**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to follow physician orders for a surgical wound for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for clinical complications, infections and discomfort. Findings included . Resident 1 was admitted to the facility on [DATE]. Resident 1's Hospital's Skilled Nursing Facility Transfer Orders, dated 02/15/2025, showed the resident had a C2-T10 PSF, T4 Corpectomy (surgical procedure on the spine) on 02/06/2025. The orders showed discharge instructions to the SNF [skilled nursing facility] to remove the staples in the incisionthree weeks postop (post-surgery) unless there were any concerns about the incision and then call the surgeon. Review of Resident 1's electronic medical record on 05/13/2025, showed no documentation the staples were removed from the resident's incision and/or the surgeon was contacted. Resident 1's discharge orders, dated 03/03/2025, showed the resident had a follow up appointment with the surgeon on 03/20/2025. The orders showed no documentation the resident had staples in their incision and/or instructions for removal. Resident 1's progress notes, dated 03/04/2025, showed the resident was discharged to their prior living facility with medications and orders. On 05/13/2025 at 04:02 PM, Staff A, Registered Nurse Case Manager, said Resident 1 was discharged to their assisted living facility with their current orders and referrals for home health. Staff A said there was no documentation sent regarding the staples in the resident's incision and/or documentation the facility staff had removed them. On 05/13/2025 at 4:43 PM, Staff B, Director of Nursing, said the facility staff missed Resident 1's order for staple removal from the surgical incision and failed to relay the information to the assisted living facility. Reference WAC 388-97-1060 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents and/or their representatives were provided accurate information regarding the risks and benefits associated with proposed drug therapies for 2 of 5 sampled residents (Residents 11 & 73) reviewed for unnecessary medications. The failure to accurately identify medication/drug class and associated adverse side effects (ASEs) detracted from residents' ability to make informed decisions about proposed drug therapies, and placed them at risk for making treatment decisions based on inaccurate information. Findings included . Review of the facility's Psychotropic Drug Utilization policy, dated 12/2024, showed a psychotropic drug was defined as any drug that affects brain activities associated with mental process and behavior. In the event a psychoactive medication was ordered, licensed staff would obtain informed consent for the use of the medication prior to initiating therapy. 1) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest) and post-traumatic stress disorder (PTSD, traumatic event that triggers thoughts/distress/anxiety). Review of the EHR showed Resident 11 was receiving Abilify (anti-psychotic medication, decreases symptoms of disconnect with reality) for depression and post traumatic stress disorder (PTSD). The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 11 was able to make needs known and was cognitively intact. Review of Resident 11's consent form for Abilify on 04/04/2024 listed Abilify as an antidepressant. During an interview on 12/11/2024 at 11:32 AM, Staff E, Unit Manager/Licensed Practical Nurse, said the purpose of reviewing risk and benefits during consent for psychotropic medications was so residents would know what the side effects were, what the medication did, and how the medication could help them. For informed consent, Staff E said the residents needed to know the class the drug was and what medication they were to receiving. Staff E said that antipsychotic medication consent should go over antipsychotic risks and benefits, and for Resident 11, the Abilify consent was incorrectly done under antidepressant but should have been redone to be an antipsychotic medication. During an interview on 12/11/2024 at 2:16 PM, Staff B, Director of Nursing Services, said the resident or their power of attorney needs to be informed about the risk and benefits of psychotropic medications, for informed consent. When asked if the risks and benefits were the same for an antidepressant and an antipsychotic, Staff B said they were not exactly the same. Staff B said Resident 11 should have had their Abilify consent done as an antipsychotic, and it was an error that it was completed as an antidepressant. 2) Resident 73 admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed the resident was cognitively impaired, had diagnoses of anxiety, depression and agitation, and received antianxiety, antidepressant and antipsychotic medication during the assessment period. On 10/11/2024 a new order was obtained for Nuedexta (a central nervous system agent) daily for pseudobulbar affect (PBA, causes episodes of uncontrollable laughing, crying, or anger that were unrelated to mood). An Authorization for Psychoactive Medication consent form, dated 12/11/2023, showed staff presented Nuedexta to the resident as an antipsychotic medication and a mood stabilizer. The indications for use were documented as calling out, yelling, and dementia with behaviors (agitation). On 12/12/2024 at 12:38 PM, when asked if Nuedexta was accurately identified as an antipsychotic medication and mood stabilizer Staff L, Unit Manager, stated, No. When asked if calling out, yelling, and dementia with agitation were appropriate indications for use of Nuedexta, Staff L said no and acknowledged Resident 73 was provided inaccurate drug information for Nuedex, to include the drug class, indications for use and potential adverse side effects. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interview, and record review the facility failed to obtain an assessment, orders, consent, and develop a care plan for the use of potential restraints for 1 of 4 residents (Resident 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . Resident 91 readmitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set, an assessment tool, dated 09/19/2024, showed Resident 91 was dependent with mobility abilities, was rarely/never understood, and was moderately impaired for daily decision making. On 12/10/2024 at 2:49 PM, Resident 91 was observed in bed with body pillows (longer than standard pillows) on both sides of their bed positioned under the fitted sheet. Review of Resident 91's Electronic Health Record showed no assessment, consent, orders, or care plan documentation for the body pillows. On 12/11/2024 at 8:45 AM, Resident 91 was observed eating breakfast in bed with body pillows on both sides of the bed positioned under the fitted sheet. On 12/12/2024 at 6:23 AM, Resident 91 was observed to have one standard pillow on the left side of their bed, positioned under the fitted sheet. On 12/12/2024 at 6:52 AM, Staff J, Certified Nursing Assistant, when asked why body/standard pillows had been placed for Resident 91, Staff J said staff put pillows there because Resident 91 moved back and forth, could turn themselves, and sometimes their feet would slide off the bed. Staff J said they knew the pillow should not be under the fitted sheet and they were placed there to keep Resident 91 from falling out of bed. On 12/12/2024 at 12:12 PM, Staff L, Unit Manager, said they were conducting an audit for the use of body pillows due to there not being orders, care plan, or consent and those things should have been done, especially if the resident could not remove the pillows themselves. When asked about an assessment for bed pillows, Staff L said she would have to follow up with the Director of Nursing (DNS), and she believed a policy discussion was on the horizon. On 12/13/2024 at 2:03 PM, Staff B, Director of Nursing Services, said for the use of body/bed pillows his expectation was that an assessment, consent, orders, and a care plan would be done, and these had not been done. Reference WAC 388-97-0620(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure Minimum Data Set Assessments (MDS), assessment tool, were accurate for 2 of 25 sampled residents (Residents 54 and 11). This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life. Findings included . 1) Review of the Electronic Health Record (EHR) showed Resident 54 was admitted on [DATE]. Resident 54 had diagnoses of retention of urine and neuromuscular dysfunction of the bladder (problem with bladder control). Resident 54 had a suprapubic catheter (small tube that drains urine from bladder by an incision through the abdomen). Resident 54's Annual MDS, dated [DATE], documented they had an indwelling catheter (including suprapubic catheter and nephrostomy tube) and for urinary continence that they were always incontinent (no episodes of continent voiding). Further review of the MDS showed that for urinary continence another option that was available but was not selected was, Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days). During an interview on 12/13/2024 at 10:10 AM, Staff B, Director of Nursing Services (DNS), said they had spoken to the MDS nurse and clarified that Resident 54 had a catheter and should not have been coded as incontinent, and this did not meet expectations. Review of an email communication on 12/13/2024 at 10:37 AM, showed Staff G, MDS Nurse/Registered Nurse (RN) stated, Continence is coded 'not rated in the MDS anytime a resident has a urinary catheter for all 7 days regardless of catheter changes or leaking. 2) Review of the EHR showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest), anxiety (increased stress), and post-traumatic stress disorder (traumatic event that triggers thoughts/distress/anxiety). Review of Resident 11's Level 2 Preadmission Screening and Resident Review (PASRR, a screening form for mental illness and/or intellectual disability), dated 10/07/2023, provided the facility with information on interventions to help care for Resident 11. Review of the Significant Change MDS, dated [DATE], showed that Resident 11 did not have a Level 2 PASRR selected. For the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, the form had No selected. This left the rest of the questions related to the Level 2 PASRR conditions blank. During an interview on 12/12/2024 at 10:30 AM, Staff H, MDS Manager/RN, said Resident 11's 10/15/2024 MDS was documented incorrectly, the Level 2 PASRR should have been documented, and that they needed to modify it. During an interview on 12/13/2024 at 11:53 AM, Staff B, DNS, said it did not meet expectations that the Level 2 PASRR was not documented in the MDS for Resident 11. Reference WAC 388-97 -1000 (1)(b) .

**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 the resident's mental health diagnoses and Level II PASRR evaluations were timely referred and completed for 1 of 5 residents (Resident 73) reviewed for PASRRs. The failure to ensure Level I PASRRs were accurately completed, and residents were timely referred for Level II PASRR evaluations, placed residents at risk for inappropriate placement, and not receiving timely and necessary mental health services to meet their mental health needs. Findings included . Resident 73 admitted to the facility on [DATE]. The Annual Minimum Data Set Assessment, dated 09/25/2024, showed the resident was severely cognitively impaired, and had diagnoses of non-Alzheimer's dementia (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform basic tasks) with agitation, and anxiety (a common reaction to stress that can cause physical, mental, and behavioral symptoms) and depressive (a serious mental illness that can affect how you feel, think, and act) disorders. A Mental Health Evaluation, dated 03/06/2023, documented Resident 73 had active diagnoses of major depressive disorder, anxiety disorder and dementia with agitation. A Level I PASRR dated 01/24/2023, documented Resident 73 had a diagnosis of anxiety disorder and determined a Level II PASRR evaluation referral was required for serious mental illness. The assessment did not include the resident's depressive disorder or dementia with behaviors/agitation diagnoses. Review of Resident 73's Electronic Health Record revealed no documentation for a Level II PASRR evaluation. On 12/16/2023 at 9:09 AM, Staff M, Social Services Clinician, said Resident 73's Level I PASRR was inaccurate and needed to be redone. Documentation was requested to show the resident's level II PASRR evaluation referral was made and/or the evaluation had been completed. No further documentation was provided. Reference: WAC 388-97-1915 (1)(2) (a-c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest) and post-traumatic stress disorder (traumatic event that triggers thoughts/distress/anxiety). The Significant Change MDS, dated [DATE], showed Resident 11 was able to make needs known, was cognitively intact, and had documented delusions. <Pain Management Care Plan> Review of the EHR showed Resident 