records (MAR) showed Resident 127's midnight dose of IV cefazolin was not consistently administered at the ordered time/intervals: - On 04/25/2025 the midnight dose was administered at 2:53 AM, 3 hours late. - On 04/27/2025 the midnight dose was administered at 6:27 AM, 6.5 hours late. - On 04/28/2025 the midnight dose was administered at 5:31 AM, 5.5 hours late. - On 04/30/2025 the midnight dose was administered at 5:35 AM, 5.5 hours late. - On 05/02/2025 the midnight dose was administered at 4:50 AM, 5 hours late. - On 05/05/2025 the midnight dose was administered at 4:23 AM, 4.5 hours late. On 05/09/2025 at 11:33 AM, Staff C, Resident Care Manager (RCM), said facility nurses failed to administer Resident 127's IV cefazolin in accordance with the physician's order or professional standards of practice. Review of the April and May 2025 MAR and TAR showed Resident 127 had an order to change the PICC dressing every 72 hours, with instruction to measure the external length catheter and resident's arm circumference with each dresing change. The MAR/TAR did not provide a place for staff to record the measurements. Review of the Electronic Health Record (EHR) showed no PICC external catheter length or resident's arm circumference measurements were documented, upon admission or with the 72-hour dressing changes as ordered. The MAR/TAR showed facility nurses signed they measured the arm circumference and PICC external length with PICC dressing changes on 04/26/2025, 04/29/2025, 05/05/2025 and 05/08/2025 as ordered. On 05/09/2025 at 11:25 AM, Staff C, Resident Care Manager, acknowledged there was no documentation to show staff measured Resident 127's arm circumference and PICC line external length upon admission or with the 72 hour PICC dressing changes. When asked if facility nurses erroneously signed for tasks they did not complete Staff C, RCM, said yes. Resident 127 had an order to monitor IV insertion site for signs and symptoms of infection every shift. Review of the April and May 2025 Treatment Administration Records (TAR) showed staff failed to sign they completed the task on 04/24/2025 at 6:00 AM; 04/26/2025 at 6:00 PM; 04/28/2025 at 6:00 AM; and 04/29/2025 at 6:00 PM. Resident 127 had an order for oxygen at two liters per minute continuously via nasal canula to keep oxygen saturation greater than 92%. Review of the April 2025 TAR showed staff failed to sign they administered the oxygen on 04/26/2025 evening shift; 04/29/2025 day shift; and 04/29/2025 evening shift. Resident 127 had an order to check oxygen saturation every shift. Review of the April 2025 TAR showed staff failed to check the resident's oxygen saturation on 04/26/2025 evening shift; 04/28/2025 day shift; and 04/29/2025 evening shift. Review of Resident 127's May 2025 TAR showed Resident 127 had an order for staff to measure their upper arm circumference and the external length of their PICC upon admission and every 72 hours with the PICC dressing change. Review of the May 2025 TAR showed staff failed to sign the task off as completed on 05/01/2025 and 05/08/2025. Staff did sign the task was completed on 05/05/2025, but review of the EHR showed no documentation of the resident's arm circumference PICC external length was present. Resident 127 had an order to change their primary administration set (IV tubing) every 24 hours. Review of the May 2025 TAR showed staff failed to sign the task off as completed on 05/03/2025, 05/04/2025 and 05/08/2025. On 05/12/2025 at 3:41 PM, Staff C, RCM, said it was the expectation nurses administer medications and perform treatments as ordered by physician, and to only sign for tasks they completed. <Blanks on the MAR and TAR> 3) Resident 20 was admitted to the facility on [DATE] with multiple diagnosis including depression and atrial fibrillation (a common type of arrhythmia where the heart beats irregularly and often rapidly). The Quarterly MDS, dated [DATE], documented Resident 20 was cognitively intact. A review of Resident 20's MAR and TAR for April 2025 showed the listed orders had blank boxes (no documentation) on the dates and times below: -High Calorie/High Protein Nectar Thick Liquids three times a day for supplement for healing on 04/13/2025, 04/15/2025, and 04/16/2025 at 2:00 PM. -Eliquis two times a day on 04/13/2025, 04/15/2025, and 04/16/2025 at 2:00 PM. -Monitor for Antidepressant Medication side effects every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM. -Monitor for Antipsychotic Medication side effects every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM. -Target Behavior: Insomnia document every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM. - Target Behavior: Major Depressive Disorder document every shift on 04/09/2025, 04/16/2025, 04/23/2025, 04/24/2025, and 04/28/2025 from 6:00 AM to 6:00 PM, and on 04/17/2025 and 04/18/2025 from 6:00 PM to 6:00 AM. On 05/09/2025 at 9:45 AM, Staff C, RCM said the blanks on the MAR/TAR meant it was not given, or it was not done, and it should be given and if not it should be documented why if there was a refusal of another reason. On 05/12/2025 at 11:30 AM, Staff B, Director of Nursing said the blanks mean they were not documented on the MAR or TAR, and she said any medication or treatment should be documented on administration. Refer to F760 Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i) .

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** 2) Resident 48 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], showed Resident 48 was rarely o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 48 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], showed Resident 48 was rarely or never understood and sometimes understands, and had constipation during the assessment window. Review of Resident 48's medications for bowel stimulation showed three medications: 1. MOM, by mouth as needed for constipation, give at bedtime or at resident preferred time if no bowel movement on 3rd day 2. Dulcolax suppository(Bisacodyl), insert 1 suppository rectally every 24 hours as needed for constipation if no results from MOM after 12 hours. 3. Fleet enema, insert 1 application rectally every 24 hours as needed for constipation if no results from Dulcolax in 4-6 hours. If no results from enema, notify provider. Review of Resident 48's bowel record showed three stretches of no bowel movement from 04/18/2025 to 04/22/2025 (5 days), 04/26/2025 to 04/29/2025 (4 days), and 05/01/2025 to 05/05/2025 (5 days). Review of the EHR showed no bowel medications were given during those days. Review of Resident 48's care plan for alteration in bowel elimination showed they had the goal of a normal bowel movement at least every 3rd day, with interventions to follow the facility protocol for bowel management. On 05/12/2025 at 10:13 AM, Staff C, RCM, after reviewing Resident 48's bowel records and the three stretches without bowel movements, said the bowel medications were either not started or not documented on, and it should have been done. Reference WAC 388-97-1060 (1) Based on interview and record review, the facility failed to ensure the bowel protocol was implemented, bowel movements were monitored and/or documented on, for 2 of 6 residents (Residents 56 & 48) reviewed for unnecessary medication and constipation. This failure placed residents at risk of bowel obstructions, pain, and a diminished quality of life. Findings included . Review of the facility's policy titled, Management of Constipation, revised 11/2023, showed the facility monitored bowel movements through point of care documentation (computer charting system used most frequently by nursing assitants) and clinical alerts. After 64 hours of no/small bowel movement, the nurse would assess and determine if the bowel protocol would be initiated and document findings, and interventions would be documented on the clinical alert. The standard bowel protocol would be as follows: 1. Milk of Magnesia (MOM) after 8 shifts of no bowel movement 2. Bisacodyl suppository if no results from the MOM 3. Fleets Enema if no results from the Bisacodyl suppository 1) Resident 56 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 56 was able to be understood and understands. During an interview on 05/05/2025 at 4:05 PM, Resident 56 reported they had both constipation and diarrhea. Review of Resident 56's orders showed three bowel stimulation orders: 1. Dulcolax suppository (Bisacodyl), insert 1 suppository rectally every 24 hours as needed for constipation if no results from MOM after 12 hours 2. Senna oral tablet, give 2 tablets by mouth every 6 hours as needed for constipation 3. MiraLax oral packet, give 1 packet by mouth one time a day for constipation hold for loose stool Review of the previous 30 days of bowel movements, showed Resident 56 had no documented bowel movements from 04/19/2025 to 04/24/2025 (6 days). Review of the electronic health record (EHR) showed no bowel medications were given during those dates. During an interview on 05/09/2025 at 10:31 AM, Staff C, Resident Care Manager (RCM), said they started the bowel protocol medications and would progress through the steps until a bowel movement was charted. Staff C alert charting should also be started. For Resident 56, Staff C said that based on the charting it looked like the resident had not had a bowel movement during those days, but the resident had reported they had one verbally. When asked if this was confirmed, due to no staff being identified and the resident being dependent on staff for changing their brief, Staff C said the they thought the conversation had happened the week of April 21st, but siad they did not have documentation of this conversation and there should have been. Staff C reviewed the EHR and confirmed there were not bowel medications given during that time frame, and there was no alert charting.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to consistently provide weekly skin assessments and failed to impleme...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to consistently provide weekly skin assessments and failed to implement supplements as recommended for wound healing for a pressure ulcer (PU, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 2 sampled residents (Resident 24) reviewed for pressure ulcers. These failures placed residents at risk of developing avoidable pressure ulcers and/or delayed healing of pressure ulcers and a diminished quality of life. Findings included . Review of the facility policy, titled Documentation-Skin Conditions revised on 12/2024 documented weekly skin assessments were to be documented weekly using the Total Body Skin Evaluation. <Failed to do weekly skin assessments> Resident 24 admitted to the facility 03/06/2020. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 01/23/2025, documented Resident 24 had one Stage 3 (involves damage to the innermost layer of skin tissue, exposing the fatty tissue underneath), PU. On 05/08/2025 Staff O, Wound Care Nurse Practitioner said Resident 24's Stage 3 PU had been identified on 06/13/2024. Record review showed Resident 24 had a Total Body Skin Evaluation (assessment) done on 05/14/2025 (no PU identified on this assessment) and did not have another Total Body Skin assessment until over 4 weeks later, on 06/19/2024 (PU documented). On 05/12/2025 at 12:41 PM, Staff C, Resident Care Manager, when asked what type of evaluations were completed for skin assessments said, Total Body Evalutions were to be done weekly by floor nurses. When asked if [NAME] Body Evaluations were being done weekly for Resident 24, Staff C looked in the Electronic Health Record (EHR) and said it did not look like they were being completed weekly, and it did not meet her expectations. When asked what the facility was doing to prevent Resident 24 from developing the Stage 3 PU, Staff C said repositioning, peri care, putting barrier cream on, and if staff were completing the Total Body Evaluation's the PU could have been prevented. Staff C said if there was a red mark on the skin, it could have been prevented before the skin opened (PU developed). When asked if the Total Body Evaluations were being completed prior to Resident 24 developing the PU, Staff C said, not as often as they should have been, not weekly. Staff C acknowledged the missing assessments between 05/14/2024 and 06/19/2024 and said staff missing those assessments was not acceptable. <Failure to provide wound healing supplement> On 05/08/2025 at 9:31 AM, Staff O, Wound Care Nurse Practitioner, when asked if she had made any nutrition recommendations for wound healing, said she had recommended a supplement, Arginade (Powdered supplement which is added to a liquid that can improve wound healing) to the facilities Registered Dietician, a couple of months previously. Staff O said she made recommendations, and it was up to the facility staff to follow up on them. Review of Resident 24's EHR documented the following Wound Pros Progress Report signed by Staff O: On 11/18/2024 conversation with facility dietician (Staff G's first name indicated here) about significant wound. She is prescribing nutritional supplements. Recommend Vitamin C and zinc, and Arginaid wound supplement. Record search of Resident 24's orders showed no order for Arginaid had been implemented. On 05/08/2025 at 12:38 PM, Staff G, Registered Dietician, when asked what specific supplements the facility used to promote wound healing said, Arginaid, it truly works. When asked what steps the facility was taking to promote wound healing for Resident 24, Staff G said Resident 24 had Arginaid and Zinc in the past. Staff G said Arginaid was started in November of 2024, and Resident 24 had taken it for a whole month. When asked to provide documentation that Resident 24 had received the supplement Arginaid, Staff G looked at Resident 24's orders and Medication Administration record and said, I can't seem to find it. Staff G said that since Resident 24 required honey thick fluids (a thicker consistency of liquids) and that Arginaid is not a honey thick liquid that maybe staff couldn't do it and that was why it wasn't done. When asked if Arginaid could have been made honey thick consistency (with added thickener) for Resident 24, Staff G said it was worth trying. On 05/08/2025 at 2:03 PM, Staff G said Resident 24 had tried the supplement Arginaid mixed in thickened water, that nursing had said they were ok mixing it for Resident 24 and that Resident 24 was liking it. When asked why this had not been attempted at the time the recommendation was made for Resident 24, Staff G said Arginaid would have had to have been put in a liquid that could be thickened to honey thick consistency, kitchen staff couldn't do it, but nursing could. Reference WAC 388-97-1060 (3)(b) .

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided in ac...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided in accordance with professional standards of practice for 1 of 1 resident (Resident 127) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC line, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, PICC dressing changes, measuring external length to verify the line had not migrated, and arm circumference to monitor for swelling. deep vein thrombosis. These failures placed residents at risk for loss of vascular access, infection, and other potential negative outcomes. Findings included . Resident 127 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/29/2025, showed the resident was cognitively impaired, had a diagnosis of pneumonia and received IV antibiotic therapy via PICC during the assessment period. Review of Resident 127's electronic health record (EHR) showed the following IV therapy orders: a) Cefazolin IV every 8 hours for six weeks for a diagnosis of bacteremia. b) Flush unused lumens with 10 milliliters (ml) normal saline and follow with heparin every 8 hours. c) Monitor IV insertion site for signs and symptoms of infection every shift. d) Change the PICC dressing every 72 hours. Measure the external catheter length and resident's arm circumference with each dressing change. The physician orders did not include direction to: a) Flush the PICC dressing before and after medication administration. b) To change the needleless injection caps on each lumen with dressing changes, after each blood draw and as needed. On 05/06/2025 at 11:18 AM, Resident 127 a PICC was observed to the resident's right upper arm. The PICC dressing was clean, dry, and intact, and dated 05/05/2025. Review of the May 2025 Medication and Treatment Administration Records (MAR/TAR) showed on 05/01/2025 Resident 127's PICC dressing was due to be changed, the external catheter length measured, as well as the resident's arm circumference. Further review showed no place was provided to record the measurements and staff failed to sign that the tasks were completed as ordered. On 05/08/2025, Resident 127's PICC dressing change, and measuring of the external length and the residents arm circumference were again due. The TAR showed that the nurse signed off that the tasks were completed. On 05/09/2025 at 10:31 AM, Resident 127's PICC dressing was still dated 05/05/2025, This showed the dressing was not changed on 05/08/2025 as ordered and signed for. Review of the EHR showed no PICC external catheter length or resident arm circumference measurements were documented. On 05/09/2025 at 11:25 AM, Staff C, Resident Care Manager, acknowledged there was no documentation to show staff measured Resident 127's arm circumference and PICC line external length upon admission and every 72 hours with the PICC dressing changes as ordered. Staff C also confirmed there were no orders in place to change the needleless injection caps, to flush the PICC line before and after medication administration. Staff C confirmed facility nurses had erroneously signed for tasks they did not complete on 04/26/2025, 04/29/2025, 05/05/2025 and 05/08/2025. Reference WAC 388-97-1060 (3)(j)(ii) .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

. Based on interview and record review, the facility failed to have a system in place that ensured periodic reconciliation and accounting for all controlled medications, for 1 of 1 medication carts (E...

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. Based on interview and record review, the facility failed to have a system in place that ensured periodic reconciliation and accounting for all controlled medications, for 1 of 1 medication carts (East B cart) reviewed for narcotic records. The failure to consistently reconcile controlled medications at shift change and to co-sign the ledger to show both nurses validated the accuracy of the medication count, placed residents at risk for misappropriation of their medication and detracted from the facility's ability to promptly identify potential diversion. Findings included . On 05/09/2025 at 7:52 AM, two controlled medication books/ ledger were observed on the East B medication cart. One ledger contained the count for schedule two medications (drugs that have a high potential for abuse and are regulated under the Controlled Substances Act) and the other for schedule three and four medications (drugs with low to moderate potential for abuse and/or addiction). On 05/09/2025 at 11:18 AM, Staff C, Resident Care Manager (RCM), said facility nurses were supposed to count all schedule two, three and four medications at shift change (twice a day due to 12-hour shifts). After counting and validating all medications were accounted for, both nurses would co-sign each medication ledger to validate that the counts were correct. Review of schedule three and four medication ledger showed facility nurses signed the ledger to validate the schedule three and four medications were accounted for as follows: - In January 2025, nurses signed the schedule three and four medication count was correct for one of 62 shift changes (01/17/2025). - In February 2025, nurses signed the schedule three and four medication count was correct for 0 of 56 shift changes. - In March 2025, nurses signed the schedule three and four medication count was correct for one of 62 shift changes (03/20/2025). During an interview on 05/09/2025 at 7:45 AM, when asked why nurses were not signing that the schedule three and four medications were counted and the count was accurate at shift change, Staff L, Licensed Practical Nurse, stated, Some nurses sign in that book, some don't. I figure we did the count we can just sign once for both books. On 05/09/2025 at 11:34 AM, Staff C, RCM, said nurses were expected to count controlled medications daily at shift change with both nurses (oncoming and off going) signing each ledger to validate the counts were accurate. When asked if that had occurred for the schedule three and four medications on the East B cart Staff C stated, No. Reference WAC 388-97-1300(1)(b)(ii), (c)(ii-iv) .

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 127) reviewed for intravenous (I...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 127) reviewed for intravenous (IV) therapy, was free of significant medication errors. The failure to administer IV antibiotics at ordered times/intervals, placed residents at risk for ineffective treatment of infection, prolonged antibiotic therapy and associated adverse side effects. Findings included . Resident 127 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool), dated 04/29/2025, showed the resident was cognitively intact, had a diagnosis of bilateral lower lobe pneumonia (infection in both sides of lower lungs), and received IV antibiotics during the assessment period. Review of the electronic health record (EHR) showed the resident had a 04/23/2025 order for IV Cefazolin (antibiotic) every eight hours at 8:00 AM, 4:00 PM and Midnight, with direction to infuse over one hour via Peripherally Inserted Central Catheter. Review of the April 2025 Medication Administration Record (MAR) showed Resident 127's IV cefazolin was administered as follows: - On 04/27/2025 the midnight dose of IV cefazolin was administered on 04/27/2025 at 6:27 AM, six and half hours after the scheduled time and 14 hours after the previous dose (04/26/2025 at 4:00 PM). The nurse then administered the 04/27/2025 8:00 AM dose at 9:29 AM, two hours after the previous dose completed. -On 04/28/2025 the midnight dose of IV cefazolin was administered on 04/28/2025 at 5:31 AM, five and half hours after the scheduled time and 13 hours after the previous dose. The nurse then administered the 04/28/2025 8:00 AM dose at 8:35 AM, two hours and four minutes after the previous dose completed. -On 04/30/2025 the midnight dose of IV cefazolin was administered on 04/30/2025 at 5:35 AM, five and half hours after the scheduled time and 14 hours after the previous dose. The nurse then administered the 04/30/2025 8:00 AM dose at 8:47 AM, two hours and 12 minutes after the previous dose completed. -On 05/02/2025 the midnight dose of IV cefazolin was administered on 05/02/2025 at 4:50 AM, five hours late and 13 hours after the previous dose. The nurse then administered the 05/02/2025 8:00 AM dose at 8:19 AM, two hours and 29 minutes after the previous dose completed. -On 05/05/2025 the midnight dose of IV cefazolin was administered on 05/05/2025 at 4:23 AM, four and a half hours late and 13 hours after the previous dose. The 05/05/2025 8:00 AM dose was then administered at 8:19 AM, two hours and 56 minutes after the previous dose completed. On 05/09/2025 at 11:33 AM, when asked if facility nurses administered Resident 127's IV cefazolin at the prescribed times and intervals, Staff C, Resident Care Manager, stated, No. Staff C confirmed facility nurses' pattern of administering the resident's midnight doses four to five hours late and then failed to adjust the administration time of the next dose. Staff C acknowledged this resulted in 13-14 hours between the 4:00 PM and midnight dose, and 2-3 hours between the midnight and 8:00 AM dose, rather than every eight hours as ordered. Reference WAC 388-97-1060 (3)(k)(iii) .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

. Based on observation, interview and record review, the facility failed to ensure medications were stored at proper temperatures, dated when opened when required, and expired medications were discard...

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. Based on observation, interview and record review, the facility failed to ensure medications were stored at proper temperatures, dated when opened when required, and expired medications were discarded in accordance with professional standards of practice for 2 of 2 medication rooms (East and [NAME] Medication rooms) and 1 of 2 medication carts (West A cart) reviewed. This placed residents at risk of taking and/or receiving expired/outdated medications and biologicals. Findings included . <East Medication Room> On 05/13/2025 at 11:40 AM, observation of the medication refrigerator showed it contained 11 bags of intravenous cefazolin (to be stored at 37.5 - 41 degrees Fahrenheit (F)), multiple unopened insulin pens (to be stored at 36 - 46 degrees F), and an opened multi-use vial of Tuberculin purified protein derivative (PPD, to be stored at 35 - 45 degrees F). Review of the refrigerator temperature log showed staff had not checked the medication refrigerator temperature since October 2024 (greater than six months prior). On 05/09/2025 at 11:42 AM, Staff C, Resident Care Manager (RCM), said nurses should have been checking and recording the medication refrigerator internal temperature at least once daily, but acknowledged they failed to do so. <West Medication Room> On 05/09/2025 at 11:56 AM, a multi-use vial of Tuberculin PPD was stored in the freezer and had an open date of 03/18/2025 (56 days prior). On 05/09/2025 at 11:58 AM, Staff C, RCM, said the Tuberculin vial should have been stored in the refrigerator between 35 - 45 degrees F and discarded 30 days after the open date, but was not. <East A Medication Cart> Review of the East medication cart showed the following: 1) Resident 45 had a medication card of benzonatate 100 mg which expired 06/19/2024. 2) Resident 16 had a medication card of mirtazapine 7.5 mg that expired 05/31/2024. On 05/13/2025 at 12:24 PM, Staff C, RCM, said the above referenced medications were expired and needed to be discarded. Reference WAC 388-97-1300 (2) .

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program that ensured accurate...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program that ensured accurate and complete information (signs/symptoms) was collected monitored and/or documented on for 2 of 3 monthly infection line listings (a document that tracks resident infections) reviewed (February 2025 & April 2025). The facility also failed to implement a process for documenting on McGeer's Criteria (tool that provided criteria to show if antibiotics were indicated), that included provider notification, intervention implemented (if provider wanted to continue or stop the antibiotic and the reason for it), and an accurate list for tracking residents that did and did not meet criteria, for 1 of 1 residents (Resident 26) reviewed for McGeer's Criteria. These failures placed residents at risk for unnecessary antibiotic use, development of [NAME]-drug-resistant organisms (MDROs), and other negative health outcomes. Findings included . Review of the facility's policy titled, Antibiotic Stewardship, revised October 2019, documented the purpose of the antibiotic stewardship program was to monitor the use of antibiotics. The facility policy documented orientation, training and education of staff would emphasize the importance of antibiotic stewardship and would include how inappropriate use of antibiotics affects individual residents and the overall community. Review of the Nebraska Antimicrobial Stewardship Assessment and Promotion Program's document titled, Revised McGeer Criteria for Infection Surveillance Checklist, dated 11/05/2024, lists criteria for treatment with antibiotics. For cellulitis (a common, potentially serious bacterial skin infection), soft tissue, or wound infection, the resident must meet the following criteria: 1.Must fulfill at least 1 criterion- Pus at wound, skin, or soft tissue site. Or 2. At least four of the following new or increasing signs or symptoms: A. Heat (warmth) at affected site B. Redness (erythema) at affected site C. Swelling at affected site D. Tenderness or pain at affected site E. Serous (clear fluid) drainage at the affected site. F. At least one of the following: Fever, Leukocytosis (a high level of white blood cells in the blood), Acute change in mental status, Acute functional decline. <Failure to meet McGeer's Criteria and add to April Line Listing> Resident 26 admitted to the facility 06/21/2020. Resident 26 had a diagnosis of Bullous Pemphigoid (a rare skin condition causing large, fluid-filled blisters). An order in the electronic health record (EHR) showed Resident 26 was prescribed an antibiotic on 03/04/2025, doxycycline, two times a day for left thigh cellulitis for 10 days. A physician progress note, dated 03/04/2025, documented Resident 26 had new redness of left thigh lesion and no other new symptoms were listed. The resident was noted to still be taking a topical steroid skin medication for skin lesions, which was instructed to not be applied to the infected lesion. Another provider progress note, also dated 03/04/2025, documented Resident 26 had new redness surrounding the left thigh lesion, without abscess (collection of pus) or lymphangitis (infection or inflammation of the lymphatic vessels) noted. Review of the March 2025 Infection Control Line Listing showed Resident 26 had an entry on 03/04/2025 for a wound infection of the left thigh. The signs and symptoms listed were serosanguinous drainage (common wound drainage that is a combination of clear watery fluid and blood, typically normal and expected during wound healing) and redness. No other symptoms were found. Review of Resident 26's vital signs showed there were no temperature readings done in 2025, the facility did not rule out if the resident had a fever on 03/04/2025. Review of McGeer's Criteria and the EHR showed Resident 26 did not meet the criteria for antibiotic treatment. A second order in the EHR showed Resident 26 was prescribed an antibiotic on 04/28/2025, doxycycline, two times a day for cellulitis of the left hand for 10 days. A physician documentation progress note, dated 04/25/2025, documented due to increased redness left hand concern? new infection. Started patient on Doxycycline, Probiotic and dose of Oxycodone QHS [every night] for pain relief. Will recheck next week and if infection improved will start short course of oral steroids. She has an appointment to see dermatologist in May. Review of McGeer's Criteria and the EHR showed Resident 26 again did not meet criteria for antibiotic treatment. Review of the April 2025 Infection Control Line Listing, showed it was missing the entry for Resident 26. On 05/13/2025 at 8:27 AM, Staff A, Administrator/ Infection Preventionist, was interviewed along with Staff B, Director of Nursing. When asked if McGeer's criteria was the infection assessment tool the facility used to determine if a resident required antibiotic treatment, Staff B confirmed it was. Staff B confirmed the facility was using McGeer's Criteria when a provider prescribed an antibiotic. When asked how the facility communicated McGeer's criteria to the provider when residents were not meeting criteria, Staff B said it was communicated, the decision was made by the provider to continue or discontinue the antibiotic, and their expectation was for the provider to have documented this conversation. When asked where the documentation was of McGeer's criteria being reviewed, Staff B said it would help if the provider documented that. Staff B was unable to recall any specifics regarding the two 10-day courses of antibiotics prescribed for Resident 26 or if McGeer's criteria was reviewed by the facility. When asked how the facility was meeting antibiotic stewardship for Resident 26, Staff B said she could not recall a specific conversation before the initiation of antibiotics, that there was usually a discussion had if McGeer's criteria was met or not, and that the reasoning for antibiotics should have been documented by the provider. Regarding the second course of doxycycline started on 04/28/2025 not being on the April Infection Control Line Listing, Staff B said any antibiotic started should be on the line listing. On 05/15/2025 at 2:13 PM, Additional documentation was received from Staff A, Administrator, with an Infection Screening Evaluation that can be utilized in the EHR. This screening tool was based on McGeer's or Loeb's (another clinical decision-making tool to determine if an antibiotic should be started for suspected infections) criteria. The last completed Infection Screening Evaluation found in the EHR for Resident 26 was from 2022. <Incomplete Line Listing Documentation> Review of the February 2025 line listing showed, under type of symptoms/diagnosis, the following entries lacked documentation of signs/symptoms: 1. Date of onset lists Hospitalization -Type of Symptoms/Diagnosis lists Cholecystitis [inflamed gallbladder] (No signs/symptoms documented) 2. Date of onset lists Hospitalization-Type of Symptoms/Diagnosis lists UTI [urinary tract infection](No signs/symptoms documented) 3. Date of onset lists 02/06/2025- Type of Symptoms/Diagnosis lists Wound Infection-continued ongoing infection (No signs/symptoms documented) 4. Date of onset lists Hospitalization- Type of Symptoms/Diagnosis lists Osteomyelitis [bone and muscle infection] (No signs/symptoms documented) 5. Date of onset lists Hospitalization- Type of Symptoms/Diagnosis lists UTI (No signs/symptoms documented) 6. Date of onset lists Hospitalization- Type of Symptoms/Diagnosis lists Cellulitis LUE [skin infection left upper extremity] (No signs/symptoms documented) 7. Date of onset lists Hospitalization- Type of Symptoms/Diagnosis lists Osteomyelitis (No signs/symptoms documented) 8. Date of onset lists 02/21/2025- Type of Symptoms/Diagnosis lists Foley removal, followed by urology [tube into bladder/urinary tract and bladder specialist] (No signs/symptoms documented) 9. Date of onset lists 02/14/2025- Type of Symptoms/Diagnosis lists Went to ER (emergency room) for edema, rtn with UTI [returned with urinary tract infection] (No signs/symptoms documented) 10. Date of onset is blank- Type of Symptoms/Diagnosis is also blank, treatment was Cipro (antibiotic) started on 02/25/2025 (No signs/symptoms documented) 11. Date of onset lists 02/03/2025- Type of Symptoms/Diagnosis lists UTI- had a fall, went to hospital (No signs/symptoms documented) 12. Date of onset lists Hospitalization- Type of Symptoms/Diagnosis lists Cellulitis BLE (Both lower extremities) (No signs/symptoms documented) 13. Date of onset lists Hospitalization- Type of Symptoms/Diagnosis lists Sepsis [blood infection] (No signs/symptoms documented) 14. Date of onset lists Hospitalization- Type of Symptoms/Diagnosis lists Cellulitis (No signs/symptoms documented) On 05/13/2025 at 8:27 AM, when asked if signs and symptoms should be tracked on the line listing, Staff B said symptoms should be documented and kept together to be tracked. No Associated WAC .

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure informed consent was obtained prior to admini...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure informed consent was obtained prior to administering psychotropic medications, and/or ensure consent forms accurately identified the type of medication (drug class) and associated risks and benefits of use for 3 of 5 residents (Resident 62, 48, & 28) reviewed for unnecessary medications. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with end-of-life care and psychotropic medications and a diminished quality of life. Findings included . 1) Resident 62 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/24/2025, showed the resident was severely cognitively impaired, had a diagnosis of depression, demonstrated signs and symptoms of delirium (a serious change in mental abilities, resulting in confused thinking and a lack of awareness of someone's surroundings) such as an altered level of consciousness and inattention, and required antipsychotic and antidepressant medication during the assessment period. Review of the May 2025 Medication Administration Record (MAR) showed Resident 62 had an order for aripiprazole (an antipsychotic medication) every morning for depression. A Psychopharmacologic Medication Informed Consent form, dated 04/21/2025, showed the resident was prescribed aripiprazole, which staff identified as an antidepressant, and education was provided about the risks and benefits associated with antidepressant medications. The document showed Resident 26 provided informed consent to initiate the antipsychotic medication, despite being assessed with severe cognitive impairment and signs and symptoms of delirium. On 05/12/2025 at 3:37 PM, Staff C, Resident Care Manager (RCM), said the informed consent form for Resident 62's aripiprazole inaccurately identified the medication as an antidepressant rather than an antipsychotic. Staff C confirmed this resulted in the resident being educated about the risks and benefits associated with antidepressant medications rather than antipsychotic medications. When asked if it was possible for Resident 62 to make an informed decision about the use of aripiprazole, given staff provided inaccurate information about the type of medication it was and the associated risk and benefits of Staff C stated, No.2) Resident 48 was admitted to the facility on [DATE]. The Significant change MDS, dated [DATE], documented Resident 48 was rarely/never understood, and decision making was severely impaired. Resident 48 had diagnoses that included depression and anxiety disorder. Review of Resident 48's orders showed she had the following physician's orders: 1. Antipsychotic medication, quetiapine, 25 MG (milligrams), give 1 tablet two times a day, ordered 01/03/2025. (This was an increase from the previous dose of quetiapine, 25 MG, give 0.5 tablet two times a day.) 2. Antianxiety medication, lorazepam, ordered 03/24/2025. Review of Resident 28's consents showed no consent for the increase in the dose for quetiapine, ordered on 01/03/2025. Review of Resident 28's records showed no consent for the medication lorazepam. On 05/12/2025 at 10:30 AM, when asked if consent was obtained with the the quetiapine dose change, Staff C said she could not find a consent for the higher dose and it should have been done. When asked if there was consent for the lorazepam medication, Staff C said there was not, and there should have been a psychotropic consent evaluation. Staff C said consents are done with dose changes or when orders change. 3) Resident 28 was admitted to the facility on [DATE] with a diagnosis of dementia. The Quarterly MDS, dated [DATE], showed Resident 28 was rarely understood or rarely understands. Review of Resident 28's consents for psychotropic medications the resident was currently taking, showed the following: 1. Antipsychotic medication, quetiapine, originally consented 12/31/2024 by resident 2. Antidepressant medication, trazadone, no consent found 3. Antidepressant medication, escitalopram, consent obtained 12/31/2024 by resident. During an interview on 05/12/2025 at 2:09 PM, Staff C, RCM, said Resident 28 was unable to provide informed consent. When asked about consent for quetiapine and escitalopram on 12/31/2024, Staff C said it was not documented but the resident's son was there. When asked if the son could provide consent when they were not the active power of attorney (POA), Staff C said the POA should have given consent, not the son. Staff C was unable to find a consent for trazadone. During an interview on 05/13/2025 at 10:43 AM, Staff B, DNS, said their expectation for informed consent is that it be obtained prior to initiating psychotropic medications, and documented on. That consent should be obtained by the resident if they are their own party, if not, then their POA. Reference WAC 388-97-0300(3)(a), -0260,-1020(4)(a-b) .

CONCERN (E)

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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 37 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 37 was cognitively i...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 37 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 37 was cognitively intact. A physician's order, dated [DATE], documented Resident 37 had weights discontinued, related to comfort care status. Resident 37's Palliative/EOL needs care plan documented Resident 37 was initiated for EOL care services on [DATE]. On [DATE] at 8:16 AM, Resident 37 said they were unaware that they had been placed on EOL care, no one had ever talked to them about it. Resident 37 said hospice services had never been discussed or offered by the facility. On [DATE] at 2:02 PM, Resident 37's Durable Power of Attorney (DPOA, legal decision maker) said no one from the facility had spoken with them or offered services regarding end-of-life care or hospice. On [DATE] at 8:22 AM, Staff C, RCM, said when placing a resident on EOL care services the provider had a conversation with the resident and /or the resident representative, the conversation would be documented in the EHR. When asked about Resident 37's reason for transition to EOL care services, Staff C said she was unable to speak to that and it would need to be a conversation with the provider. When asked to look for documentation about the provider's conversation, regarding why Resident 37 was placed on EOL care, Staff C was unable to locate documentation supporting a conversation with Resident 37 or their representative. On [DATE] at 9:20AM, Staff B, DNS, said when a resident was placed on EOL services the provider would have a conversation with the resident or family regarding services. Staff B said providers notes were documented in a different system and then transferred to the facility's EHR. Staff B said they had been witness to and had their own discussion with the provider and residents about EOL services. When asked to look for documentation about the provider's conversation, regarding why Resident 37 was placed on EOL care, Staff B said it would take too long to look through all the provider's notes. When explained that Staff C had reviewed the EHR for EOL documentation and none was found, Staff B said the expectation was there should have been a documented conversation from the provider in the EHR regard EOL care services. 4) Resident 15 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 15 was severely cognitively impaired. A physician's order, dated [DATE], documented Resident 15 had weights discontinued, related to comfort care status. Resident 15's Palliative/EOL needs care plan documented Resident 15 was initiated for EOL care services on [DATE]. On [DATE] at 9:24 AM, Resident 15's DPOA, said the facility had never spoken to them about EOL care or hospice services. Resident 15's DPOA said they knew Resident 15 had dementia, but did not feel Resident 15 should have been on EOL care yet. Resident 15's DPOA said they know no one had spoken with them about EOL services, because they always thought EOL services would mean taking Resident 15 out of the facility and they did not want Resident 15 moved from the facility. On [DATE] at 8:22 AM, Staff C, RCM, reviewed Residents 15's EHR, to locate provider documentation regarding a conversation with Resident 15's DPOA. Staff C located a provider's note, dated [DATE], documenting Resident 15's weight had been discontinued, but no other documentation supporting a conversation had taken place with the resident or the resident's DPOA. Staff C said there absolutely should have been documentation supporting a conversation with the resident or the resident's DPOA. On [DATE] at 9:20AM, Staff B, DNS, said the expectation was that a conversation was documented from the provider regarding placing a resident on EOL care services. 5) Resident 24 admitted to the facility [DATE]. The Quarterly MDS, dated [DATE], documented Resident 24 was rarely/never understood, rarely/never understood others and was severely impaired in making decisions of daily life. A physician's order, dated [DATE], was for D/C (discontinue) weights due to comfort care. A physician's order, dated [DATE], was for Do Not Resuscitate (DNR)-comfort care. On [DATE] at 10:58 AM, Resident 24's DPOA, when asked about Resident 24's health, said from what they had seen, Resident 24 had lost tons of weight. When asked if they knew what comfort care was, Resident 24's DPOA said no, they did not know anything about it. When asked if Resident 24 was on comfort care at the facility, the DPOA said I probably did, I don't know they don't tell me a whole lot there. When asked about Resident 24's weight loss and how she could tell Resident 24 had lost weight, the DPOA said by his legs, feet, arms and face, he looks like a skeleton. Resident 24's DPOA said they had asked the facility questions, but they did not like to answer the questions. When Resident 24's DPOA was asked if they would want periodical weights done for Resident 24 to monitor if he was losing weight, said that would be good. 6) Resident 45 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 45 was able to be understood and understands. On [DATE] at 8:22 AM, Resident 45 said it had been a while since they had a care conference. Resident 45 reported they wanted to leave/discharge. Review of the discharge care plan, updated [DATE], did not show that Resident 45 was hoping to discharge. During an interview on [DATE] at 10:31 AM, Staff B, DNS, after looking in the EHR, said they could not find a care conference evaluation for Resident 45 for [DATE], and their expectation was for there to have been documentation that a care conference occurred and who attended. After asking about Resident 45's discharge plan, Staff B said the resident's family member was not ready yet to have them discharged , this was not in the care plan and should have been. 7) Resident 28 was admitted to the facility on [DATE] with a diagnosis of dementia. The Quarterly MDS, dated [DATE], showed Resident 28 was rarely understood or rarely understands. On [DATE] at 2:03 PM, Resident 56's family member said they did not think a care conference had occurred recently. Review of a social work form from [DATE], showed no documentation on if any care conference had occurred for Resident 28's representatives. During an interview on [DATE] at 10:31 AM, Staff B, DNS, said they did not see a record that a care conference had been done for Resident 28 on [DATE], that the MDS assessment was done on [DATE], and yes there should have been a care conference. Reference WAC 388-97-1000(1)(a), -1020(2)(f) Based on interview and record review, the facility failed to ensure residents were included in care conferences and discussions on their person-centered plans of care for 7 of 18 sampled residents (Resident 58, 56, 37, 15, 24, 45, & 28). This failure placed residents at risk of having services discontinued or started without being fully informed or involved, not having preferences honored at end of life, and unidentified/unmet care needs. Findings included . 1) Resident 58 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 58 was able to be understood and understands. Review of Resident 58's Portable Orders for Life-Sustaining Treatment (POLST), signed [DATE], showed Resident 58 had elected no Cardiopulmonary Resuscitation (CPR) in the event they were found with no pulse and/or were not breathing. For situations when the individual had a pulse and/or was breathing, there were three options to choose from: full treatment, selective treatment, or comfort focused treatment. Selective treatment was, Primary goal is treating medical conditions while avoiding invasive measures whenever possible. Use medical treatment, IV fluids and medications, and cardiac monitor as indicated. Do not intubate. May use less invasive airway support (e.g., CPAP, BiPAP, high-flow oxygen). Includes care described below. Transfer to hospital if indicated. Avoid intensive care if possible. This was not selected on Resident 58's form. Resident 58 had elected comfort-focused treatment, Primary goal is maximizing comfort. Relieve pain and suffering with medication by any route as needed. Use oxygen, oral suction, and manual treatment of airway obstruction as needed for comfort. Individual prefers no transfer to hospital. EMS [Emergency Medical Services]: consider contacting medical control to determine if transport is indicated to provide adequate comfort. Review of Resident 58's electronic health record (EHR) showed they had been to the hospital three times in [DATE]: [DATE] to [DATE],[DATE] to [DATE], and [DATE] to [DATE]. Review of Resident 58's care plan for discharge, showed Resident 58 wished to return/discharge to home after their wound healed. During an interview on [DATE] at 8:10 AM, Resident 58 was asked if the facility had obtained their permission to be sent to the hospital, and said no. When asked if there was a scenario in which they would want to go to the hospital, Resident 58 said yes, they would want to go if they had an infection that needed to be cleared up. After reviewing the three options on the POLST (full treatment, selective treatment, or comfort focused treatment), Resident 58 said they would like to be transferred to the hospital if it would save their life. During an interview on [DATE] at 8:41 AM, Staff B, DNS, when asked if there was any documentation outside of the POLST form for resident preferences, said during care conferences or in the care plan. Staff B said the expectation was for documentation if there were any changes in resident preferences. When asked about Resident 58 being sent to the hospital three times, Staff B looked in the care plan and said they did not see anything specific in the care plan regarding this, and the progress notes did not have verbiage that the resident consented to the transfers. When asked if Resident 58 had consented, then what were their expectations for Resident 58 being re-evaluated on their preferences, Staff B said they expected another conversation and to see if they needed to modify Resident 58's goals of care. Regarding the POLST not being updated since the hospitalizations, Staff B said their expectation was for there to be documentation if a conversation occurred. When asked if it was possible residents could elect comfort care thinking it was related to down the line, not their current status, Staff B said if residents had elected for comfort measures only, then in the event they changed their mind or wanted to be sent to the hospital, they had the option and could change this any time 2) Resident 56 was admitted to the facility on [DATE] and had diagnoses of malnutrition and depression. The Significant Change MDS, dated [DATE], showed Resident 56 was able to be understood and understands, had several days of feeling down, depressed, or hopeless, and had half or more of the days feeling little interest or pleasure in doing things. Review of Resident 56's medications showed they were taking bupropion, an antidepressant for depression and smoking cessation, with a start date of [DATE]. Review of Resident 56's progress note from [DATE], showed Resident 56 had expressed to nursing staff that they were done, tired, did not want CPR, or to be sent to the hospital. Staff documented that Resident 56 understood their medications would be discontinued, and morphine (opioid medication) and ativan (antianxiety medication) would be started to keep them comfortable. Resident 56 was noted to have refused medications and eating. The note said a new POLST was signed by the resident that day. Review of Resident 56's provider progress note, date of service [DATE], documented Patient discussed with [provider] that he has lost his appetite and also reviews this with me today. He is trying to keep caloric intake up with protein shakes, etc. Review of Resident 56's records showed they had weights discontinued on [DATE], and their last weight was taken on [DATE]. During an interview on [DATE] at 3:56 PM, Resident 56 reported they had lost weight and were not okay with this. Review of two interdisciplinary notes, from [DATE] and [DATE], showed that Resident 56 had weight warnings for significant weight loss. The notes listed those in attendance, but did not list the resident. Nutritional plans of care were reviewed, no documentation was found of Resident 56 being involved or made aware of the decisions to not change the plan of care and to continue not obtaining weights. Review of Resident 56's care plans showed a care plan, initiated on [DATE], for Palliative/Hospice Care/End of Life Care per resident request with the interventions of Provide end of life care as needed to meet the needs of the resident. None of the interventions showed Resident 56 had been involved in planning their end-of-life (EOL) care, nor had their individualized preferences/goals been reviewed or obtained. Resident 56 also had an anti-anxiety medication care plan, initiated on [DATE], which did not involve the resident's goals for the medication usage during EOL. During an interview on [DATE] at 9:52 AM, Resident 56 was asked about their preference on having their weight obtained, said they wanted to have weights obtained to let their body be in a healthier state, and said they would like this to be done weekly. When asked about EOL preferences, Resident 56 said they did not remember a general discussion on preferences. On [DATE] at 3:05 PM, when asked if they had been told how long they had to live, Resident 56 said no. When asked about their plan of care regarding EOL and their anti-anxiety medication, said they were currently not having any symptoms of anxiety but were open to taking the medication if they did, and to their knowledge had never taken it. On [DATE] at 10:10 AM, Staff C, Resident Care Manager (RCM), was interviewed with Staff G, Registered Dietician, present. Staff G reported that after Christmas, Resident 56 had been having an emotional time with sadness. On [DATE] at 10:40 AM, Staff C, RCM, was not able to find any documentation that Resident 56 was notified of the [DATE] significant weight loss. When asked if there was a discussion with the resident about the weight loss and interventions available, Staff C was unable to provide documentation and said it should have been documented. On [DATE] at 10:49 AM, Staff C was asked what Resident 56's EOL goals were. Staff C said it used to be that Resident 56 did not want to go to the hospital and wanted to die. Staff C added that it sounded like this needed to be reassessed. After reviewing Resident 56's palliative/hospice care/EOL care plan, Staff C said there was not much to go off of regarding Resident 56's preferences, and it needed to be more individualized. When asked how staff would know how to honor Resident 56's personal preferences regarding EOL care, Staff C said they would not know unless the care plan was individualized. When asked if there was a difference in Resident 56's care now versus if they were actively dying, Staff C said yes, for now they would be getting weights, trying to get Resident 56 out of bed, and trying to do more. If Resident 56 was actively dying, then they would be monitoring and trying to keep the resident comfortable and going by the resident's wishes. On [DATE] at 8:41 AM, when asked how the facility knew residents were not going through a period of depression when they had the initial decision, since the provider had mentioned that a resident refusing medication could initiate a conversation for end of care services, Staff B, DNS said the nurses should continue to have those conversations, behavior health should be involved, and they should look for a reason.

CONCERN (E)

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

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents were free of chemical restraints for 5 of 6 resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents were free of chemical restraints for 5 of 6 residents (Residents 39, 62, 48, 28 and 56) reviewed for unnecessary medications or pain. The failure to ensure psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had adequate indications for use, resident specific target behaviors (TB) were identified and monitored, gradual dose reductions (GDRs) were performed, non-drug interventions were attempted prior to administration of as needed (PRN) psychotropic medications, and PRN psychotropic medication orders did not exceed 14 days unless a documented clinical rationale was provided, placed residents at risk of receiving unnecessary psychotropic medications, experiencing adverse side effects such as sedation, decline in physical function, and other negative health outcomes. Findings included . 1) Resident 39 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/15/2025, showed the resident was cognitively intact, had diagnoses of depression, anxiety, and bipolar disorder, and required antianxiety and antidepressant medication during the assessment period. Review of the electronic health record (EHR) showed Resident 39 had the following psychotropic medication orders: a) Buspirone (an antianxiety medication) 30 milligrams (mg) twice daily for major depressive disorder. b) Duloxetine (an antidepressant medication) 30 mg every morning and 60 mg at bedtime for major depressive disorder. A mood and behavior problem related to diagnoses of Post Traumatic Stress Disorder (PTSD), bipolar and anxiety disorders care plan, revised 03/03/2025, identified the TBs for anxiety disorder as Anxiety D/O [disorder], and the TBs for the resident's PTSD and Bipolar disorder as Bipolar disease and PTSD and directed staff to document the number of occurrences of each. On 05/13/2025 at 12:27 PM, Staff C, Resident Care Manager (RCM), said TBs should reflect the behaviors that manifest from the underlying diagnoses of anxiety, PTSD, and bipolar. Staff C said TBs should not be a restatement of the diagnosis. When asked how the facility could assess the effectiveness of each medication if the TB behavior had not been identified for each specific medication, Staff C indicated they could not. Additionally, Staff C confirmed Resident 39's buspirone was for anxiety, not depression as documented in the order. 2) Resident 62 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had severe cognitive impairment, a diagnosis of depression, demonstrated signs and symptoms of delirium (a serious change in mental abilities, resulting in confused thinking and a lack of awareness of someone's surroundings), altered level of consciousness and inattention, and required antipsychotic and antidepressant medication during the assessment period. Review of the May 2025 Medication Administration Record (MAR) showed Resident 62 had the following psychotropic medication orders: a) Aripiprazole (an antipsychotic) every morning for depression. b) Quetiapine (an antipsychotic) twice a day for depression. c) Duloxetine (an antidepressant) daily for depression. A hospital Discharge summary, dated [DATE], showed the resident received Aripiprazole and Quetiapine for hallucinations and delirium secondary to sepsis. The Psychopharmacologic Medication Informed Consent form, dated 04/21/2025, for the use of aripiprazole (an antipsychotic), which staff identified as an antidepressant, documented it was for depression. A Psychopharmacologic Medication Informed Consent form, dated 04/21/2025, for the use of quetiapine (an antipsychotic), documented it was for depression. A pharmacy admission Medication Review Report, dated 11/27/2024 (prior admission), documented Resident 62 received two antipsychotic medications, quetiapine and aripiprazole for psychosis. The following recommendation was made, Please consider risk vs benefit and consider dose reduction or perhaps discontinuation of quetiapine. Under Physician Response, the provider checked the box I have re-evaluated this therapy and DO NOT wish to implement any changes due to the reasons below. Under Rationale the provider documented New admit. Requires both antipsychotics at this time. No clinical rationale for performing a GDR or discontinuing the quetiapine as recommended were provided. An antidepressant medication care plan, dated 04/30/2025, showed a goal of Will be free from discomfort or adverse reactions related to antidepressant therapy. No goal was established for the use of the antidepressant medication (e.g. a decrease in the TBs the medication was initiated to treat). The TBs for duloxetine were identified as self-isolation, and withdrawn and loss of interest in usual activities. An antipsychotic use care plan, dated 04/30/2025, documented Resident 62 received antipsychotic medications to treat depression. The goal of the antipsychotic therapy was to have no negative outcomes or drug related complications from antipsychotic medication use. The care plan failed to identify any goals for the use of the antipsychotic medications. Additionally, the TBs the antipsychotic medications were initiated to treat, were not identified. On 05/12/2025 at 4:05 PM, Staff C, RCM, confirmed the hospital discharge summary indicated the quetiapine and aripiprazole were for hallucinations and delirium related urinary sepsis. When asked if Resident 62 had completed their antibiotics for their urinary tract infection, Staff C stated, Yes. When asked what the indication for use was for the antipsychotic medications, Staff C reviewed documentation and stated, It changed from delirium to depression. I have not seen any behaviors related to delirium since he has been here. It doesn't look like he needs to be on the these [Antipsychotics]. Staff C, acknowledged there was no clear indication for use for the quetiapine and aripiprazole, no TBs were identified, and no goal for the antipsychotic medication therapy was established. 3) Resident 48 was admitted to the facility 02/07/2024 and had diagnoses of depression and anxiety disorder. The Significant Change MDS, dated [DATE], showed Resident 48 was rarely or never understood by others, and sometimes understands. Review of Resident 48's medication orders showed lorazepam, ordered 03/24/2025, every 4 hours as needed for end of life (EOL) care, anxiety for 6 months. Review of Resident 48's EHR showed no documentation was located that Resident 48 was assessed by the provider every 14 days with a clinical rationale documented for the ongoing use of lorazepam, or documentation that other treatments were deemed clinically contraindicated. Record review of the May 2025 MAR showed that TBs were ordered for Resident 48's anxiety disorder. When reviewing the order, it showed the TB to be treated was anxiety disorder, and staff were instructed to document the number of occurrences. The order did not include what Resident 48's anxiety typically looked like, or any anxiety symptoms that might be treated with the listed interventions or documented on. Review of Resident 48's record showed no Non Pharmacological Interventions (NPIs) were in place for the anxiety medication lorazepam. On 05/12/2025 at 10:30 AM, Staff C, when asked to provide documentation that the provider had assessed Resident 48 every 14 days and had a clinical rational based on that assessment and documentation that it was useful/reasoning for ongoing use, Staff C said Resident 48 had episodes of tearfulness, was at times panicked, had panic attacks, and the staff had tried taking her outside for fresh air, activities around the facility, and nothing was working so they put her on lorazepam as needed. When asked if the use of lorazepam was reviewed by the provider every 14 days, Staff C said it should be done every 14 days, and she thought it was. Staff C said a 6-month order was not acceptable for that type of medication, and did not provide additional documentation. Staff C said that TBs for Resident 48 should have been specific for her anxiety, such as crying or putting a blanket over her face, it needed to be more specific. When asked if staff were providing and documenting NPIs prior to giving Resident 48 as needed lorazepam, Staff C said they would try things such as activities, taking Resident 48 outside for fresh air, and calling Resident 48's daughter, but that the NPIs were not specific for the medication lorazepam, and should be individualized for each medication, monitored, tracked and updated by adding to the interventions. 4) Resident 28 was admitted to the facility on [DATE] with diagnoses of dementia, insomnia (trouble sleeping), and depression. The Quarterly MDS, dated [DATE], showed Resident 28 was rarely understood or rarely understands. Resident 28's orders were reviewed and five psychotropic medications were found: 1. Antidepressant: escitalopram, in the morning for dementia with behavioral disturbance 2. Antidepressant: trazodone, at bedtime for sleep issue 3. Antipsychotic: quetiapine, in the morning and in the evening for dementia 4. Antipsychotic: olanzapine, at bedtime for delusions 5. Antianxiety: lorazepam, as needed every 8 hours for agitation Review of the EHR showed no active diagnosis for psychosis or anxiety. Review of Resident 28's TBs showed they had monitors for aggressive behavior, anxiety, and depression with none specifying what medication they were linked to or if they were for dementia behaviors. Documentation of the behaviors observed in the MAR/TAR said no, instead of describing what behaviors there were. Review of TBs on the TAR showed blanks (no documentation) on 02/14/2025 for the 6:00 AM to 6:00 PM shift and 03/08/2025 and 03/13/2025 for 6:00 PM to 6:00 AM shifts. Review of as needed lorazepam usage, showed there was no option for staff to document NPIs on the order. Resident 28 did have a NPI order for shift, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Three dates in April were reviewed and were as follows: 1. 04/01/2025, lorazepam was given at 2:00 PM for anxiety and agitation. Under the TB monitors, no aggression or anxiety was noted for the 6:00 AM to 6:00 PM shift, no NPI was documented on these monitors. 2. 04/03/2025, lorazepam was given at 11:02 AM for anxiety/agitation. Under the TB monitors, no aggression or anxiety was noted for the 6:00 AM to 6:00 PM shift, no NPI was documented as given on these monitors. 3. 04/11/2025, lorazepam was given at 8:00 AM for anxiety and agitation. Under the TB monitors, no aggression or anxiety was noted for the 6:00 AM to 6:00 PM shift, no NPI was documented as given on these monitors. During an interview on 05/12/2025 at 1:42 PM, Staff Q, Licensed Practical Nurse, when asked what Resident 28's anxiety looked like, said fidgety, they would redirect with snacks or walk with them, the resident tries to get out (of the building). Staff Q said yesterday Resident 28 became aggressive and threw their coffee on an aide after trying to redirect, but was fine after that and did not remember the incident. Staff Q said they would give medications, it would not work immediately and could take hours, and then Resident 28 would sleep for hours. Staff Q said Resident 28 is rarely aggressive. When asked about the NO documentation on the behavior observed section of the TB monitors, Staff Q said it was not detailed enough. When asked about Resident 28's depression, Staff Q said they talk about work, but its more confusion, they are not alert and oriented to reality, and staff would provide a busy box to distract. When asked how they assess episodes of worthlessness, down, loss of pleasure from usual activities, Staff Q said no they were not able to assess any of these because if you ask Resident 28 a question, they answer something totally different. During an interview on 05/12/2025 at 2:09 PM, Staff C, RCM, when asked if it was common for residents who have dementia to have anxiety with it, said yes. For possible triggers to make Resident 28 anxious, Staff C said them not being able to get up, being seated or in bed, needing to be redirected to sitting in their chair, and wanting to go (be on the move). For NPI for Resident 28's behaviors, Staff C said they participate in activities, hit on wood, read the paper, follow staff up and down the halls (from wheelchair). When asked if they looked into any route causes for the behaviors that led to the prescription for lorazepam, Staff C said just the dementia. Staff C added that in Resident 28's past, they were a hard worker, always working on cars or in the shop, and they sometimes say they need firewood or a case of beer. When asked how they would know a TB, such as anxiety or aggression, was related to medication usage and not just dementia, Staff C said they would say dementia, that the medication might be having the opposite effect rather than helping. Staff C said after taking medications, Resident 28 can have an increase in behaviors including restlessness. Staff C looked in the EHR and agreed the orders for TB monitors did not distinguish between the class of medications being monitored and that NPI were not being monitored on the lorazepam order itself. During this interview, when asked about blanks on the TAR for TB monitors, Staff C said this did not meet expectations as it meant it was not done. When asked about staff documenting a number of behaviors, and then NO as behavior observed, Staff C said this counteracted the number of behaviors and should have listed what the behavior was. When asked if Resident 28's agitation, which may or may not have been related to dementia, if it had a threshold for the level of agitation that was acceptable, Staff C said agitation would be expected, the threshold should be made clear, and they should have a baseline documented for Resident 28. When asked how the facility was attempting to minimize the usage of lorazepam, Staff C said by making it a last resort, trying different things such as activities, movies, fresh air, and this should be clear in the orders and care plans. Staff C confirmed the current order for lorazepam had been active since 04/09/2025 and was over 14 days, and that Resident 28's order on 01/07/2025 which ended on 02/14/2025, was over 14 days. During this interview, Staff C was asked about Resident 28's TB monitor for depression that said, Worthlessness, down, loss of pleasure from usual activities, and said it was almost impossible to assess for the resident, that they were limited by only being able to assess non-verbal questions. When asked about the gradual dose reduction being contraindicated on 03/14/2025 due to resident continues to exhibit behaviors, psych provider to follow, and asked why if behaviors can be anticipated in residents with a diagnosis of dementia, said right right. When asked about the fasting blood glucose and lipid profile requested by the psych provider on 04/20/2025, Staff C said it was not done due to Resident 28 being noncompliant, they did not want to continue because it was making the resident uncomfortable, and they took that as a refusal. Staff C, when asked if there was documentation of this, said there should be but there probably was not. 5) Resident 56 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], showed Resident 56 was able to be understood and understands. Review of Resident 56's orders showed lorazepam was first ordered on 12/27/2024. The most recent order for lorazepam showed it had a start date of 04/09/2025, was past the 14 days allowed, and had no end date listed. Review of the MAR for December 2024, January 2025, February 2025, March 2025, April 2025, and May 2025 showed Resident 56 was not taking lorazepam. During an interview on 05/08/2025 at 1:30 PM, Staff P, Physicians Assistant, when asked about the lorazepam order, said that residents suddenly want to take lorazepam and the facility might not have it available, they had to reorder it every two weeks, and they had it happen when at 2:00 AM on a Sunday a resident had nothing. Staff P then added that a provider was on call 24 hours a day and staff could always call for lorazepam. During an interview on 05/09/2025 at 10:10 AM, Staff C, RCM, said for as needed psychotropic medication, it was dependent on resident symptoms and was based on the individual. When asked if Resident 56's lack of lorazepam usage meant they did not have any mild anxiety, air hunger, or EOL symptoms, Staff C said that was their understanding. When asked if the 04/09/2025 lorazepam order that was discontinued the previous day, if this was greater than 14 days and had previously not had an end date, Staff C said yes, there was not an end date listed until yesterday (when it was discontinued). Reference WAC 388-97-0620 (1)(a) .

CONCERN (E)

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

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 39 was admitted to the facility on [DATE]. Review of the 01/30/2025 discharge MDS, showed the resident was transferr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 39 was admitted to the facility on [DATE]. Review of the 01/30/2025 discharge MDS, showed the resident was transferred to acute care on 01/30/2025, return anticipated. Review of the EHR showed no documentation was present to show Resident 39 was offered a bed hold as required. On 05/13/2025 at 2:50 PM, Staff C, RCM, said they were unable to find documentation to show that a bed hold was offered. On 05/13/2025 at 3:03 PM, when asked for documentation to show the ombudsman was notified of Resident 39's 01/30/2025 transfer to acute care Staff A said she would look for some. No further documentation was provided. Reference WAC 388-97-0120 (4) Based on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 19 and 39) and ombudsman notification for 3 of 4 sample residents (Residents 19, 75 & 39) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital, protection of resident rights during transfers, and a diminished quality of life. Findings included . 1) Resident 19 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 04/21/2025, documented Resident 19 was moderately cognitively impaired. A review of the Electronic Health Record (EHR) showed Resident 19 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 19's EHR showed documentation that Resident 19's bed hold notice was dated 04/15/2025 and signed on 05/05/2025 (greater than 24 hours after transfer). On 05/09/2025 at 9:29 AM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM) said the bed hold was not signed on 04/15/2025 and it looks like Resident 19 was not notified within 24 hours. On 05/09/2025 at 11:30 AM, Staff B, Director of Nursing (DNS), said the Bed hold should be dated, signed and locked on the same day. A review of a document titled [Facility] residents leaving the building during the month of April 2025 dated 05/02/2025 did not list Resident 19. On 05/09/2025 at 1:06 PM, Staff A, Administrator, said she did not put Resident 19 on the list because she did not think they stayed overnight. After looking in the EHR, Staff A said, the Ombudsman did not receive notification and they should have. A review of a documented dated 05/12/2025 said I realized when I sent you our report, I missed the residents that went to the hospital but returned again. Resident 19 was listed. On 05/13/2025 at 10:17 AM, Staff A, Administrator, said she sent this document yesterday, on the 12th, and wanted to provide it so we could see she corrected her error. 2) Resident 75 admitted to the facility 02/04/2025. The Admission, MDS, dated [DATE], documented Resident 75 was cognitively intact. According to a 02/06/2025 Alert Progress note, Resident 75 requested to sign out of the facility against medical device to go home. A second note on 02/06/2025 noted Resident 75 had exited the facility via a cab and was in route to her house against medical advice. On 05/09/2025 at 9:33 AM, Staff A, Administrator, was asked to provide documentation that the ombudsman had been notified of Resident 75's discharge. Staff A said she would look for it. On 05/12/2025 at 3:16 PM, Staff A was asked again for the documentation that ombudsman had been notified of Resident 75's discharge and was unable to provide documentation. On 05/13/2025 at 10:50 AM, Staff A provided a written document that stated she was unable to find the February report to the Ombudsman.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident 62 was admitted to the facility on [DATE]. Review of the 04/21/2025 hospital discharge summery showed the resident w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident 62 was admitted to the facility on [DATE]. Review of the 04/21/2025 hospital discharge summery showed the resident was receiving aripiprazole and quetiapine (antipsychotic medications) for hallucinations and acute delirium secondary to sepsis. An antipsychotic use care plan, dated 04/30/2025, documented Resident 62 received antipsychotic medications for depression. The goal of the antipsychotic therapy was to have no negative outcomes or drug related complications from antipsychotic medication use. The care plan failed to identify any goals for the use of the antipsychotic medications. Additionally, the specific target behaviors (TBs) the antipsychotic medications were initiated to treat were not identified (e.g. hallucinations, delirium). On 05/12/2025 at 3:37 PM, Staff C, RCM, acknowledged the care plan was not personalized or resident specific and said the goal of antipsychotic medication treatment should have been identified, the resident's delirium and hallucinations should have been addressed, and the specific TBs each medication was initiated to treat should have been identified. An antidepressant medication care plan, dated 04/30/2025, showed a goal of Will be free from discomfort or adverse reactions related to antidepressant therapy. No goal was established for the use of the antidepressant medication (e.g. a decrease in the TBs the medication was initiated to treat.) The TBs were identified as isolation, withdrawn and loss of interest in usual activities. On 05/12/2025 at 3:37 PM, Staff C, RCM, said the care plan should have included the goal of antidepressant medication therapy. 5) Resident 39 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident had diagnoses of Post Traumatic Stress Disorder (PTSD), bipolar disorder, and anxiety disorder, and received antianxiety and antidepressant medications during the assessment period. A mood and behavior problem related to diagnoses of PTSD, bipolar and anxiety disorders care plan, revised 03/03/2025, identified the TBs for anxiety disorder as Anxiety D/O [disorder], and the TBs for the resident's PTSD and Bipolar disorder as Bipolar disease and PTSD and directed staff to document the number of occurrences of each. On 05/13/2025 at 12:27 PM, Staff C, RCM, said TBs should reflect the behaviors that manifest from the underlying diagnoses of anxiety, PTSD, and bipolar. Staff C said TBs should not be a restatement of the diagnosis. 6) Resident 127 was admitted to the facility on [DATE]. On 05/06/2025 at 11:25 AM, Resident 127 was observed to have dark discoloration that encompassed both forearms from elbow to wrist. The resident said they had been that way for years and indicated it was senile purpura (a condition that causes purple, brown, or red bruises on the skin, especially on the arms and hands.) Review of Resident 127's comprehensive care plan showed the senile purpura was not addressed. On 05/12/2025 at 3:27 PM, Staff C, RCM, said the senile purpura to both of Resident 127's forearms should have been care planned. 7) Resident 20 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 20 received non-medication interventions and pain medications as needed. Resident 20 was cognitively intact. A review of Resident 20's care plan showed a focus of Potential for/Actual acute/chronic pain as described or exhibited by non-verbal indicators related to right ankle fracture Initiated on 12/23/2024 and revised on 01/31/2025. The interventions include anticipating need for pain relief and responding to any complaint of pain and monitor/record/report to nurse resident complaints of pain or requests for pain treatment. On 05/12/2025 at 10:30 AM Staff C, RCM, said while looking at the care plan for pain that it was a template and indicated it was not resident centered or individualized for Resident 20. On 05/12/2025 at 11:30 AM Staff B, DNS, said Resident 20's pain care plan was a basic template, and she did not see any specifics. Staff B said it should have contained customized interventions to counteract their pain. 8) Resident 16 was admitted to the facility on [DATE]. The Quarterly MDS dated [DATE] indicated they were moderately cognitively impaired. A review of Resident 16's care plan showed a focus of dependent on staff for activities, cognitive stimulation, social interaction related to immobility initiated on 02/17/2022 and revised on 01/31/2025. The interventions included ensuring the activities resident attends are compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed; compatible with individual needs and abilities; and appropriate age and staff will provide one to one time every week. On 05/09/2025 at 11:58 AM Staff C, RCM, said while looking at Resident 16's activity care plan that it should include specific activities Resident 16 likes to do such as watch movies. On 05/12/2025 at 11:30 AM Staff B, DNS, said Resident 16's activity care plan was not individualized and person centered and it should contain examples of what kind of activities they like to do. A review of Resident 16's comfort care, care plan shows a focus of an advance directive initiated on 07/09/2024 and revised on 02/05/2025 with an intervention of refer to Cardiopulmonary Resuscitation consent form for specific instructions - comfort care. On 05/09/2025 at 11:58 AM Staff C, RCM, said that the comfort care, care plan did not direct staff on how to care for Resident 16 and it should have contained specific things for Resident 16 that provide comfort. On 05/12/2025 at 11:30 AM Staff B, DNS, said the comfort care care plan did not have anything customized to Resident 16's care and preferences. 9) Resident 37 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 37 was cognitively intact. Resident 37's Palliative/End of Life needs care plan documented Resident 37 was initiated for end-of-life care services on 05/06/2024. Resident 37's Palliative/End of Life needs care plan documented, Provide end of life care as needed to meet the needs of the resident. Adjust/review Advance Directive as needed. Alert MD with resident status changes. The care plan provided no individual resident centered preferences, goals or interventions. 10) Resident 15 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 15 was severely cognitively impaired. Resident 15's Palliative/End of Life needs care plan documented Resident 15 was initiated for end-of-life care services on 05/06/2024. Resident 15's Palliative/End of Life needs care plan documented, Provide end of life care as needed to meet the needs of the resident. Adjust/review Advance Directive as needed. Alert MD with resident status changes. The care plan provided no individual resident centered preferences, goals or interventions. On 05/09/2025 at 8:22 AM, Staff C, RCM, reviewed Residents 37's and 15's Palliative/End of Life needs care plan, then stated, the care plans were absolutely not individualized person centered and they should have been. At 9:20 AM, Staff B, DNS, reviewed Residents 37's and 15's Palliative/End of Life needs care plan and said those were cookie cutter(meaning all the same) care plans. Staff B said the expectation was that care plans should be individualized person-centered plans. 11) Resident 24 admitted to the facility 03/06/2020. The Quarterly MDS, dated [DATE], documented Resident 24 was rarely/never understood, rarely/never understood others and was severely impaired in making decisions of daily life. On 05/06/2025 at 8:18 AM, Resident 24's bed was observed to be pressed against a fall mattress, which was between the bed and the wall. On 05/08/2025 at 9:18 AM, Resident 24's bed was observed against the wall, with no fall mattress in between the bed and the wall. Review of Resident 24's care plan showed that there was no care plan in place for their bed being against the wall. On 05/12/2025 at 12:31 Staff C, RCM when asked what elements needed to be in place before a bed was put against the wall said, a safety device evaluation, orders, it should be added to the care plan, and a consent. When asked if there was a care plan for Resident 24's bed against the wall, Staff C said she could not see it, and it should be there. Review of Resident 24's care plans showed there was a Palliative Care End of Life needs care plan. For a goal it documented Resident 24's palliative needs will be met. The care plan did not specify the palliative needs for Resident 24. Under interventions the care plan documented provide end of life care as needed to meet the needs of resident, again it did not specify what Resident 24's end of life care needs might be. Another intervention listed on the care plan was Alert MD with resident status changes, it did not specify what type of changes staff should alert the MD for. On 05/12/2025 at 9:55 AM, when asked if Resident 24's palliative care plan was person centered and individualized Staff C said, it is cookie cutter, it is not individualized as it should be. Refer to F553 Reference WAC 388-97-1020(1), (2)(a)(b) Based on interview and record review, the facility failed to provide residents with care plans that were comprehensive, individualized and person centered, updated, and/or accurate for 11 of 18 sampled residents (Residents 28, 56, 45, 63, 39, 127, 20, 16, 37, 15, & 24) reviewed. This failure placed residents at risk of unidentified and unmet care needs, and a diminished quality of life. Findings included . 1) Resident 28 was admitted to the facility on [DATE] with diagnoses of dementia and depression. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 28 was rarely understood or rarely understands. Review of Resident 28's past 30 days of meals monitor, showed three meals were refused. Review of Resident 28's nutritional risk care plan, showed standard interventions to monitor and record food/fluid intake, monitor weight, obtain and monitor labs, and serve diet as ordered. The care plan did not mention any refusals of meals or any alternatives/preferences if Resident 28 did not want to eat the provided meal. During an interview on 05/12/2025 at 1:59 PM, Staff C, Resident Care Manager (RCM), when asked about Resident 28 being at risk for weight loss, said the facility was using snacks to calm the resident, providing them throughout the day as a non-pharmacological interventions (NPI) for when the resident was upset. When asked about there being documentation that Resident 28 refused meals, Staff C said yes this should be in the care plan, and it should also include interventions or alternatives when refusals occur. Review of Resident 28's anti-anxiety medication care plan listed it was related to a diagnosis of anxiety disorder, and did not list it was related to dementia. Resident 28 did not have an active diagnosis of anxiety disorder. During an interview on 05/12/2025 at 2:09 PM, Staff C, RCM, said Resident 28 had depression and dementia, but no diagnosis of anxiety. When asked if the care plan listed what an acceptable level of agitation was for Resident 28, Staff C said they would expect this in the care plan and it was not there. Review of Resident 28's impaired cognition/dementia care plan, showed interventions of asking yes/no questions, monitoring changes in cognitive function, providing simple, consistent, directive sentences, breaking tasks into one step at a time, and provide the resident with necessary cues-stop and return if agitated. During an interview on 05/12/2025 at 2:09 PM, Staff C, RCM, listed some interventions to help with Resident 28's anxiety as activities, following staff up and down halls, reading a paper, and hitting on wood. Resident 28 was described to be impulsive. When asked if Resident 28's care plans were updated to include what were possible triggers or what interventions were used for behaviors, Staff C said it was not individualized for him. During an interview on 05/13/2025 at 10:43 AM, Staff B, Director of Nursing [NAME] (DNS), was asked if the facility did any of the following: develop a care plan with measurable goals and interventions to address the care and treatment for a resident with dementia, create a care plan that was individualized and person-centered, and monitored the effectiveness of the interventions. Staff B looked in the electronic health record (EHR) and said no, they did not see anything specific to Resident 28. When told there was a lack of documentation supporting the facility had used the care plan to identify, document, and communicate specific targeted behaviors and expressions of distress, as well as desired outcomes, and implemented individualized, person-centered interventions, Staff B said their expectation for residents with a dementia diagnosis, was there would be documentation on how they were presenting, identified goals and interventions, to assist the staff to navigate their care. 2) Resident 56 was admitted to the facility on [DATE], and had diagnoses of malnutrition and chronic pain. The Significant Change MDS, dated [DATE], showed Resident 56 was able to be understood and understands. Review of Resident 56's anti-anxiety medications care plan, showed medication was related to anxiety disorder. No diagnosis of anxiety was found in the EHR. During an interview on 05/09/2025 at 10:10 AM, Staff C, RCM, looked at Resident 56's care plans and regarding the care plan saying Resident 56 had anxiety disorder, said Resident 56 did not have a diagnosis of anxiety. Review of Resident 56's acute/chronic pain care plan, showed it was not resident specific as it did not include pain goals for the chronic pain, specifics on medications being given to the resident, what did and did not work for pain management for the resident, and NPI that was effective for the resident. During an interview on 05/07/2025 at 2:25 PM, Staff N, Licensed Practical Nurse (LPN), was asked about Resident 56's pain. Staff N said that when Resident 56 was outside of the window for morphine, that no other medication from Resident 56's orders worked (ibuprofen), and if offered, Resident 56 would say it did not help. For NPI for pain management, Staff N said turning and distraction could help. During an interview on 05/09/2025 at 10:10 AM, Staff C, RCM, said a pain care plan should include where the pain was, what medication was being given for the pain, goals to achieve such as a 2/10 pain goal, any interventions, and NPI such as activities and games. When asked about Resident 56's alleged refusals for ibuprofen or NPI, Staff C looked at Resident 56's care plan and said it was a pain template and not individualized. Review of Resident 56's progress notes showed they were reviewed for significant weight loss on 02/14/2025 and 03/06/2025. Review of Resident 56's care plans showed this weight loss was not added. During an interview on 05/09/2025 at 10:40 AM, Staff C, RCM, said Resident 56's significant weight loss should have been added to the care plan. On 05/05/2025 at 4:05 PM, Resident 56 reported having both constipation and diarrhea. Review of the EHR showed Resident 56 had no bowel movement documented from 04/19/2025 to 04/24/2025. Review of Resident 56's care plans showed no constipation care plan, with no goals and interventions. During an interview on 05/09/2025 at 10:31 AM, Staff C, RCM, said Resident 56 had risk factors for constipation and said they should have had a care plan for this and did not have one. Resident 56's care plan on palliative/hospice care/end of life care showed no individualized interventions and goals. Under interventions it only had two: 1.Provide end of life care as needed to meet the needs of the resident. 2.Adjust/review Advance Directive as needed. During an interview on 05/09/2025 at 10:49 AM, Staff C, RCM, said Resident 56's end of life care plan was not individualized, there was not much for staff to go off of, was not individualized enough for staff to know how to honor Resident 56's personal preferences, and did not include religious preferences. 3) Resident 45 was admitted to the facility on [DATE], with a diagnosis of kidney disease. Review of the Quarterly MDS, dated [DATE], showed Resident 45 was understood by others and understands, and was receiving dialysis treatments. Review of Resident 45's care plans showed the dialysis care plan was minimal and missing specifics including contact information for dialysis concerns and dialysis weight goals. During an interview on 05/09/2025 at 10:58 AM, Staff C, RCM, when asked about Resident 45's care plan for dialysis, said the care plan should have the residents goal weight and had to follow up to obtain this number. When asked if the care plan had information such as access site for dialysis, arm to avoid, who to contact for dialysis related emergencies and their contact information, Staff C said there were no specifics. Review of Resident 45's care plan for discharge, showed there was no active discharge plan. Under interventions, it stated, Does not wish to discharge from the center at this time. No active discharge plan in place. On 05/06/2025 at 8:22 AM, Resident 45 said they had wanted to leave/discharge. During an interview on 05/13/2025 at 10:27 AM, Staff B, DNS, said Resident 45's family member was not ready for Resident 45 to be discharged , this should have been in the care plan and was not. Staff B said the last time there was a care conference the RCM updated them that the goal was to discharge, but the home was not ready.