11 currently received an as needed narcotic (strong pain medication) for pain management, as well as scheduled doses of acetaminophen (mild pain medication). Review of Resident 11's care plans showed a care plan for pain that did not include narcotic usage or non-pharmacological (non-medication) interventions. During an interview on 12/11/2024 at 11:32 AM, Staff E, UM/LPN, said their expectation for the pain care plan was that it would be tailored to the resident, such as how the resident liked to be comfortable and how they wanted their pain managed. For Resident 11, Staff E said they did not see any non-pharmacological interventions for pain management in the care plan, and their expectation was for the narcotic and non-pharmacological interventions to have been included. During an interview on 12/11/2024 at 2:16 PM, Staff B, DNS, said their expectation for a pain management care plan was it should have interventions, it should include non-pharmacological interventions, and it should mention narcotics if they were on any. For Resident 11, Staff B said the care plan missing non-pharmacological interventions for pain management and not mentioning the narcotic Resident 11 was on, should have been addressed. <Psychotropic Non-Pharmacological Intervention Care Plan> Review of Resident 11's EHR showed they were receiving daily psychotropic medications. Review of Resident 11's psychotropic medication care plans showed there were no non-pharmacological interventions listed. During an interview on 12/12/2024 at 11:23 AM, UM/LPN, said they were unable to find non-pharmacological interventions for Resident 11's psychotropic medication in the care plan. <Infection Control Precautions> 5) Resident 59 was admitted on [DATE]. An observation of Resident 59's door from the hallway, on 12/12/2024 at 8:18 AM, showed that they were on a precaution for Aerosol Generating Procedure (AGP, procedure that produce very small particles in the air) overnight. Review of Resident 59's care plans showed that they were receiving CPAP (an aerosol generating procedure) but did not include anything about AGP. During an interview on 12/16/2024 at 9:33 AM, Staff F, Infection Preventionist (IP)/LPN, said the care plan should include if a resident was on an AGP, and for Resident 59 it was not in the care plan and should have been. During an interview on 12/16/2024 at 3:09 PM, Staff B, DNS, said Resident 59 should have had their care plan updated to have shown the interventions being done. 6) Resident 51 was admitted on [DATE]. Review of Resident 51's care plans showed that they were receiving CPAP and did not have a care plan for an AGP. During an interview on 12/16/2024 at 9:33 AM, Staff F, IP/LPN, said Resident 51 also needed to have an AGP care plan. Reference WAC 388-97-1020(1), (2)(a)(b) 3) Resident 91 readmitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed Resident 91 had diagnoses including dysphagia (difficulty swallowing foods or liquids), and Moderate Protein-Calorie Malnutrition (not consuming enough protein and calories to meet nutritional needs), was rarely/never understood, and it was very important to Resident 91 to do their favorite activities. Review of Resident 91's physicians orders showed the following order for diet, General Diet, diet Dysphagia Ground texture, thin consistency, EBC/fort [Every Bite Counts, fortified] foods to encourage consumption related to unspecified severe protein-calorie malnutrition. Resident 91's ADL care plan documented interventions for eating and diet as: Independent with eating with set-up. General, regular texture thin fluids. On 12/16/2024 at 11:56 AM, Staff L, UM, said it did not meet expectations that Resident 91's care plan did not reflect the correct diet, and it was incorrect. <Failure to have person centered Care Plan> Review of Resident 91's care plan showed the following under interventions/tasks: when the resident choose not to participate in organized activities, the resident prefers to (SPECIFY) for social and sensory stimulation, initiated 07/01/2024. On 12/11/2024 at 12:05 PM, Staff L, UM said the care plan indicating SPECIFY without including specific information for Resident 91 did not meet expectations for a resident specific care plan Based on interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to included resident specific information for 5 of 25 sampled residents (Residents 59, 78, 91, 11 & 51) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs. Findings included . 1) Resident 59 was admitted to the facility on [DATE] with diagnosis of sleep apnea (a sleep disorder characterized by repeated pauses in breathing during sleep). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/06/2024, showed the resident required supervision to substantial assistance with activities of daily living (ADL) and was cognitively intact. Resident 59's altered respiratory status/difficulty breathing care plan, dated 05/16/2022, listed the resident had a continuous positive airway pressure (CPAP, a treatment for sleep apnea and other breathing disorders that involves wearing a mask that delivers a constant stream of pressurized air through the nose during sleep). On 12/12/2024 at 11:01 AM, Staff B, Director of Nursing (DNS), said Resident 59's care plan should include information on how to contact the vendor/pulmonologist if there was a concern or problem with the CPAP and he said they would update the care plan. 2) Resident 78 was admitted to the facility on [DATE] with a diagnosis of chronic pain. The Quarterly MDS, dated [DATE], showed the resident required partial to setup assistance with ADLs and was cognitively intact. A review of Resident 78's care plan, dated 04/11/2024, listed a problem of acute and chronic pain. On 12/11/2024 at 12:57 PM, Staff E, Unit Manager (UM)/Licensed Practical Nurse (LPN), said non-pharmacological interventions (NPIs) should be on Resident 78's care plan and the expectation was that the NPIs would be tailored specifically to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Failure to timely transcribe and/or timely carry out laboratory orders> 3) Resident 51 admitted to the facility 07/31/2024. Review of the Significant Change MDS, dated [DATE], showed Resident 51 had diagnoses including heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively) and generalized edema (fluid accumulation that affects the whole body) and was severely cognitively impaired. An order request, dated 11/29/2024, sent by facility staff to Resident 51's physician, documented Resident 51 had significant edema to both lower extremities and was taking Lasix and spironolactone (medications that promotes removal of excess fluid from the body) with little improvement to edema. Further review of the order request showed Resident 51's physician had responded on 12/02/2024 with new orders to draw laboratory tests for basic metabolic panel (BMP) and magnesium, as well as to increase the dose of the medications Lasix and spironolactone. A progress note, dated 12/02/2024, documented Resident 51's physician was in to see the resident and received a orders to increase Lasix to 160 mg [milligram] and increase spironolactone to 50 mg. Labs to be drawn 12/3 BMP and magnesium. A review of the laboratory test results showed labs for BMP and magnesium were not drawn until 12/11/2024. On 12/16/2024 at 3:05 PM, Staff C, ADNS, regarding laboratory tests being ordered for Resident 51 on 12/02/2024 and not being drawn until 12/11/2024, said normally it would be drawn in the next couple of days, especially with a change of medication, it may have gotten missed or wasn't done right away. At 3:18 PM, Staff L, Unit Manager/Licensed Practical Nurse (LPN), said if laboratory tests were ordered she would expect them to be done the next business day. At 3:27 PM, Staff L reviewed the order requisition for Resident 51's labs. Staff L said staff had requested the date of service for Resident 51's labs to be drawn on 12/11/2024, it should have been requested for 12/03/2024. <Failure to lock medication cart> 4) On 12/11/2024 at 2:54 PM, a medication cart located on the Bay Unit, outside of room [ROOM NUMBER] was observed with the latch not flush with the cart indicating it was unlocked. The medication drawers were easily opened. At 2:55 PM, a facility guest walked past the unlocked cart. At 3:00 PM, staff walked by the unlocked cart. At 3:01 PM, staff walked past the unlocked cart. At 3:03 PM, staff walked past the unlocked cart. At 3:07 PM, Staff N, Registered Nurse, walked up to the unlocked medication cart, 13 minutes after the initial observation that the cart was unlocked. Staff N said this was their assigned cart and it should have been locked. On 12/12/2024 at 9:24 AM, Staff L, Unit Manager, said her expectation was for the medication carts to be locked when staff were away from them. 5) Resident 40 readmitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed Resident 40 had diagnoses including hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) affecting their left non dominant side, dizziness, repeated falls and was cognitively intact. <Failure to ensure self-administration assessment> On 12/09/2024 observation of Resident 40's bedside table showed a bottle of [NAME] anti-itch lotion with a prescription label on the back. Resident 40 had a physician's order for [NAME] External Lotion 0.5-0.5% (Camphor & Menthol), apply to affected areas topically every 6 hours as needed for skin .resident may self-administer. Review of the Resident 40's care plans showed no documentation that an assessment for the self-administration of [NAME] External Lotion had been completed. At 12:09 PM, Staff L, UM, when asked for documentation for Resident 40 that a self-administration form for [NAME] lotion had been done and documented, Staff L reviewed the Electronic Health Record (EHR) and said they would follow up. At 1:02 PM, Staff L, UM, said they were unable to locate a Self-Administration of Medication assessment tool for Resident 40. On 12/12/2024 at 12:44 PM, Staff B, DNS, said before a resident can self-administer medication a self-administration assessment should be done. <Failure to secure medication observed at bedside> On 12/09/2024 at 12:01 PM, Staff O, LPN when shown the medication bottle of [NAME] Lotion on Resident 40's bedside table said medications should not be left at the bedside. Staff O said the [NAME] lotion had been stored at Resident 40's bedside, and it would be best practice for it to be stored at the nurses' station. On 12/12/2024 at 12:44 PM, Staff B, DNS, in regards to Resident 40's [NAME] lotion having been stored at bedside, Staff B said it should have been in the nurses' cart and it should not have been stored at the bedside. Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i) Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 25 sampled residents (Residents 73, 51 and 40) reviewed for professional standards. Facility staff failed to timely transcribe and timely carry out physician orders, and/or clarify confusing or incomplete orders. Additionally, staff failed to ensure medications were secure, as nurses left the medication cart unlocked when unattended and/or left medication at a residents' bedside without an order to do so, or a self-medication assessment being completed. These failures placed residents at risk for medication errors, complications of treatments, and other potential negative health outcomes. Findings included . <Failure to Clarify Incomplete Orders> 1) Resident 73 admitted to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment, a diagnosis of heart failure and required the use of supplemental oxygen (O2) during the assessment period. Resident 73 had a 03/06/2024 order for oxygen one to five liters per minute (1-5L/min) via nasal cannula, to maintain oxygen saturation greater than 92 percent. Review of the November and December 2024 Medication Administration Records (MARs) showed the spaces provided for nurses to document the flow rate of oxygen that was administered had all been struck out (boxes contained Xs). This resulted in nurses failing to document on the MAR, for a six-week period, the amount of oxygen that had been administered. On 12/12/2024 at 12:54 PM, Staff L, Unit Manager (UM), said it was the expectation nurses document the dose of medication they administered on the MAR but acknowledged facility nurses failed to do so. Staff L said nursing should have identified the order was incomplete and/or input into the computer incorrectly, and clarified/corrected the order, but failed to do so. 2) Resident 51 admitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed the resident had severe cognitive impairment, a diagnosis of obstructive sleep apnea, and required the use of a non-invasive mechanical ventilator (continuous positive airway pressure/CPAP). Review of Resident 51's physicians' orders showed the following CPAP orders: a) Apply CPAP at bedtime and remove in the AM. b) Wipe down mask (including areas that contact