CONCERN (E)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 37 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 37 was cognitively i...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 37 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 37 was cognitively intact. A physician's order dated 07/25/2022, documented, Assess for pain and provide non pharmalogical interventions to reduce pain and document effectiveness. 1-Repositioning 2-Relaxation 3- Diversional Activities 4-Redirection. Doc number used and effectiveness. Resident 37's April and May 2025 MAR and Treatment Administration Record (TAR) documented NPIs 1-4 were used daily, even on days when Resident 37 reported no pain. The April and May 2025 MAR & TAR showed no documentation of effectiveness. Progress notes provided no documentation to support what NPIs were being used, only stated pain and did not document effectiveness. 3) Resident 40 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], documented Resident 40 was severely cognitively impaired. A physician's order dated 08/23/2023, documented, Assess for pain and provide non pharmalogical interventions to reduce pain and document effectiveness. 1-Repositioning 2-Relaxation 3- Diversional Activities 4-Redirection. Doc number used and effectiveness. Resident 40's April and May 2025 MAR and TAR documented NPIs 1-4 were used daily, even on days when Resident 40 reported no pain. The April and May 2025 MAR & TAR showed no documentation of effectiveness. Progress notes provided no documentation to support what NPIs were being used, only stated pain and did not document effectiveness. On 05/09/2025 at 8:22 AM, Staff C, RCM, reviewed Resident 37's and Resident 40's MAR and TAR's, and said they say the exact same thing. Staff C said the actual intervention needed to documented, along with the effectiveness of the NPIs. On 05/09/2025 at 9:20AM, Staff B, Director of Nursing Services (DNS), said the copy and paste item was removed from the system and they believed staff have completed the listed NPIs. When shown the MAR and TAR's for Resident 37 and Resident 40, Staff B confirmed the exact NPIs used and their effectiveness were not documented. When progress notes for both residents were shown, documenting pain only, Staff B confirmed NPIs and the effectiveness should have been documented. 4) Resident 48 was admitted to the facility 02/07/2024. The Significant Change MDS, dated [DATE], showed Resident 48 was rarely or never understood, and sometimes understood. Review of Resident 48's physician pain orders showed they had the following pain medication order in place, dated 04/30/2025: morphine, give by mouth two times a day for pain management AND give by mouth every 2 hours as needed for moderate pain, air hunger, EOL (End of Life) symptoms AND Give by mouth every 2 hours as needed for severe pain, air hunger, EOL symptoms. Review of the EHR showed there was NPI monitoring for pain and staff were instructed to provide NPI to reduce pain and document effectiveness every shift, these instructions were not linked to the morphine order. Review of Resident 48's April 2025 MAR showed staff had administered morphine 12 times, it was unclear if they attempted NPI's prior to administering the pain medication as the NPI's were not linked to the morphine order. On 05/12/2025 at 10:30 AM, Staff C, RCM, reviewed Resident 48's morphine order, and when asked how the nurse would know what was moderate pain versus severe pain without the order listing a numerical pain scale to follow (0/10 pain scale, 0 being none, with 10 being the worst), Staff C said the provider inputing the order should have added the pain scale with parameters. Regarding EOL symptoms, Staff C said the order should be more specific. Staff C, when asked if staff were providing and documenting NPIs that were attempted prior to morphine being given, said no, they did not see it in the EHR and they should be. Staff C said there should be a plan and documentation of NPI's for morphine. When asked for documentation that the facility was monitoring for adverse side effects of the administered morphine (such as slow or stopped breathing, signs of increased effort to breath, mental status changes), Staff C said they were not seeing that the facility was doing that for morphine, but it should be there for sure. Reference WAC 388-97-1060 (3)(k)(i) Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary medications by providing and documenting on non-pharmacological interventions (NPI) for pain management, having parameters for medications, and/or using non-opioid medications for 4 of 6 residents (Residents 56, 37, 40 & 48) reviewed for unnecessary medications or pain. This failure placed residents at risk of medication tolerance, increased pain, and a diminished quality of life. Findings included . 1) Resident 56 was admitted to the facility on [DATE] with diagnoses of chronic pain and muscle spasm. The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 56 was able to be understood and understands. Review of Resident 56's pain orders showed they had two as needed medications for pain: 1. Morphine, an opioid (strong pain medication), for every 3 hours as needed for end of life care (not listed for pain, no parameters/pain score listed on when to give). 2. Ibuprofen, a non-opioid, for every 8 hours as needed for headache/pain (no parameters/pain score listed on when to give). Review of the Medication Administration Record (MAR) showed the following: -04/01/2025 to 04/30/2025: morphine was given 14 times, with no ibuprofen given on any of those dates. Ibuprofen was only administered one day (04/01/2025). Morphine was given 3 times for 4/10 pain, and once for 5/10 pain. -05/01/2025 to 05/06/2025: morphine was given 5 times; no ibuprofen given. Morphine was given once for 5/10 pain, and once for 0/10 pain. Review of the electronic health record (EHR) showed no order for NPI interventions. Review of Resident 56's care plan showed NPI should be provided for pain management, such as position change, relaxation techniques, massage, smooth linens, mobility or physical activity. On 05/07/2025 at 12:13 PM, Resident 56 had their call light on due to 4/10 pain. On 05/07/2025 at 12:32 PM, Staff went into the room and told Resident 56 they would find the nurse to give pain medication. On 05/07/2025 at 1:02 PM, Resident 56 reported they were told they were outside of the timeframe to receive medication (last given at 10:14 AM that day, next dose could be given at 1:14 PM). On 05/07/2025 at 1:37 PM, Staff N, Licensed Practical Nurse (LPN), gave Resident 56 morphine and left the room. On 05/07/2025 at 1:38 PM, Resident 56 reported no NPI was given, they were not offered ibuprofen, and yes they would have taken ibuprofen. On 05/07/2025 at 2:25 PM, Staff N, LPN, said Resident 56's pain was an 8/10 when the morphine dose was given. When asked if anything improved Resident 56's pain, said morphine. When asked what NPI works for Resident 56, Staff N said turning or distraction can help. Staff N, when asked about Resident 56 being outside of the window for morphine, acknowledged they had not offered other pain medications (ibuprofen) for this specific occurrence, nor did they offer NPI. During an interview on 05/09/2025 at 10:10 AM, Staff C, Resident Care Manager (RCM), said NPIs should be offered every shift and when residents were requesting pain medication. When asked how the facility was preventing the use of unnecessary medication if pain medication orders do not have parameters on them for when to administer, Staff C said by using NPI such as going on a walk, going outside, repositioning, and that medication should not be the first step. Staff C said if a resident was not due for a narcotic/opioid pain medication, then they should be offered as needed ibuprofen or acetaminophen/Tylenol. When asked about Resident 56's ibuprofen and morphine orders not having parameters, Staff C said yes they should have parameters. When asked about there being no documented NPI for the pain medications given in March, April, and May 2025, Staff C said this did not meet expectations.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

. Based on observation, interview and record review the facility failed to store food for residents in accordance with professional standards for 2 of 2 nursing station refrigerators (East, West) revi...

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. Based on observation, interview and record review the facility failed to store food for residents in accordance with professional standards for 2 of 2 nursing station refrigerators (East, West) reviewed for food service safety. The failure to maintain documented refrigerator temperature logs placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life. Findings included . Review of the following refrigerator temperature logs located at nurses stations included the following out of range temperatures (greater than 40 degrees Fahrenheit (F): February 2025 [NAME] refrigerator: 5th 43F AM shift/ 5th 43F PM shift 8th 43F AM shift 9th 42F AM shift 10th 43F AM shift 15th 43F AM shift 16th 44F AM shift there was no documentation of corrective action taken. February 2025 East refrigerator: 11th 43F AM shift 12th 45F AM shift 19th 43F AM shift there was no documentation of corrective action taken. March 2025 [NAME] refrigerator: 4th 45F AM shift 7th 43F AM shift 11th 49F AM/42F PM shifts 12th 43F PM shift 13th 43F AM/47F PM shifts 14th 47F PM shifts 15th 45F AM/46F PM shifts 16th 43F PM shift 17th 47F PM shift 18th 44F PM shift 19th 43F AM/44F PM shifts 20th 44F AM/44F PM shifts 21st 44F PM shift 22nd 44F PM shift 23rd 44F PM shift 25th 45F AM/44F PM shifts 26th 43F AM shift 29th 44F PM shift a line was drawn through comments section Kept Fridge Shut marked next to line. April 2025 [NAME] refrigerator: 21st 42F AM shifts 22nd 45F AM shifts 23rd 42F AM shifts 28th 42F PM shifts there was no documentation of corrective action taken. April 2025 East refrigerator: 9th 44 PM 12th 42 PM 14th 43 PM 15th 45 PM 16th 48 PM 17th 47 PM 18th 47 PM 19th 47 PM 20th 47 PM 21st 47 PM 22nd 47 PM 23rd 47 PM 24th 47 PM 26th 42 PM there was no documentation of corrective action taken. On 05/07/2025 at 10:39 AM, Staff I, Dietary Manager, said refrigerator temperatures were supposed to be 40 degrees or below. When asked what the process was for when a refrigerator temperature was out of range, Staff I said staff would make sure the door was closed, wait and hour then come back and recheck the refrigerator temperature. Staff I said if the problem persisted, then they would contact maintenance and the Administrator. When shown multiple dates of out-of-range refrigerator temperatures with no corrective action documented, Staff I said the corrective action should have been documented. Staff I said out of range refrigerator temperatures were not acceptable. Reference WAC 388-97-1100 (3), 2980. .

CONCERN (E)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the binding arbitration agreements (legal document that re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the binding arbitration agreements (legal document that required the use of a third party to resolve disputes) were reviewed in a manner that explicitly informed the resident or their representative of what they were consenting to, or were understood in their entirety, for 3 of 3 residents (Residents 39, 126, & 127) reviewed for binding arbitration. This failure placed residents at risk for legal complications and a diminished quality of life. Findings included . 1) Resident 39 was admitted to the facility on [DATE]. Resident 39 signed their binding arbitration agreement on 11/25/2024. Review of the electronic health record showed Resident 39 was admitted after being in the hospital for sepsis (infection of the blood) and was re-hospitalized on [DATE] with altered mental status. During an interview on 05/07/2025 at 10:57 AM, Resident 39 was asked what their understanding of the arbitration process was, and said they did not really know. When asked if they knew they were giving up their right to litigation in a court proceeding,Resident 39 said no. When asked if they were told of their right to terminate or withdraw the agreement within 30 days of signing, Resident 39 said they did not think so. Resident 39 stated, I think maybe we went over it too quickly. I would not have signed it. They did not explain it in totality. Resident 39 explained that when they were admitted , they were getting over a urinary tract infection, had previously been hallucinating while at the hospital, and was unsure they had the mental acuity to agree to the binding arbitration agreement at that time. 2) Resident 126 was admitted to the facility on [DATE]. Resident 126's Power of Attorney (POA) signed the binding arbitration agreement on 05/05/2025. During an interview on 05/06/2025 at 3:17 PM, Resident 126's POA was asked if they understood they were giving up their right to litigation in a court proceeding and answered no. When asked what their understanding of the arbitration agreement was, Resident 126's POA said they had no idea what it involved. When asked if the arbitration agreement was explained in a way they understood, Resident 126's POA said no and stated, I want nothing to do with the arbitration agreement. 3) Resident 127 was admitted to the facility on [DATE]. Resident 127's responsible party signed the binding arbitration agreement on 04/25/2025. On 05/06/2025 at 3:25 PM, when asked who filled out their admission paperwork, Resident 127 stated, I was out of it. During an interview on 05/06/2025 at 3:37 PM, Resident 127's responsible party said they did not know what they signed and stated, I was in a state, my husband was dying for all I knew. During an interview on 05/06/2025 at 1:16 PM, Staff D, Business Office Manager, said they went over the binding arbitration agreements. When asked how they ensure the resident or representative understood the terms of the arbitration agreement, Staff D said they explained that it was mediation, that if they had a grievance it would go in front of an administrative judge, and if they did not like the result then they could go to court. Staff D said the agreement did not keep the residents from going to court, just added another step. When asked how they ensure the agreement was explained in a form or manner that accommodated the residents or his/her representative's needs, Staff D said they would change the wording, let them know it was voluntary, that it was for mediation for if they had a grievance that they wanted to sue or reach a court level decision, and that by signing the document they were giving both parties an opportunity to go before an administrative judge prior to including the court. During an interview on 05/09/2025 at 12:06 PM, Staff A, Administrator, said their expectation for staff reviewing the binding arbitration agreements was for them to be explained in a way for them to be understood. When asked what, This agreement waives the right to trial by judge or jury meant, Staff A said they (the residents/representatives) could not take it to court. When asked if it met expectations that 3 of 3 residents/representatives answered no, to if they understood they were giving up the right to litigation in a court proceeding, Staff A stated, probably not. No Associated WAC .

CONCERN (E)

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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected multiple residents

. Based on interview and record review, the facility failed to show evidence of an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement program (QAPI, a program...

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. Based on interview and record review, the facility failed to show evidence of an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement program (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice). The facility failed to provide evidence of documentation that demonstrated the development, implementation, and evaluation of a performance improvement activity for 1 of 1 sampled Process Improvement Projects (PIP) reviewed. The facility failed to provide evidence of the medical director participating in the QAPI program. This failure placed residents at risk for ongoing unmet care needs and a diminished quality of life. Findings included . Record review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Process effective July 2015, stated, The center pursues the highest quality of care and services for their customers through a data-driven, proactive approach to improving the quality of life, care, and services. The activities of QAPI involve members at all levels of our organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement corrective plan; and continuously monitor effectiveness of interventions. Each Center leadership team with Client Support Center is accountable for actively participating in the formalized and documented Quality Assurance and Performance Improvement (QAPI) process that includes efficient mechanisms for monitoring, revising, analyzing, documenting and improving process .The committee will be accountable to develop and implement corrective measures or, when necessary, initiate an action plan or assign a Performance Improvement Project(PIP). On 05/13/2025 at 2:22 PM, Staff A, Administrator, said she did not have sign-in sheets for the QAPI meetings or proof that the medical director attended the QAPI meetings at least quarterly. Staff A said the medical director was not local and does not always come in. Staff A was asked to provide documentation of a QAPI plan the facility was working on that had been successful for the committee and she said no, I don't have a plan. When Staff A was asked if they were working on anything currently? she said, let me think about it. And when Staff A was asked if they'd worked on anything in the past? she said, let me think about it. On 05/13/2025 at 3:08 PM, Staff A, Administrator, said she would follow up with the state agency and provide documentation of a Process Improvement Plan (PIP) within 48 hours of exit. On 05/13/2025 at 3:50 PM, Staff A provided a document titled [facility] QAPI meeting March 25, 2025. The document was sparse and did contain the relevant information. Staff A did not provide a PIP or sign-in sheets from the facility's QAPI meetings. Reference: WAC 388-97-1760 (1)(2) .

CONCERN (E)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected multiple residents

. Based on interview and record review, the facility failed to have a system in place for maintaining documentation of staff screening, education, offering and current COVID-19 (a contagious disease c...

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. Based on interview and record review, the facility failed to have a system in place for maintaining documentation of staff screening, education, offering and current COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) vaccination status for 12 of 12 months (May 2024 - May 2025) reviewed. These failures placed residents and staff at risk of contracting COVID-19, related complications and a diminished quality of life. Findings included . On 05/06/2025 at 1:06 PM, when asked to provide documentation of screening, education, offering and current COVID-19 vaccination status for staff, Staff A, Administrator and Infection Preventionist said they did not have any staff that agreed to take the COVID-19 vaccination. Staff A said they would talk about the importance of it, but they all had a choice. Staff A said they had last year's records, but did not have this year's records because all staff had refused the vaccination. On 05/10/2025 at 11:06 AM, Staff A was emailed a request for documentation of screening, education, offering and current COVID-19 vaccination status for 3 staff members. A subsequent email was received on 5/13/2025 at 11:45 AM, from Staff A, with an attached statement that facility staff were offered the Covid-19 vaccine, and a Vaccine Information Statement (VIS) was also attached but no staff records of screening, education, offering and current COVID-19 vaccination status was provided. Reference WAC 388-97-1320 .

Apr 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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to initiate a resident grievance for 2 of 5 sampled resident (Residen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to initiate a resident grievance for 2 of 5 sampled resident (Resident 1 and 2) reviewed for grievances. This failure placed the residents at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life. Findings included . The Facility Policy titled, Grievances, revised 02/2024, documented that the grievance process was for both residents and resident representatives, included a process for receiving, tracking and concluding for any and all concerns. Grievances were to be logged on the Grievance Log, and the resident or resident representative should receive communication within 5 days for resolution. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission MDS (minimum data set), an assessment tool, date 03/25/2025, documented Resident 1 was cognitively intact, and required substantial to maximal assistance of staff for completion of activities of daily living (ADL's). The care plan initiated on 03/18/2025 included only one Focus: ADL deficit related to COPD (chronic obstructive pulmonary disease) and included the intervention to monitor, document, and report any changes to the nurse. Review of Resident's progress notes from 03/18/2025 to 03/29/2025 showed no daily skilled clinical note entered for 03/21/2025 through 03/27/2025. A progress note, dated 03/28/3035 at 7:11am, showed Resident 1 had an episode of emesis (vomiting) during the night and the nurse notified the provider by written form and requested an antiemetic (anti-nausea medication) A progress note, dated 03/29/2025 at 1:15pm, showed the resident was lethargic, with low blood pressure, increased pulse and increased body temperature and the family strongly insisted the resident be transported to the Emergency room. A hospital admission history and physical, dated 03/29/2025, showed Resident 1 was admitted to the hospital for septic shock secondary to pneumonia. Review of the facility's grievance logs for March 24,2025 through April 23, 2025, did not show an entry related to Resident 1. On 04/22/2025 at 4:07pm, Resident 1's FM (family member) said they went to visit Resident 1 on 03/29/2025 and found the resident was not responsive. They were unable to locate nursing staff and approached staff located in the lobby, the receptionist, identified as Staff D. FM reported their concern to Staff D and reportedly the staff member raised their voice and yelled at the FM telling them, She is just sleeping, that is what people with Alzheimer's do, the nurses took her vitals, and she is fine, don't you think we know when to send someone to the hospital? FM reported that Staff D followed her back to Resident 1's room and kept talking over her. Resident 1's FM reported they left the facility and overheard Staff D taking to someone on speaker phone regarding Resident 1. Approximately 10 minutes later, after Resident 1's FM arrived home, Staff E called them and reported that Resident 1 was noted to be lethargic and offered to call 911. FM said they were called by the EMTS approximately 10 minutes later and it was reported Resident 1 had a body temperature of 102 degrees and they were administering intravenous fluids. FM said they tried to file a grievance on 3/31/2025 but there did not seem to be a formal process. FM reported they spoke to, the head nurse, about how staff treated them and concerns for lack of care. And they were told they would pass it on to the administrator. FM reported they called the facility on 04/04/2025 to follow up and Staff A told them Staff D no longer worked there and would not provide any additional details. On 04/25/2025 at 1:29pm, Staff B, Registered Nurse (RN), Director of Nursing (DNS), said if a resident's family member reported a care concern, they would review it to determine if it was grievance vsersus abuse or neglect. They would investigate to determine the resolution process and address the concerns. Staff B did not recall having a conversation with Resident 1's FM. Staff B said they were called on 3/29/2025 by Staff E and was aware of, an incident that weekend and Staff E was sending Resident 1 to the hospital. Staff B said they heard from Staff A that FM 1 reported that Staff D was rude to them, and Staff A was going to follow up after speaking to Staff D. Staff B said she would expect that an offer of formal grievance would have been extended, and they would have expected it to be on the grievance log. At 1:52pm, Staff A, Administrator, said she received most calls related to care concerns and she looked into them and gave them an answer and determined if there was something they needed to do differently to solve the issue. If it had to do with a resident decline, she would refer to Staff B. Staff A recalled talking to Resident 1's FM more than once and was working it out. Staff A did not consider staff being rude to a family member expressing concerns over resident decline, a grievance. Staff A said the family was concerned that staff were not monitoring the resident, but they were. Staff A said they did interview staff and Staff D was terminated, for other reasons. Staff A said they did not have any documentation regarding these situations and said they probably should have put it on the grievance log. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 2 was cognitively intact, medically complex, and required substantial to maximum assistance from staff for ADL's. Review of the facility's grievance log for February 2025 did not show an entry for Resident 2. On 04/25/2025 at 12:36pm, Resident 2 said they were not familiar with the facility's grievance process but had lost a pair of reading glasses shortly after admission, he reported that to a Nursing assistant. The glasses were never replaced so he had to buy another pair. At 1:21pm Staff C, Nursing Assistant, said if a resident reported missing items, they would first look for the item, for example in laundry, then get a grievance form and help the resident fill it out and turn it in to Staff A. At 1:29 Staff B, RN, DNS, said missing items were sometimes placed on a grievance form, and there was also a list in the social service office. At 1:52pm Staff A, Administrator, said that there was not a form to fill out for a missing item, when a missing item was reported they attempted to find it and if it was not found they would offer to replace it. Staff A said they kept a log of missing items. When asked about Resident 2's missing glasses, Staff A said the missing reading glasses were not logged on her list of missing items for February 2025. Staff A said she recalled hearing about them, she was going to replace them and assumed that didn't happen. Reference WAC 388-97-0460

Apr 2025 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 F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure discharge planning included assessment of resident's ability...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure discharge planning included assessment of resident's ability to manage medications, prepare or have access to prepared meals, and to handicap accessible living quarters for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress, re-hospitalization, and a decreased quality of life. Findings included . Review of the facility policy titled, Resident Discharge, revised 05/18/2023 showed that discharges must follow all state requirements to ensure safe and proper discharge for residents and it should include in the plan for the resident's continuity of care and reduction of potential transfer trauma. Resident 1 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), and assessment tool, dated 02/28/2025, showed Resident 1 was cognitively intact, required the use of a wheelchair, required daily medication via injections, and that discharge planning was occurring for the residents. The care plan focus for discharge plan, initiated 07/11/2024, showed Resident 1's discharge plan was to remain in the facility. The focus included the information that the resident was given a 30-day eviction notice, but no discharge placement was available and they would remain in the facility until placement was found. Review of the nursing home transfer or discharge notice, dated 02/10/2025, with effective date of discharge of 03/10/2025, showed the resident was being discharged due to no longer requiring skilled nursing services and he exhibited behaviors that threatened the safety of others around him. On 03/20/2025 at 5:18 PM, Resident 1's family member (FM) said Resident 1 had appealed the discharge from the facility and the hearing was postponed until 04/03/2025 so he could get legal representation for Resident 1. He understood Resident 1 had behaviors and was trying to work with CC1 (State Agency case worker) to find community placement. It was his understanding that Resident 1 would be able to remain in the facility until the rescheduled appeal hearing. Resident 1's FM said then on 03/13/2025 he received a call that the resident was being discharged to a local hotel. FM said when he arrived the resident was not able to navigate the two stairs to enter the room, the rooms were not wheelchair accessible and there were no safety bars in the bathroom. FM said medications were sent with Resident 1, but he doubted Resident 1's ability to be able to manage and self-administer them. Resident 1's FM said he called 911 shortly after arrival to the hotel due to concern Resident 1 was having a low blood sugar issue. Review of the Inpatient admission History and Physical, dated 03/13/2025, showed Resident 1 was admitted to the hospital on [DATE]. On 03/21/2025, CC2, hotel staff, said the reservation for Resident 1 was not for a handicapped accessible room and they did not offer that, they did not have ramps or grab bars in the rooms stating, the rooms are very minimal, if they needed that, this may not be the best place for them to go. At 2:02 PM, CC1 said they were trying to find placement for Resident 1, but it was challenging due to his behavior. CC1 said they were aware Resident 1 was given a 30-day notice to discharge but was under the impression it was on hold due to the appeal. CC1 said they were not told the resident was discharged to a local hotel until after the fact. CC1 did not feel that was a safe or sustainable discharge. On 3/25/2025 at 11:48 M, Resident 1 said he was still in the hospital, and said he didn't remember much about the discharge other than he appealed to the discharged and thought he would be able to stay at the facility until the hearing. Resident 1 said the facility staff brought all of their medications and insulin (medication used to manage blood glucose levels and required injection by syringe). Resident 1 said he did not recall the facility offered him the opportunity to draw up his own insulin or self-manage his meds prior to the discharge. Resident 1 said he had no idea what he was supposed to do about meals. On 4/08/2025 at 2:08 PM, Staff C, Licensed Practical Nurse, Resident Care Manager, said she made sure residents were sent home with their medications, most had someone at home to help them. When asked about residents discharging home independently, did the facility assess if they could manage medications and self-administer insulin, Staff C said, No, they don't do that . They make sure the residents know what mediations they take and when they are due. Staff C said Resident 1 was discharged like any normal resident with his meds and a copy of the medication list and said, he knew all about his medications. Staff C was not aware of a self-medication evaluation having been done. Review of Resident 1's Electronic Health Record did not show any documented evaluation/assessment done to determine Resident 1's ability to independently manage his oral medications and/or his insulin. At 2:40 PM, Staff B, Registered Nurse, Director of Nursing, said if a resident was discharging independently, they would evaluate the resident to determine if they could safely manage their medications, this was usually done by return demonstration and documented in the record under progress notes or evaluations. Regarding Resident 1, Staff B said they went over the medications with him may times, He knew what medications he was on and was able to check his blood glucose. Staff B said therapy evaluated the resident for safe ambulation to and from the bathroom, could stand and do steps, and that they tried to make it a smooth transition. and that leading up to the moment of discharge the facility had been trying to check as many things as they could off the list. Staff B said she felt Resident 1 could take care of some of the things himself. Staff B said she would expect a safe discharge to include a self-medication management assessment, handicapped accessible living space and access to or the ability to prepare meals. Documentation regarding physical therapy assessment and medication management evaluation after the 02/10/2025 discharge notice was requested. On 04/08/2025 at 3:04 PM, Staff A, Administrator, said she made the reservation for the hotel room for Resident and had offered to pay for the first week. She did not know if it was handicapped accessible or not. Staff A was not aware if a self-medication management assessment had been completed for Resident 1 but said he was able to manage his medications, if he wanted to. Staff A said she did not know if the resident had the ability to prepare meals or if his room was equipped to allow meals to be prepared and said Resident 1 had funds and could purchase food. Staff A believed Resident 1's discharge was safe for him stating he could do a lot on his own. No documentation regarding physical therapy assessment and medication management evaluation after the discharge notice was given was provided to complaint investigator. Reference WAC 388-97-0080 .

Apr 2025 3 deficiencies

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 F0655 (Tag F0655)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure baseline care plans were developed and implemented within ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure baseline care plans were developed and implemented within 48 hours of admission and included the minimum information necessary to properly care for 4 of 4 sampled residents (Residents 1, 2, 3, and 4) when reviewed for care plans. This failure placed residents at risk for unidentified and/or unmet care needs, negative health outcomes, and a decreased quality of life. Findings included . <Policy> Review of the facility policy titled, Baseline Care Plan Policy, revised 12/2024, showed the facility was to develop a baseline care plan within 48 hours of admission to direct the care team and should include the minimum healthcare necessary to properly care for the resident. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission minimum data set (MDS) and assessment tool, dated 02/09/2025, showed Resident 1 was cognitively intact, medically complex and had central line access (also known as a central venous catheter (CVC), a long, thin tube (catheter) inserted into a large vein to provide long-term access for fluids, medications, blood draws, and monitoring). The care plan, initiated 02/04/2025, did not include focus, goals or interventions related to the central line access. The resident discharged from the facility on 03/07/2025. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 2 was cognitively intact, medically complex and had a feeding tube (a thin, flexible tube inserted through the skin and into the stomach. It is used to provide nutrition and medication when a person is unable to eat or drink normally) on admission. The care plan focus for tube feedings was added on 1/21/2025, 11 days after admission. <Resident 3> Resident 3 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 3 was cognitively intact and receiving IV (intravenous -involves delivering fluids, medications, nutrients, or blood directly into a vein, bypassing the digestive system for faster absorption and action) medications, although it did not identify the type of IV access. The careplan initiated on 03/18/2025 showed one focus, for activities of daily living, with no goals or interventions. Review of the updated careplan showed revisions were made on 03/20/2025, 03/22/2025, and 03/28/2025 but did not include interventions related to Resident 3's PICC (peripherally implanted central catheter) to right upper arm. Review of Resident 3's Treatment Administration Record (TAR) showed no interventions for PICC line dressing changes implemented until 03/28/2025, 11 days after admission. <Resident 4> Resident 4 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 4 was cognitively intact, medically complex, and was receiving IV medications, the assessment did not include the type of IV access. The careplan initiated on 3/21 included potential for infection related to PICC line with the goal to not develop signs or symptoms of infection and interventions including to change the IV tubing, notify MD of signs and symptoms of IV infection, notify the nurse of loose dressing or swelling to the area, and the used of enhanced barrier precautions. Review of Resident 4 TAR showed no intervention for PICC line dressing changes implemented until 04/01/2025, 10 days after admission. On 04/02/2025 at 2:33 PM, Staff E, Nursing Assistant (NA), said they know which residents require special precautions for things like feeding tubes and IVs by what is on the [NAME] (careplan). For example, residents with a feeding tube, they would keep the head of bed elevated and for IV's they would not do blood pressures on that arm. On 04/03/2025 at 2:06 PM, Staff F, NA said they knew which residents required special precautions for things like feeding tubes and IVs by what was on the [NAME] (careplan). For example, residents with feeding tubes they would make sure the tubing was not kinked and/or it was closed and for residents with IV's they would make sure they wore gloves. At 2:30 PM, Staff D, Licensed Practical Nurse, said they knew what interventions were needed for residents by what was listed on the Medication Administration Record (MAR)/TAR. Staff D said the Resident Care Managers (RCM) developed the care plan and the initial orders. Staff D said for residents with feeding tubes they would expect tube site dressing changes and keeping the head of bed elevated. Staff D said for residents with IV's, they would expect dressing changes and orders to monitor the site for infection. At 3:14 PM, Staff C, Registered Nurse (RN), RCM, said the RCM's or Staff B, Registered Nurse, Director of Nursing Services, usually develop the baseline careplans when the resident admits to the facility. They utilize batch orders for things like IVs and tube feeding. Staff C said they would expect interventions necessary for staff to immediately provide care for newly admitted residents. At 3:58 PM, Staff B said she expected the baseline careplan to be established in the first 72 hours. Staff B said she would expect necessary interventions to be included for staff to be able to provide immediate care for newly admitted residents. Staff B was not sure why the baseline care plans were not completed but said, they are usually addressed. See F 684 Reference WAC 388-97-1020 (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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide care and services adequate to prevent hospitalization for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide care and services adequate to prevent hospitalization for 2 of 3 residents (Residents 1 & 2) reviewed for hospitalization. The facility failed to provide central line maintenance for Resident 1 resulting in hospitalization for a potential central line (also known as a central venous catheter (CVC), is a long, thin tube (catheter) inserted into a large vein to provide long-term access for fluids, medications, blood draws, and monitoring) blood infection and failed to adequately monitor Resident 2 (who was receiving nutrition via a feeding tube), following an episode of emesis, resulting in hospitalization for acute respiratory failure with hypoxia. These failures placed residents at risk for infection, hospitalization, and a diminished quality of life. Findings included . Review of the CDC; Guidelines for prevention of intravascular Catheter-related Infections, dated 2011 showed that CVC (central venous catheters) site dressings should be changed every seven days. Review of the facility policy titled, Enteral Feeding/Hydration/Tube Management, revised [DATE], showed staff were to verify the head of bed was raised to 30-45 degrees for residents receiving tube feeding. Resident 1 was admitted to the facility on [DATE]. The admission minimum data set (MDS) and assessment tool, dated [DATE], showed Resident 1 was cognitively intact, medically complex and had a central line access The care plan, initiated [DATE], did not include focus, goals or interventions related to the central line access. Review of the Medication and Treatment Administration Records (MAR/TAR) for February 2025 showed no routine dressing changes or flushes were documented. Review of a progress note, dated [DATE] at 4:04 PM, showed Staff C, RN, Resident Care Manager (RCM) performed a dressing change to the PICC line (peripherally inserted central catheter) to the right upper chest. Review of the [DATE] MAR/TAR showed no routine dressing changes were documented. Review of a progress note, dated [DATE] at 4:51 AM, showed Resident 1's son alerted staff they were concerned regarding the resident's change in mentation. The resident was confused and unable to follow directions. The facility LN attempted to give oral medication, but the resident was unable to swallow. Resident 4's son called 911. The EMT's arrived around 9:30 PM and noted the resident had elevated temperature and blood glucose. The resident was transported to the hospital. Review of the Hospital admission record, dated [DATE], showed Resident 1 was admitted for bacteremia (bacterial infection in the blood stream). A surgical consult report, dated [DATE] at 10:15 AM, showed surgical consult was sought for Central Line removal due to suspect sepsis from possible line infection. Family was consulted regarding risks and benefits and the decision to place the resident on comfort measure was made. Review of the Hospital Discharge Summary. dated [DATE]. showed Resident 1 expired at 1:38 PM. On [DATE] at 2:30 PM, Staff D, Licensed Practical Nurse, said they know how often to flush, change needless valve, and change dressing and tubing for IVs by the order on the MAR. Staff D said they would not change the dressing as that was done by the RN (Registered Nurse). Staff D said if a central line was not being accessed (no current medication orders) she would expect it to be flushed and dressed. Staff D said they would know the frequency by the order. Staff D said residents with IV access were at risk for infection if not dressed and flushed appropriately. Staff D recalled Resident 1 but did not recall any treatment regarding the central line. At 3:14 PM, Staff C said that IV batch orders were entered on admission and dressings should be changed seven days. Staff C said a deaccessed central port would still be flushed every shift and dressing changed weekly. Staff C said she recalled Resident 1 had a central line and it was not accessed. Staff C said if a line was not flushed, and a dressing was not changed that could increase the risk of infection for the resident. Staff C reviewed order for Resident 1 and said the orders for maintenance should have been there. Staff C said if the line was not to be accessed or flushed or required a dressing, she would expect there to be an order and that to be included on the careplan. At 3:58 PM, Staff B, RN, Director of Nursing, said orders for IV maintenance would be added on admission and entered into the careplan by the RCM who was doing the resident admission. Staff B said IV-line dressing should be changed weekly and flushed twice daily. She would expect deaccessed lines to be maintained per provider or pharmacy recommendations. Resident 2 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 2 was cognitively intact, medically complex and had a feeding tube (a thin, flexible tube inserted through the skin and into the stomach. It is used to provide nutrition and medication when a person is unable to eat or drink normally) on admission. The care plan focus for tube feedings was added on [DATE], 11 days after admission, and included the goal that the resident would remain free of complications of tube feeding and included interventions to monitor, document, and report to nurse/MD aspiration/fever, or shortness of breath, but did not include the intervention to keep the head of the bed elevated to decrease risk of aspiration. Review of the progress note, dated [DATE] at 2:02 PM, showed Resident 2 had two episodes of emesis, the resident was given medication to control the emesis and the tube feeding was turned off. Review of resident progress notes showed no skilled nursing assessment note for [DATE]. Review of the progress note, dated [DATE] at 2:01 PM, showed Resident 2 was administered 2 liters of oxygen due to Low sats. Review of the progress note, dated [DATE] at 6:48 AM, showed Resident 2's oxygen saturation was 82-84% on 3 liters of oxygen, they were lethargic and had a change in mentation, resident requested to go to the hospital. 911 was called and resident was transported to the hospital. Review of Resident 2's vital signs record showed no documented body temperature, oxygen levels, heart rate or respirations from [DATE] through [DATE] following the episodes of emesis, placing the resident at increased risk of aspiration pneumonia. Review of Resident 2's hospital admission record dated, showed the resident was admitted to the hospital for acute (sudden) respiratory failure hypoxia (low blood oxygen) and expired on [DATE] at 3:58 PM. On [DATE] 12:09 PM, Resident 2's Family Member (FM) 2 said they visited the resident about three times a week and frequently reported care concerns to the staff. They found out the resident was vomiting after observing dried vomit on the resident, gown and sheets, they attributed it to the pain medications they were on, and it was supposed to be discontinued but that did not happen. FM 2 said the resident continued to vomit and ended up being admitted to the hospital and died. On [DATE] at 10:25 AM, Resident 2's FM 1 said they visited Resident 2 daily and the resident reported they had been vomiting. They had a care meeting, and they reported the concern about her vomiting and were worried about her aspirating. FM 1 said they observed instances where the head of the bed was flat, and she would have to raise it when she got there and another time when there was visible dried vomit on the sheets, and she reported it to staff but it was still there when FM2 came to visit. On [DATE] at 2:33 PM, Staff E, Nursing Assistant (NA), said they would report changes such as emesis to the nurse and if a resident was receiving tube feeding it would be important to keep the head of the bed elevated to 45 degrees to ensure the resident does not aspirate. Staff E said the beds were not marked where 45 degrees was. On [DATE] at 2:06 PM, Staff F, NA said they would report episodes of emesis to the nurse and residents receiving tube feeding would need to have the head of the bed elevated to 35 degrees. Staff F said the beds were not marked but she could tell where the appropriate level would be. Staff F said they did recall Resident 2 having episodes of emesis and reported to the LN and made sure the head of bed was elevated. At 2:30 PM, Staff D, Licensed Practical Nurse, said if a resident who was receiving tube feeding had emesis, she would stop the feeding and notify the provider and monitor for fever and abnormal lung sounds and oxygen levels. Staff D said she did not recall seeing Resident 2's head of the bed flat but did recall there were nursing students, and she had to give them reminders to keep the head of the bed above 30 degrees. At 3:14 PM, Staff C, Registered Nurse (RN), Resident Care Manager, said a resident who required tube feeding would have interventions care planned to monitor for aspiration and keep the head of the bed elevated. If the resident had an episode of emesis, they would monitor for aspiration by obtaining vital signs and listening to their lung sounds. This would be documented in the progress notes and the vital signs would be under the vitals tab in the resident's record. Regarding Resident 2 she would expect frequent oxygen levels to have been checked and documented. At 3:38 PM, Staff B, RN, Director of Nursing, said a resident receiving tube feeding should have careplanned interventions that included to keep the head of the bed elevated to prevent aspiration. Staff B would expect staff to document their assessment of the resident and monitoring of pulse, temp and oxygen level in the resident record. Reference WAC 388-97-1060 (1) .

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 F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations and interview, the facility failed to ensure the resident audible call system was functioning properly a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations and interview, the facility failed to ensure the resident audible call system was functioning properly and repaired timely for 2 of 4 resident halls reviewed for call light systems. This failure placed residents at risk for delayed staff response to potential emergencies and resident needs, falls, injury and decreased quality of life. An intake reported on 03/04/2025 at 3:32 PM, documented the facility's audible call light system was not working for rooms 1-17 and manual bells were provided for the residents. On 03/07/2025 at 11:35 AM, the call light to room [ROOM NUMBER] was observed and it was noted there was no audible alarm. At 4:15 PM, Staff A, Administrator, said the repair company had been there, and they had to order a part, it had not arrived yet. They had passed out bells to the residents effected. On 03/19/2025 at 11:30 AM, Staff A said the part to repair the audible portion of the call light system had not arrived. At 11:50 AM, call light to room [ROOM NUMBER] was observed on, there was no audible alarm. At 11:51 AM, the call light for room [ROOM NUMBER] was on, the resident could be heard yelling for help. The resident was seated in their wheelchair, no manual bell was within reach. At 2:30 PM, Resident 3 was observed sitting in his wheelchair, call light not within reach, attached to the opposite side of the bed, a manual bell sat on the sink, Resident 3 said he had no idea what the bell was for. On 04/02/2025 at 11:25 AM, call light to room [ROOM NUMBER] was observed on, no audible alarm. At 11:40 AM, Staff A said the part came in but was not sure of the status of the repair. When asked if facility maintenance staff were repairing it or if an outside company was coming to repair, she replied, a little of both. At 1:03 PM, Resident 4 did not have a manual call bell. Staff present handed them their roommate's bell. On 04/03/2025 at 4:37 PM, Staff A said the audible part has been replaced/repaired but it was very light/quiet and they had a call out to the repair company to adjust the volume. At 4:44 PM, the audible alarm was tested for rooms 1-17 and no audible alarm was heard. Reference WAC 388-97-2280 (1)(a) .