skin) using a damp towel with mild detergent and warm water. Allow mask to air dry out of direct sunlight. Ensure mask is dry before use. Resident 51's CPAP orders did not include what the ordered CPAP pressure settings were, provide direction to staff to check and refill the humidifier chamber weekly and as needed, or identify that the humidifier chamber should only be filled with distilled water. On 12/16/2024 at 4:25 PM, Staff C, Assistant Director of Nursing Services (ADNS), said facility nurses should have identified Resident 51's CPAP orders were incomplete and called and clarified the orders, but failed to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to provide assistance with bathing for 1 of 5 residents (Resident 90) reviewed for activities of daily living (ADLs). The failed practice placed residents at risk for a decline in care and quality of life. Findings included . Resident 90 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 09/04/2024, documented the resident had severe cognitive impairment and required supervision for ADLs. A review of the Point of Care (nursing assistant task documentation) response history for 30 days, the 'Shower Book' and the 'Marina Daily Shower' sheets documented Resident 90 only received a shower on 11/17/2024, 12/02/2024, and 12/08/2024. A review of Resident 90's care plan, dated 11/29/202,3 listed a problem of ADL self-care performance deficit . and an intervention of if unable to perform shower, offer bed bath. On 12/12/2024 at 2:26 PM, Staff E, Unit Manager/Licensed Practical Nurse, said Resident 90 did not receive a shower during the week of November 24th because the shower aide was pulled to the floor. Staff E said the expectation would be that the resident should have been offered a bed bath if they did not have a shower aide that day. At 2:57 PM, Staff B, Director of Nursing Services, said Resident 90 did not get a shower that week because there were staff call outs, and said a bed bath should have been offered. Reference WAC 388-97-1060 (2)(c) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the EHR showed Resident 11 was admitted on [DATE]. Resident 11 had a diagnosis of reduced mobility and was receiving an as needed opioid (strong pain medication, has a potential side effect of constipation) pain medication. Review of the Significant Change MDS, dated [DATE], showed Resident 11 was dependent on staff for cares. Review of Resident 11's orders showed an order for MiraLAX powder for no bowel movement for two days. The order also included non-pharmacological interventions to be done before administering MiraLAX, which included: 1. Offered prune juice 2. Encouraged to drink more fluids 3. Increase fiber intake 4. Exercise Further review of the orders showed three more medications ordered to stimulate a bowel movement: a bisacodyl tablet for every 24 hours as needed for constipation if no bowel movement in two days with non-pharmacological interventions to be done before giving, a bisacodyl suppository with non-pharmacological interventions to be done before giving, and for failure of oral bowel medication or suppository, a fleet oil enema could be given once every 24 hours. During a past 30-day look back period on [DATE], Resident 11's bowel elimination record showed that they did not have a bowel movement on: [DATE]-[DATE] (3 days) [DATE]-[DATE] (4 days) During a review of the EHR on [DATE], there were no progress notes found, and no as needed medications provided for the dates listed above. During an interview on [DATE] at 11:32 AM, Staff E, Unit Manager (UM)/Licensed Practical Nurse (LPN), said Resident 11 should have received MiraLAX after the second day of no bowel movement. Staff E confirmed Resident 11 did not have bowel movements on the dates above, and that there was no documentation of the administration of as needed medications or non-pharmacological interventions having been done. Staff E said their expectation for staff was to review the bowel movement record every morning, to have monitored, to have reviewed as needed orders, to have passed the information on in report, and to have administered accordingly and documented. During an interview on [DATE] at 2:16 PM, Staff B, Director of Nursing Services (DNS), said their expectation was for non-pharmacological interventions to be attempted before giving a medication to stimulate a bowel movement. For Resident 11, Staff B said their expectation was for the bowel protocol to have been followed unless refused, and if the bowel protocol was not followed, then there should have been documentation of an attempt at non-pharmacological intervention. Based on interview and record review, the facility failed to implement care and services in accordance with accepted professional standards for 3 of 6 residents (Residents 82, 11, and 99) reviewed for quality of care related to bowel management and hospice services. This failure placed the residents at risk for discomfort and complications related to constipation and risk for substandard care related to lack of coordination with hospice (provides end of life orders/interventions). Findings included . <Bowel management> Facility Bowel Management Policy, dated 2024, said the licensed nurse was to check the bowel record each day. If there was no BM (bowel movement) or small BM, the nurse would implement non-pharmacological interventions. If no BM for three days or more, pharmocological interventions would also be offered. It was the responsibility of the nurse to complete documentation and to notify the medical provider if interventions were ineffective. 1) Resident 82 admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], showed Resident 82 was cognitively intact, needed extensive assistance with activities of daily living, and had a diagnosis of constipation. Review of the Electronic Health Record (EHR) for November and December showed Resident 82 did not have a BM between [DATE] and [DATE] nor between [DATE] and [DATE]. Resident 82 received daily scheduled Miralax (stimulates a bowel movement) 17 grams and Senna Plus two tablets in the AM and two tablets in the PM. PRN (as needed) bisacodyl 5 milligrams was administered on [DATE] and [DATE]. No other PRN bowel meds were documented to have been given. No non-pharmacological interventions were documented. On [DATE] at 12:41 PM, Staff D, Assistant Director of Nursing Services (ADNS), said the expectation was for aides to tell the nurse if a resident did not have a BM for two days. The nurses were expected to look at the dashboard every shift which would show no BM for two days. The nurses would document non-pharmacologic BM interventions. The nurses would document pharmacological interventions, results and/or refusal of BM meds to show attempts were made. On [DATE] at 2:12 PM, Staff C, ADNS, said the expectation was pharmacological and non-pharmacological interventions were implemented no later than day three. when a resident did not have a BM and everything should have been documented. <Hospice> 3) Resident 99 admitted to the facility on [DATE]. Review of the admission MDS showed the resident had a diagnosis of malignant breast cancer and received hospice services. Review of the hospice coordinated plan of care showed it was expired, as it was for the certification period [DATE] - [DATE]. On [DATE] at 2:03 PM, Staff L, UM, confirmed there was not a current hospice plan of care in Resident 99's EHR. When asked how they knew what disciplines and at what frequency the resident was to receive from hospice, Staff L said they were unsure. On [DATE] at 2:11 PM, Staff T, Administrative Assistant, confirmed no current hospice plan of care was present in the hospice binder and indicated they would contact hospice to obtain one. Reference WAC 388-97-1060(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure the pressure relieving device was working correctly for 1 of 3 sampled residents (Resident 81) reviewed for pressure ulcers. This failure placed residents at risk for delayed healing and further skin impairment. Findings included . Resident 81 was admitted to the facility on [DATE] with diagnoses of Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves) and malnutrition (lack of sufficient nutrients in the body). The Quarterly Minimum Data Set, an assessment tool, dated 09/23/2024 showed Resident 81 was moderately cognitively impaired, needed extensive assist for activities of daily living, and had one or more unhealed pressure ulcers. On 12/09/2024 at 10:18 AM and 3:30 PM, Resident 81 was observed lying in bed. A pressure relieving mattress was in place with a setting of 5 (1-softest setting through 5-firmest setting). On 12/10/2024 at 10:30AM, on 12/11/2024 at 9:27 AM and 10:57AM, and on 12/12/2024 at 10:26AM and 2:32 PM, Resident 81 was lying in bed. The pressure setting for the mattress was at 5. The 'New Air Mattress Guidelines,' revised 11/2024, under the section 'settings,' stated, Comfort level (on pump): To patient comfort, start at level 3 when placed, heavier patients may need firmer, and lighter patients may need softer (these setting should be included in the Care Guide/Care Plan). Resident 81's care plan, revised on 10/24/2023, indicated an air mattress was in place. Directions were to ensure air mattress was functioning properly each shift. Air mattress was to be set at level 3 due to Resident 81's weight of 107 pounds. On 12/12/2024 at 2:30 PM, Staff S, Wound Management Registered Nurse, said Resident 81 had chronic pressure areas that developed quickly and were hard to heal. When asked if Resident 81 had an air matress, Staff S said the resident did and reviewed the care plan. Staff S said the air mattress was set at level 3 for the last recorded weight of 107 pounds on 11/29/2024. On 12/12/2024 at 12:54 PM, Staff I, Licensed Practical Nurse, said residents on the [NAME] Unit were weighed weekly or more often, if needed. Staff I said air mattress settings were based on weight and nurses should be monitoring the air mattress settings for accuracy each shift. On 12/13/2024 at 12:56 PM, Staff D, Assistant Director of Nursing Services, said pressure reducing mattresses were set per manufacturer guidelines and weight. Staff D observed Resident 81's mattress was at the level 5 setting and said it should have been on level 3 for maximum effectiveness. The setting should be on the Treatment Administration Record, a monitoring tool for nurses, to be signed off on each shift. Staff D did not know why a weight had not been obtained for Resident 81 since 11/29/2024. WAC -388-97-1060 (3)(a) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Nebulizer Services> 3) Resident 81 admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 81 was moderately cognitively impaired and had diagnoses of respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in the body) and chronic (continuing over a long period of time) cough. On 12/09/2024 at 10:18 AM, Resident 81 was observed lying in bed. A nebulizer machine was noted to be on the right side table. The tubing was labeled 12/04 and the mouth piece was attached to the nebulizer container. The set was in a unlabeled plastic bag. Resident 81's care plan, revised 06/14/2024, noted Resident 81 had an altered respiratory status and was at high risk for developing pneumonia (an infection that inflames the air sacs in the lungs) and/or acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Treatments via the nebulizer and the care of associated equipment were not on the care plan. The MARs showed a start date of 02/05/2024 for Ipratropium-Albuterol Solutuion 0.5-2.5 (3)mg (milligram)/3ml (millileter) two times a day for wheezing/SOB (shortness of breath). Document lung sounds prior to treatment and post treatment. Document time to set up, administer, assess, and clean equipment and inhale three milliliters orally every four hours as needed for wheezing/SOB. Document lung sounds prior to treatment and post treatment. Document time to set up, administer, assess and clean equipment. There was no documentation for lung sounds or for cleaning of the equipment. There were no directions on how to clean, replace, or store the equipment. On 12/13/2024 at 12:00 PM, Staff D, ADNS, said the nurses should be following the policy on how to care for the nebulizer equipment. Staff D said the instructions should have been on the Treatment Administration Record (TAR) so nurses could sign off when it was completed. On 12/13/2024 at 1:57 PM, Staff C, ADNS, said the expectation was that the cleaning and care of the nebulizer equiment needed to be on the TAR and that nurses would sign off once completed. Reference WAC 388-97-1060 (3)(j)(vi) Based on observation, interview and record review, the facility failed to ensure oxygen (O2), continuous positive airway pressure services (CPAP, an external device that provides a fixed pressure to keep breathing airways open while you sleep), and breathing treatments via nebulizer (a machine that turns liquid medicine into a mist that can be inhaled) were provided in accordance with accepted professional standards of practice for 3 of 5 residents (Residents 73, 51 and 81) reviewed for respiratory care. The failure of staff to document the amount of O2 administered, to ensure O2 orders included checking and replacing of humidifier bottles, and CPAP orders included the prescribed pressure settings, type of mask to be used (e.g. nasal pillows, nasal mask, full face mask), direction to check and refill the humidifier reservoir, and identification of the solution to be used (e.g. distilled water), placed residents at risk for ineffective assisted ventilation and unmet respiratory needs. Findings included . Review of the facility's Oxygen Administration policy, dated 12/2024, showed oxygen tubing, nasal cannulas, humidifier bottles, and the O2 external filter on O2 concentrators, should be changed weekly. Review of the facility's CPAP/BIPAP Support policy, dated 2024, showed it directed staff to: a) Set the settings on the CPAP machine as prescribed. b) Wipe the machine down with warm soapy water and rinse at least once a week. c) Refill humidifier chamber with clean distilled water only. d) Clean the humidifier chamber weekly and dry. e) to disinfect the humidifier chamber, place vinegar-water solution (1:3 ratio) into humidifier. Soak for 30 minutes and rinse thoroughly. Review of the facility's Departmental (Respiratory Therapy) Prevention of Infection Policy, dated 2024, under subtitle Infection Control Related to Medication Nebulizers/Continuous Aerosol showed it directed staff to: 1. Obtain equipment (i.e., administration set-up, plastic bag, gauze sponges). 2. Wash hands. After completion of therapy: 1. Remove the nebulizer container; 2. Rinse the container with fresh tap water; 3. Dry on a clean paper towel or gauze sponge. 4. Take care not to contaminate internal nebulizer tubes. 5. Wipe the mouthpiece with damp paper towel or gauze sponge. 6. Store the circuit in plastic bag, marked with date and resident's name, between uses. 7. Wash hands. 8. Discard the administration set-up every seven (7) days. <Oxygen Services> 1) Resident 73 admitted to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment, a diagnosis of heart failure and required the use of supplemental O2 during the assessment period. On 12/10/2024 at 9:14 AM, Resident 73 was observed lying in bed receiving O2 via nasal cannula (NC) at 2 liter per minute (L/min). Observation of the O2 concentrator showed there was a humidifier bottle attached, dated 12/03/2024 that had approximately 1/4 inch of fluid remaining and only bubbled sporadically. Resident 73's physicians' orders showed the following 03/06/2024 O2 orders: a) O2 at 1-5 L/min via NC, titrate to keep O2 saturation (O2 sat) above 92 percent. b) Change oxygen tubing once a week on Tuesdays. The orders did not include instruction to staff to check and replace the humidifier bottle as needed or direct staff to clean the O2 concentrator external filter weekly. Review of the November and December 2024 Medication Administration Records (MARs) showed for the O2 at 1-5 L/min via NC, titrate to keep oxygen saturation (SpO2) above 92 percent, order, staff were provided a place each shift to document the resident's O2 sat and the number of hours the O2 was in use. No place was provided to document how many L/min of O2 the resident was administered. Additionally, there was no direction to staff to change the resident's humidifier bottle or to replace the external filter on the O2 concentrator weekly, as directed in the facility policy. On 12/12/2024 at 12:54 PM, when asked if they could determine how many L/min of O2 the resident received each shift from 11/01/2024 - 12/12/2024 Staff L, Unit Manager, stated, No. Staff L said it was the expectation that each nurse document on the MAR how many L/min of O2 the resident was administered to maintain their O2 sat greater than 92 percent, but acknowledged they failed to do so. Staff L then explained that direction to staff to change the O2 concentrators external filter and humidifier bottle weekly, should have been included in Resident 51's O2 maintenance orders, but was not. <CPAP Services> 2) Resident 51 admitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed the resident had severe cognitive impairment, a diagnosis of obstructive sleep apnea, and required the use of a non-invasive mechanical ventilator (CPAP). Review of Resident 51's physician's orders showed the following CPAP orders: a) Apply CPAP at bedtime and remove in the AM. b) Wipe down mask (including areas that contact skin) using a damp towel with mild detergent and warm water. Allow mask to air dry out of direct sunlight. Ensure mask is dry before use. The orders did not include what the ordered CPAP pressure settings were, direction to staff to check and refill the humidifier chamber with clean distilled water only, and to clean the humidifier chamber weekly or to disinfect the humidifier chamber utilizing a 1:3 ration of vinegar and water. On 12/16/2024 at 4:25 PM, Staff C, Assistant Director of Nursing Services (ADNS), said Resident 51's CPAP orders should have included the ordered CPAP pressure settings, direction to staff to check and refill the humidifier chamber weekly and to disinfect the humidifier chamber to use a 1:3 ratio of water and vinegar and let soak for 30 minutes before thoroughly rinsing the chamber out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to promptly notify the ordering provider of laboratory results that fell outside of clinical reference ranges for 1 of 5 sample residents (Resident 73) reviewed for unnecessary medications. This failure placed residents at risk for delayed treatment and potential negative outcomes. Findings included . Review of the facility's, Provider Notification - Labs policy, dated 12/2024, showed the facility must promptly notify the attending provider of lab results that fall outside of clinical reference ranges. Delayed notification may contribute to delayed changes to the treatment plan. Promptly meant that results would be relayed with little or no delay to the ordering physician, or in accordance with facility policy regarding which labs require immediate versus non- immediate notification. Lab results requiring non-immediate provider notification could be placed in the providers folder for review upon next visit. 1) Resident 73 was admitted to the facility on [DATE]. The Annual Minimum Data Set, an assessment, dated 09/25/2024, showed the resident had severe cognitive impairment, diagnoses of diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high) and heart failure. Resident 73 received diuretic medication (medications that help reduce fluid buildup in the body) and hypoglycemic medication (medication to maintan blood sugar levels) during the assessment period. Resident 73 had a 03/17/2023 order for metformin (a diabetic medication) daily and a 03/06/2023 order for spironolactone (a diuretic medication, for heart failure) daily. A provider note, dated 05/22/2024, documented Resident 73 had elevated blood glucose levels and had their three-month blood draw scheduled for 05/24/2024. The provider ordered an A1C (a blood test that reflects your average blood glucose levels over the past 3 months) be added to the three month blood draw which also included: a complete blood count (CBC, a blood test used to look at overall health and find a wide range of conditions, including anemia, infection and leukemia); thyroid stimulating hormone (TSH, blood test that measures this hormone); complete metabolic panel (CMP, a routine blood test that measures 14 different substances in a sample of your blood); B-type natriuretic peptide (BNP, high BNP level means you may have heart failure or that your heart failure is getting worse); and vitamin D and B12 levels. Review of Resident 73's electronic health record showed an A1C was not drawn until 07/02/2024, 41 days later. The resident had an elevated A1C of 6.1, outside of the clinical reference range. Review of the lab showed the provider was not notified of the A1C result until 08/05/2024, 34 days after the lab results were available. Additionally, the labs that were to be drawn every three-months (TSH, B12, vitamin D, BNP, CBC, CMP and BNP), as of 12/16/2024, still had not been drawn as ordered. On 12/12/2024 at 1:14 PM Staff L, Unit Manager, confirmed Resident 73's A1C results were outside of the clinical reference range and were not reported to the provider for greater than a month. Staff L acknowledged the labs ordered to be drawn every three-months still had not been drawn. On 12/16/2024 at 3:43 PM, Staff C, Assistant Director of Nursing Services, said the labs were to be drawn every three-months and should have already been drawn as ordered. Staff C also said a 34-day delay between receiving lab results that were outside of clinical reference ranges, and notification of the provider, did not meet the expectation of prompt notification of the provider. Reference WAC 388-97-1260(3)(a), (4)(b), -0320(1)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest) and anxiety (increased stress). Review of the Significant Change MDS, dated [DATE], showed that Resident 11 was no longer on hospice (end of life care with limited interventions). Review of Resident 11's care plans, showed that a care plan for psychotropic drug (medication that affects the mental state) use still mentioned that Resident 11 was on comfort care (hospice), and was last revised 10/06/2024, before Resident 11 was discharged from hospice. The same care plan had an intervention, last revised 10/06/2024, for lorazepam (anti-anxiety medication) as needed every two hours for anxiety and/or restlessness. Review of the Electronic Health Record (EHR) showed Resident 11's lorazepam dose was discontinued on 11/7/2024. During an interview on 12/11/2024 at 11:32 AM, Staff E, UM/ Licensed Practical Nurse (LPN), said Resident 11's care plan was not updated since it still mentioned hospice and their care plan should have been revised when they were discharged from hospice. Staff E reported Resident 11 was not receiving lorazepam, that it had been discontinued. During an interview on 12/11/2024 at 2:16 PM, Staff B, Director of Nursing Services (DNS), said their expectation for revising care plans was for any significant change, change of condition, or any new orders or recommendations from the provider. Regarding Resident 11's care plan mentioning hospice, Staff B said their expectation was that it would have been completed timely and been up to date. 5) Resident 91 was admitted on [DATE]. On 12/11/2024 at 10:20 AM, an observation of Resident 91's door from the hallway showed no signage was posted that indicated the resident required any transmission based precautions. Review of Resident 91's care plan showed an intervention, initiated 12/30/2023, for enhanced barrier precautions (EBP, infection control precaution of wearing gown and gloves during high contact activities during resident care). During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN, said Resident 91 was not on EBP, did not need to be on EBP currently, the care plan needed to be updated, and this did not meet expectations. During an interview on 12/16/2024 at 2:59 PM, Staff B, DNS, said the care plan for Resident 91 should have been updated. 6) Resident 8 was admitted on [DATE]. Review of Resident 8's care plans showed on 07/31/2024, a care plan for aerosol contact isolation had been initiated. Resident 8 was no longer on this precaution on 12/09/2024. During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN said Resident 8's care plan needed to be updated, and their care plan did not meet expectations. During an interview on 12/16/2024 at 3:07 PM, Staff B, DNS, said this did not meet expectations. Reference WAC 388-97-1020(2)(c)(d) 3) Resident 81 was admitted to the facility on [DATE] with diagnosis of Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves) and malnutrition (lack of sufficient nutrients in the body). The Quarterly MDS, dated [DATE], showed Resident 81 was moderately cognitively impaired and did not receive nutrition via a feeding tube. On 12/10/2024 at 2:24 PM, review of Resident 81's care plan, revised 09/23/2024, showed a PEG (Percutaneous Gastrostomy) tube (used when someone is unable to eat or drink enough food or liquids to meet their nutritional needs) had been placed on 01/31/2024 and was pending discontinuation. On 12/10/2024 at 2:30 PM, a note from a medical provider, dated 09/27/2024, said the PEG tube was removed on 09/27/2024. On 12/11/2024 at 4:05 PM, Staff C, Assistant Director of Nursing Services, said care plans should be updated quarterly and/or with significant changes, by either the Unit Manager or the MDS nurse. The expectation was that care plans were updated as changes took place. Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 25 sampled residents (Residents 73, 99, 81, 8, 11 and 91) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 73 admitted to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment, diagnoses of dementia with agitation, and anxiety and depressive disorders. Resident 73 required treatment with antidepressant, antianxiety, and antipsychotic medications during the assessment period. A psychotropic drug use CP, revised 10/25/2024, showed the resident received clonazepam (an anxiolytic medication) and Seroquel (an antipsychotic medication) for anxiety. Staff were directed to monitor behaviors and document them on the behavior flowsheet. The CP did not indicate what behaviors the resident's anxiety manifested, no target behaviors (TBs) were identified that each medication was initiated to treat. On 12/12/2024 at 12:38 PM, Staff L, Unit Manager (UM), said the CP inaccurately identified the diagnosis for the use of Seroquel as anxiety, rather than dementia with severe agitation. Staff L, also said that the specific TB(s) a medication was initiated to treat should be included in the CP. Resident 73 started on mirtazapine (an antidepressant medication) daily on 04/03/2024. The indication for use was depression with a decreased appetite. Loss of interest in food was the identified TB. Review of the psychotropic drug use CP, revised 10/25/2024, showed Resident 73's mirtazapine use was not identified or addressed on the CP. On 12/12/2024 at 12:43 PM, Staff L, UM, said, Resident 73's mirtazapine should have been included on the psychotropic drug CP, but was missed. An order for Nuedexta (a central nervous system agent), dated 03/12/2023, showed it was initiated to treat pseudobulbar affect (PBA, a neurological disorder that causes uncontrollable bouts of emotion such as laughing and crying). Review of the Behavior Monitors CP, revised 10/25/2024, showed the resident was started on Nuedexta for involuntary crying/laughter related to Major Depressive Disorder (MDD), rather than PBA as stated in the order. On 12/16/2024 at 10:47 AM, Staff L, UM, said the CP was inaccurate and needed to be updated/revised to reflect a diagnosis of PBA. 2) Resident 99 admitted to the facility on [DATE]. Review of a Behavior Monitors CP, revised 10/29/2024, showed direction to staff to monitor the number of times the target behavior (SPECIFY) related to (SPECIFY Dx), (SPECIFY medication) occurred during the shift. On 12/16/2024 at 10:27 AM, Staff L, UM, said Resident 99's behavior CP was incomplete and needed to be updated to include what psychotropic medication was in use, the supporting diagnosis and the resident specific target behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review the facility failed to comprehensively assess residents for the use of bed rails/mobility bars for 4 of 5 residents (Residents 11, 51, 40,and 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy, titled Proper Use of Side Rails, revised 09/2024, documented side rails will not be offered to residents on admission. A full assessment will be completed and informed consent obtained prior to authorizing the use of side rails. 1) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest), anxiety (increased stress), and post-traumatic stress disorder (traumatic event that triggers thoughts/distress/anxiety). The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 11 was able to make needs known and was cognitively intact, but had documented delusions. The MDS showed that Resident 11 was dependent (helper does all the effort) for positioning for: 1. rolling left to right 2. sit to lying 3. lying to sitting on side of bed 4. sit to stand 5. chair to bed transfer Review of Resident 11's document, titled Assessment and Consent for Safety Enabling Device-V2, dated 04/04/2024, showed that Resident 11 had bilateral side rails ½ size for bed mobility. The form had a section that said Explain Why it is not a restraint and filled in is the answer enhanced bed mobility. Review of the document showed that it was missing: 1. Any attempt to use an alternative 2. Assessment of the resident for risk of entrapment prior to installation Review of Resident 11's orders showed the side rails, ordered 04/04/2024, were for enhanced mobility and were not to be used for patients with confusion or altered mental status unless recommended by therapy. Review of the EHR showed Resident 11 had a fall on 07/23/2024. A progress note from later that day described Resident 11 as having hallucinations, and telling staff they wanted to get into bed despite already being in bed. During an observation and interview on 12/12/2024 at 8:25 AM, Resident 11 had upper bilateral bed rails/mobility bars in an up position. Resident 11 said they were never instructed on how to lower them, did not use the mobility bars to independently position in bed, and only used the mobility bars when being repositioned by staff. During an interview on 12/13/2024 at 9:15 AM, Staff E, Unit Manager (UM)/LPN, said normally Physical Therapy/Occupation Therapy (PT/OT) was responsible for an evaluation within the first 24 hours of admission, to assess whether mobility bars were appropriate for the resident. Staff E said consent was required because they could be considered a restraint, and then the resident would need an order and care plan. When asked when mobility bars were contraindicated, Staff E said for residents that no longer need them, such as from a change of condition. In this situation, then a reevaluation would be needed to determine if they were appropriate or if it was unsafe. Documentation was requested to show if Resident 11 had any assessment completed, related to mobility bar safety, continued necessity and re-assessments after the 07/23/2024 fall. During a follow up interview on 12/13/2024 at 1:53 PM, Staff E, UM/LPN, said the requested documentation did not exist. Staff E said their expectation was for better assessments for mobility bars in resident rooms, and that the lack of documentation did not meet expectations. During an interview on 12/16/2024 at 3:25 PM, Staff B, Director of Nursing Services (DNS), when provided the list of documentation requested for Resident 11 that did not exist, said it did not meet expectations. When asked about Resident 11's fall in July, said it did not meet expectations that it was not reevaluated. 2) Resident 91 readmitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed Resident 91 had diagnoses including slurred speech and aphasia (a language disorder that affects a person's ability to communicate), and was rarely/never understood. Review of Resident 91's document titled, Assessment and Consent for Safety Enabling Device, showed no area indicating an evaluation/assessment was done. The form did not identify what less restrictive options were attempted, did not evaluate for safety or entrapment concerns or propose ways to reduce risks to the resident. Observation on 12/09/2024 at 9:08 AM, showed Resident 91 had two bed rails/mobility bars by the head of the bed, positioned up. On 12/11/2024 at 12:08 PM, Staff L, UM, said Resident 91 had bed rails and they used them. On 12/12/2024 at 6:52 AM, Staff J, Certified Nursing Assistant (CNA), said Resident 91 could not independently release the bed rails/mobility bars. 3) Resident 40 readmitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed Resident 40 had diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting their left non dominant side, dizziness, and repeated falls and was cognitively intact. Review of Resident 40's document titled, Assessment and Consent for Safety Enabling Device, showed no area indicating an evaluation/assessment was done. The form did not identify what less restrictive options were attempted, did not evaluate for safety or entrapment concerns or propose ways to reduce risks to the resident. Observation and interview on 12/12/2024 at 7:41 AM, showed Resident 40 had two bed rails/mobility bars by the head of the bed, positioned up. Resident 40 said she could not release the bed rails by herself. 4) Resident 51 admitted to the facility 07/31/2023. Review of the Significant Change MDS dated [DATE] showed Resident 51 had diagnoses that included hemiplegia and hemiparesis affecting their right dominant side and was severely cognitively impaired. Review of Resident 51's document titled, Assessment and Consent for Safety Enabling Device, showed no area indicating an evaluation/assessment was done. The form did not identify what less restrictive options were attempted, did not evaluate for safety or entrapment concerns or propose ways to reduce risks to the resident. Observation on 12/12/2024 at 8:22 AM, showed Resident 51 had two bed rails/mobility bars by the head of the bed, positioned up. On 12/12/2024 at 6:56 AM, Staff J, CNA, said Resident 51 could not independently release the side rails to the downward position. On 12/11/2024 at 2:19 PM, Staff L, UM/LPN, said only the form titled Assessment and Consent for Safety Enabling Device was being done and there was no additional document of a safety assessment done prior to placement of bed rails/mobility bars. On 12/13/2024 at 10:53 AM, Staff B, DNS, said there should be an evaluation/assessment done prior to placement of side rails/mobility bars, and a periodic reevaluation to see if they are still beneficial, safe, and appropriate for the resident. When asked for documentation for Resident's 51, 40, and 91 that an evaluation or assessment had been done for bed rails/mobility bars, Staff B said they would follow up on that. Additional documentation was provided on 12/13/2024 at 1:11 PM, by Staff B, DNS, for Resident 51 and 91. Review of the documentation showed no assessments for side rails/mobility bars. No additional documentation was received for Resident 40. During a follow up interview on 12/13/2024 at 2:03 PM, when specifically asked for bedrail assessments, Staff B, DNS, was unable to provide any documentation that bedrail assessments had been completed. Reference WAC 388-97-1060 (3)(g) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the EHR showed Resident 11 was admitted on [DATE]. The Significant Change MDS, dated [DATE], showed Resident 11 was able to make needs known and was cognitively intact. Review of Resident 11's orders showed that they were being given acetaminophen three times a day for pain and had an order for morphine (narcotic pain medication) as needed for every two hours. Review of the MAR on 12/10/2024, for November 2024 and 12/01/2024 to 12/09/2024, showed Resident 11 received morphine 12 times total in November and only once thus far in December. Pain scores were not found with scheduled acetaminophen administration. Review of the EHR showed no documentation of NPIs used for November and December 2024. Review of the previous five weekly pain assessments showed pain score out of 10 where 1 is mild pain and 10 is worst pain possible: 12/05/2024 no pain location listed, current pain 1, worst pain 1 11/28/2024 no pain location listed, current pain 1, worst pain 1 11/21/2024 no pain location listed, current pain 1, worst pain 1 11/14/2024 no pain location listed, current pain 1, worst pain 1 11/07/2024 no pain location for medications (does mention Orajel for tooth ache); No pain scores provided During an interview on 12/11/2024 at 8:29 AM, Resident 11 said they would be interested in switching to a longer acting medication for pain, had not had any discussion with the facility on changing the morphine order, and was not asked for a pain score every time acetaminophen was given. During an interview on 12/11/2024 at 3:48 PM, Resident 11 said once a week someone came and asked if they were having pain or not, but they did not remember being asked to give a specific number. Resident 11 said they did not know if they needed scheduled acetaminophen three times a day. During an interview on 12/11/2024 at 11:32 AM, Staff E, UM/LPN, said pain management was reviewed when there was a change of status such as discharging from hospice. When asked for documentation that Resident 11's narcotic pain medication, morphine, was reevaluated after Resident 11 was discharged from hospice, Staff E was unable to provide documentation. Staff E said their expectation was that staff would follow up with the provider on the necessity for pain management, or that a discussion was had on if there was an alternative option. Staff E said there was not a discussion on longer acting pain medication for Resident 11. Staff E reviewed the MAR and reported Resident 11 only received morphine three times thus far in December. Staff E said their expectation for pain management was that staff would use a pain scale, have documented the location of the pain, followed up on if the pain medication was effective, and documented a progress note of the NPIs implemented. During this interview, Staff E confirmed that there was no documentation in the EHR under progress notes of NPIs for pain, for Resident 11. Staff E said there were no pain scores connected to the scheduled acetaminophen dose, that the order needed to be updated to include scores, and that staff would not know if the acetaminophen was effective without the scores. During an interview on 12/11/2024 at 2:16 PM, Staff B, DNS, said their expectation when a resident was discharged from hospice was that medications would have been reviewed for appropriateness and staff should have referred to provider to re-evaluate medications. Staff B said Resident 11 used morphine only 12 times in November 2024, and that number did not reflect that they had persistent chronic pain. When asked if Resident 11 needed every two-hour PRN narcotic pain medication, Staff B said no because Resident 11 was not receiving medication every day. When asked about Resident 11 not having NPIs documented, Staff B said nurses had the opportunity to document in progress notes or the administration record. During this interview, Staff B said for scheduled pain medication, staff always gave the medication even when there was no pain. Staff B said Resident 11 was being monitored weekly with pain assessments for the continued need for acetaminophen. Staff B said the weekly assessments let staff know if the acetaminophen was needed. Staff B stated the resident reported the acetaminophen relieved pain during the last assessment, so the medication was still needed. When asked their expectation if a general resident that received scheduled acetaminophen was having pain scores obtained with each administration and the resident reported no pain each time for a week, Staff B said they would expect staff to review if the medication was needed. 