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to thoroughly investigate an injury for 1 of 3 residents (Resident ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to thoroughly investigate an injury for 1 of 3 residents (Resident 1) reviewed for accidents. Facility failure to complete thorough investigations placed residents at risk for further falls and injuries, potential abuse, and other negative health outcomes. Findings included . Resident 1 was admitted to the facility on [DATE] with a right hip fracture. The admission Minimum Data Set (MDS), an assessment tool, dated 01/09/2025, showed Resident 1 was cognitively intact. The care plan, initiated 01/06/2025, showed Resident 1 required extensive assistance for bed mobility and transfers with the goal for improved function. The facility incident report, dated 01/26/2025 at 2:00 AM, showed Resident 1 was found on the floor next to her bed. Staff documented the resident was assessed and no injury was found, and the resident was assisted back to bed. It was documented the resident reported pain to her right hip but declined offer of acetaminophen. Documentation did not include how the resident was assisted back to bed. A nursing note, dated 01/26/2025 at 11:32 AM, showed Resident 1 was noted with right hip pain, swelling and shortened right lower limb. The resident was transported to the emergency room for evaluation. A nursing note, dated 01/26/2025 at 5:02 PM, showed Resident 1 was diagnosed with a dislocated right hip and would require manipulation in the surgical unit, to relocate the hip. On 02/24/2025, Resident 1's Power Of Attorney (POA) said Resident 1 told her multiple times that she did not fall out of bed, reporting, I didn't fall, I was thrown into the bed. She kept telling me, He threw me POA said this was reported to staff, but they did not do anything about it. Review of the facility investigation documentation for the incident on 01/26/2025 did not include staff or resident interviews/statements. There was no documented follow up with the resident to determine how the injury occurred. On 03/07/2025, at 3:15 PM, Staff C, Registered Nurse, Resident Care Manager, said during an investigation of a fall, they would interview nursing assistants, nurses, the resident and or their roommate. This information would be included in the packet. At 3:38 PM, Staff A, Administrator, said a facility investigation was expected to include staff interviews and the resident. Staff A said they would see if there was additional information available, as Staff B was not there that day. Reference WAC 388-97-0640 (6)(a)(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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure behavioral health care and services were provided for one ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure behavioral health care and services were provided for one of six sampled residents (Resident 2) reviewed for behavioral health services. This failure placed residents at risk for increased behaviors, not receiving necessary services to meet their mental health needs and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 12/18/2024, showed the resident was cognitively intact, medically complex and had verbal behaviors directed toward others that significantly interfered with the resident's participation in activities and social interactions and intruded on the privacy and activity of others. The care plan focus for behavioral problems, initiated on 11/29/2023 and updated on 03/03/2025, identified the resident had the potential to make sexually inappropriate comments to female residents. Goals for the resident initiated on 11/29/2023 and revised on 03/07/2025, included the resident would accept care from caregivers, have socially appropriate behaviors when conversing with female residents, and have no injury to self or others. Interventions included approach in a calm manner, talk with resident, document behaviors, discuss and reinforce why behavior is unacceptable, intervene as necessary to protect rights and safety of others. A level two PASARR (preadmission screening and resident review) evaluation (a tool used to identify individuals with mental illness) was completed on 09/16/2024. A social services note, dated 12/25/2023 at 11:44 AM, showed Resident 2 had a history for making inappropriate comments towards staff/women about womens' bodies. A social services note, dated 12/27/2023 at 1:45 PM, showed a care conference for Resident 2 with discussion about Resident 2's many sexual and physical abuse moments and how multiple women at [the facility] refuse to be around him. Resident 2's Family member requested Resident 2 see a neurologist. A social services note, dated 01/02/2025 at 9:17 AM, showed Resident 2 was pursuing a housekeeper and trying to grab her and kiss her. When Resident 2 was approached by social services and the housekeeping supervisor, he shouted an expletive at them. A social services note, dated 01/02/2025 at 2:46 PM, showed Resident 2 made an inappropriate sexual comment with physical gestures to a female staff member. On 01/02/2025 at 3:34 PM, Resident 2 returned from appointment with a referral for a neurology consult. A behavioral health provider note, dated 01/07/2025 at 8:30 AM, showed provider was aware of the staff reports of sexually inappropriate behaviors. There were no changes to his treatment plan. A life enrichment note, dated 01/14/2025 at 3:51 PM, showed Resident 1 was asked to stop touching and kissing a resident's hand and was observed following the female resident when she left the area, necessitating staff intervention. A behavioral health provider note, dated 02/06/2025 at 8:15 AM, showed the resident continued with sexually inappropriate behaviors despite recent medication changes. The note included, staff reports he refused care; he is irritable on assessment. staff report patient continues to make sexually inappropriate comments, touching staff and residents, being aggressive with residents. There were no changes to his treatment plan. An incident note, dated 02/09/2025 at 5:53 PM, by Staff I, Registered Nurse (RN), showed Resident 2 was involved in a resident to staff verbal and physical altercation in which Staff I, was injured, requiring first aid and later medical attention. Local law enforcement was notified. A mood and behavior note, dated 02/09/2025 at 6:00 PM, by Staff J, Licensed Practice Nurse (LPN), showed Resident 2 went on to verbally and physically attack them as they were trying to help Staff I and diffuse the situation. An alert note, dated 02/10/2025 at 12:07 PM, by Staff B, RN Director of Nursing, showed the IDT (interdisciplinary team) determined the resident was no longer in need of skilled services and able to perform Activities of Daily Living (ADLs) independently and manage his medications. Resident 2 was provided with a notice of discharge. Continued behaviors have threatened the safety and health of other individuals, which is why the resident is being handed a discharge notice. A behavioral health provider note, dated 02/18/2025 at 8:30 AM, showed that staff reported physical aggression with staff and was given a notice of discharge due to his ongoing behavior and he has been self-isolating. Resident 2 reported, he did something bad and was given a [30-day discharge notice]. He reported he feels crappy, angry and sad. The note showed he appeared irritable, angry with poor insight to his behavior, stating he didn't do anything wrong. Behavioral interventions were recommended. These interventions were already part of the established careplan. A health status note, dated 02/28/2025 at 3:17 PM, showed the resident had intact cognition, was moderately depressed with thoughts he would be better off dead, denied, self-harm and verbalized frustration with virtual mental health visits, stating they are always during bingo. A social services note, dated 03/03/2025 at 11:35 AM, showed Resident 2 was given a 30-day notice of discharge but there was no discharge plan available. On 02/21/2025 at 10:02 AM, Staff I, Registered Nurse (RN) said Resident 2 had a long history of inappropriate behaviors and he continued to say and do sexually inappropriate things. Staff I said on 02/10/2025 Resident 2 intentionally rammed his wheelchair into her causing an injury to her left heel which required medical attention. On 03/07/2025 at 12:50 PM, Resident 2 said, regarding his behaviors, he may have said some things he shouldn't have said to the nurse, but he did not intend to hurt her, Resident 2 alleged he was unaware Staff I was behind his chair. Resident 2 said he did not feel his mental health needs were being met, stating, I get a 3-minute telehealth visit every two weeks, she asks me the same questions each time and nothing ever changes, I would prefer to talk to someone in person and I need to see a neurologist. At 1:06 PM, Staff E, LPN, said they were afraid of Resident 2 for herself and the residents, Staff E said there had been no recent resident to resident altercations involving Resident 2, but she witnessed several, maybe 6-8 months ago. Staff E felt residents were at risk due to Reisdent 2's behaviors. At 2:46 PM, Staff D, Social Services Assistant, said Resident 2 had behavioral issues, they have personally been subject to his sexually inappropriate behavior. Staff D said he knows what he is doing is wrong but won't stop the behavior. Staff D said Resident 2 was regularly seen by the behavioral health provider, but he does not always comply. Staff D said they do not have an in person mental health provider. Staff D said she was not aware of any incidents involving other residents. At 3:15 PM, Staff C, RN, Resident Care manager, said the facility had a telehealth mental health provider who serviced the facility two times a month. Staff C said there were no in person services available. Staff C said she was not aware of any residents who see providers in the community. Resident 2 had a long history of making inappropriate sexual comments, getting mad and verbally aggressive to residents and staff, recalling an incident about a month prior where the resident blocked another resident from leaving a common room. Staff C said they protected other residents by being aware of his location at all times, stating he spends a lot of time in his room. Staff C felt Resident 2's behavioral health needs were not being met but it was due to his refusals. Staff C felt other residents were at risk if Resident 2 was left unattended. At 3:40 PM, Staff A, Administrator, said Resident 2 was not appropriate for the facility and has tried to discharge him but there was not a safe plan at the present time. Staff A said there was not a recent resident to resident incident involving Resident 2, rather one female resident voiced they were uncomfortable around him and a previous incident involving Resident 2 blocking a doorway. The resident was assisted out of the room by another door. They protect other residents by watching him and monitoring his behavior. Staff A felt Resident 2's behavioral health needs were being met. Staff A said they did not offer in person mental health services or transport residents to community mental health providers. No Associated WAC .

Jan 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to ensure services provided met professional standards of practice ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 4 sampled residents (Resident 1) reviewed for quality of care when facility staff 1. failed to assess, monitor and/or document resident responses to interventions on a daily basis for newly admitted residents receiving skilled services and 2. failed to obtain and document vital signs for residents at risk for sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection. It can lead to organ failure, shock, and death). These failures placed residents at risk for rehospitalization, health complications, and decreased quality of life. Findings included . The facility policy titled, Documentation, revised on 05/12/2023, showed frequency of documentation was dictated by the clinical needs of the resident, as well as state and federal requirements. Nursing documentation should be found in the medical record and included assessments, narrative notes, and vital signs. According to, Lippincott Manual of Nursing Practice (11th ed., pp. 936-964), Sepsis is characterized by a systemic inflammatory response in the presence of suspected or confirmed infection. Symptoms would include increased body temperature, heart rate and respirations and decreasing blood pressure and urinary output. The resident may also present with decreased level of consciousness, confusion, anxiety or agitation. Resident 1 was admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 11/13/2024, documented Resident was cognitively intact, had an indwelling catheter (tube into the bladder to drain urine) and was medically complex. Review of Resident 1's electronic health record (EHR) showed that no vital signs (blood pressure, pulse, respirations, or temp) were obtained on 11/10/2024, 11/11/2024, 11/12/2024, 11/13/2024, 11/4/2024 and 11/15/202. There were no nursing assessment notes documented for Resident 1 on 11/08/2024, 11/09/2024, 11/10/2024, and 11/11/2024. An Alert Note, dated 11/16/2024 at 1:11 PM, showed the resident requested to be transferred to the Emergency Department (ED), the resident was noted to have uncontrollable shaking, staff were unable to obtain vital signs, 911 was called and the resident was transferred to the hospital. A hospital H&P (history and physical) note, dated 11/16/2024, showed the resident had purulent matter (potential evidence of infection) in her Foley (indwelling) catheter, was hypotensive (low blood pressure), tachycardic (fast heart rate), and had abdominal pain. The resident was admitted for sepsis. A facility admission note, dated 11/22/2024 at 5:28 PM, showed Resident 1 was readmitted back to the facility. Review of Resident 1's EHR showed no vital signs were obtained from 11/23/2024 through 12/10/2024. There were no nursing assessment notes on 11/24/2024, 11/28/2024, 11/29/2024, 11/30/2024, 12/01/2024, 12/02/2024, 12/04/2024, 12/05/2024, 12/08/2024, or 12/09/2024. Review of Daily Skilled Notes for 12/06/2024 and 12/07/2024 showed the notes to be identical but written by Staff D on 12/06/2024 and Staff E on 12/07/2024. The same note was entered again on 12/10/2024 by Staff D. A provider note, dated 12/11/2024, by Provider A, showed Resident 1 was found to be acutely ill, anxious, with rapid breathing and heart rate, and decreased oxygen levels. Staff had reported the resident refused their meds that morning. 911 was called and the resident was transported to the hospital. The Emergency Department Encounter Note, dated 12/11/2024, showed Resident 1 was admitted for sepsis. On 12/31/2024 at 1:44 PM, Resident 1's Family Member (FM1) said regarding the first hospital admission, when they arrived on 11/16/2024 to visit Resident 1, they were found to be screaming and no one came into the room to check her, staff were at the nurses' station but did not come in to help her until FM1 asked them. FM1 said regarding the second hospital admission, staff had informed him when he arrived that day, 12/22/2024, that Resident 1 had not taken her morning medication. FM1 said they had found Resident 1 without covers on and they did not look well, stating, they were kind of in a daze. FM1 said they summoned staff to help and when staff took Resident 1's vital signs and everything was low, staff then called 911. On 01/09/2025 at 11:44 AM, Provider A, Physician's Assistant, said Resident 1 was medically complex, staff had not alerted them that the resident was ill but rather the resident was scheduled for a routine visit that day. Provider A found Resident 1 on 12/11/2024 to be acutely ill, she assessed the resident and alerted staff to call 911. When asked would they expect staff to perform a daily skilled assessment and obtain vital signs on a resident at risk for sepsis, Provider A said they would expect the facility to follow their protocols. On 01/13/2025 at 1:52 PM, Staff E, Licensed Practical Nurse (LPN), said vital signs should be obtained every shift and documented in the resident's record. Staff E said a daily skilled note was assigned and should be in the resident's record. Staff E said it was not usually accepted practice to copy and paste clinical notes. Staff E said they had not received any training on prevention of or recognizing sepsis. At 1:59 PM, Staff C, LPN, Resident Care Manager (RCM), said if a resident readmitted to the facility for sepsis, they would expect a daily skilled note and vital signs to be obtained and documented in the record. Staff C said they had recent in-services but could not recall if they were regarding sepsis. At 2:07 PM, Staff B, Registered Nurse, Director of Nursing, said if a resident was readmitted due to sepsis, they would expect daily skilled nursing assessments and vitals to be documented in the resident's record. Staff A said they covered sepsis in previous month's meeting. Reference WAC 388-97-1620 (2)(b)(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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview the facility failed to maintain a safe, clean and comfortable environment through maintenan...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview the facility failed to maintain a safe, clean and comfortable environment through maintenance of the hallway carpets for 3 of 3 halls (East, Mid, and [NAME] B) observed. This failure has the potential to place residents at risk for not having a clean, homelike environment and a diminished quality of life. Findings included . On 12/17/2024 at 3:27 PM, it was reported a family member for a resident had removed resident from the facility because the facility was found to be dirty, filthy, and gross and the carpets were not cleaned or vacuumed, and there was a bad odor. On 12/31/2024 at 1:44 PM, Collateral Contact 1 said the building was a mess and was run down. On 01/09/2025 between 12:24 PM, and 12:30 PM, the following were observed in the East Hall: - Mostly brown and some pink stains in front of rooms 1 through 3 - Scattered debris of small white pieces of paper and plastic - Brown matter smeared into the carpet measuring approximately 1 by 2 inches outside of room [ROOM NUMBER] - Dark brown stain on the left side of the doorway for room [ROOM NUMBER] measuring approximately 12 by 3 inches. - Dark, brown stain measuring approximately 8 by 8 inches outside of room [ROOM NUMBER] - Dark, brown stain measuring approximately 6 by 8 inches outside of room [ROOM NUMBER] - Small, dark stains, too numerous to count outside of East Hall nurses' station At 12:34 PM, the following were observed in the Mid Hall: - Too numerous to count stains between rooms 11-24 - Dark stain to left side of doorway measuring approximately 10 by 12 inches outside of room [ROOM NUMBER] - Stains also noted outside of rooms 16, 18, 19, 20, and 22. At 12:39 PM, the following were observed in the [NAME] B Hall: - multiple small dark stains outside of rooms 26, and 28. - reddish brown substance smeared on carpet, measuring approximately 1 by 2 inches outside room [ROOM NUMBER] On 01/13/2025 at 11:32 AM, the following were observed outside the East Hall: - Stain outside of staff training room measuring approximately 12 by 24 inches - Multiple small dark stains in hall between rooms [ROOM NUMBERS]. - Stain outside room [ROOM NUMBER] measuring approximately 9 by 7 inches and scattered bits of pieces of white material, resembling tissue. - Outside of medical supply room door, near East Nurses Station, multiple dark brown stains with the largest measuring approximately 4 by 6 inches. At 11:37 AM, the following were observed in the Mid Hall: - dark brown stain, measuring approximately 10 by 16 inches, on the right side of the hall, between rooms [ROOM NUMBERS] - gray matter smeared on ground approximately 2 by 3 inches outside of doorway of room [ROOM NUMBER] - multiple small scattered dark stains and scattered bits of debris outside rooms 16-24 - multiple white drip stains between room [ROOM NUMBER] and 24. At 1:15 PM, Staff F, Housekeeping staff, said the carpets did not represent a clean home-like environment, but the facility was supposed to get new flooring. At 1:16 PM, Staff G, Housekeeping Assistant, said they cleaned the carpets weekly, and would be increasing cleaning to twice weekly. Staff G said they did not document when the carpets were cleaned. Staff G said they tried to maintain the carpet, but the age of the carpet showed. Staff G said the flooring was supposed to be replaced. Staff G said the current flooring did not represent a clean and home-like environment. At 2:07 PM, Staff B, Registered Nurse and Director of Nursing Services, said they were not sure how often the carpets were cleaned; they would prefer them to be cleaner. Staff B said some flooring was replaced but then it stopped, and they were not sure when the remaining would be replaced. At 2:23 PM, Staff A, Administrator, said carpets were cleaned weekly but there was no specific day. Staff A said there was no documentation available to show when carpets were cleaned. Staff A did not know when they were last cleaned. Staff A said the carpets did not represent a clean home-like environment; they had been trying to get the flooring replaced. Reference WAC 388-97-0880 .

Nov 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to consistently provide care and services as ordered fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to consistently provide care and services as ordered for non-pressure wounds for 1 of 5 residents (1) reviewed for quality of care. This failure placed residents at risk for worsening wounds, infection, and decreased quality of life. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 10/19/2024, documented the resident was cognitively intact, medically complex and had an infection and non-pressure wounds of the foot, requiring dressings. The care plan focus for right lower ulcer with gangrene (a serious condition that occurs when body tissue dies due to a lack of blood flow or a bacterial infection), initiated on 10/14/2024, included interventions to treat wound as per MD orders. A physician's order, dated 10/12/2024, instructed staff to paint all toes and gangrene [of right foot] with 10% provodine/iodine, let dry, cover with non-adherent gauze and secure with roll[ed] gauze daily and as needed. A physician's order, dated 10/12/2024, instructed staff to cleanse the right lateral (outer) and medial (inner) ankle with normal saline and gauze, pat dry, and sure prep to skin around wound, apply iodasorb gel to wound bed, cover with non-woven gauze, and secure with roll gauze, change every three days and as needed for 50% soilage/breakthrough drainage or dislodgement. Review of Resident 1's October 2024 Treatment Administration Record showed no documentation that wound care to the right gangrenous toes was provided on 10/15/2024, 10/19/2024, 10/23/2024, 10/24/2024, and 10/25/2024. There was no documentation that wound care was provided to the lateral and medial ankle on 10/19/2024 and 10/25/2024. On 10/29/2024 at 9:05am, Family Member (FM)1 said they had visited Resident 1 on 10/26/2024 and noted daily dressings had not been done, they reported the concern to the nursing assistant. On 10/31/2024 at 3:46 pm, Resident 1's FM 2 said daily dressings were not being done. During observation of wound care, the dressing to the right foot was observed and an area of approximately 10 centimeters of light brown drainage soaked through the medial (inner) ankle and an incontinence brief had been placed around the dressing. The great toe and second, third and fourth toes of the right foot were black and necrotic (gangrenous), without odor noted. Staff C assisted with wound care and confirmed ankle wound care was to be performed every three days and the toes were to be dressed daily. Review of Resident 1's November 2024 Treatment Administration Record from 11/01/2024 through 11/06/2024 showed no documentation that wound care to the right gangrenous toes was provided on 11/01/2024 and 11/03/2024. On 11/07/2024 at 2:59 pm, Staff C, Licensed Practical Nurse, Resident Care Manager, said if dressings were ordered to be changed daily, she would expect them to be changed and documented daily. Staff C said she was aware of the omission and spoke to the nursing staff about it. Staff C said if staff were unable to complete the dressing due to a medical appointment or the resident not being at the facility during the day, she would expect the night shift to do it. At 6:32pm, Resident 1's FM 3 said they observed Resident 1 on multiple occasions at his 5:00pm dialysis appointment with dressings that had not been changed that day or the day before. They said there was frequently drainage visible. On 11/08/2024 at 1:58pm, CC 1 said during the first two weeks of service, Resident 1 would frequently arrive to his appointments with drainage seeping through the dressing. At 4:13pm, Staff B, Registered Nurse, Director of Nursing, said she believed the nurses were overlapping the dressings and recently clarified the orders, but if it was ordered daily, she would expect it to be done and documented daily. Reference WAC 388-97-1060 (1) .

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 F0557 (Tag F0557)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 2 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 2 of 5 residents (2, 3) reviewed for dignity and respect. This failure placed residents at risk for unmet needs, diminished self-worth, and continued episodes of disrespect. Findings included . Review of the facility policy, titled Resident Rights, dated 08/2022, showed the purpose was to treat each resident with dignity and respect, and in a manner that promotes maintenance or enhancement of self-esteem. Review of the Facility Grievance Log from 09/25/2024 to 10/25/2024 showed five entries from five different residents. All five entries were related to how staff treated or spoke to residents. The log showed: On 09/26/2024, a resident reported between the hours of 8pm and midnight, a staff member was unkind to him when he requested a blanket. The facility summary report showed the resident had dementia and could not identify a staff member or recall the incident. Staff reported there were no problems. The resident was made, care in pairs. On 09/30/2024, a resident reported they felt uncomfortable with the care and speech from a staff member. The grievance form identified Staff F as yelling at the resident and being rude, and not listening to the residents' needs and felt that Staff F should not have been working in that setting. The facility summary report showed the staff member felt they provided proper care, and the staff member would no longer be assigned to provide care to the resident. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The admission minimum Data Set (MDS), and assessment tool, dated 10/12/2024, documented Resident 2 was cognitively intact. On 10/25/2024 at 2:43pm, Resident 2 said that one evening her call light was on for over 35 minutes, when she went to the nurses station she found that Staff F, Nursing Assistant, was at the nurses station on the phone, Staff F came to her room [ROOM NUMBER] minutes later, Resident 2 requested ice in a bag and Staff F told her she was using too many bags and to untie and reuse the one she had. Resident 2 said she reported the concern to Staff C, who told her there were multiple reported concerns regarding Staff F. Review of the Grievance log from 09/25/2024 through 10/25/2024 showed an entry for Resident 2 that documented: On 10/11/2024, Resident 2 reported they felt a staff member was not a good fit for caring for residents. Review of the Facility Grievance Form showed Resident 2 reported that night shift staff did not respond to her call light for 45 minutes and when she went to the nurses' station staff told her they would help her after they finished eating their apple, that they had not started eating yet. The facility summary showed there was no identified caregiver and night shift was spoken to as a whole about being nice to the residents. <Resident 3> Resident 3 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 3 was cognitively intact. A complaint intake, dated 10/16/2024 at 1:46pm, showed it was reported that on 10/15/2024 facility staff had treated Resident 3 rough during care and when the resident reported it hurt, the staff member told her she should have moved faster. Review of the Grievance Log from 09/25/2024 through 10/25/2024, showed an entry for Resident 3 that documented: On 10/18/2024 Resident 3 reported the NAC was rough when moving her leg. The facility grievance summary report showed the caregiver gave her statement and would no longer be assigned to provide care to the resident. On 11/07/2024 at 2:59 pm, Staff C, Licensed Practical Nurse, Resident Care Manager (RCM), said she knew Resident 2 filled out grievance forms and did not like the way she was treated. Staff C said she did not recall if there were other reported concerns regarding Staff F. Staff C said she was not aware of other resident reports regarding treatment from staff. Staff C said they could not recall when the last Inservice regarding resident rights or respect and dignity was and had attended an in-service held earlier that day. On 11/08/2024 at 3:17pm, Staff E, Social Services Director, said he did not recall when the last in-service on resident rights or respect and dignity was. He had attended the all-staff meeting the day before. He was not aware of multiple resident reports of being treated with less than dignity and respect within a 30-day period. At 4:05pm, Staff A said there were multiple grievance regarding Staff F, and she spoke to her about how she talks to people and changed her schedule. There was no written record of this. Staff A said they talk about the grievances at the morning stand up meeting and she is trying to address it and get staff to respond kindly. Staff A was not able to provide documentation that staff education was provided as a group or individual following multiple reported concerns by residents over a 30-day period of time. At 4:15pm, Staff B said she was aware of some of the grievances but not specifics, she was not aware of multiple residents reporting concerns regarding Staff F and had not identified a concern of multiple resident reports of being treated without dignity and respect. Reference WAC 388-97-0860(1-2) .

Oct 2024 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure resident representatives were notified of changes in condi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure resident representatives were notified of changes in condition for 2 of 4 sampled residents (1 and 2) reviewed for notification of changes when resident family members were not notified of new pressure wounds. This failure prevented the residents' representative from participating in discussions about resident care decisions and placed the residents at risk for delayed medical treatment, diminished quality of life, and increased pain. Findings included . The facility policy titled, Notification of Change in Condition, revised 05/2024, showed the residents' representative should be made aware of any significant changes in the residents' physical, mental or psychosocial status. If the residents' condition was not crucial the representative would be notified at the earliest convenient time during business hours. Notification should be documented in the progress notes. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The quarterly minimum data set (MDS), an assessment tool, dated 07/07/2024, documented Resident 1 had moderate cognitive impairment, required substantial to maximal assist for activities of daily living (ADLs), was always incontinent of bowel and bladder, had no pressure injuries, and was at risk for pressure injuries. The care plan focus for potential for pressure ulcer of coccyx and heels related to decreased mobility and incontinence, initiated on 03/03/2020 and revised on 06/16/2021, included the goal for the resident to have intact skin free of redness, blisters or discoloration. Interventions included to inform resident/family/caregivers of any new areas of skin breakdown. A wound provider note, dated 07/18/2024, showed Resident 1 had a new unstageable wound measuring 4.66 centimeters(cm) in length and 4.38 cm in width and was covered by 100% necrotic (slough/eschar) tissue to the right lateral buttock and identified the wound as not unavoidable. A wound provider note, dated 08/15/2024, showed Resident 1 had a new stage 2 pressure ulcer, measuring 7.5 cm in length and 5.02 cm in width, to the center midline coccyx and identified the wound as not unavoidable. A wound provider note, dated 09/19/2024, showed the center midline coccyx wound had the status of deteriorating and had clinical signs of infection that included redness, purulent (white/yellow/green) drainage, increased wound size, delayed healing, and change in wound appearance. The wound had increased in size and measured 7.26 cm in length and 7.0 cm in width. Review of Resident 1's electronic health record (EHR) from 06/27/2024 through 09/19/2024 did not show any documentation that Resident 1's FM was informed of the discovery of either wound. On 10/09/2024 at 4:40 PM, Collateral Contact (CC 1) said they were not informed the resident had wounds and was shocked at the state of them when made aware of them on 09/18/2024. On 09/19/2024 The family called 911 and had the resident transported to the ER. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairment, was dependent on staff for all ADLs, was always incontinent of bowel and bladder, was at risk for pressure injuries, was not on a turning/repositioning program and had one stage 3 pressure ulcer (full thickness loss of skin, fat and granulation tissue (pink red tissue composed of blood vessels and collagen may be visible) that was not present on admission. The care plan focus for an [unstaged] pressure ulcer of center midline sacrum (lower back) related to decreased mobility, initiated on 07/30/2024, included the goal for the pressure wound to show signs of healing and remain free of infection. A physician's order, dated 08/16/2024, directed staff to cleanse the wound with wound cleanser, pat dry with gauze, apply collagen to the wound bed, followed with calcium alginate with silver, apply skin prep to peri wound and cover with a silicone bordered dressing, in the morning every Tuesday, Thursday (done by wound provider), and Saturday. A wound provider note, dated 09/19/2024, showed a stage 3 center midline sacrum wound, measuring 0.88 cm in length and 0.87 cm in length, with a status of unchanged. The wound care orders included dressing changes 3 times weekly and as needed for soiled or loose dressing. Review of Resident 2's EHR record from 07/19/2024 through 10/18/2024 did not show documentation Resident 1's family member was notified of the discovery of the stage 3 sacral wound. On 09/26/2024 at 5:12 PM, CC 2, said they were aware of a recent incident regarding bruises and something on his face but was not aware that Resident 2 had any wounds. On 10/18/2024 at 1:46 PM, Staff C, RN, RCM, said when new wounds were discovered, staff were to notify the provider, Staff B (Registered Nurse and Director of Nursing) and the resident's family or POA. At 2:44 PM, Staff B, said they try to notify family when new wounds are discovered and she would have expected there to be documentation in the record if they attempted to contact family. At 3:58 PM, Staff A, Administrator, said they usually notify family of new wounds, and they would expect that to be documented in the medical record. Reference WAC 388-97-0320 1(a)(b)(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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to provide care and services consistent with professional standards f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to provide care and services consistent with professional standards for 1 of 4 residents (Resident 2) reviewed for quality of care when the facility staff failed to document assessment and monitoring of the resident for latent injuries, resolution of injuries, and potential adverse side effects of medications for multiple incidents involving the resident. This failure placed all residents at risk for unmet needs, declining health, and decreased quality of life. Findings included . The policy titled, Alert Charting, revised on 05/2023, documented that residents were to be placed on alert for a minimum of 72 hours for the following: resident care issues, changes in condition, medication changes, falls, and psychosocial harm. Documentation should include vital signs, physical assessment, resident's response, and symptoms. Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS/an assessment tool), dated 07/25/2024, showed Resident 2 had severe cognitive impairment and was dependent on staff for all ADLs. The care plan focus for at risk for falls, initiated 03/07/2020 and revised on 06/14/2021, included interventions to monitor/document/report for 72 hours post fall for signs and symptoms of pain, bruising, change in mental status .and required the use of a mechanical lift for transfers. A facility investigation report, dated 09/13/2024 at 6:30 AM, showed Resident 2 was observed to have bruising to the left forearm measuring 9.0 centimeters (cm) x 1.5 cm, bruise to right eyebrow measuring 3.7 cm x 1.4 cm and a blister, bruise and swelling to right upper lip measuring 3.6 cm x 2.5 cm x 2 cm. The facility investigation found the lip swelling/bruising/blister was attributed to a recent oral procedure and the resident was started on an antibiotic to for an oral infection. The arm and forehead bruising was attributed to potentially being caused by the mechanical lift. The facility ruled out abuse and all parties were notified. A physician's order, dated 09/14/2024, instructed staff to give an antibiotic twice daily for 10 days, for oral infection. Review of Resident 1's progress notes, from 09/13/2024 to 09/19/2024, did not show any documentation of monitoring of Resident 1 for injuries noted or response to the initiation of antibiotics. An incident note, dated 09/19/2024 at 12:24 AM, showed the resident was found on the floor next to his bed with an abrasion above his right eye. A facility investigation report, dated 09/19/2024 at 2:16 AM, showed Resident 2 was found on the floor, assessed for injuries and an abrasion was noted above his right eye. Nursing staff were to continue to monitor for any post-fall injuries or complications Review of progress notes, from 09/19/2024 to 09/29/2024, showed only one entry for monitoring the use of antibiotics, and no entries for monitoring for latent injuries or resolution of injuries. On 10/17/2024 at 9:48 AM, Staff E, Nurse Tech, said she could document some things on residents but not all things, as she was not permitted to assess. Staff E said she would alert the Registered Nurse (RN) if there was something that needed to be documented. On 10/18/2024 at 1:13 PM, Staff G, Med Tech, said she did not document on the residents on alert and identified Staff C as the one who would do that if needed. At 1:46 PM, Staff C, RN, Resident Care Manager, said if a resident had a fall, a new skin issue, or an antibiotic was started, the resident would be placed on alert and a daily skilled note would be completed by staff. When asked if nurse techs and med techs can perform that task, Staff C said nurse techs should be doing that. If the med techs needed to document on a resident, they would alert a nurse and they would make the note. Staff C said she reviewed the dashboard and looked at alerts and if there was no charting she would talk to staff to get a note in there. At 2:36 PM, Staff B, RN, DNS, said residents should be placed on alert if new bruising was found, experienced a fall, or a new antibiotic was started. Staff B said she would expect the resident to be monitored and assessed for latent injuries for at least 72 hours and would expect a daily skilled note documented in progress notes or daily skilled evaluations. At 3:58 PM, Staff A, Administrator, said they would expect documentation in the medical record of monitoring residents following falls, discovering of bruising, and initiation of antibiotics. Reference WAC 388-97-1060(1) .