2) Resident 355 admitted to the facility on [DATE] with a diagnosis of age-related osteoporosis (a condition where the bones become weak and brittle) with current pathological fracture (bone fracture caused by weakness of the bone structure). The Medicare 5-Day MDS showed Resident 355 was moderately cognitively impaired and was able make needs known. Review of the MAR showed an order for Tramadol (a narcotic used to treat moderate to severe pain). The order was for 100 mg every six hours as needed for pain. Resident 355 received 12 doses from December 1st through December 9th. Resident 355's care plan, dated 11/21/2024, said to monitor/document the side effects of the pain medication. There was no documentation on the side effects of the pain medication or of NPIs. On 12/10/2024 at 3:21PM, Staff D, Assistant Director of Nursing Services, said the expectation was that pain medications would have side effect monitoring and non-pharmocological interventions on the Treatment Administration Record (TAR). 4) Resident 24 was admitted to the facility 04/09/2024. Review of the Quarterly MDS, dated [DATE], showed Resident 24 had a diagnosis of chronic pain and was moderately cognitively impaired. Review of the MARs, dated November 2024 and December 2024, showed Resident 24 had an order for oxycodone every every hours PRN, with no NPIs documented. On 12/16/2024 at 12:16 PM, Staff L, UM said NPIs should be part of the pain medication orders and documented on the MAR. When asked to provide documentation that NPIs had been attempted for Resident 24, Staff L said there was no documentation this had been done. Reference WAC 388-97-1060 (3)(k)(i) Based on interview and record review, the facility failed to use nonpharmacological interventions (NPI, nonmedicated methods of achieving an outcome) prior to the use of as needed (PRN) pain medications for 4 of 8 sampled residents (Residents 11, 24, 78 and 355) when reviewed for unnecessary medications and pain. This failure placed residents at risk of avoidable side effects, taking unneeded medications, and a diminished quality of life. Findings included . 1) Resident 78 was admitted to the facility on [DATE] with diagnoses including dementia and chronic pain. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 10/17/2024, showed the resident required partial to setup assistance with activities of daily living (ADLs) and was cognitively intact. A review of Resident 78's Electronic Health Record (EHR) showed an order for oxycodone 5 milligram (mg, a unit of measurement for weight in the metric system) every 4 hours as needed for chronic pain and an order for acetaminophen 325 mg tablet, to give two tablets for mild pain/fever every six hours. A review of Resident 78's Pain Tool, dated 12/10/2024, listed Repositioning Warm blanket/towel Distraction on Phone/Tv Coloring pages as What non-pharmacological interventions reduce pain/discomfort. A review of the Medication Administration Record (MAR) for November 2024 showed Resident 78's PRN oxycodone was given 29 times and the acetaminophen was given 21 times and no NPIs were documented as provided in Resident 78's progress notes. A review of the MAR for December 2024 showed Resident 78's PRN oxycodone was given ten times and the acetaminophen was given five times and no NPIs were documented as provided in Resident 78's progress notes. On 12/11/2024 at 1:36 PM Staff B, Director of Nursing Services (DNS), said he did not see NPIs being documented for Resdient 78 in a progress note and his expectation was that the nursing staff document NPIs more when a resident complains of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . AMENDED 01/02/2024 Based on interview and record review, the facility failed to ensure 7 of 7 sampled residents (Residents 11, 73, 78, 27, 62, 22, and 82) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to fully complete the Abnormal Involuntary Movement Scale (AIMS, an assessment used to determine the severity of abnormal movements in a patient's body) for residents using antipsychotic (a class of drugs used to treat mental health conditions characterized by psychosis) medication. The facility also failed to identify, monitor, and document observed target behaviors and non-pharmacological interventions. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, unmet needs, and a diminished quality of life. Findings included . Review of the facility policy titled, Psychotropic Drugs Utilization, dated 12/2024, documented, A. Movement disorder evaluation will be completed (AIMS, DISCUS [Dyskinesia Identification System: Condensed User Scale (DISCUS), assessment tool], etc). This record will remain in the resident's chart. D. Targeted unacceptable behavior will be defined. Acceptable levels of this activity will be indicated in the care plan. (see Target Behavior Reference Guide) E. Specified behaviors to be modified will be defined if applicable. IV. The specific behavior or manifestation of the disordered thought process and the medication side effects to be monitored will be identified for each resident in their Care Plan. V. Data collection will be done on the medication administration record. VII. Documentation of observed adverse reactions will be on the medication administration record and will be summarized monthly. VIII. Staff will continue to document significant behaviors or unusual behaviors or levels of behavior in the progress notes, as they are observed on a daily and shift-to-shift basis . XI. Each psychotropic medication will be monitored separately and documented independently. 1) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest) and post-traumatic stress disorder (PTSD, traumatic event that triggers thoughts/distress/anxiety). The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 11 was able to make needs known, was cognitively intact, and had documented delusions. Review of Resident 11's orders showed they were receiving two psychotropic medications: 1. Duloxetine (an antidepressant) once a day for major depressive disorder 2. Abilify (an antipsychotic) once a day for PTSD and depression <AIMS Assessment Form> Review of Resident 11's care plan showed they were supposed to have AIMS assessments done every six months and as needed, initiated 02/17/2023, due to being on psychotropic medications. Resident 11's AIMS forms completed on 03/27/2024, 05/01/2024, and 11/01/2024 were reviewed, and all were missing the top section on the form (the part that asks the resident to perform certain tasks). During an interview on 12/11/2024 at 8:29 AM, Resident 11, after reviewing some of the questions from the top of the AIMS form that was blank, said the facility has not asked them to do them. Question seven was reviewed, Ask resident to tap thumb, with each finger, as rapidly as possible for 10-15 seconds: separately with right hand, then with left hand, and Resident 11 said they had not been asked to do that. During an interview on 12/11/2024 at 11:32 AM, Staff E, Unit Manager (UM)/Licensed Practical Nurse (LPN), said Resident 11's last AIMS form was not filled out completely as Resident 11 could complete some of tasks in the section left blank. Staff E said their expectation was to redo the AIMS assessment with all the tasks Resident 11 was capable of completing, with every box filled out with what Resident 11 could and could not complete. During an interview on 12/11/2024 at 2:16 PM, Staff B, Director of Nursing Services (DNS), said the whole form for the AIMS should be attempted. For Resident 11, Staff B said it did not meet expectations that the last AIMS form had the top section blank, and their expectation was that staff would have attempted and documented an attempt to fill out the top of the form, with a reason documented if a question was not performed. <Psychotropic Medication Behavior Monitoring> Review of Resident 11's EHR showed documentation that Certified Nursing Assistant's (CNAs) were documenting that behaviors occurred, with behaviors noted in the past 30 days on: 11/18/2024 at 5:59 AM 11/19/2024 at 8:39 PM 11/25/2024 at 9:59 PM Review of Resident 11's EHR, showed no further documentation of follow up to those behaviors being noted. No progress notes were found on those dates. No descriptions of the behaviors were found. During an interview on 12/11/2024 at 11:32 AM, Staff E, UM/LPN, when asked what the process was for behavior monitoring, said the CNA should chart and mark if a behavior happens, but cannot be descriptive. Staff E said some nurses charted on behavior monitoring also, which allowed them to write a progress note. Staff E said that behaviors needed to be monitored to investigate them, in order to know what correct interventions were needed, to determine if social services needed to be involved, if there needed to be a care conference, and if the resident needed to be put on an alert. When asked what behaviors Resident 11 had on 11/18/2024, 11/19/2024, 11/25/2024, Staff E said they were unable to find a progress note for those dates, and their expectation was for nurses to write a progress note if Resident 11 was having behaviors. During an interview on 12/11/2024 at 2:16 PM, Staff B, DNS, said when a behavior was witnessed, the CNAs were to tell the nurses, then the nurses were to provide interventions. Regarding Resident 11's behaviors, Staff B said their expectation was for Resident 11 to have been placed on alert and have monitored behaviors. <Psychotropic Medications Without Non-pharmacological Interventions> Review of Resident 11's EHR showed no documentation of non-pharmacological interventions being implemented, despite Resident 11 receiving psychotropic medication and having documented behaviors. During an interview on 12/11/2024 at 2:16 PM, Staff B, DNS, said for psychotropic medications, CNAs were able to provide non-pharmacological interventions if there were behaviors noted. Staff B said nurses had the opportunity to chart on non-pharmacological interventions when they administered psychotropic medications, and that nurses should chart in the progress notes. During an interview on 12/12/2024 at 11:23 AM, Staff E, UM/LPN, said they were unable to find any documentation that Resident 11 had non-pharmacological interventions done for psychotropic medications. 6) Resident 82 admitted to the facility on [DATE] and was diagnosed with major depressive disorder on 05/30/2024 and anxiety disorder on 12/02/2024. The Quarterly MDS, dated [DATE], showed Resident 82 was cognitively intact and was able to make needs known. A review of the EHR showed a PRN order for lorazepam (a psychotropic medication that produces a calming effect on the brain and nerves) 0.5mg. Give 0.25mgs every six hours as needed for anxiety until 11/11/2025.The medication start date was 11/11/2024. Directions to staff were: Document behaviors exhibited and non-pharmacological interventions used before giving PRN Ativan: 1. Yelling 2. Inability to self-soothe 3. Temper outburst 4. Inconsolable crying 5 refusing care. Interventions were: 1. Redirection 2. Food/beverage 3. Reassurance 4. Offered activities/exercise 5. Offer warm blanket 6. Manage pain. A review of the December MAR showed Resident 82 had received the PRN dose on the 3rd, the 6th, and the 10th. There was no documentation of behaviors exhibited or of non-pharmacological interventions. On 12/11/2024 at 4:08 PM, Staff C, Assistant Director of Nursing Services (ADNS), said lorazepam should not be ordered as a PRN for longer than two weeks as there was not sufficient documentation by the ordering provider. Behaviors exhibited should have been documented. Non-pharmacological interventions should have been implemented and documented before lorazepam was given. 