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to prevent the development of pressure ulcers (PU - injury to skin a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to prevent the development of pressure ulcers (PU - injury to skin and underlying tissue resulting from prolonged pressure), perform/document regular skin assessments, and to consistently complete provider ordered wound care for 4 of 4 sampled residents (Residents 1, 2, 3, & 4) reviewed for pressure ulcers. These failures placed residents at risk for continued deterioration or pressure ulcers/injuries, infection and pain. Findings included . According to the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Manual, dated October 2023, pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface. In addition, external factors, such as excess moisture and tissue exposure to urine or feces, can increase the risk. The Documentation-Skin Conditions facility policy, dated 02/24/2023, showed a weekly skin assessment would be documented using the total body skin evaluation/assessment. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 07/07/2024, documented Resident 1 had moderate cognitive impairment, required substantial to maximal assist for activities of daily living (ADLs), was always incontinent of bowel and bladder, had no pressure injuries, was at risk for pressure injuries and was not on a repositioning/turning program. Review of the care plan focus, initiated 03/03/2020 and revised 06/16/2021, for potential pressure ulcer of coccyx and heels related to decreased mobility and incontinence, showed the goal was for Resident 1 to have intact skin, free of redness, blisters or discoloration. Review of the care plan focus for bowel incontinence, initiated 10/10/2022, included the goal the resident would not have skin breakdown related to bowel incontinence. Review of the care plan focus for complete bladder incontinence, initiated 01/03/2024, included the goal for the resident to remain free from skin breakdown. Review of Resident 1's weekly skin evaluation, under evaluations, showed the resident's last recorded total body skin evaluation was 06/19/2024. Review of a wound provider note, dated 07/18/2024, showed Resident 1 had a new unstageable wound measuring 4.66 centimeters (cm) in length and 4.38 cm in width and was covered by 100% necrotic (slough/eschar) tissue to the right lateral buttock and identified the wound was avoidable. Review of the care plan focus for unstageable pressure ulcer of right buttock related to impaired mobility, and bowel and bladder incontinence, initiated 07/22/2024, included the goal for the pressure wound to show signs of healing and remain free of infection. Review of a wound provider note, dated 08/15/2024, showed the right lateral buttock wound measured 2.76 cm in length and 3.47 cm in width and had a status of deteriorating. Review of a wound provider note, dated 08/15/2024, showed Resident 1 had a new Stage 2 pressure ulcer measuring 7.5 cm in length and 5.02 cm in width to the center midline coccyx and identified the wound as avoidable. Review of a wound provider note, dated 08/22/2024, recommended a dressing change three times weekly and as needed for soilage and loose dressing. Review of a physician's order, dated 08/23/2024, instructed staff to cleanse the wound with wound cleanser and pat dry with gauze, apply medical grade honey to the wound bed followed by calcium alginate. Apply skin prep generously to peri wound, cover with silicone bordered dressing and secure with tape. Every Tuesday, Thursday (done by wound provider) and Saturday, for unstageable pressure ulceration. Review of a wound provider note, dated 08/29/2024, showed the center midline coccyx wound measured 2.85 cm in length and 2.4 cm in width and covered by 100% necrotic tissue. The wound status was changed from Stage 2 to unstageable since wound bed is now obstructed by necrotic tissue. The wound care recommendations included dressing changes 3 times weekly and as needed for soiled or loose dressing. Review of a physician order, dated 08/30/2024, instructed staff: Wound care to Right lateral Buttock cleanse with wound cleanser and pat dry with gauze, apply collagen to wound bed followed by oil emulsion gauze and calcium alginate, ply skin prep to peri wound and cover with silicone foam dressing. Every Tuesday, Thursday (done by wound provider) and Saturday, for unstageable pressure ulceration. Review of a wound provider note, dated 08/29/2024, showed the right lateral buttock wound status was unchanged and measured 3.17 cm in length and 2.88 cm in width. Review of a wound provider note, dated 09/19/2024, showed the right lateral buttock wound status was unchanged and measured 3.62 cm in length and 2.95 cm in width. Review of a wound provider note, dated 09/19/2024, showed the center midline coccyx wound had the status of deteriorating and had clinical signs of infection including redness, purulent (white/yellow/green) drainage, increased wound size, delayed healing, and change in wound appearance. The wound had increased in size and measured 7.26 cm in length and 7.0 cm in width. Review of the July, August, and September 2024 Treatment Administration Record (TARs) showed the following: July 2024 TAR -showed documentation Resident 1 did not have any skin impairments identified with weekly skin assessments, with all four-week entries showing a (-), indicating no skin impairment. August 2024 TAR -showed wound care was not performed on 08/24/2024. -showed no skin assessments were documented for Resident 1. September 2024 TAR -showed wound care was not performed on 09/14/2024. -showed no skin assessments were documented for Resident 1. Review of the Hospital admission record, dated 09/19/2024 through 09/26/2024, showed Resident 1 was emergently transported to the ER at the request of family due to a pressure wound. On 09/20/2024 at 5:32 PM, Collateral Contact (CC) said they had visited Resident 1 on 09/18/2024 and was concerned when staff informed them the resident was declining and had a wound. When CC requested to see the wound, staff pulled up Resident 1's dress and pulled down her brief and the wound had no dressing on it and was covered in feces. On 10/09/2024 at 4:40 PM, CC said they visited Resident 1 on 09/19/2024 and had to insist Resident 1 be transported to the ER for care. Resident 1 was admitted for sepsis and osteomyelitis, and they felt the resident should have been transported sooner. CC said they were never notified about the wounds or the severity of them. On 10/10/2024 at 12:58 PM, Staff D, Nursing Assistant (NAC), said if a wound did not have a dressing on it, they would tell the nurse so they could change it. Staff D said she did recall times when the wound did not have a dressing on it. On 09/18/2024, in particular, she reported it to the nurse, and it was changed. Staff D said the wound had an odor for a week or two and she reported it to the student nurse (nurse tech). On 10/11/2024 at 9:00 AM, Provider B, Nurse Practitioner and Wound Specialist, said Resident 1 had two wounds and one had worsened over the last two weeks. When she saw the resident last, the wound looked infected. Provider B said she removed the old dressing as part of her routine care; and if it is not in place, it would be documented on their notes. After reviewing their notes, Provider B indicated during visits on 08/15/2024, 08/29/2024, 09/05/2024, 09/12/2024 and 09/19/2024 the notes showed there was no dressing present. Provider B said if a wound was not covered it would likely impede healing and increase risk of infection. When asked if she had a concern the facility staff were not keeping the wound covered by a dressing, Provider B said they had prescribed the dressing to be three times a week and as needed, and it was up to the facility to manage that. Provider B said they discussed her concerns of the wound not being covered with Staff B, Director of Nursing Services and Registered Nurse (RN). On 10/17/2024 at 9:48 AM, Staff E, Nurse Tech, said she assisted with wound care for Resident 1 and said due to bowel and bladder incontinence and location of the wound, it would be hard to keep a dressing on. At 1:28 PM, Provider A, Physician's Assistant, said they were not highly involved in the management of the facility's wounds. Provider A said she was aware Resident 1 had a wound but had not seen the wound, and they had not been informed there was a healing issue with the wounds. At 4:06 PM, Staff F, Nurse Tech, said she had dressed Resident 1's wound on two occasions, and she let Staff B know there was an odor. On 10/18/2024 at 1:13 PM, Staff F, Medication Assistant, said they do not perform wound care. They would get Staff C if a resident needed wound care. Staff F said wound care typically was done on Tuesdays, Thursdays (by wound specialist) and Saturdays. If a wound needed to be dressed due to soilage and loose dressing, she would tell Staff C. When asked if they would document the as needed dressing on the treatment record, Staff F stated, I guess you would. I would have to check. That would be a good idea. At 1:46 PM, Staff C, RN and Resident Care Manager (RCM), said Resident 1 had wound care ordered three times a week, but she had daily dressings due to soilage. Staff C said she had not observed the wound but was under the impression it was healing. At 2:36 PM, Staff B said she had not seen Resident 1's wounds. Staff had not reported to her the wound had an odor. Staff B said Provider B did not say there was a concern Resident 1's wound was not being kept covered or it needed to be changed if it was soiled. Staff B said she knew staff were changing it if it got soiled. Because of the location, it was easy to become soiled and would be changed as needed. When asked if that would be documented in the record, Staff B said it would be documented in a progress note. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairment, was dependent on staff for all ADLs, was always incontinent of bowel and bladder, was at risk for pressure injuries, was not on a turning/repositioning program and had one Stage 3 pressure ulcer (full thickness loss of skin, fat and granulation tissue-pink red tissue composed of blood vessels and collagen may be visible) that was not present on admission. Review of the care plan focus for potential for pressure ulcers related to impaired mobility and bowel and bladder incontinence, initiated 03/03/2021, included the goal for the resident to have intact skin free of redness, blisters or discoloration. Review of the care plan focus for bowel incontinence, initiated 06/09/2020 and revised 04/21/2021, included the goal the resident would not have skin breakdown related to bowel incontinence. Review of the care plan focus for bladder incontinence, initiated 06/09/2020, included the goal for the resident to remain free from skin breakdown. Review of the care plan focus for an un-staged pressure ulcer of center midline sacrum (lower back) related to decreased mobility, initiated 07/30/2024, included the goal for the pressure wound to show signs of healing and remain free of infection. Review of a physician's order, dated 08/16/2024, directed staff to cleanse the wound with wound cleanser, pat dry with gauze, apply collagen to the wound bed, followed with calcium alginate with silver, apply skin prep to peri wound and cover with a silicone bordered dressing in the morning every Tuesday, Thursday (done by wound provider), and Saturday. Review of a wound provider note, dated 09/19/2024, showed a Stage 3 center midline sacrum wound, measuring 0.88 cm in length and 0.87 cm in length, with a status of unchanged. The wound care orders included dressing changes three times weekly and as needed for soiled or loose dressing. Review of Resident 2's July 2024, August 2024 and September 2024 TAR showed wound care was not performed on 08/24/2024, 8/27/2024, 09/03/2024, 09/10/2024 and 09/14/2024. No documentation could be found that the wound care was provided by the oncoming shift. Review of Resident 2's weekly skin evaluation under Evaluations showed the resident's last recorded total body skin evaluation was 06/19/2024. Review of August 2024 TAR showed no skin assessments were documented for Resident 2. Review of September 2024 TAR showed no skin assessments were documented for Resident 2 On 10/17/2024 at 9:48 AM, Staff E, Nurse Tech, said they were not able to complete wound care. They had 20 residents to care for and there was not enough time. Staff E said they reported to Staff B and to the oncoming shift that tasks were not completed. At 4:06 PM, Staff F, Nurse Tech, said they were not able to complete wound care on 09/10/2024 because they had 10 wound dressing to do. They reported to the oncoming shift it was not done. On 10/18/2024 at 2:44 PM, Staff B said they were not aware of staff concerns they were not able to complete wound care. When asked if wound care was done on Tuesday, Thursday and Saturday and needed to be completed as needed for soilage or loose dressing, and where would that be documented, Staff B said they had just been documenting it on a progress note, and wound care as needed for soilage or loose dressing was not entered into the TAR as a separate order. <Resident 3> Resident 3 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 3 was medically complex, had moderate cognitive impairment, required substantial to maximal assist for ADL's, was always incontinent of bowel and bladder, was at risk for pressure injuries, was not on a turning/repositioning program and had one Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) that was not present on admission. Review of the care plan focus for potential for pressure ulcers related to impaired mobility and frequent bladder incontinence, initiated 02/23/2023 and revised 06/11/2024, included the goal for the resident to have intact skin free of redness, blisters or discoloration. Review of the care plan focus for bladder incontinence, initiated 02/24/2023, included the goal for the resident to remain free from new skin breakdown. Review of the care plan focus, initiated 06/11/2024, for a Stage 4 pressure ulcer of the sacrococcyx (lower back/tailbone) related to decreased mobility and incontinence included the goal for the pressure wound to show signs of healing and remain free of infection. Review of the care plan focus for bowel incontinence, initiated 06/18/2024, included the goal that the resident would not have skin breakdown related to bowel incontinence. A wound provider note, dated 09/12/2024, showed a sacrococcyx Stage 4 pressure ulcer measuring 0.65 cm in length and 1.02 cm in width with a status of unchanged. Review of Resident 3's weekly skin evaluation under Evaluations showed the resident's last three recorded total body skin evaluations were 06/19/2024, 08/21/2024, and 10/01/2024. Review of August 2024 TAR showed no skin assessments were documented for Resident 3. Review of September 2024 TAR showed no skin assessments were documented for Resident 3. Review of October TAR showed no skin assessments were documented for Resident 3. <Resident 4> Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 4 had severe cognitive impairment, required substantial to maximal assist for ADLs, was always incontinent of bowel and bladder, was at risk for pressure injuries, was not on a repositioning/turning program, had one unstageable pressure injury that was not present on admission. Review of the care plan focus for bowel incontinence, initiated 11/18/2019 and revised 04/21/2021, included the goal that the resident would not have skin breakdown related to bowel incontinence. Review of the care plan focus for bladder incontinence, initiated 02/18/2020 and revised 08/19/2020, included the goal for the resident to remain free from new skin breakdown. Review of Resident 4's weekly skin evaluation under Evaluations showed the resident's last recorded total body skin evaluations was on 06/19/2024. Review of a wound provider note, dated 07/11/2024, showed Resident 4 had a new unstageable center midline coccyx pressure injury, measuring 3.5 cm in length and 5.1 cm in width and identified the wound as not unavoidable. Review of the care plan focus for potential for pressure ulcers related to impaired mobility and dermal frailty, initiated 08/01/2024, included the goal for the resident to have intact skin free of redness, blisters or discoloration. Review of the care plan focus, initiated 08/01/2024, for an un-staged pressure ulcer of the center midline coccyx (tailbone) related to decreased mobility and dermal frailty, included the goal for the pressure wound to show signs of healing and remain free of infection. Review of a wound provider note, dated 09/25/2024, showed the coccyx wound status was unchanged, and measured 3.61 cm in length and 2.5 cm in width. Review of August 2024 TAR showed no skin assessments were documented for Resident 4. Review of September 2024 TAR showed no skin assessments were documented for Resident 4. Review of October TAR showed no skin assessments were documented for Resident 4. On 10/18/2024 at 1:46 PM, Staff C, RN and RCM, said resident skin was monitored by documenting a total body evaluation weekly in the electronic charting system. Staff C said NA staff also alert her if they find an issue and then she assessed the resident, and the resident was placed on alert and monitored and an order for treatment was obtained. Staff C said she reviewed daily charting and looked at alerts on the dashboard to see if documentation was not done. At 2:44 PM, Staff B said her expectation was resident skin was monitored weekly under evaluation with a total body skin evaluation, and some residents were on the TAR under weekly skin checks. When asked what the facility was doing to address pressure wounds in the facility, Staff B said they were starting this month to have LN and NA staff training with a focus on wounds and shadow the wound providers. At 3:58 PM, Staff A, Administrator, said they do discuss wounds as part of QAPI (quality assurance, performance improvement) meetings. The facility did not have a structured meeting to focus on pressure wounds. They discuss it as part of the daily clinical meeting. Reference WAC 388-97-1060 (3)(b) .

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for qu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for quality of care, was provided care, in accordance with professional standards of practice. The facility failed to secure an order for administration and monitoring for the continuous positive airway pressure (CPAP: an external device that provides a fixed pressure to keep breathing airways open while you sleep) therapy. This failed practice placed residents at risk for ineffective assisted ventilation, worsening health conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Non-Invasive Ventilation, revised on 06/2023, showed residents receiving CPAP therapy would have the services provided as directed by the physician's order and the order would include the pressure and duration of use, amount of supplemental oxygen used, if applicable, and mask size and mode of delivery. The policy also indicated the resident would be monitored for potential complications. Resident 1 admitted to the facility on [DATE] and had diagnosis including obstructive sleep apnea (OSA, a decrease or complete halt in airflow for longer than 10 seconds at least five times per hour). The Medicare 5-day Minimum Data Set (MDS), an assessment tool, dated 08/20/2024, showed the resident had moderate cognitive impairment and was medically complex. A social services note, dated 09/06/2024 at 5:24 PM, documented Resident 1's spouse reported Resident 1's CPAP machine was missing. The note documented Staff C, Social Services Director, reported the missing CPAP to nursing. A physician's order, dated 09/18/2024, entered by the provider, documented staff were to assist patient with CPAP machine every evening, at bedtime. A medication administration note, dated 09/21/2024 at 8:21 PM, documented the patient will not wear at night. A medication administration note, dated 09/25/2024 at 1:11 AM, by Staff D, Registered Nurse (RN), documented the CPAP machine was not administered. Review of the September 2024 Medication Administration Record (MAR) for CPAP usage showed: No staff signature for 09/18/2024 and 09/19/2024. Staff documented as administered on 09/20/2024. Staff documented as refused on 09/21/2024. Staff documented as administered on 09/22/2024 and 09/23/2024. Staff documented as other- see nurses notes on 09/24/2024. Staff documented as administered on 09/25/2024 and 09/26/2024. On 09/19/2024 at 2:59 PM, Resident 1 said they had previously used their CPAP machine at home but was not currently using it at the facility, although it had been there at some point, but it was lost. Resident 1 said the facility staff were aware it was missing. Observations of Resident 1's room showed some tubing and a mask near the sink and no CPAP machine was observed. On 09/20/2024 at 11:59 AM, Resident 1's family member said they brought Resident 1's CPAP machine to the facility but it was never set up and was missing currently and they were concerned that the CPAP was not being used by Resident 1. On 09/27/2024 at 1:37 PM, Staff C, Social Services Director, said when Resident 1's family member reported the missing CPAP (09/06/2024 per notes), he was able to find some hoses and he later found out that Staff A had the CPAP machine but did not know who it belonged to. At 2:00 PM, Staff D, RN, said she had never seen the CPAP machine and had worked a few days prior and was not able to locate it. Observation of Residents room did not show a CPAP machine. The tubing and masks observed on 09/19/2024 were in the same location near the sink. At 2:10 PM, Staff A, Administrator, said she had the CPAP machine and had it stored for safe keeping because the resident did not have an order for the CPAP. Staff A said she recalled a conversation with Staff B and the provider regarding the need for an order. A request was made to observe the CPAP machine. At 2:27 PM, Staff B, Director of Nursing, RN, said they were aware Resident 1's family member brought in a CPAP and an order had been put in for Resident 1. Staff B said if a provider entered the order, a nurse would confirm it before it would be implemented. Staff B said they would expect a CPAP order to include the settings and monitoring. At 2:35 PM, Staff A said they were not able to locate the CPAP machine, the staff member she gave it to, Staff E, Central Supply/Transportation, had thrown it away believing it was broken. Staff A said they would replace the CPAP machine for Resident 1. Reference WAC 388-97-1060 (3)(j)(vi) .

Jul 2024 16 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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interviews, and record review, the facility failed to initiate and complete a thorough grievance invest...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interviews, and record review, the facility failed to initiate and complete a thorough grievance investigation for 1 of 5 residents (Resident 27) who were reviewed for grievances. The facility failed to ensure there was a resolution for lost property and for concerns related to sitting in soiled briefs. These failures placed the resident at risk for frustration, skin impairment, loss of dignity, and a diminished quality of life. Findings included . The facility's Grievance Policy, revised 01/27/2023, stated, If the grievance is an allegation of neglect, please take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. The center strives to complete the review of grievances within 5 business days of receipt. <Lost property> Resident 27 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS), an assessment tool, dated 06/18/2024, showed the resident was cognitively intact and needed extensive assistance for Activities of Daily Living (ADLs). On 07/23/2024 at 9:29 AM, Resident 27 stated, I asked a person who worked in the office to use my debit card to purchase some supplies for me, but she lost my card and didn't tell me until the next day. Resident 27 said her phone had been turned off due to non-payment. On 07/24/2024 at 9:40 AM, Staff A, Administrator, said the card was taken from Resident 27 by an activities person to shop for the resident, but that person no longer worked for the facility. When asked if there was a grievance created for an investigation, Staff A stated, no, there wasn't that I'm aware of. At 2:59 PM, Staff K, Accounts Receivable Coordinator, said somewhere around 07/03/2024 she had been made aware Resident 27's debit card had been lost. Staff K said she had gone with the employee that had lost the debit card to the resident's room the next day to call the bank to stop the card, and to order another one. When asked if either Staff K or the other employee had created a grievance for the investigation, she stated, no, I didn't know that I needed to. When asked if anyone had followed up with Resident 27 about her new card, she stated, no. <Sitting in soiled briefs> On 07/22/2024 at 12:14 PM, Resident 27 stated, my friend was here with my [NAME]. The dog went under my chair and when he came out, he was wet with urine. I had just gotten back from therapy and the aides told me they were busy passing lunch and couldn't change me. Nobody came to talk to me about it until a couple of days ago. On 07/23/2024 at 3:28 PM, Staff F, Social Services Director, stated, I went to see this resident in the room a couple of weeks ago about a room change request. The resident handed me a Grievance Form about sitting in urine and I gave it to the Administrator. At 4:15 PM, Staff A said she went and talked to Resident 27 the other day along with Staff F because, this resident always changes stories. She said the resident told her the delay in care was due to the resident and Staff I not being comfortable with each other. When asked if Staff I, Certified Nurse Assistant (CNA) still provided care for this resident, she stated, depends on staffing, if we are short, then she has to. On 07/25/2024 at 11:18 AM, Staff I, CNA stated, I have only taken care of this resident once, but I don't remember what day. The resident yells at staff. I don't remember anything about a wet brief. I heard about this, but it wasn't me, it was another staff member. When asked if she still cared for the resident, she stated, I try not to. The Grievance Form, completed by the resident and a friend, was dated 07/08/2024. The Grievance Summary Report, dated 07/19/2024, said Staff A spoke with Resident 27 about the discomfort with Staff I, CNA. The recommendations on the form stated, change care givers, change staff caring for resident. The are for 'reviewed by Interdisciplinary Team' was dated 08/15/2024. The grievance was not logged on the facility Grievance Logs. Resident 27's Care Plan, dated 07/16/2024, was not updated with interventions related to the incident. It did not specify that Staff I should not provide care. There were no progress notes, including psychosocial (involving both psychological and social aspects) monitoring, related to the incident. Reference WAC 388-97-0460 .

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 21> Resident 21 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed Resident 21 was cog...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 21> Resident 21 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed Resident 21 was cognitively intact. On 07/22/2024 at 3:29 PM, Resident 21 said Staff L, Certified Nursing Assistant, had jerked her up in bed and hit her head on the side rail about a week and a half ago. Resident 21 stated, she threw me down so hard in bed. Review of the facility's January 2024 through 07/22/2024 Incident Log, documented no incident was logged for an allegation of abuse for Resident 21. On 07/22/2024 at 4:49 PM, Staff A, Administrator was informed of the allegation against Staff L. Staff A said she knew it had happened and said she had seen the bruise on Resident 21. On 07/25/2024 at 9:46 AM, when asked how her investigation was going regarding Resident 21's allegation of abuse, Staff A, Administrator, said Staff L had turned Resident 21 over and bumped her head. Staff L had then reported the incident to the nurse who was working that day, but the nurse had not gone forward with the information until Staff A had followed up with her about it. Staff A said when she opens an investigation, she looks to see what has been written in the chart, meets with the resident and staff, and would suspend and review if it was serious. She said if it was abuse, they must follow it further, report it, and let corporate know. Regarding suspension of staff during an investigation she said it varied, it didn't always happen if it was an accident, it depended on the severity of the allegation. Staff A stated, [Staff L] is a strong person, I have watched her, she is not rough. I don't find her rough. When asked if she had reported the above incident to the State hotline, Staff A, stated no, it wasn't rough treatment. Reference WAC 388-97-0640 (5)(a) Based on observation, interview and record review, the facility failed to report resident allegations of abuse to the state agency within 24 hours as required, for 2 of 5 residents (Residents 23 & 21) reviewed for abuse and neglect. These failures resulted in delayed investigations into alleged abuse, and placed residents at risk for abuse, psychosocial harm, and decreased quality of life. Findings included . Review of the facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property policy, dated 08/2022, showed the facility would report all alleged incidents of abuse or incidents that resulted in serious bodily injury immediately, but not later than two hours after the allegation was made. Other allegations that did not include abuse or serious bodily injury, would be reported to the State Agency not later than 24 hours after an allegation is made. <Resident 23> Resident 23 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 07/02/2024, showed the resident was cognitively intact, displayed no signs or symptoms of delirium, demonstrated no behaviors towards others, and had no rejection of care. On 07/22/2024 at 12:12 PM, Resident 23 reported on 07/20/2024, Staff M, Certified Nursing Assistant (CNA), treated her like a piece of meat. The resident said Staff M entered their room without saying anything and started roughly pushing them onto their right side. Resident 23 indicated she told Staff M to stop because it hurt, but Staff M replied we started it this way, so we are going to finish it and kept pushing despite the resident's reports of pain and pleas to stop. Resident 23 stated, I'm afraid of [Staff M] and don't want her back in here again. At 12:23 PM, Staff D, LPN, entered the resident's room. When asked about the incident, Staff D confirmed the resident had reported being handled roughly. On 07/25/2024 at 10:58 AM, Staff D, LPN, said when they came on shift, they overheard the night nurse and staff talking about the allegation, so they knew it had been reported. Staff D said during their first round with Resident 23, the resident had also informed Staff D of the incident and wanted the aide's name. When asked what specifically Resident 23 had reported to Staff D, Staff D said that the aide was rough with care, it caused pain, they were left exposed, and didn't want that caregiver again. Staff D then stated, I think the night nurse reported it to [Staff B, Director of Nursing (DNS)], as well. Review of the facility's July 2024 Incident Log on 07/25/2024 at 1:49 PM, showed Resident 23's allegation was not logged. Staff B, DNS, who was present during the review said nothing was logged because this was the first they had heard of the incident. On 07/26/2024 at 10:20 AM, when informed that Staff D, LPN, confirmed Resident 23 had informed them of the incident and they said they overheard the night nurse talking about the incident, Staff B, DNS, said the staff member who the allegation was reported to should have ensured the resident's immediate safety, obtained statements, and then notified their supervisor and the state hotline. When asked if there was any documentation to show those things occurred, Staff B, DNS, stated, no.

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** . Based on interview and record review, the facility failed to provide residents a written notice detailing the reasons for disc...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide residents a written notice detailing the reasons for discharge/transfer and to provide a copy of the notice to the state Ombudsman office as required for 1 of 3 sampled residents (Resident 32) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds. Findings included . Resident 32 was admitted to the facility on [DATE]. The Annual Minimal Data Set, (MDS, an assessment tool) date 05/21/2024, documented Resident 32 was cognitively intact. Resident 32 was hospitalized from [DATE] until their return on 05/15/2024. The Electronic Health Record showed no documentation of a transfer notice or an Ombudsman notification. On 07/25/2024 at 11:30 AM, Staff B, Director of Nursing Services, said she did not have a copy of the transfer notice or Ombudsman notification. When asked if a transfer notice/Ombudsman notification should have been completed, Staff B said yes. Reference WAC 388-97-0120 (2) (a-d) .

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide the resident and/or resident representative, a written no...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide the resident and/or resident representative, a written notice of the facility's bed-hold policy at the time of transfer for 1 of 3 sampled residents (Resident 32) reviewed for hospitalizations. This failure placed residents at risk for emotional distress and a diminished quality of life. Findings included . Resident 32 was admitted to the facility on [DATE]. The Annual Minimal Data Set, (an assessment tool), date 05/21/2024, documented Resident 32 was cognitively intact. Resident 32 was hospitalized from [DATE] until their return on 05/15/2024. The Electronic Health Record showed no documentation of a bed hold notice. On 07/25/2024 at 11:30 AM, Staff B, Director of Nursing Services, said she did not have a copy of the bed hold notice. When asked if a bed hold notice should have been completed, Staff B said yes. Reference WAC 388-97 -0120 (4) .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to ensure the Minimum Data Sets (MDS), an assessment tool, accurate...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to ensure the Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 1 of 35 sampled residents (Residents 32) reviewed for MDS accuracy. The failure to accurately assess residents nutritional needs, placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 32 was admitted to the facility on [DATE]. The annual Minimal Data Set, (an assessment tool), dated 05/21/2024, documented Resident 32 was cognitively intact. The MDS, selection K, for Resident 32 read, Yes, on a prescribed weight loss regimen. On 07/25/2024 at 11:30 AM, Staff B, Director of Nursing Services, said Resident 32 was not on a prescribed weight-loss regimen. Staff B said she would have to check with the MDS Coordinator to know why Resident 32 was checked as being on a weight-loss regimen. At 2:26 PM, Staff E, Registered Dietitian, said Resident 32 was not a weight-loss regimen and Resident 32 had no calorie or diet restrictions. Reference WAC 388-97-1000 (1)(b) .

CONCERN (D)

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** . Based on observations, interview, and record review, the facility failed to ensure ongoing communication and collaboration occ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interview, and record review, the facility failed to ensure ongoing communication and collaboration occurred with the dialysis (procedure to clean and filter waste from the blood) center for 1 of 1 sampled resident (Resident 32) reviewed for dialysis. These failures placed residents at risk for unidentified medical complications, adverse health outcomes, and unmet care needs. Findings included . The undated Dialysis Management (Hemodialysis) policy including the following directions: 1. Review the Dialysis Center Communication for pertinent information from the Dialysis Clinic and transcribe the information into section II.B of the Dialysis Center Communication Records UDA (User Defined Assessment) in the EMR (Electronic Medical Record) 2. If original is not returned with resident, contact Dialysis Center 3. Retain the original document in the hard chart behind the assessment tab 4. Check vital signs upon return post-dialysis and per physician's orders The Service Agreement for Northwest Kidney Centers, dated 02/2019, documented the medical management of facility's resident would be under the direction of the resident's attending physician. The facility would retain primary responsibility for the development and implementation of the resident's plan of care. Resident 32 was admitted to the facility on [DATE]. The Annual Minimal Data Set, (MDS, an assessment tool), date 05/21/2024, documented Resident 32 was cognitively intact. Resident 32 attended dialysis treatment three times a week on the following days: 07/05/2024, 07/08/2024, 07/10/2024, 07/12/2024, 07/15/2024, 07/19/2024, 07/22/2024 & 07/24/2024. Resident 32's EMR documented the last communication between the facility and dialysis center as 07/05/2024. Resident 32's weights completed by the facility as followed: 07/21/2024 10:25 240.8 Lbs (pounds) 07/18/2024 12:43 264.0 Lbs 07/15/2024 12:35 263.9 Lbs 07/12/2024 08:42 263.9 Lbs 07/09/2024 09:39 262.4 Lbs 06/30/2024 08:18 262.4 Lbs 06/27/2024 10:42 262.1 Lbs 06/24/2024 15:13 262.3 Lbs Resident 32's post treatment dialysis records (from the dialysis center) showed Resident 19's weights as followed: 07/05/2024 117.3 Kg (258.60223 lbs) 07/08/2024 117.1 Kg (258.16131 lbs) 07/10/2024 115.1 Kg (254.63391 lbs) 07/12/2024 114.3 Kg (251.98837 lbs) 07/15/2024 113.0 Kg (249.122 lbs) 07/19/2024 110.0 Kg (242.508 lbs) 07/22/2024 111.0 Kg (244.713 lbs) 07/24/2024 110.1 Kg (242.72895 lbs) The above weights from the dialysis center showed a 7.3% weight loss in the previous 30 days and a 17.1% weight loss in the previous six months. On 07/25/2024 at 1:28 PM, Staff E, Registered Dietitian, said nursing staff was responsible for obtaining the communication binder for the updated communication sheets regarding communication between the dialysis center and the facility. Staff E said the facility should not have been using the facility weights that were obtained and should have only been using the post-treatment dialysis weights from the dialysis center. Staff E said when weightloss was identified the facility would place the resident on alert to be discussed at the next interdisciplinary team meeting, for plan of care changes and recommendations. Staff E said the registered dietitian should have been doing weekly weight checks and check ins with the resident. At 1:57 PM, Staff B, Director of Nursing Services, said medical records was responsible for obtaining all documentation for the dialysis center. Staff B said the dialysis facility was sending them once a week but due to a recent change in management they were now only sending them once a month. When asked if the communication binder had been obtained weekly, would the weights have been identified sooner, Staff B, said, yes, we would have had a better understanding of the weight loss. At 2:05 PM, Staff G, Medical Records, said they were responsible for obtaining all dialysis records. Staff G said there had been no communication with the dialysis since 07/05/2024. Reference WAC 388-97-1900(1), (6) (a-c) .

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to assess and maintain safety of quarter bed rails for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to assess and maintain safety of quarter bed rails for 1 of 4 sampled residents (Resident 3) reviewed for accidents. This failure placed the resident at risk of injury and a diminished quality of life. Findings included . Resident 3 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 02/10/2024, documented the resident was cognitively intact and required supervision assistance with Activities of Daily Living (ADL's). On 07/22/2024 at 11:14 AM, Resident 3 had a quarter rail attached to the right side of the bed. The rail was leaning away from the bed, and when tested, moved forwards and backwards and side to side. Resident 3 stated, It's been like that for a long time. I just pulled the commode against it so it doesn't move when I get up. On 07/23/2024 at 3:12 PM, Staff H, Registered Nurse, said quarter rails should not move once attached so would not present a hazard. Staff H said if they did become loose, the aides would tell her and she would let maintenance know. On 07/24/2024 at 10:15 AM, Staff I, Certified Nursing Assistant, was asked if she ever tested the bed rails and she said she did and could tighten them if they were loose. She was asked to test Resident 3's rail and stated, This is way too loose, Staff I attempted to tighten the rail but was unable. When asked if a loose rail could cause injury, she stated, yes, absolutely. At 10:52 AM, Staff B, Director of Nursing, said nursing completed safety enabling assessments every quarter but did not test the devices. She said maintenance completes the testing and audits. At 3:22 PM, Staff J, Maintenance Director, said they try to complete safety enabling device testing monthly but doesn't always get to them. He said they rely on nursing staff to tell them if a device needs to be adjusted. Reference WAC 388-97-0230 .

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to monitor behaviors for 1 of 5 sampled residents (Resident 33) revi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to monitor behaviors for 1 of 5 sampled residents (Resident 33) reviewed for Unnecessary Medications. This failure placed residents at risk of experiencing behaviors without appropriate interventions to attain and/or maintain their highest practicable physical, mental and psychosocial well-being and a decreased quality of life. Findings Included . Resident 33 was admitted on [DATE] with diagnoses including anxiety disorder (excessive worrying and feelings of fear, dread, and uneasiness) and depression (feelings of hopelessness and persistent sadness). The 5-day Minimum Data Set (MDS), an assessment tool, dated 05/26/2024, showed the resident was cognitively intact and was independent to needing set up assistance with activities of daily living (ADLs). A review of Resident 33's Medication Administration Record (MAR) for January 2024 showed the resident started the medication, Escitalopram Oxalate, in the morning for depression and anxiety on 01/17/2024. A review of Resident 33's MAR for April 2024 showed the monitors for antidepressant side effects started on 04/17/2024. A review of Resident 33's MAR for July 2024 showed target behavior monitoring for psychoactive medication related to anxiety started on 07/17/2024. On 07/24/2024 at 9:55 AM, Staff L, Registered Nurse and Float Infection Preventionist said the monitoring should be started when the medication was ordered. At 10:19 AM, Staff B, Director of Nursing and Registered Nurse said once an antidepressant was ordered the monitoring should have been added with it. Reference WAC 388-97-1060 (3)(k)(i) .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to provide prompt dental services for 1 of 3 sampled r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to provide prompt dental services for 1 of 3 sampled residents (Resident 6), reviewed for dental services. This failure placed the resident at risk for unmet dental needs, nutritional compromise, and a diminished quality of life. Findings included . Resident 6 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS), an assessment tool, dated 05/29/2024, documented the resident was cognitively intact and needed extensive assist for Activities of Daily Living (ADL's). On 07/22/2024 at 11:46 AM, Resident 6 stated, I have been waiting for some bottom dentures. He said his lack of lower dentures affected his ability to eat and to enjoy his food. The facility Dental Policy, revised 12/30/2022, stated, the social services department will work to assist/and or coordinate services such as routine dental services. The procedure section stated, identify those residents who need routine services that include fitting dentures. Dental care services documentation showed Resident 6 was visited on 11/22/2023 and on 05/24/2024 for hygiene visits. Recommendations included, wants a future lower partial or full denture when discharged . A Social Services note, dated 01/19/2024, documented Resident 3 had hoped to return home to live with a brother who would provide care, but the brother was having health issues of his own. The note stated Resident 3, plans to stay with us for now. On 07/24/2024 at 1:32 PM, Staff G, Medical Records, said she didn't know if any referral had been made for his lower dentures. Reference WAC 388-97 -1060 (3)(j)(vii) .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

. Based on observation and interview, the facility failed to provide proper infection prevention techniques for 1 of 3 sampled residents (Resident 35) reviewed for pressure ulcer/injury. This failure ...

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. Based on observation and interview, the facility failed to provide proper infection prevention techniques for 1 of 3 sampled residents (Resident 35) reviewed for pressure ulcer/injury. This failure put residents at risk for infection and a diminished quality of life. Findings included . On 07/23/2024 at 12:39 PM, Staff C, Registered Nurse, Unit Manager, and Staff G, Certified Nursing Assistant, Medical Records, began wound care for Resident 35. Staff C retrieved scissors from her pocket and began to cut Alginate (a wound care product) with the scissors. At 1:02 PM, Staff C said that when she pulled her scissors out of her pocket, they were considered dirty, and the scissors should have been cleaned before proceeding to use them during wound care. On 07/24/2024 at 9:51 AM, Staff B, Director of Nursing Services, said it was not acceptable for equipment from staff pockets to be used for wound care. Reference WAC 388-97-1320 (2)(a) .

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 53> Resident 53 was admitted to the facility 01/24/2024 with diagnoses including Post-Traumatic Stress Disorder,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 53> Resident 53 was admitted to the facility 01/24/2024 with diagnoses including Post-Traumatic Stress Disorder, Schizoaffective Disorder (a disorder that affects a person's ability to think, feel and behave clearly), psychotic disturbance (a mental condition that causes people to have difficulty distinguishing between reality and fantasy), and mood disturbance. The Quarterly MDS, dated [DATE], showed that Resident 53 was cognitively intact. A physician's order, dated 07/15/2024, documented Resident 53 was prescribed lorazepam, a psychotropic medication that affects a person's mental state, to treat anxiety. Resident 53's EMR did not show documentation of an informed consent from the resident or the resident's representative for the administration of lorazepam. On 07/24/2024 at 9:22 AM, Staff I, Minimum Data Set Registered Nurse, said for a psychotropic medication a consent should have been completed. On 07/24/2024 at 9:29 AM, Staff B, Director of Nursing Services, said consent was needed for a psychotropic medication and she could not locate an informed consent for lorazepam for Resident 53. She said her expectation was prior to psychotropic therapy a consent was done. Reference WAC 388-97-0300(3)(a) Based on interview and record review, the facility failed to obtain informed consents for 2 of 5 sampled residents (Residents 33 and 53) reviewed for psychoactive medications. This failure placed residents and/or legal representatives at risk of not being fully informed to make decisions about their medications prior to administration. Findings Included . <Resident 33> Resident 33 was admitted on [DATE] with diagnoses including anxiety disorder (excessive worrying and feelings of fear, dread, and uneasiness) and depression (feelings of hopelessness and persistent sadness). The 5 day Minimum Data Set (MDS), an assessment tool, dated 05/26/2024, showed the resident was cognitively intact and was independent to needing set up assistance with activities of daily living(ADLs). A review of Resident 33's Medication Administration Record (MAR) for January 2024 showed the resident started the medication, Escitalopram Oxalate, an antidepressant, in the morning for depression and anxiety on 01/17/2024. A review of the electronic medical record (EMR) showed Resident 33 signed a consent on 01/24/2024 explaining the risks and benefits of the medication, Escitalopram Oxalate. On 07/24/2024 at 9:55 AM, Staff L, Registered Nurse and Float Infection Preventionist said, the nurse should complete the resident's consent before starting an antidepressant medication. On 07/24/2024 at 10:19 AM, Staff B, Director of Nursing and Registered Nurse said, the consent should be done prior to starting the medication.

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> Resident 27 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 27> Resident 27 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact and needed extensive assist for Activities of Daily Living. On 07/23/2024 at 9:29 AM, Resident 27 stated, I asked a person who worked in the office to use my debit card to purchase some supplies for me, but she lost my card and didn't tell me until the next day. She said her phone was turned off due to non-payment. On 07/24/2024 at 09:40 AM, Staff A, Administrator, said the card was accepted from Resident 27 by an activities person to shop for the resident, but that person no longer worked for the facility. When asked if there was a grievance created for an investigation, she stated, No, there wasn't that I'm aware of. At 2:59 PM, Staff K, Accounts Receivable Coordinator, said somewhere around 07/03/2024, she was made aware that Resident 27's debit card had been lost. She said she went with the employee that had lost it to the resident's room the next day to call the bank to stop the card, and to order another one. When asked if either the employee or herself created a grievance for investigation, she stated, No, I didn't know that I needed to. When asked if anyone had followed up with Resident 27 about her new card, she stated, No. Refer to F609 Reference WAC 388-97-0640 (6)(a)(b) <Resident 21> Resident 21 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed Resident 21 was cognitively intact. On 07/22/2024 at 3:29 PM, Resident 21 said Staff L, Certified Nursing Assistant, had jerked her up in bed and hit her head on the side rail about a week and a half ago. Resident 21 stated, she threw me down so hard in bed. Review of the facility's January 2024 through 07/22/2024 Incident Log, documented no incident was logged for an allegation of abuse for Resident 21. On 07/25/2024 at 9:46 AM, when asked how her investigation was going regarding Resident 21's allegation of abuse, Staff A, Administrator, said Staff L had turned Resident 21 over and bumped her head. Staff L had then reported the incident to the nurse who was working that day, but the nurse had not gone forward with the information until Staff A had followed up with her about it. Staff A said when she opens an investigation, she looks to see what has been written in the chart, meets with the resident and staff, and would suspend and review if it was serious. She said if it was abuse, they must follow it further, report it, and let corporate know. Regarding suspension of staff during an investigation she said it varied, it didn't always happen if it was an accident, it depended on the severity of the allegation. Staff A stated, [Staff L] is a strong person, I have watched her, she is not rough. I don't find her rough. When asked if she had suspended Staff L while she was investigating, Staff A stated, because it was behind the time, I did not put her on suspension. Based on observation, interview and record review, the facility failed to timely initiate and thoroughly investigate allegations of abuse, neglect, and/or misappropriation for 3 of 5 residents (Residents 23, 21 & 27) reviewed for abuse and neglect. The failure to immediately investigate an allegation of staff to resident abuse, identify the alleged perpetrator (AP), and implement interventions to ensure the alleged victims (AV) and other residents' safety, placed residents at risk for continued abuse/neglect, psychosocial harm, and decreased quality of life. Findings included . Review of the facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property policy, dated 08/2022, showed when allegations are made that met the definition of abuse, neglect, exploitation, mistreatment or misappropriation the center would: a) Thoroughly investigate all alleged violations and retain documents showing that all alleged violations are thoroughly investigated. b) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process. c) Report results to all investigations to the Executive Director or designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days. d) Take all necessary corrective actions if the alleged violation is verified. <Resident 23> Resident 23 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 07/02/2024, showed the resident was cognitively intact, displayed no signs or symptoms of delirium, demonstrated no behaviors towards others, and had no rejection of care. On 07/22/2024 at 12:12 PM, Resident 23 reported on 07/20/2024, Staff M, Certified Nursing Assistant (CNA), treated her like a piece of meat. The resident said Staff M entered their room without saying anything and started roughly pushing them onto their right side. Resident 23 said she told the Staff M that she was unable to roll to the right due to the rheumatoid arthritis in their right shoulder and it hurt. The resident said Staff M responded that they started it that way, so they were going to finish it (that way) and kept pushing despite the reported pain and pleas to stop. Resident 23 explained, because she rolled me to my right, I was lying with all my weight on the [attends]. So [Staff M] was pushing my top shoulder toward the right while pulling the attends and my lower half to the left. The friction caused from pulling the attends out with all my weight on it, caused the dressing to my buttocks to [shear] off. The resident said Staff M then told them not to move and left to go get the nurse to replace the dressing. Resident 23 reported they were left on their right side grasping on to the siderail, uncovered, undressed from the waist down, with the window curtains, privacy curtain and door to the room wide open, leaving them exposed for approximately 20 minutes until the nurse came. The resident said they reported the incident to the night nurse (did not know name) and to Staff D, Licensed Practical Nurse (LPN), the day shift nurse. On 07/25/2024 at 10:58 AM, Staff D, LPN, said when they came on shift, they overheard the night nurse and staff talking about the allegation, which to Staff D showed it had been reported. Staff D also said during their first rounds of residents, Resident 23 told them about the incident and wanted to know the aide's name because they did not want them again. When asked what specifically Resident 23 had reported, Staff D said Resident 23 told them that the aide was rough with care, it caused pain, they were left exposed, and they didn't want that caregiver again. Review of the facility's July 2024 Incident Log on 07/25/2024 at 1:49 PM, showed Resident 23's allegation was not logged. Staff B, DNS, who was present during the review said nothing was logged because this was the first they had heard of the incident. Review of the facility's July 2024 Incident Log showed Resident 23's allegation was not logged. On 07/25/2024 at 1:49 PM, Staff B, Director of Nursing (DNS), said it was not logged and an investigation had not been initiated because they were unaware of the incident. On 07/26/2024 at 10:20 AM, when informed Staff D, LPN, said they had overheard the night nurse talking about the incident, showing they were aware, and that Staff D had confirmed Resident 23 reported it to them, Staff B, DNS, said the investigation should have been initiated at that time, but acknowledged the investigation was not initiated until 07/25/2024, five days after the incident was reported.