7) Resident 22 admitted to the facility on [DATE]. The Quarterly MDS dated [DATE], showed Resident 22 was moderately cognitively impaired, was dependent on staff for most ADLs, and had diagoses of depression and dementia. A review of the MAR showed Resident 22 recieved two psychotropic medications: buproprion HCI ER (an anti-depressant) oral tablet extended release 100 mg every morning for major depressive disorder. Start date of 12/07/2023. duloxetine HCI (an anti-depressant) oral capsule delayed release 60 mg daily for depression/pain. Start date of 01/30/2024. A review of the CNA November task list showed Resident 22 exibited behaviors on 11/13/2024, 11/14/2024, 11/15/2024, 11/17/2024 and on 11/19/2024. The CNAs charted non-med interventions did not alter behaviors. The charting did not specify what those interventions were. There was no documentation completed by the nurse. On 12/11/24 at 04:08 PM, Staff C, ADNS, said the expectation was that the nurses monitored for side effects and the aides monitored for behaviors. They made a check mark and then were expected to tell the nurse. The nurse was expected to assess, chart, and put the resident on alert. Staff C noted these behaviors were not addressed and that there was a breakdown in the system. Non-pharmacologic interventions and behavior monitoring should have been on the Treatment Administration Record to be signed off by the nurse, for both psychoactives and narcotics. Reference WAC 388-97-1060 (3)(k)(i) 4) Resident 27 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit (communication difficulty caused by cognitive impairment), major depressive disorder, anxiety disorder and unspecified dementia (decline in mental abilities that affect daily life), with other behavioral disturbances. The Quarterly MDS, dated [DATE], documented Resident 27 was severely cognitively delayed with limited communication abilities. Resident 27's orders showed they were receiving four psychotropic medications: 1. venlafaxine (an antidepressant) once a day for depression. 2. buspirone (an antianxiety) two times a day for anxiety. 3. lorazepam (an antianxiety) three times a day and PRN for anxiety. 4. mirtazapine (an antianxiety) one time a day for appetite stimulant. Review of Resident 27's EHR showed no documentation or implementation of target behavior monitoring for any of the psychotropic medications. 5) Resident 62 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), major depressive disorder, anxiety disorder, unspecified psychosis (a mental health condition characterized by a loss of contact with reality), and unspecified dementia, severe with agitation. The Quarterly MDS, dated [DATE], documented Resident 62 was severely cognitively delayed, with limited communication abilities. Resident 62's orders showed they were receiving three psychotropic medications: 1. Lexapro (an antidepressant) once a day for depression/anxiety. 2. Seroquel (an antipsychotic) two times a day for agitation. 3. buspirone (an antianxiety) twice a day for anxiety. Review of Resident 62's EHR showed no documentation or implementation of target behavior monitoring for any of the psychotropic medications. On 12/12/2024 at 10:48 AM, Staff B, DNS, said target behaviors and monitoring should have been implemented and documented in the EHR. 3) Resident 78 was admitted to the facility on [DATE] with diagnoses including depression and anxiety. The Quarterly MDS, dated [DATE], showed the resident required setup to partial assistance with activities of daily living (ADLs) and was cognitively intact. A review of the EHR showed an order for Lexapro (a drug used to treat depression and certain anxiety disorders) 5 milligrams (mg) to be given in the morning for depression and an order for buspirone (an antianxiety medication) 5 mg to be given in the morning for anxiety. A review of the EHR showed Behavior Tracking #2 Did monitored behavior, tearfulness, statements of sadness, related to Depression DX r/t use of Lexapro occur during shift? If so, then notify LN.and yes was documented on 11/26/2024 and 12/5/2024. A review of the progress notes revealed no corresponding notes from the nurse. A review of the EHR showed Behavior Tracking #3 Did monitored behavior, break through anxiety AEB panic attacks, related to anxiety dx r/t use of Buspar occur during shift? If so, then notify LN. and yes was documented on 11/21/2024 and 12/3/2024. A review of the progress notes revealed no corresponding notes from the nurse. On 12/11/2024 at 12:57 PM, Staff E, UM/LPN said we don't have behavior monitors and her expectation was that monitors be ordered so that if there were increased depression or anxiety symptoms, an adjustment could be made. On 12/11/2024 at 1:36 PM, Staff B, DNS said the CNAs documented behavior monitoring in Point of Care (POC) and if there were behaviors, the CNAs would report them to the nurse. The nursing staff would charted by exception when Resident 78 has those behaviors. When the DNS was asked if the nursing staff were documenting the behaviors the CNAs were charting for Lexapro and Buspirone, he said I don't see any documentation in the progress notes for Resident 78 . 2) Resident 73 admitted to the facility on [DATE]. Review of the Annual MDS showed the resident had severe cognitive impairment, diagnoses of dementia with agitation, and anxiety and depressive disorders. Resident 73 required treatment with antidepressant, antianxiety, and antipsychotic medications during the assessment period. A psychotropic drug use care plan (CP), revised 10/25/2024, showed the resident received clonazepam (an antianxiety medication) and Seroquel (an antipsychotic medication) for anxiety. Staff were directed to monitor behaviors and document them on the behavior flowsheet. The CP did not indicate what behaviors the resident's anxiety manifested; no specific target behaviors (TBs) were identified that each medication was initiated to treat. A Behavior Monitor CP, revised 10/25/2024, identified the TBs for each psychotropic medications as follows: a) clonazepam- anxiousness as evidenced by calling out. b) Seroquel- agitation related to dementia with inability to self-soothe. c) mirtazapine- diminished appetite or lack of interest in food. d) Nuedexta (not a psychotropic medication)- involuntary crying/laughter, related to Major Depression Disorder. On 12/12/2024 at 12:38 PM, Staff L, UM, said the CP inaccurately identified the diagnosis for the use of Seroquel as anxiety, rather than dementia with severe agitation. Staff L, also said that the specific TB(s) a medication was initiated to treat should be included in the CP. A 09/30/2024, Pharmacist's Recommendation to Prescriber note, showed a recommendation to perform a gradual dose reduction (GDR) of the residents Seroquel to 25 milligrams (mg) three times daily. The recommendation was approved by the physician on 10/02/2024 and implemented. A 11/16/2024, Order Request, documented Resident 73 was calling out multiple times throughout the evening shift. A copy of 09/30/2024 GDR recommendation was attached. The provider responded on 11/18/2024 with an order to return the resident's Seroquel order to 25mg twice daily and 50 mg at bedtime. Review of the EHR showed Resident 73 had not demonstrated any increase in behaviors to include agitation, which had been identified as the target behavior for the use of Seroquel, since the 10/02/2024 GDR was initiated. The 11/16/2024 nurses note and order request was the first time a nurse had documented increased calling out, or any other behavior issues. No documentation was present to support the determination of a failed GDR. Additionally, calling out was the identified TB for the use of clonazepam, not Seroquel. On 12/12/2024 at 1:14 PM, Staff L, UM, confirmed calling out was the identified TB for the use of clonazepam not Seroquel. When asked if there was any documentation to support Resident 73 had demonstrated increased agitation since the Seroquel GDR was performed Staff L stated, not that I see. No further information or documentation was provided to support the determination that the resident had a failed GDR of their Seroquel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review the facility failed to ensure residents on enhanced barrier precautions (EBP, infection control precaution of wearing gown and gloves during high contact activities during resident care) had precaution signage implemented correctly for 5 out of 14 residents (Residents 19, 576, 59, 24, and 155) reviewed for EBP, that infection control precautions were followed for 2 of 3 residents (Residents 54 and 91) sampled for observation of infection control practices, the antibiotic surveillance was accurate and complete, the Legionella Water Management Program identified and monitored internal areas of risk, and to store and clean continuous positive airway pressure machines (CPAP, device that uses mild air pressure to keep breathing airways open while you sleep) for 1 of 3 residents (Resident 51) reviewed for CPAP. This failure placed residents at risk for spread of infection, health complications, unidentified care needs, and a diminished quality of life. Findings included . Review of the facility policy titled Enhanced Barrier Precautions, reviewed 10/2024, defines enhanced barrier precautions as, the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organisms] as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The policy showed clear signage will be posted by the door outside of the room and the wall above the resident bed indicating EBP precautions. The policy also showed a True Blue magnet would be used as signage outside of resident rooms on the door frame. Review of the facility policy titled, Influenza, Prevention and Seasonal Control, dated 09/2024, showed under Standard Precautions hand hygiene should be performed by staff frequently, including before and after resident contact, after any contact with potentially infectious material, and before/after removal of PPE such as gloves. < EBP Isolation Precaution Signage> 1) Review of Resident 19's Electronic Health Record (EHR) showed they admitted to the facility on [DATE], were on dialysis and had a wound. Review of the document titled Marina Isolation Precautions, provided on 12/13/2024, listed Resident 19 as being on EBP. Observation on 12/10/2024 at 9:34 AM, showed there was no EBP signage for Resident 19's room. 2) Review of Resident 576's EHR showed they admitted to the facility on [DATE] and had a urinary catheter. Observation on 12/13/2024 at 12:47 PM, showed Resident 576 did not have EBP signage posted on the door or in their room. 3) Review of Resident 159's EHR showed they admitted to the facility on [DATE]. Review of the document titled Bay Isolation Precautions, provided on 12/13/2024, listed Resident 159 as being on EBP for a slow healing wound. Observation on 12/13/2024 at 12:41 PM, showed Resident 159 had no EBP signage outside of their room. 4) Review of Resident 24's EHR showed that they admitted to the facility on [DATE]. Review of the document titled Bay Isolation Precautions, provided on 12/13/2024, did not have Resident 24 listed as being on an isolation precaution such as EBP. During an interview on 12/12/2024 at 8:58 AM, Staff L, Unit Manager (UM)/Licensed Practical Nurse (LPN), said residents with wounds or urinary catheters would need to be on EBP. Staff L said that Resident 24 was no longer on EBP. During an observation and interview on 12/12/2024 at 9:07 AM, Resident 24 was observed to have a True Blue EBP sticker on their side of the room on their wall. Staff L, UM/LPN looked at wall, removed the sign from the wall, and said that the signage was put up for the wrong resident, as Resident 24's roommate, Resident 155, was missing signage. Staff L said Resident 24 no longer needed to be on EBP as they no longer had a wound, but it was possible the signage was left up in error. 