CONCERN (E)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 18> Resident 18 was admitted to the facility on [DATE]. The quarterly, MDS, dated [DATE], documented Resident 18...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 18> Resident 18 was admitted to the facility on [DATE]. The quarterly, MDS, dated [DATE], documented Resident 18 was cognitively intact. Resident 18's admitting PASRR, dated 11/21/2023, documented no serious mental illness indicators. There were no other PASRR's in Resident 18's electronic health record (EHR). Resident 18 was prescribed an antidepressant for depression. On 07/25/2024 at 10:19 AM, Staff F, SSD, confirmed Resident 18's PASRR documented no serious mental illness indicators. Staff F said this should have been caught and a new PASRR should have been completed. Reference WAC 388-97- 1915 (1-2) Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the care plan for 2 of 5 residents (Resident 17 and 18) reviewed for PASRRs. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Resident 17> Resident 17 was admitted to the facility on [DATE] with multiple diagnoses. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 05/17/2024, documented the resident was severely cognitively impaired. According to a Level 1 PASRR, dated 09/20/2023, Resident 17 had a Serious Mental Illness (SMI) of anxiety disorder (mental health condition), dementia (characterized symptoms affecting memory and social abilities) and mood disorders (characterized by persistant depressed mood or loss of interest in activities). Referal for a Level 2 evaluation was indicated on the Level 1 PASRR. Per facility documentation, the level 2 PASRR was not completed. On 07/25/2024 at 9:55 AM, Staff F, Social Service Director (SSD), said he could not find documentation of an invalidation request sent by fax. Staff F stated, the previous social services missed that. She never contacted them to follow up. On 7/25/2024 at 2:43 PM, Staff B, Director of Nursing Services said it was her expectation to complete PASRRs in a timely manner. Staff B was unable to provide further documentation that a Level 2 PASRR had been completed.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

. Based on observation and interview, the facility failed to ensure medications were stored, labeled, and dated when opened and/or discarded when expired for 1 of 1 medication room (East Medication) a...

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. Based on observation and interview, the facility failed to ensure medications were stored, labeled, and dated when opened and/or discarded when expired for 1 of 1 medication room (East Medication) and 1 of 2 medication carts (East medication carts) observed. These failures placed residents at risk to receive incorrect and/or expired medications. Findings included . <East Medication Room> Observation of the East Medication room on 07/26/2024 at 10:35 AM, with Staff C, Unit Manager (UM), revealed the following expired, opened and undated and/or improperly stored medication: 1) Resident 117 - a Novolin 70/30 insulin pen, was opened and undated. The manufacturer guidelines showed the insulin pen should be discarded 28 days after opening. On 07/26/2024 at 10:39 AM, Staff C, UM, said because Resident 117's Novolin 70/30 flex pen was opened and undated and it needed to be discarded. 2) A Refrigerator Temperature Log located on the counter next to the medication refrigerator, directed staff to record the medication refrigerators temperature twice daily to ensure it is maintained between 36 - 46 degrees Fahrenheit (F). If the temperature was not within range, staff were instructed to adjust the temperature and re-check in 30 minutes. If still out of range staff were to move items out of the refrigerator. Review of the medication refrigerator temperature log for May, June and July 2024 showed: May 2024: The AM and PM temperatures were recorded for only 1 of 31 days. June 2024: The AM temperature was recorded for 3 of 30 days, and the PM temperature was recorded for 2 of 30 days. July 2024: The AM and PM temperatures were recorded only once through 07/26/2024 (26 days). On 07/26/2024 at 10:47 AM, Staff C, UM, said staff were expected to check and record the temperature of the medication refrigerator twice a day as directed, but acknowledged they failed to do so. <East Medication Cart> Observation of the East medication cart on 07/26/2024 at 10:53 AM, with Staff C, UM, revealed the following expired and/or undated medications: 1) An opened and undated Wixela inhaler, for Resident 51. 2) An opened and undated Wixela inhaler, for Resident 167. 3) Nineteen expired cards of calcium acetate, for Resident 43. The individual cards had various expiration dates, but all expired prior to 07/26/2024. Review of the manufacturer's recommendations for Wixela inhalers, showed the inhalers were good for one month after opening. On 07/26/2024 at 10:56 AM, Staff C, UM, said facility staff should have dated Resident 51's and 167's Wixela inhalers when opened, and discarded Resident 43's nineteen expired cards of calcium acetate, but failed to do so. Reference WAC 388-97-1300(1)(b)(ii), (c)(ii-v), 1300 (2) .

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview, the facility failed to serve foods that were appetizing, palatable, and served at the prop...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview, the facility failed to serve foods that were appetizing, palatable, and served at the proper temperature for 5 of 7 (Residents 23, 18, 39, 116 and 61) sampled residents reviewed for dining. The failure to ensure meals were served at appropriate temperatures, with a good presentation, and that were palatable, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss, and a diminished quality of life. Findings included . <Resident Council Meeting> On 07/25/2024 at 10:30 AM, during a Resident Council Meeting , residents expressed the following food quality concerns: 1) No hot items on the bistro menu 2) Hot food is cold and cold food is melted or warm. Example: ice cream is served melted 3) Failure to follow the menu, menu says one thing and that is not what is delivered on tray 4) Poor presentation - unable to determine what some foods are supposed to be, don't go the extra mile 5) Food is frequently unpalatable, the quiche was horrible last night, and the pizza is frequently rock hard. 6) Concerns about food are not being addressed, suggestions and likes/dislikes are not being followed. 7) Some residents receiving items on their trays that are listed allergies. <Resident Interviews/Observations> <Resident 18> On 07/22/2024 at 2:30 PM, Resident 18 said the food comes out cold, that the scrambled eggs and bacon were cold and the only thing that was good were the salads. <Resident 39> On 07/22/2024 at 11:33 AM, Resident 39 said the food was not good, and the staff did not know how to cook. Resident 39 said the pizza was so hard it couldn't be cut with a knife. The resident indicated he loved ice cream, but the ice cream was never served frozen and by the time it was delivered it was soup. <Resident 116> On 07/23/2024 at 9:16 AM, Resident 116's family member said they had attempted to eat the facility food the day prior and the food was 'terrible' and the carrots weren't cooked and there had been a pile of noodles that were still hard/uncooked and a blob that they thought might have been spinach. <Resident 61> On 07/22/2024 at 2:10 PM, Resident 61 said the food was not good, it was served cold, and they only received one butter for four slices of toast. <Resident 23> On 07/22/2024 at 12:37 PM, Resident 23 said, most of the food is garbage and that's being polite. Resident 23 said the food was served ice cold. Resident 23 said sometimes the vegetables were al [NAME], but other times they were mush. At 12:48 PM, Resident 23's lunch meal was delivered with a container of chocolate ice cream. When the container was opened a brown soupy liquid was observed. The ice cream was melted with exception of an approximately 1 x 1 inch small ball of frozen liquid in the middle. Reference WAC 388-97-1100(1)(2) .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

. Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges for 3 of 6 (East Nurse, [NAME] Nurse and Prep)ref...

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. Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges for 3 of 6 (East Nurse, [NAME] Nurse and Prep)refrigerators reviewed for food service. These failures placed residents at risk for food-borne illness and a diminished quality of life. Finding included . Review of the April 2024, May 2024, June 2024, and July 2024 temperature logs for the [NAME] Nurse refrigerator, East Nurse refrigerator and Prep refrigerator, showed refrigerator temperatures were recorded at over 41 degrees Fahrenheit (F) on the following dates: <West Nurse refrigerator> April 2024, AM, temperature readings: 1st 43F, 2nd 42F, 3rd 42F, 4th 42F, 6th 42F, 7th 42F, 8th 43F, 9th 42F, 10th 42F, 11th 42F, 13th 42F, 14th 43F, 15th 43F, 16th 42F, 17th 45F, 18th 42F, 19th 42F, 20th 45F, 21st 44F, 22nd 42F, 23rd 46F, 24th 49F, 25th 42F, 26th 43F, 28th 50F. April 2024, PM, temperature readings: 6th 42F, 7th 42F, 8th 42F, 9th 42F, 15th 42F, 17th 45F, 18th 45F, 19th 46F, 20th 46F, 24th 45F, 25th 45F, 27th 49F. May 2024, AM, temperature readings: 1st 42F, 2nd 43F, 3rd 42F, 5th 42F, 6th 43F, 7th 48F, 8th 42F, 9th 42F, 10th 42F, 11th 42F, 12th 42F, 13th 42F, 14th 49F, 15th 43F, 16th 43F, 17th 42F, 18th 42F, 19th 42F, 20th 42F, 23rd 43F, 24th 43F, 25th 43F. May 2024, PM, temperature readings: 1st 59F, 2nd 43F, 3rd 50F, 4th 50F, 5th 40F, 6th 44F, 7th 44F, 8th 45F, 9th 50F, 10th 45F, 11th 45F, 12th 43F, 13th 50F, 14th 47F, 15th 49F, 17th 42F, 18th 48F, 19th 48F, 20th 42F, 21st 42F, 23rd 43F, 27th 42F, 28th 44F. June 2024, AM, temperature readings: 1st 42F, 3rd 42F, 4th 43F, 6th 42F, 7th 42F, 8th 43F, 9th 42F, 10th 42F, 11th 45F, 12th 42F, 13th 42F, 14th 42F, 16th 43F, 17th 45F, 20th 42F, 21st 42F, 22nd 42F, 23rd 43F. June 2024, PM, temperature readings: 1st 48F, 2nd 46F, 3rd 42F, 4th 42F, 10th 42F, 11th 42F, 12th 42F, 13th 42F, 14th 42F, 15th 42F, 20th 42F. July 2024, AM, temperature readings: 16th 42F, 17th 50F, 18th 42F, 22nd 42F. July 2024, PM, temperature readings: 8th 43F, 9th 43F, 10th 45F, 16th 44F. <East Nurse refrigerator> April 2024, AM, temperature readings: 1st 42F, 5th 42F, 6th 42F, 7th 42F, 16th 42F, 19th 43F, 21st 43F, 26th 43F, 28th 42F. April 2024, PM, temperature readings: 1st 42F, 14th 58F, 15th 45F, 16th 42F, 17th 42F, 24th 45F, 25th 45F, 27th 45F, 28th 50F. May 2024, AM, temperature readings: 1st 43F, 2nd 43F, 3rd 43F, 4th 42F, 5th 42F, 6th 50F, 7th 43F, 8th 49F, 9th 43F, 10th 42F, 11th 45F, 12th 45F, 13th 50F, 14th 49F, 18th 42F, 19th 42F, 24th 42F, 27th 48F, 28th 42F, 29th 42F, 30th 42F, 31st 49F. May 2024, PM, temperature readings: 3rd 48F, 4th 45F, 5th 45F, 6th 47F, 8th 49F, 9th 50F, 10th 45F, 11th 45F, 12th 50F, 13th 51F, 15th 49F, 16th 43F, 18th 45F, 19th 45F, 23rd 42F, 27th 45F. June 2024, AM, temperature readings: 4th 42F, 5th 42F, 7th 42F, 8th 48F, 9th 42F, 10th 42F, 11th 45F, 12th 48F, 13th 42F, 14th 42F, 15th 48F, 20th 42F, 21st 49F, 24th 42F, 28th 42F, 30th 42F. June 2024, PM, temperature readings: 1st 45F, 3rd 45F, 4th 45F, 5th 45F, 11th 45F, 12th 48F, 19th 49F, 20th 45F, 21st 45F, 22nd 45F, 23rd 45F. July 2024, AM, temperature readings: 1st 49F, 2nd 42F, 3rd 42F, 5th 42F, 7th 51F, 8th 48F, 12th 42F, 14th 42F. July 2024, PM, temperature readings: 1st 42F, 2nd 49F, 6th 52F, 7th 48F, 8th 51F, 9th 51F, 13th 51F, 18th 42F, 19th 58F, 20th 42F. <Prep refrigerator> July 2024, AM, temperature readings: 3rd 42F, 5th 42F, 6th 45F. On 07/22/2024 at 10:52 AM, Staff H, Dietary Manager, said when temperatures were out of required ranges they would recheck the temperature and document on the log if corrections made. When shown temperatures for the Prep refrigerator were over 41 degrees and lacked documentation of what was done about elevated temperatures, Staff H said there should have been documentation of what was done about it. On 07/24/2024 at 2:31 PM, when asked who was responsible for obtaining temperature logs for the unit refrigerators, Staff H said she was. Reference WAC 388-97-2980 .

Jul 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 F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 1 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 1 of 3 residents (1) reviewed for dignity and respect, when staff failed to provide toileting assistance when requested by the resident, prior to their physical therapy session. This failure placed residents at risk for embarrassment, anxiety, and diminished self-worth. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/18/2024, identified Resident 1 was admitted for orthopedic after care, was cognitively intact, and was dependent on staff for toileting transfers and toileting hygiene. Resident 1's Activity of Daily Living (ADL) self-care deficit care plan, initiated on 06/12/2024, included interventions directing staff to use a mechanical (Hoyer) lift for transfers. Resident 1's bowel elimination care plan, initiated on 06/21/2024, included interventions to assist the resident with toileting each time they rounded and as needed. On 06/25/2024 at 2:00 PM, Resident 1 said the day prior, 06/24/2024, staff had come to get the resident up for her therapy session and the resident told staff she had to poop. Resident 1 said staff told her she had a brief on, and the resident should wait until after therapy. Resident 1 said she had to do therapy with a soiled brief. Resident 1 identified Staff C as her physical therapist. Resident 1 said when her session was over, Staff C went and told facility staff that Resident 1 needed to be changed. Resident 1 said the whole experience made her feel really bad. At 2:29 PM, Staff C, Physical Therapist, said he was aware that the day prior Resident 1 had a stool soiled brief, and he was under the impression that they changed her prior to getting up and during the transfer she became incontinent. Staff C said Resident 1 had told him she had a bowel movement and she agreed to participate in therapy. Staff C said he reported to a Nursing Assistant (NA) that Resident 1 needed to be changed after the session and identified Resident 1's NA as Staff D. On 07/01/2024 at 1:21 PM, Resident 1 said during care on 06/24/2024, she told staff she had to go poop and they still kept getting me ready and then I had to go in my brief. Resident 1 reported she had a bowel movement before she was put in her wheelchair. She reported staff told her that she had a brief on. Resident 1 stated, I told them I had to go, I felt like they didn't care. I felt ashamed, I don't want to be treated like that. Resident 1 said again that she told Staff C and participated in some therapy that day and then was changed. At 1:32 PM, Staff D said she was assigned to Resident 1 on 06/24/2024 and she recalled she and another NA assisted Resident 1 up that day and she did not recall the resident reported she needed to have a bowel movement. Staff E said she was asked by therapy to change the resident and was under the impression the resident had a bowel movement during or following therapy. On 7/11/2024 at 1:20 PM, Staff B, Director of Nursing (DNS), Registered Nurse (RN) said she would expect staff to stop the process of getting a resident ready for therapy if the resident said they needed to have a bowel movement. Staff B said she would expect the resident to be toileted. At 1:40 PM, Staff A, Administrator, said she would not expect staff to continue getting a resident up for therapy who reported they needed to have a bowel movement. Reference (WAC) 388-97-0880 (1)(a)(2) .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to timely and thoroughly investigate an allegation of neglect for 1 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to timely and thoroughly investigate an allegation of neglect for 1 of 3 residents reviewed for abuse and neglect. This failure placed residents at risk for unidentified/continued abuse/neglect, not identifying corrective actions to prevent further neglect, and a diminished quality of life. Findings included . The facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Origin, and Misappropriation of Resident Property, dated 08/2022, showed staff were to thoroughly investigate all allegations and to retain documentation of a thorough investigation. The facility defined neglect as the indifference or disregard for resident care, comfort or safety that could result in physical harm, pain, mental anguish, or emotional distress. The investigation should include suspension of the alleged staff member(s), initiating an incident report in the identified resident's electronic health record, resident and staff interviews, interviews of other residents, observation of the resident involved and updating the residents care plan to include medical, nursing, physical, psychosocial needs or preferences as a result of the alleged incident. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/18/2024, identified Resident 1 was admitted for orthopedic after care, was cognitively intact, and was dependent on staff for toileting transfers and toileting hygiene. Resident 1's Activity of Daily Living (ADL) self-care deficit care plan, initiated on 06/12/2024, included interventions directing staff to use a mechanical (Hoyer) lift for transfers. Resident 1's bowel elimination care plan, initiated on 06/21/2024, included interventions to assist the resident with toileting each time they rounded and as needed. On 06/25/2024 at 2:00 PM, Resident 1 said the day prior, 06/24/2024, staff had come to get the resident up for her therapy session and the resident told staff she had to poop. Resident 1 said staff told her she had a brief on, and the resident should wait until after therapy. Resident 1 said she had to do therapy with a soiled brief. Resident 1 identified Staff C as her physical therapist. Resident 1 said when her session was over, Staff C went and told facility staff that Resident 1 needed to be changed. Resident 1 said the whole experience made her feel really bad. At 2:33 PM, the above allegation of neglect was reported to Staff A, Administrator. Staff A was told that Staff C was interviewed by the State Agency Surveyor (SAS) who had corroborated the information the Resident 1 had told SAS and identified Staff D as the Nursing Assistant (NA) assigned to Resident 1 the day of the allegation, 06/24/2024. On 07/01/2024, review of the facilities updated incident and grievance logs for 06/01/2024 through 07/01/2024 showed no entries for the reported concern regarding Resident 1. On 07/01/2024 at 1:21 PM, Resident 1 said during care on 06/24/2024, she told staff she had to go poop and they still kept getting me ready and then I had to go in my brief. Resident 1 reported she had a bowel movement before she was put in her wheelchair. Resident 1 reported staff told her that she had a brief on. Resident 1 stated, I told them I had to go, I felt like they didn't care. I felt ashamed, I don't want to be treated like that. Resident 1 again said she told Staff C and participated in some therapy that day and then was changed. Resident 1 said no one from the facility had followed up or asked her any questions regarding the reported concern. At 1:32 PM, Staff D said no one from the facility had spoken to her about the reported concern. Review of the facility's updated incident and grievance logs dated 06/11/2024 through 07/11/2024, on 07/11/2024, did not show an entry for Resident 1's reported concern. On 07/11/2024 at 1:20 PM, Staff B, Director of Nursing, Registered Nurse, said she recalled Staff A telling her that she was told by the SAS that a resident had reported a scenario of not being toileted and that Staff A was processing it as a grievance. Staff B said she did not get a grievance form. At 1:40 PM, Staff A said she spoke to Staff D a few days after the SAR reported the allegation to her. Staff A said she spoke to some of the therapy staff, who had no knowledge of the reported concern. Staff A said she did not speak to Staff C, the Physical Therapist. Staff A said she also spoke to Resident 1 a few days later but did not ask specifically about the allegation. When asked if she considered what the SAS reported to her on 06/25/2024 was an allegation of neglect, Staff A replied, if it was true. Staff A was not able to provide documentation of a investigation. Staff A said, she intended to process it as a grievance, but, had not done that. See Also F557 Reference WAC 388-97-0640 (6)(a)(b) .

Jul 2024 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 F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure care plan conferences were held with the resident and/or r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure care plan conferences were held with the resident and/or resident representative for 1 of 4 sampled residents (Resident 4) reviewed for participation in care planning. This failure placed residents and/or resident representatives at risk of not being fully involved and informed of decisions about care and services and a diminished quality of life. Findings included . The facility policy titled, Care Conferences, revised 05/2023, showed the facility would hold a care conference upon admission, quarterly, with significant changes, and as requested by the resident/family, or other team members. The facility would notify the resident and resident representative of the scheduled care conference and document under care conference progress notes. After completion, the care conference was to be summarized in a care conference progress note. Resident 4 was admitted to the facility on [DATE]. The admission minimum data set (MDS), an assessment tool, dated 5/30/2024, documented Resident 4 was cognitively intact and medically complex. Review of Resident 4's electronic health record from 05/24/2024 to 06/13/2024 showed no care conference had been conducted or offered. On 06/12/2023 at 9:03 AM, CC 1, Power of Attorney for Resident 4, said they were not included in care planning. CC 1 said they made numerous calls to the facility to inquire about the status of Resident 4 and they were not offered or included in a care conference at any time. CC 1 said they were aware that the choice of palliative services was made but CC 1 was not sure what that entailed or why hospice was not offered. On 06/13/2024 at 2:25 PM, Staff C, Social Services Director, said generally they try to schedule a care conference within three days of resident admission and then they reevaluate the need for one every 7-10 days. When asked specifically about Resident 4, Staff C said there had not been a care conference. Staff C attributed it to there being a backlog of care conferences and some things have fallen through. At 3:00 PM, Staff B, Director of Nursing, said that care conferences were typically scheduled during the resident's first week, but it was challenging at times. Staff B said the care conference should include the family if the resident preferred. Staff B was not able to answer specifically regarding Resident 4 and deferred to Staff C. On 07/01/2024 at 1:42 PM, Staff A, Administrator, said care conferences were held upon admission and quarterly. Staff A said if a resident or family member declined a care conference, they would expect there to be documentation in the electronic health record. Staff A said they would expect there to have been a care conference for Resident 4 and they would have to look into why that did not happen. Reference WAC 388-97-1020 (2)(e)(f) .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 4 sampled residents (Resident 4) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life. Findings included . The facility policy titled, Notification of Change in Condition, revised 05/2024, showed that clinicians would immediately inform the resident representative when there was a significant change in the resident's physical, mental or psychosocial status. Staff were to notify the provider and resident representative and document in the progress note. Resident 4 was admitted to the facility on [DATE]. The admission minimum data set (MDS), an assessment tool, dated 5/30/2024, documented Resident 4 was cognitively intact and medically complex. A daily skilled note, dated 06/06/2024 at 10:35 AM, documented Resident 4 was comfortable, had no indications of pain or discomfort and was getting up multiple times during the day. A provider note, dated 06/11/2024, documented Resident 4 was found sleeping in bed, awakened but was confused and with significant jaundice (when the liver can't efficiently process red blood cells as they break down and cause yellowing of the skin and whites of the eyes). On 06/13/2024 at 12:30 PM, Resident 4 was observed lying in bed with their eyes closed and obvious jaundice. Resident 4's meal tray was on their overbed table and appeared untouched. Resident 4 roused to voice but was not able to confirm if they needed assistance with eating their meal. Resident 4 grimaced upon attempting to move, and nodded their head up and down when asked if they were in pain. At 12:35 PM, Staff F, Licensed Practical Nurse, was informed of Resident 4's possible discomfort and need for assistance. Staff F said Resident 4 had really declined over the past two days, previously [they] had been getting up and feeding [themselves]. At 12:40 PM, Staff D, Physician's Assistant, said when Resident 4 had first arrived at the facility they were alert and able to talk very well, but Resident 4 had been experiencing a decline, but that was expected. Staff D said they would expect the facility staff to update family with changes if they wished to be informed. At 3:00 PM, Staff B, Director of Nursing, Registered Nurse, said they would expect staff to notify family of significant changes in a resident, such as: not getting out of bed or not eating. A progress note, dated 06/13/2024 at 11:53 PM, documented Licensed Nursing (LN) staff had entered Resident 4's room at 8:20 PM and found resident non-responsive and with a breathing change. The LN called Resident 4's POA to inform them of status change. The LN went back to Resident 4 at 8:35 PM to administer pain medications and discovered the resident had passed away. Resident 4's POA was then notified of Resident 4's death at 8:46 PM. On 06/17/2023 at 5:15 PM, CC 1, Resident 4's POA, said the first they were told there had been a change in condition for Resident 4 was about a half an hour before they were called and notified of Resident 4's passing. CC 1 said no one had informed them there had been a decline over the prior few days. On 07/01/2024 at 1:42 PM, Staff A, Administrator, said they would expect staff to notify a resident's POA the same day the resident had changes in condition, such as: not getting out of bed or not eating. Reference (WAC) 388-97-0320(1)(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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Residents 1,2,3,4) reviewed for quality of care when staff failed to assess, monitor and/or document resident responses to interventions on a daily basis, for newly admitted residents receiving skilled services. These failures placed residents at risk for unmet needs, declining health, and decreased quality of life. Findings included . The facility policy titled, Alert Charting, revised 05/2023, showed staff were to document according to Medicare charting guidelines while the resident was covered by Medicare or managed care. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 5/31/2024, documented Resident 1 was cognitively intact and admitted for orthopedic care. Review of Resident 1's Electronic Health Record (EHR) from 05/25/2024 to 06/10/2024 showed no skilled nursing assessment documentation (clinical progress notes) on 05/26/2024, 05/27/2024, 05/28/2024, 05/29/2024, 05/30/2024, 05/31/2024, 06/01/2024, 06/02/2024, 06/03/2024, 06/04/2024, 06/08/2024, and 06/09/2024; 12 of 16 days reviewed. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The admission MDS dated , 05/21/2024, documented Resident 2 was cognitively intact and admitted for orthopedic care. Review of Resident 2's EHR from 05/15/2024 to 06/10/2024 showed no skilled nursing assessment documentation (clinical progress notes) on 05/17/2024, 05/18/2024, 05/19/2024, 05/20/2024, 05/22/2024, 05/23/2024, 05/24/2024, 05/25/2024, 05/26/2024, 05/27/2024, 05/28/2024, 05/30/2024, 05/31/2024, 06/01/2024, 06/02/2024, 06/03/2024, 06/06/2024, 06/07/2024, 06/08/2024, 06/09/2024, 06/10/2024; 21 of 26 days reviewed. <Resident 3> Resident 3 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was cognitively impaired and medically complex. Review of Resident 3's EHR from 05/31/2024 to 06/06/2024 showed no skilled nursing assessment/clinical progress notes on 06/01/2024, 06/02/2024, 06/03/2024, 06/04/2024; 4 of 7 days reviewed. <Resident 4> Resident 4 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 4 was cognitively intact and medically complex. Review of Resident 4's EHR from 05/24/2024 to 06/10/2024 showed no skilled nursing assessment/clinical progress notes on 05/25/2024, 05/26/2024, 05/27/2024, 05/29/2024, 06/01/2024, 06/02/2024, 06/03/2024, 06/04/2024, 06/05/2024, 06/07/2024, 06/08/2024, 06/09/2024, and 06/10/2024; 13 of 17 days reviewed. Record Review showed, on 05/28/2024, Resident 4 chose a palliative approach to care with the discontinuation of their chronic medications and the provider gave new orders for pain and anxiety medications, both actions which generally require residents are placed on alert with increased monitoring and documentation and notification/discussion with resident's representative. would be to monitor and document the resident's response to the changes and to be able to notify Resident 1's POA of changes in condition. On 06/13/2024 at 3:00 PM, Staff B, Director of Nursing, Registered Nurse, said newly admitted residents were monitored and assessed according to their admission diagnosis and the EHR system alerted staff to who needed documentation. Staff B said they would expect a daily skilled or progress note for the first seven to 14 days of their admission. Staff B said they did not have a system to audit/review charting for completion, but the unit managers and the MDS nurse would usually bring it to Staff B's attention if there has been an issue with documentation not being completed. Staff B said they spoke about it that morning. At 3:15 PM, Staff E, RN said they were alerted to which residents needed daily assessment notes via the EHR system. When asked how often and or what duration a newly admitted resident should be documented on, Staff E said it depended on the resident but usually, at least, every 72 hours and for a week at a minimum. Staff E said they were able to complete all of the required daily documentation. Reference WAC 388-97-1060 (1) (3)(vi) See F580. .

May 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0691 (Tag F0691)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure residents who required ileostomy (surgically...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure residents who required ileostomy (surgically created opening in the bowel for the discharge of body wastes into a collection bag) care received services consistent with professional standards for 1 of 4 residents (Resident 1) reviewed for quality of care. The failure to obtain orders for frequency of ostomy care, which supplies to use and lack of prompt attention to resident request for ostomy care placed residents at risk for skin breakdown and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 03/21/2024, documented Resident 1 was cognitively intact and had an ostomy. Review of the care plan, initiated 03/19/2024, documented Resident 1 had an ileostomy, and the goal was for the resident to verbalize any leaking or loosening of the device. Staff interventions included to notify the nurse if the appliance was leaking, monitor stoma (the portion of bowel outside the abdomen) appearance and peristomal skin (skin around the stoma) for breakdown during appliance changes and change the appliance if leaking, itching, burning, or if the wafer (skin barrier that goes around the stoma) was dislodged. Review of the March 2024 Treatment Administration Record (TAR) showed no order to change the ileostomy appliance. A daily skilled note, dated 03/25/2024 at 6:47 PM, by Staff C, Registered Nurse, documented Resident 1's ostomy bag was changed. A provider note, dated 03/26/2024, documented Resident 1 was having trouble with her ostomy bag leaking but that has been taken care of. Review of the April 2024 TAR showed no order to change ileostomy appliance. A Health Status Note, dated 04/05/2024 at 10:38 AM, by Staff C, documented Resident 1's ostomy bag was changed. Review of the Electronic Health Record (EHR) from 04/06/2024 through 04/18/2024 did not show any other documentation the ostomy was changed during that time. On 04/18/2024 at 12:57 PM, Resident 1's ostomy bag was observed coming loose and they reported they had asked for the bag to be changed at 11:50 AM. Resident 1 said she has had the ostomy since 1988 and normally managed it herself but since her right arm fracture, could no longer manage it. Resident 1 said they usually changed the bag every five days and relayed that information to staff and reported they were not using the correct supplies. Resident 1 said the ostomy bag had only been changed about three times since admission to the facility. Resident 1 said staff seemed to not want to change the ostomy appliance unless the wafer was completely off, and stool was leaking. Resident 1 said staff did not change the appliance promptly and on one occasion it was leaking for over three hours and burning their skin. Resident 1 said it was very embarrassing and left them feeling humiliated. At 1:07 PM, Resident 1 again requested their ostomy appliance be changed. At the conclusion of the interview at 1:38 PM, staff had not addressed her concerns, nearly two hours after her initial request. A Health Status Note, dated 04/29/2024 at 5:24 PM, by Staff C, documented Resident 1's ostomy was changed. Review of Resident 1's EHR from 04/19/2024 through 05/17/2024 did not show any other documentation the ostomy appliance had been changed. Review of May 2024 TAR showed an order initiated on 5/15/2024 for ostomy change every Monday and Friday. On 05/15/2024 at 3:10 PM, Resident 1 said the facility continued to use the supplies they had on hand to manage her ostomy; she had a friend bring her supplies from home and they had been using them now. Resident 1 said she reached out to her home medical supplier on 05/10/2024 and they offered to fax the facility a list of the supplies she needed to manage her ostomy. Resident 1 said she also supplied a handwritten note to Staff B but did not receive any follow up. Resident 1 said the facility was not using the proper supplies and the wafer would be lumpy and crack and she felt leaking underneath the wafer as it would burn her skin, but staff would look at it and tell her it didn't need to be changed because it wasn't leaking. Resident 1 reported staff attentiveness had not improved but her arm has healed, and she could better manage it herself if she had the right supplies. At 3:30 PM, Staff B, Registered Nurse (RN), Director of Nursing, (DNS) said how frequently the ostomy wafer was changed and what supplies were needed for an ostomy was based on the order written. Staff B said they would expect that order to be in the record. Staff B said if a resident requested ostomy care or change, she would expect staff to address it immediately. Regarding Resident 1, Staff B said the resident was used to a particular product that the facility did not have and they had recently received that information. Staff B said it was her expectation the ostomy would be changed on a regular basis. At 4:03 PM, Staff C said the frequency of the ostomy change would be in the TAR and she believed it was every three days. Staff C said she would know what supplies to use by the order in the TAR. Staff C said if a resident requested an ostomy change that should be addressed right away. Regarding Resident 1, Staff C said Resident 1 would pick at the appliance and then it would come off. Staff C said Resident 1's appliance was changed at least once a week. Staff C could not recall wether it was scheduled to be changed at regular intervals or if there was an order for the brand/type of supplies to be used. Reference WAC 388-97-1060(3)(j)(iii) .

Apr 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident 3) reviewed for quality of care when staff failed to assess, monitor and/or document respiratory assessments and resident response to intervention. These failures placed residents at risk for unmet needs, declining health, and decreased quality of life. Findings included . The policy titled, Alert Charting, revised on 05/2023, showed residents were to be placed on alert for a minimum of 72 hours for the following: resident care issues, changes in condition, medication changes, falls, and psychosocial harm. The policy showed documentation should include vital signs, physical assessment, resident's response and symptoms. Resident 3 was admitted to the facility on [DATE] with diagnosis of a stroke, obstructive sleep apnea (when breathing is interrupted during sleep), anxiety and developmental delay. The Quarterly Minimum Data Set, an assessment tool, dated 01/18/2024, documented Resident 3 was cognitively intact, required staff assistance for activities of daily living, and had not displayed shortness of breath. The care plan, initiated 02/07/2022, documented interventions included to monitor for shortness of breath or trouble breathing when sitting at rest, lying flat or with exertion, to monitor vital signs, pulse oximetry (a noninvasive measurement of oxygen saturation on the blood, often referred to as the fifth vital sign) and restlessness that may indicate hypoxia (inadequate oxygen) and encourage prompt treatment of any respiratory infection. A provider notes, dated 03/06/2024, documented Resident 3 had reported congestion that started the day before. The provider notes documented Resident 3's lung sounds were normal oxygen saturation of 98% on room air. The provider note documented two medications (a bronchodilator that opens airways to make it easier to breathe and an expectorant that loosens chest congestion) were ordered for the resident on an as needed bases for 14 days for cough/congestion. Review of March 2024 Medication Administration Record showed that the expectorant was used on 03/06/2024 at 5:05 PM with ineffective results and the bronchodilator was used on 03/07/2024 at 5:57 AM, on 03/08/2024 at 8:16 PM, and 03/09/2024 at 5:53 AM, all with effective results. Review of Resident 3's electronic health record from 03/06/2024 to 03/11/2024 did not show documentation of licensed nurses' assessment of the resident's respiratory status, following the implementation of new medication orders to treat/manage the residents reported cough/sob. An alert note, dated 03/11/2024 at 5:37 PM, documented Resident 3 had reported shortness of breath, was wheezing and their oxygen saturation had dropped to 80%. The provider was contacted and an order for nebulized bronchodilator was obtained and administered to the resident, following treatment the resident's oxygen saturation was 89% and the resident was transported to the emergency room for further evaluation. A hospital Emergency Department (ED) note, dated 03/11/2024, documented Resident 3 had reported they were complaining of shortness of breath for a week and worsening the two days prior to transportation to the hospital. The ED note documented Resident 3 had abnormal lung sounds and was in respiratory distress. On 4/10/2024 at 11:40 AM, in reference to their recent hospitalization, Resident 3 said she did not recall staff listening to her lungs or obtaining her oxygen levels in the days leading up to her hospitalization. Resident 3 reported she had asked multiple staff members, multiple times, to go to the hospital and was told no. On 04/11/2024 at 2:29 PM, Staff C, Licensed Practical Nurse, Unit Manager, said residents were assessed and documented on if something was going on. Staff C said staff knew who to document on by them being on alert charting. Staff C said residents would be placed on alert if they had returned from the hospital, had an incident, or started an antibiotic. When asked if a resident was displaying respiratory symptoms or started new medications would they be placed on alert and assessed and documented on; Staff C said depending on the medication, but the respiratory symptoms would probably just be passed on in report. When asked specifically about Resident 3 and her new order for a bronchodilator and expectorant, would she expect the resident to be placed on alert, Staff C said. no, we don't do that here, we pass it on in report. When asked if there was any documentation in Resident 3's record that staff were monitoring her respiratory status prior to her hospitalization, Staff C was unable to locate any information. When asked if the resident had been placed on alert would staff have done more to assess her respiratory status, Staff C said, Yeah, sure. Staff C said Resident 3 was not placed on alert because there were no changes to her day-to-day activity level, and she could not recall Resident 3 asking to go to the hospital. On 4/11/2024 at 3:40 PM Staff B, Registered Nurse, Director of Nursing, said Residents should be placed on alert and monitored for any new changes or treatments. Staff B said they would have expected a resident who had a cough and congestion and was received new orders for bronchodilator and expectorant to have been placed on alert and staff to assess and document in the record. Reference WAC 388-97-1060 (1) (3)(vi) .

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra that drains into a bag) were provided with catheter care and management in a manner that minimized the risk for complications and catheter related urinary tract infections for 2 of 2 residents (Residents 4 and 5) reviewed for urinary catheters. These failures placed residents at risk for catheter associated urinary tract infections, other potential health complications, and decreased quality of life. Findings included . The facility policy titled, Indwelling Catheters, revised 07/2023, documented a catheter care plan would be initiated for residents admitted with an indwelling catheter in place and residents would receive catheter care every shift. <Resident 4> Resident 4 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 03/10/2024, documented Resident 4 was cognitively intact, dependent on staff for activities of daily living (ADLS), had an indwelling catheter and was medically complex. The care plan, initiated 03/13/2024, identified Resident 4 as having altered urinary elimination due to having an indwelling catheter and the goal was that the resident would remain free of UTI (urinary tract infection) and catheter related complications. Interventions included changing the catheter as ordered, checking the system every shift, emptying the bag every shift, and ensuring tubing and drainage bags were below the level of the bladder. The care plan included direct to monitor and document signs and system of UTI. The care plan did not include the task of providing catheter care by thoroughly cleansing the insertion site of the indwelling catheter every shift. Review of Resident 4's [NAME] (instructions to nursing assistants) for bladder tasks, directed Nursing Assistants to check the catheter system every shift, empty drainage bag every shift, ensure the catheter tubing and drainage bag were below the level of the bladder, keep catheter tethered to prevent tension or trauma and report changes in urine to the nurse. The [NAME] did not instruct staff to perform catheter care which included thoroughly cleansing the catheter insertion site every shift. Review of the Emergency Department provider note, dated 03/19/2024, documented Resident 4 was admitted to the hospital for acute UTI, among other diagnosis, and was found to have notable lesions with ulcerations and pus to his penis. On 03/27/2024 at 9:37 AM, Collateral Contact (CC 2) said when Resident 4 had arrived at the emergency department and a physical assessment was completed, Resident 4 was found with wounds to his penis and were attributed to lack of catheter care/cleansing. Review of Resident 4's electronic health record for 03/04/2024 to 03/19/2024 did not show documentation regarding wounds to the penis or documentation that catheter care was performed by staff. On 04/10/2024 at 3:20 PM, Resident 4 said he had a catheter while he was at the facility and staff had not cleaned it thoroughly and it became infected. Resident 4 said he reported burning to his penis to the staff and they did not do anything about it stating, it seemed the staff were trying to do the absolute minimum they could do. Resident 4 said he was not able to visualize the area and was not aware of the wounds or drainage or odor. Resident 4 said he was treated with antibiotics for the wounds and a UTI, while in the hospital. Resident said the wounds had healed, and he no longer had the catheter. <Resident 5> Resident 5 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired, was dependent on staff for ADLs, and had an indwelling catheter. Review of a daily skilled note, dated 03/25/2024 at 6:44 PM, documented Resident 5 had a fall and their catheter was pulled out and the provider was notified and order was received to send a urine sample for urinalysis. Review of a provider note, dated 03/27/2024, documented Resident 5's urine sample was positive for infection and they would be started on an antibiotic. Review of Resident 5's [NAME] for bladder tasks, directed NA staff to check the catheter system every shift, empty drainage bag every shift, ensure the catheter tubing and drainage bag were below the level of the bladder, keep catheter tethered to prevent tension or trauma and report changes in urine to the nurse. The [NAME] did not instruct staff to perform catheter care which included thoroughly cleansing the catheter insertion site every shift. Review of Resident 5's electronic health record for 03/14/2024 to 03/25/2024 did not show documentation that catheter care was performed by staff. On 04/11/2024 at 1:03 PM, Staff E, Nursing Assistant, said that staff knew which residents required catheter care by the care plan ([NAME]) and catheter care included thoroughly cleansing the area. Staff E said catheter care was documented in the electronic health record under tasks. At 3:15 PM, Staff D, Licensed Practical Nurse, Unit Manager, said staff knew which residents required catheter care by the care plan and staff would document catheter care under tasks. Staff D said the task gets placed on the care plan by the resident care managers. Staff D said she could not recall Resident 4 and was not aware of any wounds related to the catheter. Staff D was unable to find documentation that catheter care was performed for Resident 4 and 5. At 3:40 PM, Staff B, Registered Nurse, Director of Nursing, said that residents should receive catheter care every shift and as needed and the care should be documented in the resident's record. Reference WAC 388-97-1060 (3)(c) .

Dec 2023 3 deficiencies 1 Harm

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

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to intervene timely and/or provide necessary supervision during a res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to intervene timely and/or provide necessary supervision during a resident-to-resident altercation for 2 of 3 residents (Resident 1 & 2) reviewed for accidents and supervision with known histories of agitation and inappropriate behaviors. Resident 1 experienced harm when they developed a subdural hematoma (blood pooling on surface of the brain) during the altercation. The failure to provide adequate interventions and supervision during resident altercations placed all resident at risk for potential injuries or harm. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriation of Resident Property, dated 08/2022, documented that staff were trained in the utilization of appropriate interventions to deal with aggressive and detrimental reactions of residents, they were trained how to provide protection for the residents. Staff were to prevent adverse events by ongoing supervision of residents and recognitions of signs of resident-to-resident frustration or stress and to identify, intervene, and correct situations where residents with needs and behaviors might lead to abuse. When staff identified events such as resident to resident altercations, they were to provide for the residents' immediate safety by moving the resident to another room or unit. Review of the facility's incident reporting log, for [DATE], showed a resident-to-resident altercation between Resident 1 and Resident 2 occurred on [DATE] at 9:15 PM in a common area of the facility and Resident 1 sustained injuries. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated [DATE], documented they had moderate cognitive impairment, sometimes could make themselves understood and/or understand others. The MDS also documented Resident 1 displayed verbal and physical behaviors that significantly interfered with the resident's care and placed others at significant risk of physical injury and was dependent on two staff members for bed mobility, transfers, toileting, and dressing. Resident 1 was dependent on a wheelchair for mobility. The care plan for behavioral problems related to anxiety and agitation, initiated on [DATE], documented Resident 1 could be verbally and physically abusive at times. Goals included to have no injury to self or others and interventions included to intervene as necessary to protect the rights and safety of others, approach in a calm manner, divert attention, and remove the situation and to take resident to an alternate location as needed. An incident note, dated [DATE] at 10:45 PM, documented Resident 1 was dragged out of the wheelchair to the floor by another resident [Resident 2] who was showing signs of aggression and incapacitation including speech and odor of alcohol. An alert note, dated [DATE] at 4:37 PM, documented Resident 1 was pronounced deceased at 3:35 PM. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact, displayed verbal behaviors that significantly interfered with residents' care/put others at risk for injury, was intrusive to others and significantly disrupted the living environment. Resident 2 was independent for all activities of daily living and used no assistive devices. The care plan focus for behavioral problems related to alcohol abuse, insomnia, anxiety, and auditory hallucinations, initiated on [DATE], documented interventions included the resident would report they was drinking alcohol at times, mostly in the evening and the resident may experience elevated mood/behaviors towards others, and staff were to intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, and remove from the situation and take to alternate location as needed. A mood and behavior note, dated [DATE] at 9:11 PM, documented Resident 2 was noted to be drunk and belligerent during and after medication administration. <Incident> The facility investigation report showed on [DATE] at 9:15 PM, that Resident 1 was sitting in their wheelchair near the nurses' station when Resident 2, who appeared to be intoxicated, approached Resident 1 and attempted to pull up Resident 1's pants. Staff intervened and asked for Resident 2 to move back and away from Resident 1. Resident 2 became verbally aggressive to staff. The staff stayed at the nurse's station to observe, Resident 2 then re-approached Resident 1 and after Resident 1 grabbed Resident 1's arm, Resident 2 aggressively pulled back which caused Resident 1's wheelchair to tip over. Resident 1 was assessed for injury and a 5-centimeter (cm) x (by) 2 cm bruise was noted over Resident 1's left eye. Resident 1 was transferred back to their wheelchair. An incident note, dated [DATE] at 12:03 PM, by Staff B, Registered Nurse/Director of Nursing, documented events from the previous evening, [DATE], including that Resident 2 appeared, per staff, to be intoxicated, was being verbally abusive to staff, ignoring staff directions and persisted in initiating contact with Resident 1, Staff B documented Resident 2 was observed instructing Resident 1 to grab on this, bite on this while holding their arm out to them. Resident 1 grabbed onto Resident 2's arm and when Resident 2 was unsuccessful in pulling their arm away, Resident 2 pulled aggressively, causing Resident 1's wheelchair to topple over on its side where Resident 1's head struck the floor. All staff witness statements were reviewed and were similar and consistent with the facility investigation and incident notes as documented above. Review of facility incident log showed Resident 1 had no documented falls since admission. The Coroner's Report for the death of Resident 1, dated [DATE] 09:00 AM, as time of examination, documented Resident 1's cause of death was an accident and the manner of death to be a subarachnoid hemorrhage (bleeding in the space that surrounds the brain) as a consequence of blunt force trauma to the head. <Staff Interviews> On [DATE] at 4:26 PM, Staff F, Nursing Assistant (NA) said Resident 1's usual behaviors were to yell, grab and swear, but once they were in bed for the night, they were usually good until early morning. Staff F said Resident 2's usual behaviors were dependent on if they seemed under the influence of something, and if so, they would be loud with the other residents and be more involved than was necessary. Regarding the incident on [DATE], Staff F recalled Resident 2 had returned to the facility at approximately 8:30 PM that night and initially went to their room. Staff F said Resident 2 came back out some minutes later and told staff that Resident 1 needed help getting their pants pulled up. Staff F accompanied by Staff I (NA) went to another room to attend to another resident and Staff G (NA) and Staff H (NA) were at the nurses' station. When Staff F and Staff I came out of the other resident's room, approximately 5 minutes later, Staff G and H were assisting Resident 1, while Resident 2 was interfering with the process and sticking their arm out and was not responding to direction to leave the area. Staff F said they were able to get Resident 2 to move back from Resident 1. When they finished providing care to Resident 1, Staff F, G, and H went behind the nurses' station and Staff I remained in front of the station to observe. Staff F said after a few minutes, Staff I entered the nurses' station and that was when Resident 2 approached Resident 1 again and Resident 1 grabbed Resident 2's arm and yanked [their] arm and [Resident 1] fell to [their] left side. Staff F said Resident 1 was not removed from the area because they needed the resident to settle down before they would be able to provide care. On [DATE] at 4:02 PM, Staff H, said the usual behaviors for Resident 1 were to yell, use vulgar language and grab onto people. Staff H said usual behaviors for Resident 2 depended on if Resident 2 seemed under the influence of alcohol, they would not listen to staff, would be loud and mean. Staff H said Resident 2 continued interfering with care they were providing Resident 1, and did not respond to verbal direction from staff. Resident 2 kept saying things to Resident 1 on the night of the incident and Resident 1 was swearing back. Staff H said they were charting at the nurses' station when the accident occurred. Staff H said the time frame of the interaction was approximately 15 minutes. Staff H said Resident 1 was not removed from the area because they were a fall risk. On [DATE] at 4:29 PM, Staff G, said usual behaviors for Resident 1 would fluctuate depending on the day, some days Resident 1 would grab your hand and kiss it and other days Resident 1 would grab you and try to bite you, and the day of the incident, [DATE], Resident 1 was being aggressive. Staff G said Resident 2 could be aggressive towards staff. Staff G said Resident 2 returned to the facility after 8:00 PM that evening and told them Resident 1 needed help with their pants, Staff G and H were behind the nurses' station charting at the time, they instructed Resident 2 to leave the area, but Resident 2 did not listen, staff assisted Resident 1 with pulling up his pants and then returned to charting. Staff H stated, [Staff F] and I came to the area and all four nursing assistants were behind the nurses' station at the time of the accident. When asked how long the whole interaction took place, Staff G replied, Maybe 10-15 minutes. Staff G said Resident 1 was not moved from the area because they were a fall risk. On [DATE] at 5:00 PM, Staff J, Licensed Practical Nurse, (LPN) said Resident 1's usual behavior would be to grab onto people if they were close. Resident 2's behaviors were usually dependent on whether they were intoxicated, and Resident 2would yell and be confrontational. Staff J said he was not in the immediate area at the time of the altercation. Staff J said the staff's first response in a resident-to-resident altercation would be to get the residents out of immediate danger. Staff J said Resident 1 was not moved because they were a fall risk. On [DATE] at 7:01 PM, Staff I, said usual behaviors for Resident 1 were agitation and yelling. Staff I said usual behaviors for Resident 2 appeared when they seemed to be under the influence and Resident 2 would then argue with people, have slurred speech and impaired walking. Staff I said Resident 2 was physically and verbally interfering with them while they were trying to provide care to Resident 1 and Resident 2 did not respond to verbal direction of staff. Staff I said the interaction lasted not more than 10-15 minutes. When asked why Resident 1 was not moved from the area, Staff I said it was their first day assigned to this resident and the other staff said it was better to let Resident 1 calm down before trying to lay the resident down. On [DATE] at 1:38 PM, Staff E, Social Services Director (SSD), said the usual behaviors for Resident 1 was attempting to grab onto staff and cussing. Staff E said the usual behaviors for Resident 2 were aggressiveness towards staff and alcohol related behaviors. Staff E said during a resident-to-resident altercation staff should remove the threat and make sure everyone was safe. On [DATE] at 9:20 AM, Staff C, LPN, Unit Manager, said during a resident-to-resident altercation she would expect staff to separate the residents and make sure everyone was safe. She did not know why staff did not remove Resident 1 from the area at the time of the altercation. On [DATE] at 12:13 PM, Staff B, Registered Nurse (RN), Director of Nursing (DNS) said Resident 1's usual behavior could fluctuate, but Resident 1 would try to hold onto staff and could get agitated and verbally cuss. Staff B said Resident 2's behaviors would be verbal aggression and frequent intoxication. Staff B said these behaviors had been Resident 2's baseline behaviors as long as they had been at the facility. Staff B said during a resident-to-resident altercation the first action would be resident safety and separating the two residents to make sure they were safe. When asked why staff had not removed Resident 1 from the area Staff B stated, I cannot say for sure, but two of them [staff] said they felt they needed to keep [Resident 1] in an open space to watch [them]. When asked if they would have expected staff to remove Resident 1 from the area, Staff B said if it was safe to do so it was expected that staff would remove residents from the setting. On [DATE] at 11:31 AM, Staff A, Executive Director said during a resident-to-resident altercation they would expect staff to separate the residents and keep them both safe. Staff A did not know why staff did not separate Resident 1 and Resident 2. Staff A said they would have expected them to do so, But that did not happen. 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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, and record review, the facility failed to ensure professional standards of nursing practice were provided ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, and record review, the facility failed to ensure professional standards of nursing practice were provided when medications were not given as ordered for 1 of 4 sampled residents (Resident 2) reviewed for quality of care. The facility's failure had the potential to cause adverse side effects, declining mental and physical health, and decreased quality of life. Findings included . Resident 2 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact, displayed verbal behaviors that significantly interfered with resident care and put others at risk for injury, was intrusive to others and significantly disrupted the living environment. Resident 2 was independent for all activities of daily living and used no assistive devices. The MDS also documented the resident was medically complex with diagnoses including alcohol dependence, major depressive disorder, anxiety, and auditory hallucinations and was receiving antipsychotic and antidepressant medication. The MDS documented that a GDR (Gradual dose reduction) had been attempted in 2021 and was documented by a physician to be clinically contraindicated. Review of Resident 2's November 2023 Medication Administration Record (MAR) documented 16 occasions that the resident did not receive AM medications and 4 occasions where the resident did not receive PM medication due to being absent from the facility without medications. Review of Resident 2's October 2023 MAR documented 14 occasions where the resident did not receive AM medications and 11 occasions where the resident did not receive PM medication due to being absent from the facility without medications. Review of Resident 2's September 2023 MAR documented 22 occasions where the resident did not receive AM medications and 14 occasions where the resident did not receive PM medication due to being absent from the facility without medications. Review of Resident 2's August 2023 MAR documented 14 occasions where the resident did not receive AM medications and 12 occasions where the resident did not receive PM medication due to being absent from the facility without medications. On 11/20/2023 at 4:28 PM, Resident 2 said they usually left the facility about 5:30 AM and returned after 8:00 PM in the evening on most days. Resident 2 said they usually received their AM medications from the night nurse and received their PM medications from the nurse when they got back, except on the weekends when Resident 2 said they were never given their medications and did not feel comfortable asking Staff K for them. Resident 2 said they would get their medications from Staff J if they were working. Resident 2 said they reported to Staff A and B their concerns regarding Staff K and was told someone else would administer the medications. On 12/11/2023 at 4:28 PM, Staff J, Licensed Practical Nurse (LPN), said when Resident 2 left the facility in the morning they only gave Resident 2 their morning medications and if medications were repeated later in the day, Staff J did not give those. Staff J said they were not aware of how many times the resident did not receive their ordered medications and said Resident 2 was independent and able to make decisions and would sometimes refuse medications. When asked if a resident did not receive the ordered antipsychotic and antidepressant medication on a frequent basis, could that have a negative effect on their well-being, Staff J said it was possible. On 12/13/2023 at 12:38 PM, Staff K, LPN, said Resident 2 was frequently not at the facility when they worked, and could not give medications to Resident 2 if they were not present. Staff K said some medications were given to the resident prior to them getting there by the night shift nurse. Staff K reported Resident 2 was not happy with them because the resident had requested for Staff K to leave the medication at bedside for them to take at their leisure and Staff K would not do that and as a result, Staff K was not allowed to go into Resident 2's room and Resident 2 was to request when they their medication. When asked if there was a process to package the medication for the resident to take away from the facility with them, Staff K said they were not sure. Staff K said they verbally told Provider A, Physician's Assistant (PA), that the resident frequently missed their medications. Staff K said if the resident was not receiving their antipsychotic and antidepressant medications on a regular basis it would have a negative impact on their behaviors. On 12/14/2023 at 12:13 PM, Staff B said if a resident was absent from the facility, the nurse should administer the medications that were due and could send additional medications with the resident that were due later. Staff B said the provider would be notified depending on the medication and frequency of missed medications. Staff B said the provider was aware of Resident 2 missing medications and that they had attempted to have a care conference with Resident 2 to discuss the concern, but Resident 2 did not participate. Staff B was asked to provide documentation that a Provider was notified of the missed medications. On 12/14/2023 at 12:50 PM, Provider A said they were aware Resident 2 was frequently absent from the facility during the day and their primary need for skilled services was medication management. Provider A said staff would let them know if a resident was missing their medications. When the MARs for August through November were reviewed with Provider A, Provider A indicated they were not aware of the frequency that the medications were not administered. Provider A said they did not necessarily think the number of omissions would have a negative impact, stating, all medications are not equal. When asked specifically if the resident missed their antidepressant and antipsychotic medication with these frequencies could it have a negative impact on their mental health and well-being, Provider A decline to answer as they said they did not have the knowledge of those medications and deferred to Provider B, PA, Mental Health Provider. On 12/14/2023 at 10:02 AM, Resident 2 said they would usually miss their day medications about three days a week, sometimes three days in a row. Resident 2 said they did not think they missed her evening medications as frequently. Resident 2 did feel it had a negative impact on them; sometimes they felt physically sick, and could tell their anxiety was going up and down and their emotional state would be erratic. I would cry one minute and laugh the next, I felt like I was on a roller coaster. On 12/15/2023 at 11:31 AM, Staff A said a provider should be notified if a resident was frequently missing their medications, specifically regarding Resident 2, Staff A said, [Resident 2] knew what they were taking, and they have to have some accountability. When asked if missing the antipsychotic and antidepressant at the frequency it was documented as not administer on the MAR for August 2023 to November 2023 would have a negative impact on Resident 2's mental health and well-being, Staff A replied, No, not her. As of 12/20/2023 the facility had not provided documentation a provider was made aware of the frequency that Resident 2 did not receive physician ordered medications. On 12/20/2023, Provider B said they would expect to be notified if a resident was not receiving their ordered antipsychotic and antidepressant. Provider B said they were not made aware of Resident 2 missing their medications. When asked if this would have a negative effect on Resident 2's mental health and well-being, Provider B replied, Absolutely! See F 689, See F 745 Reference WAC 388-97-1620 (2)(b)(i)(ii)(6)(b)(i) .

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 F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to provide medically related social services to attain or maintain th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident 2) reviewed for behavioral health services. The facility's failure to identify, communicate, and attempt to determine the reasons behind resident's nonadherence to recommendations precluded them from developing and implementing resident specific interventions to mitigate causative factors and increase acceptance of care. This failure placed residents at risk of having unmet social service needs and a diminished quality of life. Findings included . Review of facility policy titled, Management of Psychosocial Issues, revised 06/2023, documented the facility strived to assist residents in the management of psychosocial issues. A care plan would be developed, and effectiveness of interventions would be evaluated. The resident would be included in the development of the care plan, assessed for mood problems and potential to harm self. Interventions would include continued assessments to determine reasons and triggers of difficult behaviors. The social worker or other appropriate team member (i.e., psychologist: a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) would be requested to meet with the resident. Resident 2 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS/an assessment tool), dated 07/14/2023, documented the resident was cognitively intact, displayed verbal behaviors that significantly interfered with residents' care and put others at risk for injury, was intrusive to others and significantly disrupted the living environment. Resident 2 was independent for all activities of daily living and used no assistive devices. The MDS also documented the resident was medically complex with diagnoses including alcohol dependence, major depressive disorder, anxiety, and auditory hallucinations and was receiving antipsychotic and antidepressant medication. The MDS documented that a GDR (Gradual dose reduction) had been attempted in 2021 and was documented by a physician to be clinically contraindicated. The care plan for behavioral problems related to alcohol abuse, insomnia, anxiety, and auditory hallucinations, initiated on 02/12/2021, documented interventions included the resident had reported they were drinking alcohol at times, mostly in the evening and the resident may experience elevated mood/behaviors towards others, staff were to discuss behavior and explain why behavior was inappropriate. The care plan for history of verbally abusive behaviors, initiated on 01/22/2021, included interventions to refer to a psychiatrist as needed. The care plan for depression, initiated on 01/16/2020, included interventions of administering medications as ordered and monitoring, documenting, and reporting to provider signs and symptoms of depression, anxiety, verbal/negative statements etc. The care plan for the use of antipsychotic medication, initiated on 01/22/2021, included interventions to monitor for drug related cognitive/behavior impairment. The care plan for psychosocial well-being related to dependent behavior, medications, demanding verbal behaviors, increased aggressive behaviors included to seek assistance from staff including social services but did not include a referral to a psychologist or mental health provider. Review of Resident 2's Electronic Health Record showed the resident was last seen by a mental health provider on 07/25/2023. A mood and behavior note, dated 08/13/2023 at 2:53 PM, documented the resident refused medications at scheduled times and medications were administered later. A social service note, dated 08/21/2023 at 7:43 AM, documented mental health services had been requested. A mood and behavior note, dated 10/19/2023 at 4:25 AM, documented Resident 2 was observed appearing under the influence of alcohol or some other drug throughout the night. A mood and behavior note, dated 11/08/2023 at 9:11 PM, documented Resident 2 appeared to be drunk and was being belligerent during and after medication administration. An incident note, dated 11/15/2023 at 12:03 PM, by Staff B, documented events from the previous evening (11/14/2023), including that Resident 2 appeared per staff to be intoxicated, was verbally abusive to staff, ignored staff directions and persisted in initiating contact with another resident and was observed instructing them to grab on this, bite on this while holding their arm out to Resident 1. Resident 1 grabbed onto her arm Resident 2's arm and Resident 1's wheelchair turned over on its side and the Resident head struck the floor. A social service note, dated 11/17/2023 at 8:50 AM, documented mental health services were requested. On 11/20/2023 at 4:28 PM, Resident 2 said they had not been seen by a mental health provider very often, that their roommate had passed away about a month prior and they had not been offered any counseling. Resident 2 said the facility had lowered their antipsychotic medication without discussing it with them and when Resident 2 reported their concern to staff, they said they would have to talk to the provider and when Resident 2 talked to Provider A, they instructed Resident 2 to address it with Provider B. Resident 2 reported they could not recall the last time they had seen Provider B. Resident 2 said they would have preferred to be able to see a mental health provider monthly. On 11/21/2023 at 4:34 PM, Collateral Contact 1 said they did not feel the facility was providing for Resident 2's mental health needs and had not offered counseling after Resident 2's roommate passed away or in response to the resident-to-resident altercation that occurred on 11/14/2023. An alert note, dated 11/23/2023 at 11:55 PM, documented Resident 2 was observed by staff showing signs of incapacitation, by wobbling while walking, slurred speech and an odor of alcohol. A social service note, dated 11/27/2023 at 3:16 PM, documented Resident 2 was not able to be seen by the mental health provider due to the resident's absence from the facility. On 12/13/2023 at 1:38 PM, Staff E, Social Services Director (SSD), said residents were referred to mental health providers on admission if there were concerns or as concerns arose. Staff E said residents who were already receiving mental health services were usually seen every three months and as situations arose, such as escalating behavior, unless they were already being monitored closely. Staff E said they would refer residents to mental health services following a roommate passing if the resident reached out and felt they needed it said they would check on them. Staff E believed Resident 2 was referred to mental health services following the death of their roommate since sthey was struggling but also wanted to be away from the facility more. Staff E said they believed there was a lapse in mental health providers coming to the facility from May through September 2023. Staff E said Resident 2 was verbally aggressive and had alcoholic behaviors at baseline, as well as refusal of care. Staff E said they were aware staff reported Resident 2 was returning to the facility appearing intoxicated, but they had been that way since they came to the facility. Staff E confirmed the last time Resident 2 was seen by a mental health provider was 07/25/2023. Staff E felt this was enough oversite for Resident 2's mental health needs stating that, [Resident 2] did not need to be seen more frequently, because [Resident 2] did not want to talk to the providers and was not going to benefit from it because [Resident 2] was gone from the facility a lot. Staff E said the resident usually left prior to 6:00 AM and did not return until after 8:00 PM. On 12/14/2023 at 10:02 AM, Resident 2 said they had not seen a mental health provider in at least four months, and felt relief after the visits and said it felt like their, mental health was being cared for and it gave me someone to talk to, but the visits just stopped. Resident 2 felt like the facility was able to meet their needs, to a point but they were not able to be consistently seen by someone to talk things through, and Resident 2 reported that a recent medication them feel down and unmotivated and then Resident 2 never saw them again. Resident 2 also felt that their antipsychotic medication should not have been lowered without their being seen by the mental health provider. On 12/14/2023 at 12:13 PM, Staff B, Registered Nurse, Director of Nursing, said they were aware staff were reporting Resident 2 had been returning to the facility appearing under the influence and this was baseline for the resident. Staff B said they were not aware when Resident 2 had last been seen by a mental health provider, but the last mental health visit was not able to be provided because Resident 2 was not at the facility. Staff B said for the prior few months Resident 2 would leave daily prior to 8:00 AM and return after 6:00 PM. On 12/14/2023 at 12:50 PM, Provider A, Physician's Assistant, said they were not aware staff were reporting Resident 2 was returning to the facility appearing intoxicated. Provider A was aware the resident was gone from the facility a considerable amount of time and said it had impacted their ability to see Resident 2, but she was not sure how long this had been occurring. Provider A said mental health services were offered to Resident 2 and confirmed they were last seen by a mental health provider in July of 2023. Provider A said they were not aware of any gap in provision of mental health providers to the facility. Provider A was not involved in the GDR Process and that would have been handled by the mental health provider. On 12/15/2023 at 11:31 AM, Staff A said they were aware staff were reporting Resident 2 was returning to the facility appearing under the influence, but they had not seen an escalation in the behavior. Staff A reported that since about mid-Summer, Resident 2 had been leaving the facility at approximately 5-6 AM and returning about 8:00 PM. Staff A said Resident 2 had not received mental health services because Resident 2 refused. On 12/20/2023 at 10:38 AM, Provider B, Physician's Assistant, Mental Health Provider, said they typically saw residents every month unless they were doing well, then every three months. Provider B said they would be at the facility weekly or more and facility staff would let Provider B know which residents needed to be seen, they usually received a list from Staff E, but there would not necessarily be information regarding what the concerns were. Provider B said they would expect to be notified if a resident was returning to the facility appearing intoxicated on a regular basis. Provider B would expect to be notified of a GDR for an antipsychotic medication. Specifically, regarding Resident 2, Provider B confirmed the last time they saw Resident 2 was in July of 2023 and Provider B recalled they tried and failed a reduction of the antipsychotic and would not have recommended it be attempted again. Provider B said it was difficult to see the resident regularly due to their absences from the facility. See also F-689 Reference WAC 388-97-0960 (1) .

Dec 2023 2 deficiencies 1 Harm

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to identify, assess, and monitor a pressure ulcer (PU - an injury to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to identify, assess, and monitor a pressure ulcer (PU - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and to implement orders timely to prevent the PU from deterioration and infection for 1 of 3 sampled residents (1), reviewed for PUs. Resident 1 experienced harm when the facility did not identify, monitor, or implement orders to care for a PU resulting in the resident developing septic shock (a potentially fatal condition when organs fail as a result of an infection) and a Stage 3 PU (full thickness loss of skin exposing subcutaneous tissue). This failure placed residents at risk for wound infection, delayed healing, increased pain, and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including a stroke and heart failure. The Minimum Data Set (MDS ), an assessment tool, dated 10/12/2023, documented Resident 1 had severe cognitive impairment and was dependent on staff for activities of daily living . The hospital wound notes for Resident 1, dated 09/25/2023, (prior to admission to the facility), documented Resident 1 had impaired skin on the buttocks due to friction and incontinence associated dermatitis and there was scattered breakdown of the skin but that it was in a stage of healing and there were no signs of infection. Resident 1's admission Evaluation - Skin Integrity notes, dated 10/06/2023, documented Resident 1 had a small skin tear on their buttocks with a dressing that was clean, dry, and intact. Resident 1's Total Body Skin Evaluation, dated 10/06/2023, documented Resident 1's right buttock had a small skin tear and the dressing was clean, dry, and intact. Resident 1's nursing progress notes, dated 10/06/2023, documented Resident 1 had a small skin tear to the buttock with the dressing clean, dry, and intact. Resident 1's provider visit notes, dated 10/09/2023, documented Resident 1's skin was intact with no lesions. No orders were provided for skin integrity concerns. The facility admission History and Physical, dated 10/13/2023, documented Resident 1's skin had no rashes or lesions and Resident 1's skin was warm and dry. The Wound Clinic notes, dated 10/12/2023, documented Resident 1 had an unstageable PU to the buttock. The wound measured 10 centimeters (cm) x 9 cm x 0.2 cm. The wound had heavy, bright red drainage. A picture of the wound showed black tissue covering Resident 1's buttock with some of the underlying tissue visible. The tissue appeared bright red and raw with some additional black tissue. The notes document the resident was receiving daily dressing changes and the wound clinic provided the following orders: - Cleanse the wound with cleanser and pat dry with gauze. Apply oil emulsion gauze to the wound bed, followed by alginate (used for wounds with heavy drainage). - Cover with foam with silicone bordered dressing, change three times weekly and as needed. Use bordered gauze between scheduled dressing changes and PRN (as needed) for soiled or loose dressing. - Note: The wound clinic will change dressings once weekly and the facility staff nurse is to change twice weekly. These wound care orders recommended by the Wound Clinic on 10/12/2023 were never transcribed onto the treatment record or implemented . Resident 1's care plan, dated 10/16/2023, documented Resident 1 was admitted with an unstageable pressure ulcer. This timeline of being admitted with an unstageable pressure ulcer was inconsistent with Resident 1's admission Evaluation, Total Body Skin Evaluation, initial progress notes, and initial Provider Visit notes as referenced above. It was not clear upon record review if the resident had no skin impairment, a small skin tear to the right buttock, or an unstageable pressure ulcer. Resident 1's care plan, dated 10/16/2023, documented interventions for staff to assess, monitor, and document on the status of the PU, including for nursing to monitor the dressing daily and turn, reposition, and support the resident's heels with pillows. Interventions also included family would be informed of any new areas of skin breakdown. Physician orders for Resident 1, dated 10/16/2023, documented staff would cleanse the wound with wound cleanser, pat dry, apply impregnated gauze (gauze with the oil in it) to the wound bed, followed by alginate and to cover with silicone-bordered dressing. The order was transcribed and initiated on 10/17/2023. This was the only dressing change documented during the resident's stay. Provider notes for Resident 1, dated 10/19/2023, documented Resident 1 developed a fever, high pulse, and low blood pressure. Resident 1's skin was documented as having no visible lesions, no rash and the resident required transportation to the hospital for further evaluation. Progress notes for Resident 1, dated 10/19/2023, documented Resident 1 was found unresponsive with fast, shallow breathing and staff were unable to arouse the resident. The resident was sent to the hospital. A Change in Condition Evaluation for Resident 1, dated 10/19/2023, documented Resident 1 would be transporting to the hospital for a change in vital signs and altered mental status. The document had no notations regarding Resident 1's PU. On 11/17/2023 at 3:26 PM, Resident 1's family member and Collateral Contact 1 (CC1) said they had concerns with the care of the resident's skin. CC1 said Resident 1 had some skin concerns in the past but understood the skin had improved prior to admission to the hospital. During the resident's stay at the facility, CC1 said they had noted concerns with repositioning and bathing. CC1 said they had voiced their concerns and had not noted any changes in care. CC1 said facility staff had not reported concerns about Resident 1's skin during this time. CC1 said on 10/19/2023, they went to visit Resident 1 and found them lethargic and ill appearing. CC1 said they were very concerned about what was going on because they had not been notified. CC1 said they were Resident 1's Power of Attorney (POA). CC1 said Resident 1 was sent to the hospital and as they rolled the resident off the stretcher, they saw a large wound on the resident's buttock. CC1 said Resident 1's buttock wound was black. CC1 said they did not feel the wound was cared for properly and Resident 1 required immediate surgery to address the infection in the wound. CC cried as they described the pain and procedures Resident 1 required. CC1 said Resident 1 eventually passed away from the infection in the PU. The hospital History and Physical, dated 10/19/2023, documented Resident 1 had been found by CC1 appearing ill when she saw him at the facility. Upon arrival to the hospital, the resident was found to be in severe septic shock due to the large PU on their buttock and documented, this appears to be the source of infection and shock. The surgical notes, dated 10/25/2023, documented Resident 1 required surgical interventions to remove necrotic skin on the wound. On 12/04/2023 at 2:40 PM, Staff E, Certified Nursing Assistant, said residents at risk for PUs should be turned frequently and provided good hygiene. Staff E said they usually could get residents turned as they needed to, unless they were short staffed. Staff E said this happened more than it should. Staff E said if she found a wound on a resident, she would report it to the nurse in charge. Staff E said she had gone above the nurse's head on some occasions because the nurse did not respond to the reported skin concerns. At 2:48 PM, Staff D, Resident Care Manager and Licensed Practical Nurse (LPN), said staff should assess a resident's skin upon admission and document any concerns. Any concerns should be reported to Staff B, Director of Nursing Services and Registered Nurse. The nurse should obtain orders to care for the resident's wound and develop care plan interventions. Wounds should be monitored weekly by nursing and the wound clinic. If a resident developed a wound after admission, the staff should follow the same process. Staff B said the electronic medical record cued the nursing staff to do each of the tasks. At 3:03 PM, Staff B said staff should assess a resident's skin upon admission or when there was a change in the condition of the skin. The staff should document the wound characteristics and monitor weekly. The wound clinic assessed wounds weekly. The care plan should reflect the interventions needed to treat the PU. Staff B said she recalled Resident 1 had a PU prior to admission and was not aware of concerns. Upon review of Resident 1's record, Staff B said nursing staff did not identify or documented the presence of a PU on Resident 1's buttock. Staff B said nursing staff were required to assess the wound. Staff B said the record did not include measurements or characteristics of Resident 1's PU. Staff B said the wound clinic gave orders for caring for Resident 1's PU, which were not implemented until 10/16/2023. Staff B said the record did not show documentation the POA was notified of the status of the resident's skin or of the change in the resident's condition. The record did not show the transporting hospital was notified of the presence of a PU on 10/19/2023. At 3:29 PM, Staff A, Administrator, said she was not aware of concerns with Resident 1's care and would need to review the record. Reivew of an email communication on 12/06/2023 at 11:56 AM, Staff A documented Resident 1 was sent to the facility without wound care orders. Staff A documented, the facility did fail in classifying the wound the same as the hospital and was not seen by wound care until six days after admission. Staff A documented, the nursing unit was slow in delivery of care. 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a change in cond...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 3 sampled residents (1) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke. The Minimum Data Set (MDS), dated [DATE], documented Resident 1 had severe cognitive impairment and was dependent on staff for activities of daily living. The care plan for Resident 1, dated 10/16/2023, documented Resident 1's family would be informed of any new areas of skin breakdown. Progress notes for Resident 1, dated 10/10/2023, documented Resident 1 had an an episode of vomiting during therapy, the resident had appeared lethargic and a anti-nausea medication was ordered. The record did not contain documentation of notification of POA. The Wound Clinic notes, dated 10/12/2023, documented Resident 1 had an unstageable PU to the buttock which measured 10 centimeter (cm) x 9 cm x 0.2 cm. The wound had heavy, bright red drainage. The record did not show the POA was notified. Care conference notes, dated 10/13/2023, documented the POA was not active but the resident had expressed wishes to have his family member/Collateral Contact (CC) 1 be their POA. On 11/17/2023 at 3:26 PM, CC 1 said Resident 1 haddevelop a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) and had a significant change in condition requiring hospitalization and that they were not notified of these changes. CC 1 said they were very involved in the resident's care and it was clear they were to be notified. On 12/04/2023 a 3:03 PM, Staff B, Director of Nursing Services and Registered Nurse, said POAs should be notified with any change of condition. Staff B said the record did not show documentation the POA was notified of the status of the resident's skin or of the change in the resident's condition. At 3:29 PM, Staff A, Administrator, said POAs should be notified of a change in condition. Reference WAC 388-97-0320 .

Aug 2023 18 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview, the facility failed to ensure residents dependent on staff for eating assistance were offe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview, the facility failed to ensure residents dependent on staff for eating assistance were offered dining assistance in a timely manner for 6 of 10 sampled residents (1, 8, 30, 33, 42 & 127) reviewed for resident rights related to dining services. This failure placed residents at risk for excessive wait times, cold food and a diminished quality of life. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/05/2023, showed Resident 1 was totally dependent on staff for eating assistance. On 08/22/2023 at 5:19 PM, Resident 1 was observed sitting at a table waiting for assistance to eat his meal. The meal tray was on the table in front of Resident 1. At 5:27 PM, Resident 1 was still waiting for assistance with his meal tray in front of him. At 5:34 PM, Staff I, Certified Nursing Assistant (CNA)/Medical Records, was observed starting to assist Resident 1 with his meal. The observed wait time was 15 minutes although it was unknown how long Resident 1 had been waiting prior to the beginning of the observation at 5:19 PM. 2) Resident 8 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], showed Resident 8 required one person assistance from staff with eating. On 08/21/2023 at 11:56 AM, Resident 8 was observed sitting in the dining room at a table, waiting for her meal. At 12:04 PM, Staff M, CNA, said Resident 8's lunch tray was on the hall cart and they were waiting for it. Staff M said Resident 8 liked to come early. Other residents, who had entered the dining room after Resident 8, were observed with their trays and were eating. At 12:13 PM, Resident 8's lunch tray was observed being delivered. The observed wait time was 17 minutes although it was unknown how long Resident 8 had been waiting prior to the beginning of the observation. 3) Resident 30 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], showed Resident 30 required one person assistance from staff for eating. On 08/21/2023 at 11:56 AM, Resident 30 was observed to have her lunch tray placed in front of her. When Resident 30 reached for her meal, Staff N, CNA, pushed the tray to the other side of the table, out of Resident 30's reach then left the dining room. At 12:00 PM, Staff N was observed returning with a gown to use as a clothing protector for Resident 30, applied it then left again. The meal tray continued to be on the table across from Resident 30, out of her reach. At 12:04 PM, Resident 30 was given her meal tray and was observed to be able to consume her meal after setup from staff. 4) Resident 33 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 33 required one person assistance from staff for eating. On 08/21/2023 at 11:56 AM, Resident 33 was observed waiting for meal assistance with his lunch tray on the table in front of him. There were two staff assisting residents to eat in the dining room. At 12:14 PM, a third staff was observed beginning to assist residents to eat but Resident 33 remained waiting. At 12:22 PM, Resident 33 was observed being provided eating assistance. The observed wait time was 26 minutes although it was unknown how long Resident 33 had been waiting prior to the beginning of the observation. 5) Resident 42 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 1 required one person assistance from staff for eating. On 08/21/2023 at 11:56 AM, Resident 42 was observed waiting for eating assistance with her lunch tray on the table in front of her. At 12:14 PM, Resident 42 was observed being provided eating assistance by staff. The observed wait time was 18 minutes although it was unknown how long Resident 42 had been waiting prior to the beginning of the observation. On 08/22/2023 at 5:19 PM, Resident 42 was observed sitting in the dining room waiting for assistance to eat her dinner. The meal tray was in front of her. At 5:29 PM, Staff J, CNA, said she was going to warm up Resident 42's food before feeding her as it had sat a long time and left with the meal tray. At 5:34 PM, Staff J was observed returning with warmed up food and starting to assist Resident 42. The observed wait time was 15 minutes although it was unknown how long Resident 42 had been waiting prior to the beginning of the observation. 6) Resident 127 was admitted to the facility on [DATE]. The admission MDS had not been completed. On 08/22/2023 at 5:19 PM, Resident 127 was observed sitting in the dining room with his dinner tray in front of him. At 5:25 PM, Resident 127 was observed to not have assistance or redirection to eat. Resident 127 picked at the meal but was unable to independently eat and was observed pushing back from the table in his wheelchair. At 5:29 PM, Resident 127 was observed sitting in the middle of the dining room. Staff I was the only staff in the dining room to assist all the residents who required assistance with eating. When asked about Resident 127 not eating more than a few bites, Staff I said Resident 127 was a supervise only. At 5:35 PM, Resident 127 was observed to be asleep. At 5:37 PM, Staff I was observed waking up Resident 127 to move him out of the way, pushed him farther back from the table and did not redirect him to eat. Staff were moving out residents who had finished the meal. On 08/21/2023 at 12:22 PM, Staff H, CNA, and Staff M, CNA, said about 10-12 residents ate in the dining room at a time and there was usually 3-4 staff to assist. Staff H said all the residents got fed, some just had to wait because they did one resident at a time. On 08/21/2023, during the lunch meal in the main dining room, there were two staff providing eating assistance until 12:14 PM when a third staff came to assist. On 08/22/2023, during the dinner meal in the main dining room, there was one staff providing eating assistance until 5:34 PM when a second staff came to assist. On 08/22/2023 at 6:25 PM, Staff B, Director of Nursing Services and Registered Nurse, said typically residents were transferred to the dining room about 10 minutes prior to trays coming out. Staff B said CNAs were assigned to the dining room to help with feeding residents. Staff B said the expectation was to immediately pass out meal trays and residents should not wait more than 10 minutes with tray in front of them before being provided eating assistance. Reference WAC 388-97-0180 (1-4) .

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 1 of 5 sampled residents (Resident 58) reviewed for right to be informed about treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life. Findings included . Resident 58 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated 05/21/2023, documented Resident 58 was cognitively intact. A physician's order, dated 05/18/2023, documented Resident 58 was prescribed Citalopram (an antidepressant). Resident 58's Electronic Health Record (EHR) did not show documentation of a consent from the resident or the resident's representative for the administration of citalopram. On 08/24/2023 at 11:09 AM, Staff D, Resident Care Manager and Registered Nurse (RN), said all psychotropic medication required an order form the physician and a consent from the resident or resident representative. Staff D said there should have been a consent obtained. At 11:57 AM, Staff B, Director of Nursing Services and RN, said she expected all staff to obtain an order and a consent prior to the administration of any psychotropic medication. Staff B said the consent should have been obtained prior to administration of the medication. Reference WAC 388-97-0260 (1)-(3) .

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 F0572 (Tag F0572)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a newly admitted resident was informed of their rights and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a newly admitted resident was informed of their rights and responsibilities as a resident in the facility for 1 of 1 sampled residents (126) reviewed for notice of rights and rules. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life. Findings included . Resident 126 was admitted to the facility on [DATE]. The Discharge Return Anticipated Minimum Data Set, an assessment tool, dated 08/09/2023, documented the resident's short-term and long-term memory was OK. The complaint intake, dated 07/24/2023 at 4:58 PM, showed Resident 126 was concerned she did not receive an admission packet when she was admitted to the facility. Resident 126's Electronic Medical Record (EMR) did not show documentation of either a verbal or written discussion of resident rights and responsibilities. A signed acknowledgements of rights and responsibilities was not located in Resident 126's EMR. On 08/24/2023 at 2:57 PM, Staff B, Director of Nursing Services and Registered Nurse, said she expected new residents to be informed of their resident rights via the admission packet. After reviewing Resident 126's EMR, Staff B said she could not locate an admission packet in the resident's EMR. On 08/25/2023 at 9:32 AM, Staff A, Administrator, said the rules of the facility were explained verbally to new-admission residents. Staff A said resident rights information was contained in the admission packet, and social services would also inform residents of their rights if the resident were to ask them. Staff A was unable to provide documentation of a signed acknowledgments of the Resident 126 receiving resident rights and/or responsibilities. Staff A stated, We missed a few along the way, and we found our error. Reference WAC 388-97-0300 (1)(a)(7)(b) .

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents' medical information was maintained...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the electronic health records (EHR) for 1 of 1 sampled residents (Resident 37) reviewed for privacy and confidentiality. This failure placed residents at risk of having their medical information not kept confidential and a diminished quality of life. Findings included . Resident 37 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 05/25/2023, showed Resident 51 was cognitively intact. On 08/24/2023 at 11:16 AM to 11:24 AM, a laptop on top of a medication cart was left open, unsupervised, unlocked, and the screen revealed private resident information to include Resident 37's name, date of birth , room number, diagnoses, and medications. At 1:06 PM, Staff O, Resident Care Manager and Licensed Practical Nurse, said resident privacy on a laptop should be maintained by pressing the lock icon to hide the screen at any time the staff member left the direct area of the laptop. At 1:46 PM, Staff B, Director of Nursing Services and Registered Nurse, said the staff expectation was they locked the laptop screen whenever they stepped away from the medication cart. Reference WAC 388-97-0360 .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to maintain and provide a safe, sanitary, and homelike...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to maintain and provide a safe, sanitary, and homelike environment for 1 of 3 sampled residents (Resident 4) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life. Findings included . Resident 4 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 07/01/2023, documented Resident 4 was cognitively intact. On 08/21/2023 at 3:31 PM, Resident 4's room was observed to have missing sections of paint and sheet rock, 8 inches long at the head of the bed, a one-inch section of tile missing next to the heating vent on the floor, and a 6-inch hole (missing paint and sheet rock) in the wall with 6 inches of mesh metal netting sticking out of the wall. Resident 4 said the room had been in this condition for a long time. On 08/24/2023 at 10:18 AM, Staff E, Maintenance Director, said he did not complete a daily check of residents' rooms, because he did not have the time. Staff E said he completed his monthly inspection of resident care equipment and if he had seen any concerns, he would address it. When asked about the condition of Resident 4's room, room [ROOM NUMBER]; Staff E said he had just been informed of the concerns by the Fire Marshall the day before. Staff E said the hole in the wall was caused by the resident's wheelchair pedals hitting the wall. At 11:09 AM, Staff D, Resident Care Manager and Registered Nurse (RN), said it was her expectation that staff were assessing the conditions of the residents' rooms daily and reporting any concerns to maintenance. Staff D said staff could either let her know about the concerns or write it in the maintenance logs at any of the nurses' stations. At 11:57 AM, Staff B, Director of Nursing Services and RN, said she expected housekeeping to visually inspect each resident room daily and report any concerns to maintenance. Reference WAC 388-97-0880 (1) .

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints for 1 of 1 sampled residents (127) reviewed for physical restraints. This failure placed residents at risk for injury and a decrease quality of life. Findings included . The facility's policy entitled, Safety Device-Least Restrictive, dated 09/2022, documented, The center will us[sic} a safety device as indicated, to attain or maintain a resident's highest practicable well-being . 5) Complete a Safety Device Data Collection, Assessment, and Information evaluation: a. For each safety device when initiated or, b. For each safety device when State regulation requires a signature for consent. Resident 127 was admitted to the facility on [DATE]. Resident 127 was a new admission and a Minimum Data Set, an assessment tool, had not been completed, and his baseline cognitive status was described as confused. On 08/21/2023 at 2:36 PM, Resident 127's left side of the bed was observed to be up against the wall. The electronic medical records did not show documentation of a signed consent for the bed against the wall. On 08/24/2023 at 3:20 PM, Staff B, Director of Nursing Services and Registered Nurse, said a resident should be assessed, have an order, care planned and have a signed consent to have the bed against the wall. Staff B said she was not able to find a consent for Resident 127's bed against the wall. Reference WAC 388-97-0620 (1)(b) .

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency wit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours and failed to log the incident in the facility's reporting log for 1 of 2 sampled residents (Resident 58) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk for abuse and neglect. Findings included . Resident 58 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 05/21/2023, documented Resident 58 was cognitively intact. On 08/21/2023 at 11:27 AM, Resident 58 said about a month ago an employee of the facility, Staff F, Registered Nurse (RN), attempted to choke me. Resident 58 said he was sitting in his wheelchair while Staff F was providing care to his roommate. Resident 58 said Staff F walked over to him and put his hand around his neck. Resident 58 was observed demonstrating using his own hand to the front of his neck and stated, Went like this. Resident 58 said Staff F did not apply pressure on his throat and then quickly removed his hand. Resident 58 said he told Staff B, Director of Nursing Services and RN, about the incident. Review of the facility's February 2023 through 08/20/2023 Accident and Incident reporting log documented no incident logged for potential abuse of Resident 58. On 08/24/2023 at 11:09 AM, Staff D, Resident Care Manager/RN, said if her staff observed any type of abuse, she expected her staff to deescalate the situation, ensured the resident was safe and then report it immediately. Staff D said staff were expected to report it to herself, the Director of Nursing Services, the Administrator, Social Services, the State hotline, Law Enforcement, the doctor and the family. At 11:57 AM, when asked about the staff being informed of the incident by Resident 58, Staff B stated, Not him directly, but from Staff G, RN. Staff B said Staff G had reported that Resident 58 was having behavioral issues during this time. Staff B said when Resident 58 was questioned about the incident, Resident 58 said Staff F had choked him, but then retracked his statement and reported Staff F was rude to him verbally. When asked about verbal abuse being reportable, Staff B said verbal abuse was abuse and it should have been reported to the hotline. Reference WAC 388-97-0640 (5)(a) .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan addressed weight ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan addressed weight loss for 1 of 1 sampled residents (Resident 20) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 20 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 06/08/2023, documented Resident 20 was cognitively intact. Resident 20's Comprehensive Care Plan, dated 06/02/2023, documented prevent unplanned significant wt. (weight) changes, promote healing through review dates. Monitor weight as indicated. A Physician's order, dated 06/02/2023, ordered Resident 20 to be weighed every Friday on evening shift from 06/02/2023 until 06/30/2023. The Electronic Medical Record (EMR) documented Resident 20 weighed 348 pounds on 06/05/2023. The EMR documented Resident 20 weighed 286 pounds on 06/29/2023. No weights were obtained for the following days: 06/09/2023, 06/16/2023 & 06/23/2023. This resulted in a 62-pound weight loss, equaling a 17.82% weight loss in less than one month. A Nutrition Progress Note, dated 07/04/2023, documented Resident 20 had a significant weight change, more than 5 percent in 30 days. The Comprehensive Care Plan was not updated and showed no interventions for the weight loss. On 08/24/2023 at 11:09 AM, Staff D, Resident Care Manager and Registered Nurse (RN), said weights were completed weekly, unless otherwise specified. Staff D said the computer system does not alert them if there was a significant change in weight. Staff D said she was unaware of any weight changes for Resident 20. At 11:57 AM, Staff B, Director of Nursing Services and RN, said the facility had a Dietitian that came in weekly and reviewed all resident weights and was alerted them to significant weight changes. The Dietitian would reach out to other programs for recommendations. When asked about Resident 20's weight loss, Staff B said Resident 20's weight upon admission was inaccurate. On 08/25/2023 at 8:33 AM, when asked about the Physician's order to obtain weights, Staff D said staff were to obtain Resident 20's weight every Friday evening shift from 06/02/2023 until 06/30/2023. After reviewing the missing weight measurement dates, Staff D said the missing dates for Resident 20 were not acceptable and should have been obtained per the order. Staff D said the care plan should have been updated to address the weight loss. At 8:37 AM, Staff B said the physician's order was for Resident 20's weight to be obtained every Friday, starting 06/02/2023 and ending on 06/30/2023. Staff B said it was standard procedure for the facility to obtain weights upon admission and follow the physician's order. After reviewing the missing weight measurement dates, Staff B said those weights should have been collected on the ordered dates. Staff B said when the weight loss was recognized, there should have been a care plan update. Reference WAC 388-97-1020 (1)(2)(a)(b) .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to obtain weekly weights per provider order and identify a weight lo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to obtain weekly weights per provider order and identify a weight loss for 1 of 1 sampled resident (Resident 20) reviewed for nutrition. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life. Findings included . Resident 20 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury. The admission Minimum Data Set (MDS), an assessment tool, dated 06/08/2023, documented Resident 20 was cognitively intact and received diuretics (medication used to reduce the amount of excess fluid in the body) for the seven days of the look back period. The 5-Day MDS, dated [DATE], showed the resident received diuretics six of the seven days of the look back period. A Physician's order, dated 06/02/2023, ordered Resident 20 be weighed ever Friday, evening shift, from 06/02/2023 until 06/30/2023. Resident 20's Care Plan, dated 06/05/2023, addressed therapeutic nutritional risk related to morbid obesity, lasix (diuretic) treatment and scalp incision. The goals was to prevent unplanned significant weight changes and promote healing. Interventions included monitoring weight as indicated. The Nutritional Assessment, dated 06/05/2023, documented to prevent unplanned significant weight changes through review dates, promote healing, and a gradual weight loss may be beneficial for overall health. The Electronic Medical Record (EMR) documented Resident 20 weighed 348 pounds on 06/05/2023. The EMR documented Resident 20 weighed 286 pounds on 06/29/2023. This resulted in a 62 pound weight loss, 17.82% in 24 days. No weights were obtained for 06/09/2023, 06/16/2023 and 06/23/2023. A Nutrition Progress Note, dated 07/04/2023, documented Resident 20 had a significant weight change, more than 5 percent in 30 days. Following the weight loss, the Care Plan did not show documentation of being updated or interventions for the weight loss. On 08/24/2023 at 11:09 AM, Staff D, Resident Care Manager and Registered Nurse (RN), said weights were completed weekly, unless otherwise specified. Staff D said the computer system does not alert them if there was a significant change in weight. Staff D said she was unaware of any weight changes for Resident 20. At 11:57 AM, Staff B, Director of Nursing Services and RN, said the facility had a Dietitian that came in weekly and reviewed all resident weights and was alerted to significant weight changes. The Dietitian would reach out to other programs for recommendations. On 08/25/2023 at 8:33 AM, after reviewing the Physician's order to obtain weights for Resident 20, Staff D said staff were to obtain Resident 20's weight every Friday, evening shift, from 06/02/2023 until 06/30/2023. After reviewing the missing weight measurement dates, Staff D said the missing dates were not acceptable and should have been obtained per the order. At 8:37 AM, Staff B said the Physician's order was for Resident 20's weight to be obtained every Friday, starting 06/02/2023 and ending 06/30/2023. Staff B said it was standard procedure for the facility to obtain weight upon admission and follow the physician's order. After reviewing the missing weight measurement dates for Resident 20, Staff B said those weights should have been collected on the ordered dates, including the admission weight. Reference WAC 388-97-1060 (3)(h) .

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment, obtain inf...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment, obtain informed consent and care plan for the use of bed rails for 1 of 1 sampled residents (Resident 1) reviewed for restraints. This failure placed residents at risk of entrapment, injury, and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive impairment and required extensive assistance of 2 staff for bed mobility. On 08/21/2023 at 1:10 PM, on 08/22/2023 at 9:46 AM and 1:46 PM, and on 08/23/2023 at 9:22 AM; Resident 1 was observed in bed with the right side of his bed against the wall and the left side rail of the bed in the up position. Record review of Resident 1's Electronic Medical Record (EMR), reviewed 08/22/2023 at 08:41 PM, showed no care planned interventions, no risk assessment, and no consent for the use of the bed rails. The EMR did not include documentation of what alternatives were attempted and failed prior to implementation of the bed rails. On 08/23/2023 at 1:46 PM, Staff B, Director of Nursing Services and Registered Nurse, said bed rails should have a safety and risk assessment prior to use, needed to be care planned, and should have a consent. Staff B said for Resident 1 these steps may not have been completed. Reference WAC 388-97-0230 .

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecti...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects and target behaviors for 1 of 5 sampled residents (Resident 58) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life. Findings included . Resident 58 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 05/21/2023, documented Resident 58 was cognitively intact. A Physician's order, dated 05/18/2023, documented Resident 58 was prescribed Citalopram (an antidepressant). Resident 58's Depression Care Plan, revised 05/30/2023, documented interventions on TARGET BEHAVIOR: Depression/Anxiety - Intervention 1: Engage in conversation, allow him time to talk. Intervention 2: Invite to participate in activities of interest. Intervention 3: Assist him as needed in contacting family. A Physician's order, date 11/11/2022, documented monitoring every shift for antidepressant side effects. Resident 58's August 2023 Treatment Administration Record (TAR) documented the following shifts side effect monitoring was not completed: 08/01/2023: evening shift 08/03/2023: evening shift 08/05/2023: evening shift 08/06/2023: all three shifts 08/07/2023: day shift 08/08/2023: evening shift 08/09/2023: evening shift 08/10/2023: day shift 08/11/2023: day shift 08/14/2023: evening shift 08/15/2023: evening shift 08/17/2023: evening shift 08/19/2023: day shift. Resident 58's Electronic Medical Record did not show documentation of antidepressant medication target behavior monitoring. On 08/24/2023 at 11:09 AM, Staff D, Resident Care Manager and Registered Nurse (RN), said to administer any psychotropic medication the facility must have an order, consent and monitoring for side effects and target behaviors. When asked about Resident 58's target behaviors monitoring, Staff D was unable to locate any monitoring of target behaviors for Resident 58. Staff D said there should be monitoring for target behaviors. After reviewing the missing shifts for Resident 58's side effect monitoring, Staff D said the missing dates were not acceptable and should have been documented. At 11:57 AM, Staff B, Director of Nursing Services and RN, said the mental health provider came in every week and reviewed all residents receiving a psychotropic medication in the facility. Staff B said all psychotropic medications were required to have side effect and target behavior monitoring in place. Staff B said there should have been monitoring for target behaviors for Resident 58. Staff B said the missing entries for Resident 58's side effect monitoring were not acceptable and the expectation was that there are no empty boxes. Reference WAC 388-97-1060 (3)(k)(i) .

CONCERN (E)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 9 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 9 was cognitively int...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 9 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 9 was cognitively intact. Resident 9's EMR documented a transfer to the hospital on [DATE], with a readmission on [DATE]. The EMR did not have documentation the resident or resident's representative was provided a written notice of transfer or the Ombudsman had been notified of the transfer. 3) Resident 20 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 20 was cognitively intact. Resident 20's EMR documented a transferred to an acute care hospital on [DATE], with a readmission on [DATE]. The EMR did not have documentation the resident or resident's representative was provided a written notice of transfer or the Ombudsman had been notified of the transfer. On 08/25/2023 at 8:33 AM, Staff D, RCM and RN, said the resident, nor the Ombudsman, had been provided with a written notice of transfer. At 8:37 AM, Staff B said the residents and the Ombudsman had not been provided with a written notice of transfer and they should have been. Reference WAC 388-97-0120 (2)(a-c) Based on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative and to the Office of the State Long-Term Care Ombudsman describing the reason for transfer for 3 of 3 sampled residents (126, 9 & 20) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 126 was admitted to the facility on [DATE]. The discharge return anticipated Minimum Data Set, an assessment tool, dated 08/09/2023, documented the resident's short-term and long-term memory was OK. Resident 126's Electronic Medical Record (EMR) documented an emergent transfer to an acute-care hospital on [DATE]. Resident 126 returned to the facility on [DATE]. The EMR did not show documentation of a written notice of transfer for Resident 126. On 08/23/2023 at 10:23 AM, Staff C, Registered Nurse (RN), said when residents were transferred to the hospital, facility staff would print the admission record or face sheet and physician's order summary and contact the resident's family. Staff C said the transfer notice given to residents was a Resident Care Manager (RCM) responsibility. On 08/24/2023 at 2:51 PM, Staff B, Director of Nursing Services and RN, said paperwork generated during a resident transfer should include the bed hold and transfer notice, face sheet, order summary, Medication Administration Record (MAR), and Physician Orders for Life Sustaining Treatment (POLST). Staff B said the transfer notice and bed hold were generated specifically to be given to the resident. Staff B said she could not locate Resident 126's transfer notice. Staff B said she was unsure of how the facility ombudsman was made aware of resident transfers out of the facility.

CONCERN (E)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 3 of 3 sampled residents (9, 20 & 126) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 9 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/30/2023, documented Resident 9 was cognitively intact. Resident 9's Electronic Medical Record (EMR) documented a transfer to the hospital on [DATE] with a readmission on [DATE]. The EMR did not show documentation of a bed-hold notice for the transfer. 2) Resident 20 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 20 was cognitively intact. Resident 20's EMR documented Resident 20 transferred to an acute care hospital on [DATE] with a readmission on [DATE]. The EMR did not show documentation of a bed-hold notice for the transfer. On 08/10/2023 at 11:09 AM, Staff D, Resident Care Manager (RCM) and Registered Nurse (RN), said she expected staff to complete bed hold notices when residents were being transferred to the hospital. Staff D said she was unable to locate a behold notice for Resident 20, but to check with the Director of Nursing Services (DNS). At 11:57 AM, Staff B, DNS and RN, said she expected the bed hold policy and all required paperwork to go with the resident when they were transferred to the hospital. Staff B said a bed hold should have been completed for Resident 9 and Resident 20. 3) Resident 126 was admitted to the facility on [DATE]. The discharge return anticipated MDS, dated [DATE], documented the resident's short-term and long-term memory was OK. Resident 126's EMR documented an emergent transfer to an acute-care hospital on [DATE]. Resident 126 returned to the facility on [DATE]. The EMR did not show documentation of a bed hold notice for Resident 126. On 08/23/2023 at 10:23 AM, Staff C, RN, said when residents were transferred, the bed hold given to residents was a RCM responsibility. On 08/24/2023 at 2:51 PM, Staff B said paperwork generated during a resident transfer should include the bed hold. Staff B said the transfer notice and bed hold were generated specifically to be given to the resident. Staff B said she could not locate Resident 126's bed hold notice. Reference WAC 388-97-0120 (4) .

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medication Administration> Resident 51 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated [DAT...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medication Administration> Resident 51 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated [DATE], showed Resident 51 was cognitively intact. The Electronic Medical Record showed Resident 51 was not out of the facility on 07/22/2023, 07/25/2023, and 08/03/2023. The July 2023 and August 2023 Medication Administration Record (MAR) showed days where the provider medication orders were not administered or completed on the following days: --On 07/22/2023 at 6:00 AM to 2:00 PM, Resident 51 was not given ten scheduled medications. --On 07/25/2023 at 11:00 AM, Resident 51 was not given one scheduled medication. --On 08/03/2023 at 2:00 PM -to 7:00 PM, Resident 51 was not given three scheduled medications. The MAR did not show documentation pertaining to the missed administrations. Progress notes did not show documentation in the EMR pertaining to the missed administrations. On 08/24/2023 at 1:06 PM, Staff O, RCM and Licensed Practical Nurse, said all medications and interventions on the MAR should be administered within the time frame stated on the MAR. Staff O said if there was a reason why orders on the MAR could not be followed or completed, the provider should be alerted and it should be documented on the MAR and in a progress note. At 1:46 PM, Staff B said all orders on the MAR should be administered within the given time frames. Staff B said if a medication was not administered it needed to be documented in both a progress note and in the MAR. Reference WAC 388-97-1600 (2)(b)(i)(ii)(6)(b)(i) Based on interview and record review, the facility failed to ensure staff with a medication endorsement were working within their scope of licensure for 4 of 4 Nurse Technicians (Staff L, Q, R & S) and 1 of 1 Certified Nursing Assistant (CNA) (Staff K), failed to ensure medications were passed according to professional standards for 1 of 1 Registered Nurse (Staff B), and failed to ensure provider medication orders were followed for 1 of 5 sampled residents (51) reviewed for services provided meet professional standards regarding medication administration. This failure placed residents at risk for inaccurate assessments, medication errors, and a diminished quality of care. Findings included . <CNA Medication Assistant Scope of Licensure> The Washington State Administrative Code (WAC), state law, chapter 246-841-589 for Certified Nursing Assistant Medication Assistant (C-MA), shows a medication assistant may not perform the following tasks: assessment of a resident need for, or response to medication; administration of any schedule I (drugs with no current accepted medical use and a high potential for abuse), II (narcotics), or III (drugs with low to moderate potential for abuse and less dangerous than schedule I or II) controlled substances; and performance of any task requiring nursing judgment, such as administration of as necessary or as needed (PRN) medications. Review of [NAME] A, [NAME] B and Mid Hall Medication Administration Records, dated August 2023, showed Staff K, C-MA, signed off on skin assessments, monitoring for edema, pain assessments, diabetic foot assessments, dressing changes, and monitoring for side effects of hypnotic, sedative, and antidepressant medications. Staff K documented passing scheduled medications and PRN medications. On 08/21/2023 at 3:55 PM, Staff K said she worked under the supervision of Staff B, Director of Nursing Services and Registered Nurse (RN). Staff K said she could not pass schedule 1-3 narcotics (controlled substance like a narcotic), complete invasive/advanced wound dressing or assess a resident. At 4:56 PM, Staff B said Staff K could not assess residents or pass controlled substances. Staff B said the medication endorsement class instructor sent the policy with Staff K when she returned to the facility which laid out what she can and cannot do. Staff B said Staff K would go to a Resident Care Manager (RCM) for things she could not do like complex wound care. Staff B said she was her direct supervising RN. <Nurse Technician Scope of Licensure> The Revised Code of [NAME] (RCW), state law, chapter 18.79.350 for Nursing technicians-Nursing functions, showed a nurse technician cannot administer schedule drugs. Review of [NAME] A, [NAME] B and Mid Hall Medication Administration Records, dated August 2023, showed all the facility Nurse Technician staff (Staff L, Staff Q, Staff R, and Staff S) were passing scheduled medication consistently for residents throughout the month. On 08/22/2023 at 3:31 PM, Staff B said the Nurse Technician's scope mirrored any skill checked off in the school training program. Staff B said there was an understanding between the facility and the nursing school that the students would not administer controlled substances. Staff B said there was not a facility policy for the scope and requirements around nurse technicians. <Medications Passed in Accordance to Professional Standards> On 08/22/2023 at 8:12 AM, Staff B was observed at a [NAME] Hall medication cart and said she was assisting with narcotic medication administration for Staff K. Two unlabeled medication cups, each with a small white round pill was on the cart next to each other. Staff B crushed one of the pills and added pudding. Staff B said she could not get them mixed up because one was crushed and one is whole. Staff B said she pulled multiple residents at a time when a resident was in pain or she was rushed. Staff B took both cups of pills to give to residents at the same time. At 3:22 PM, Staff A, Administrator, said she knew about the concern regarding multiple resident medications being passed at the same time. Staff A said there were concerns about the scope of practice with Staff K doing assessments outside of her scope.

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** 4) Resident 1 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident had severe cognit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident 1 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident had severe cognitive impairment. The Fall Scene Investigation Report, dated 03/31/2023, indicated, [Resident] was found laying in a supine position (lying on their back with their face and abdomen facing upwards) in dining room . Resident description nonverbal. The facility Neurological Assessment Flowsheet, documented a fall that was unwitnessed required a total of 26 neurological checks performed at varying intervals. The Neurological Assessment Flowsheet was initiated on 03/31/2023, and 8 of the 26 neurological checks were documented as completed. On 08/24/2023 at 1:06 PM, Staff O said a neurological assessment should be completed and documented on the Neurological Assessment Flowsheet if the resident hit their head during the fall or if the resident fall was unwitnessed. Staff O said the Neurological Assessment Flowsheet outlines the intervals the neurological assessments were required to be completed and documented. At 1:46 PM, Staff B said the expectation of staff after an unwitnessed fall included completion of neurological assessments performed according to the intervals directed on the Neurological Assessment Flowsheet. Staff B said the Neurological Assessment Flowsheet for Resident 1 should have been fully completed. Reference WAC 388-97-1060 (1) 3) Resident 37 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was cognitively intact. A progress note, dated 06/07/2023, documented, CNA notified this LN [Licensed Nurse] resident had a fall during transfer. Resident found parallel to bed, all extremities spread out with a large pool of blood around head . Tennis ball sized hematoma [localized bleeding outside of blood vessels] on the back of head with laceration [cut] . Resident stated I lost my balance and fell backwards. I hit my head pretty bad. Pain 8/10 [8 out of 10 severity] to back of head, lightheadedness and dizziness noted . Paramedics arrived, did their own assessment and left for the hospital . Neuro checks initiated and resident placed on alert. The Facility Fall Investigation, dated 06/07/2023, documented the resident returned to the facility the same day, with eight staples to the wound on the back of the head. The fall investigation did not document any neuro checks related to the fall. Resident 37's EMR did not show documentation neuro checks were completed related to the 06/07/2023 fall. On 08/24/2023 at 11:01 AM, Staff C, RN, said if there was a fall in the facility, nurses would first assess the resident, initiate neuro checks if the resident hit their head, and inform the resident's doctor, the DNS, and family of the fall. Staff C said the facility had a paper used to document neuro checks. Staff C said once the nurse on the floor completed the neuro checks, the paper was given to the RCMs to review and give to medical records. After reviewing Resident 37's EMR Staff C was not able to locate neuro checks for the 06/07/2023 fall. At 3:01 PM, Staff B said when a resident sustained a fall in the facility, staff should ensure the resident's safety, nurses would assess the resident, and assess for a head injury. Staff B said if a resident sustained a head injury in the facility, staff should initiate neuro checks and call the provider for an order to send the resident to the Emergency Room. Staff B said the neuro checks were documented on a neuro check sheet, and went to medical records to be scanned into the resident's EMR. Staff B said she could not locate Resident 37's neuro checks from the 06/07/2023 fall. Staff B said she expected the neuro checks to be completed when the resident returned back from the emergency room on [DATE]. Based on interview and record review, the facility failed to perform ongoing neurological assessments (neuro checks - assesses the nervous system and identifies any abnormalities that affect function and activities of daily living) for residents after an unwitnessed fall for 4 of 4 sampled residents (19, 127, 37 & 1) reviewed for quality of care related to accident hazards. This failure placed residents at risk of having unidentified injuries, a delay in treatment, at risk for worsening conditions, health complications and a diminished quality of life. Findings included . 1) Resident 19 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 05/17/2023, showed the resident was severely cognitively impaired. The Fall Scene Investigation Report, dated 05/20/2023, indicated CNA [certified nursing assistant] alerted this writer that resident was found lying face down on the floor beside her bed . The Neurological Assessment Flowsheet was initiated and showed on 05/20/2023 from 4:30 AM to 6:30 AM the word sleeping was written. Sleeping was also written on 05/21/2023 at 3:00 AM and on 05/22/2023 at 3:00 AM. The Fall Scene Investigation Report, dated 06/30/2023, indicated resident was found on the floor about [3:45 AM] beside her bed . Resident unable to give description. A Neurological Assessment Flowsheet was not found with the investigation report or in the electronic medical records (EMR). 2) Resident 127 was admitted to the facility on [DATE]. Resident 127 was a new admission and a MDS had not been completed. The Fall Scene Investigation Report, dated 08/12/2023, indicated CNA alerted this writer that resident found lying on the floor bedside his bed at [3:10 AM] . Resident unable to give description. Resident 127's baseline cognitive status was described as confused. A Neurological Assessment Flowsheet was not found with the investigation report or in the EMR. The Fall Scene Investigation Report, dated 08/13/2023, indicated CNA alerted this writer resident was found lying on the floor beside his bed . Resident unable to give description. A Neurological Assessment Flowsheet was not found with the investigation report or in the EMR. On 08/24/2023 at 1:40 PM, Staff O, Resident Care Manager (RCM) and Licensed Practical Nurse, said if a resident had an unwitnessed fall, neuros should be initiated and completed. At 8:52 AM Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), said neurological checks were expected. Staff B said it helped them to rule out injury. Staff B said if the resident was sleeping staff should wake the resident and if the resident refused staff should document in the chart.

CONCERN (F)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

. Based on interview and record review, the facility failed to ensure sufficient staffing was available to provide necessary care, services, and supervision for 9 of 30 days review for sufficient staf...

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. Based on interview and record review, the facility failed to ensure sufficient staffing was available to provide necessary care, services, and supervision for 9 of 30 days review for sufficient staffing. This failure place resident at risk for unmet care needs and a diminished quality of life. Findings included . The PBJ (payroll-based journal) Staffing Data Report for fiscal year Quarter 2 2023 (January 1 - March 31) indicated the facility had excessively low weekend staffing. The facility's staff posting showed the following: On 07/22/2023, Noc shift (10:00 PM to 6:00 AM) had 2 LPN (Licensed Practical Nurse) and 2 NA (nursing assistant) for 71 residents. On 07/23/2023, Noc shift had 1 RN (registered nurse), 1 LPN and 2 NAs for 71 residents. On 08/08/2023, Evening shift (7:00 PM to 10:00 PM) had 1 RN, 1 LPN and 4 NAs for 79 residents. The Noc shift had 1 RN, 1 LPN and 2 NAs for 79 residents. On 08/09/2023, Evening shift had 1 RN, 1 LPN and 4 NAs for 79 residents. The Noc shift had 1 RN, 1 LPN and 3 NAs for 79 residents. On 08/15/2023, Evening shift had 1 RN, 1 LPN and 4 NAs for 80 residents. On 08/16/2023, Evening shift had 1 RN, 1 LPN and 4 NAs for 79 residents. The Noc shift had 1 RN, 1 LPN and 3 NAs for 79 residents. On 08/17/2023, Evening shift had 1 RN, 1 LPN and 4 NAs for 80 residents. The Noc shift had 1 RN, 1 LPN and 2 NAs for 80 residents. On 08/18/2023, Noc shift had 1 RN, 2 LPNs and 2 NAs for 81 residents. On 08/20/2023, Noc shift had 1 RN, 2 LPNs and 2 NAs for 81 residents. On 08/22/2023 at 5:10 PM, Staff N, NA said four staff was not enough staff for 80 residents. Staff N stated, We have three staff today because one called out. The quality of care goes down, no showers and residents yell because they don't get help when they need it. Staff N said she tries to get four rounds of check/change per shift but when they are short she can only get three. On 08/24/2023 at 2:02 PM, Staff P, NA, said the evening shift ran three or four aides and at night its even worse than that. Staff P said they are not always able to get their work done. On 08/25/2023 at 9:45 AM, Staff B, Director of Nursing Services and Registered Nurse, said the facility's goals was to have eight aides for the day shift, six for the evening shift and four aides for the noc shift. Staff B said we are below our staffing goals. Refer to 550 Reference WAC 388-97-1080 (1) .

CONCERN (F)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

. Based on interview and record review, the facility failed to ensure a comprehensive antibiotic stewardship program was in place for the facility. This failure placed all facility residents at risk f...

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. Based on interview and record review, the facility failed to ensure a comprehensive antibiotic stewardship program was in place for the facility. This failure placed all facility residents at risk for over-use and miss-use of antibiotic. Findings included . On 08/21/2023, during the entrance conference, the antibiotic stewardship program documentation was requested. On 08/22/2023, the antibiotic stewardship program documentation was requested. On 08/23/2023 at 11:15 AM, Staff A, Administrator and Registered Nurse, said she did not have a program, only pieces of one. Staff A said she would have one ready for next year. (Documentation of a antibiotic stewardship program was not provided the survey team.) No associated WAC reference .

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

. Based on interview and record review, the facility failed to ensure daily staff postings were accurate for the type of staff providing care to residents for 30 of 30 daily staff postings reviewed fo...

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. Based on interview and record review, the facility failed to ensure daily staff postings were accurate for the type of staff providing care to residents for 30 of 30 daily staff postings reviewed for staffing information. This failure placed residents and visitors at risk of not knowing what type of staff was providing care to residents. Findings included . The daily staff postings, dated 07/22/2023 to 08/21/2023, showed entries for Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants. Review of the staff scheduled, dated 07/22/2023 to 08/21/2023, showed Nurse Technicians and a Certified Nursing Assistant Medication Assistant were on the schedule to provide medication administration on the medication carts. Correlation of the schedule to the staff postings showed the facility counted the Nurse Technicians and Certified Nursing Assistant Medication Assistant as Licensed Practical Nurses (LPN). On 08/25/2023 at 9:45 AM, Staff B, Director of Nursing Services and Registered Nurse, said the Nurse Technician and the Certified Nursing Assistant Medication Assistant should not have been identified as LPNs. Staff B said the Nurse Technician should have had his own category. No associated WAC.

Jul 2023 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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents and resident representatives were provided educa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents and resident representatives were provided education on the risks and benefits including potential side effects of the COVID-19 (a highly infectious respiratory illness caused by a virus) vaccine and ensure documentation of the acceptance or refusal to receive the vaccine was in the medical record for 3 of 6 sampled residents (Residents 1, 2 & 6) reviewed for COVID-19 immunizations. This failure placed residents and resident representatives at risk of not having the opportunity to make an informed decision about the COVID-19 vaccine and the adverse health effects of this communicable disease. Findings included . The facility COVID-19 Vaccination policy, updated 06/2023, showed each resident would be screened for vaccination history, residents and/or POA (power of attorney) would be provided education regarding the risks and benefits of the vaccination and residents would be offered a COVID-19 vaccine. The policy showed the residents' COVID-19 vaccination status and related information would be documented in the immunization tab of the electronic health record (EHR). 1) Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's immunization record, on 07/17/2023, showed no documentation of a COVID-19 vaccination history. A review of Resident 1's EHR, on 07/17/2023, showed no documentation the facility provided education of the risks and benefits of the COVID-19 vaccine or that the resident was offered and declined the COVID-19 vaccine. 2) Resident 2 was admitted to the facility on [DATE]. Resident 2's medical record showed a positive COVID-19 result on 07/14/2023. A review of Resident 2's EHR, on 07/17/2023, showed no documentation the facility provided education of the risks and benefits of the COVID-19 vaccine or that the resident was offered and declined the COVID-19 vaccine. A review of Resident 2's immunization record, on 07/19/2023, showed no documentation of a COVID-19 vaccination history. 3) Resident 6 was admitted to the facility on [DATE]. A review of Resident 6's immunization record, located in the EHR, showed the resident had received COVID-19 vaccinations on 02/11/2021 and 09/21/2021. Resident 6's medical record showed a positive COVID-19 result on 07/17/2023. A review of Resident 6's EHR, on 07/20/2023, showed no documentation the facility provided education regarding the risks and benefits of a COVID-19 booster or the resident was offered and declined a COVID-19 booster. On 07/21/2023 at 1:04 PM, Staff D, Licensed Practical Nurse (LPN), said she was not sure of the process but knew residents were offered COVID-19 vaccines and boosters, and residents should sign a consent form and an order would then be obtained to administer the vaccine. At 1:22 PM, Staff C, LPN A and Resident Care Manager (RCM), said the floor nurse who did the admission screens for vaccinations would offer any needed vaccinations. Staff C said she was not sure what education was provided to residents regarding vaccinations, nor the process for documenting a refusal and had recently documented a refusal in a progress note. When asked specifically about COVID-19 vaccination status for Resident 1, Resident 2, and Resident 6, Staff C said she would have to look into it. At 1:30 PM, Staff B, Registered Nurse and Director of Nursing Services, said residents were screened upon admission for vaccination history, were offered immunizations after obtaining consent using the consent forms and then the vaccine would be administered. Staff B said documentation regarding education or refusals of vaccines could be found in a progress note or an evaluation note. At 2:15 PM, Staff A, Executive Director, said Staff B and the RCMs would look at the vaccination status for residents and offer vaccines. Staff A said she usually found documentation of refusals in the progress notes rather than under immunizations, and stated, It just depends on who is charting. Staff A said there may not have been a specific process staff followed for documenting vaccinations but she would expect the information to be in the EHR. At 3:41 PM, Staff B said she was not able to find additional documentation regarding COVID-19 vaccinations for Resident 1, Resident 2, and Resident 6. Staff B said she would expect the documentation to be in the EHR. Reference WAC 388-97-1780 (1)(2)(b)(c)(d) .

OLYMPIC VIEW CARE

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