5) Review of Resident 155's EHR showed that they admitted to the facility on [DATE] and had a urinary catheter. During an observation and interview on 12/12/2024 at 9:07 AM, Resident 155 was observed to be missing signage for EBP. Staff L, UM/LPN said Resident 155 needed to be on EBP for a urinary catheter. During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN, said it did not meet expectations that Resident 19 did not have EBP signage, Resident 576 should have been placed on EBP, and it did not meet expectations that Resident 159 only had EBP signage inside the room and nonvisible from outside the room. During an interview on 12/16/2024 at 3:07 PM, Staff B, Director of Nursing Services (DNS), said it did not meet expectations that Resident 19 and Resident 576 did not have EBP signage, and there should have been an EBP sticker (sign) outside of Resident 159's room to let staff know there was a precaution. Staff B said it did not meet expectations Resident 24 was on EBP when it was no longer needed or that Resident 155 was not on EBP for a catheter. <Observations of Infection Control Practices> 6) Review of the EHR showed Resident 54 was admitted to the facility on [DATE] and was on EBP for having a suprapubic catheter (small tube that drains urine from bladder by an incision through the abdomen). An observation on 12/12/2024 at 10:17 AM, showed Staff I, LPN, did not wear a gown during catheter care. Further observation showed Staff I only used hand sanitizer/washed hands when entering and exiting the room and missed multiple opportunities for hand hygiene. Staff I hand sanitized, entered room, touched blinds, put on gloves, then provided suprapubic catheter care (involving removal of a soiled gauze), took gloves off, opened blinds, and then washed hands. During an interview on 12/12/2024 at 11:15 AM, Staff I, LPN, said for EBP rooms, staff should wear a gown and that they should have worn a gown when caring for Resident 54. Staff I said hand hygiene should be performed after catheter care, going in or out of the room, and if staff touched anything that was 'soiled.' During an interview on 12/13/2024 at 1:19 PM, Staff F, Infection Preventionist/LPN, said it did not meet expectations that staff did not wear a gown in Resident 54's room for suprapubic catheter care and there were multiple opportunities for hand hygiene including after touching blinds or other items in the room. During an interview on 12/16/2024 at 2:58 PM, Staff B, DNS, said it did not meet expectations that staff did not wear a gown during patient care for Resident 54. 7) Review of the EHR showed Resident 91 was admitted to the facility on [DATE] and was not on a special isolation precaution. Observation on 12/12/2024 at 10:13 AM, showed Staff K and Staff J, Certified Nursing Assistants (CNA), provided care to Resident 91 using a Hoyer (assistive equipment for moving a resident). Staff K was observed to wear gloves, then touched multiple surfaces in the residents' room including Resident 91, the resident's wheelchair and the Hoyer lift. The Hoyer was moved out of the room to a storage area. Staff K was observed to not clean the Hoyer and proceeded to go down the hall. During an interview at 12/12/2024 at 10:20 AM, Staff J, CNA, said since the pandemic was no longer a factor, that the Hoyer could be cleaned any time and as needed. Staff J said it was not cleaned before and after use anymore, unless the resident was on an isolation. During an interview on 12/12/2024 at 10:26 AM, Staff K, CNA, said they do not wipe the Hoyer down after every use, only if the resident is on precautions or if it is soiled. During an interview on 12/13/2024 at 1:19 PM, Staff F, Infection Preventionist/LPN, said CNAs should clean the Hoyer between use, the observation and interviews did not meet expectations, and staff would need more education. When asked about the residents that should be on EBP and have no signage, Staff F said that was why staff should clean after each resident. During an interview on 12/16/2024 at 2:59 PM, Staff B, DNS, in response to the observation and interviews regarding the Hoyer, said standard precautions should be followed and staff needed more training on this. <Infection Surveillance> Review of a document provided on 12/10/2024 for October, November, and December 2024 antibiotic line listing (a document that facilities use to monitor residents for infection, to list symptoms of the infection, to show what organism was present in any cultures, what treatment the resident was on, if they met criteria for antibiotics, etc.), showed: 1. Multiple residents had no dates listed for when symptoms started 2. Multiple residents only had one or two symptoms listed 3. Multiple residents being treated for urinary tract infection did not have cultures listed 4. Multiple residents were missing outside records for cultures During an interview on 12/12/2024 at 3:03 PM, Staff F, Infection Preventionist/LPN, said the antibiotic line listing should be fully filled out, that not all signs and symptoms were listed on the sheet, and they had missed the onset date for symptoms. Regarding labs, Staff F said the facility had switched labs, they were unable to scan any of the labs into the records, and they were not receiving an end of the month microbiology report from pharmacy, with the last report being given in September 2024. During an interview on 12/16/2024 at 1:06 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 156 having a negative urine sample, said the resident had an additional urine test done by the urologist that was positive for yeast, and the urologist had wanted the resident to stay on the antibiotic and added an additional medication to treat the yeast. Staff F said they did not document the result from the urologist. During an interview on 12/16/2024 at 1:06 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 79 and why the line listing did not include any information on the blood cultures ran at the hospital, due to sepsis (infection of the blood) and urinary tract infection being listed, Staff F said they were unaware the hospital ran blood cultures and did not have a copy of the results. At 1:54 PM, Staff F followed up on what symptoms Resident 79 had (only low blood pressure/hypotension was listed) and said that Resident 79 had pelvic discomfort, hematuria (blood in urine), hypotension, and elevated troponin (test used to measure heart damage). During an interview on 12/16/2024 at 2:44 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 66 and how facial swelling met antibiotic criteria, said Resident 66 had facial swelling, redness, and pain. Resident 66 had a CT/computed tomography scan (a machine that takes a series of X-rays and a computer for images of bones and soft tissue) that showed the resident had parotitis (inflammation of the major salivary gland). Staff F said they did not put this information on the line listing and there should have been more information on the form. During an interview on 12/16/2024 at 2:44 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 82 having the same symptoms listed in both October and December 2024 but not listed as meeting criteria for antibiotics in December, said there were more symptoms that were left off of the antibiotic line list for October, and in December there were less symptoms and those symptoms were now baseline. When asked about Resident 82 being on antibiotics despite the resident not meeting criteria to be on one, Staff F said they did not have documentation of any conversation with the provider. Review of the surveillance documents of residents currently on transmission-based precautions titled Bay Isolation Precautions and Marina Isolation Precautions, provided on 12/13/2024, showed the list: 1. Was missing a resident with EBP signage outside their room 2. Had residents on the list, with no EBP signage outside their room 3. Had incorrect room numbers for multiple residents During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN, said this form was updated the previous day on 12/12/2024 due to a new admission requiring isolation precaution. When asked about that admission not having signage up on 12/13/2024 for EBP, Staff F said the staff that admitted the resident should have placed the resident on EBP or notified nursing, and they would follow up with admissions. When asked about the room numbers not being updated, Staff F said they could be updating the room numbers. During an interview on 12/16/2024 at 3:07 PM, Staff B, DNS, said the antibiotic line listing should have been more detailed and should have included all of the resident symptoms, and that they will give the infection preventionist more tools to track laboratory values. <Legionella Water Management Program> Review of the facility's document titled, Martha & [NAME] Health Services Legionella Water Management Program, revised 08/2024, defined Legionellosis as a condition caused by the bacterium Legionella that can reside in facility water distribution systems. The document had sections for: Areas of Risk, Control Measures and Monitoring Plan and Review Process Review of Areas of Risk showed the facility had not identified any possible internal areas of risk. The document then included ice machines and eye wash stations and explained why there were not considered areas of risk. Review of Control Measures and Monitoring Plan showed the facility was to regularly test hot water temperatures to ensure they were within acceptable limits. No ranges were listed in this section of what temperatures they were monitoring for. During an interview on 12/16/2024 at 1:56 PM, Staff F, Infection Preventionist/LPN, said temperature logs were done daily, that Legionella grew best from 77 to 113 degrees Fahrenheit (F), and then showed documentation of temperature logs. When asked what happens when the temperature was within 77 to 113 degrees F, as was noted frequently on the temperature log shown, Staff F said they continued to monitor for changes, prevented stagnation, and checked on the hot water heater/boiler. When asked if these temperature logs had identified potential areas for Legionella to grow, Staff F said no because water flows through it. Staff F said to prevent Legionella, nothing should stay in the pipes. During an interview on 12/16/2024 at 2:07 PM, Staff R, Project Manager, when asked about the provided documentation of temperature logs provided above, being mostly within the range of temperature Legionella grows best in, said the facility had never identified that area as high risk to test, and that hot water heater/boilers were left at 112 to 113 degrees F to prevent burning residents. When asked about what was done in rooms not being used, Staff R said the empty rooms were cleaned but the faucets did not need to be flushed. When asked if the area from the valve to the faucet had stagnant water in that section of the pipe, Staff R said yes that section had stagnant water, and they should develop a log to track and record flushing the sinks not being used. Review of Review Process showed the Legionella Water Management Program was approved annually by the Quality Assurance and Performance Improvement (QAPI) Team. Documentation was requested on 12/16/2024 at 11:18 AM from Staff F that the program was reviewed by QAPI, and none was provided. The facility's Legionella Water Management Program included a document titled, Developing a Water Management Program to Reduce Legionella Growth & Spead in Buildings, dated 06/24/2021, a toolkit from the Centers for Disease Control and Prevention (CDC). The toolkit had information for facilities on where Legionella could grow or spread which included: Hot and cold-water storage tanks Water heaters Water filters Faucets Shower heads and hoses Pipes, valves, and fittings Eyewash stations Ice machines CPAP machines During an interview on 12/16/2024 at 1:56 PM, Staff F, Infection Preventionist/LPN, when asked about the CDC list for where Legionella could grow, said the CPAPs would be an area of concern and this would need to be addressed in the policy. When asked how the facility was monitoring the program if there were no identified areas of concern, Staff F said that was a valid concern and they would need to address that in QAPI. During an interview on 12/16/2024 at 3:31 PM, Staff A, Administrator, said their expectation for recognizing risk for Legionella was the facility should explore more avenues than they had been. Staff A said they had not gotten any Legionella test kits because they had not identified any areas of risk.<Failure to clean CPAP humidifier reservoir> Review of the facility policy titled CPAP/BIPAP SUPPORT dated 2024, documented general guidelines for cleaning: 1. Humidifier (if used): a. use clean, distilled water only in the humidifier chamber. b. clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. Resident 51 admitted to the facility 07/31/2024. Review of the Significant Change Minimum Data Set Assessment showed Resident 51 had a diagnosis of obstructive sleep apnea (intermittent airflow blockage during sleep) and was severely cognitively impaired. On 12/10/2024 at 9:48 AM, Resident 51 had a CPAP machine on their bedside table with a humidifier reservoir visible. Review of physician's orders showed Resident 51 used a CPAP machine. No orders were located regarding cleaning of humidifier reservoir. On 12/13/2024 at 2:24 PM, Staff P, LPN, said Resident 51 had a humidifier with a reservoir tank for water placement. On 12/16/2024 at 10:39 AM, Staff Q, Registered Nurse, said the CPAP reservoirs for the humidifier should be cleaned periodically, there should be physician's orders to clean the reservoir, and it should be on the Treatment Administration Record (TAR) to make sure it was getting done. Staff Q could not locate physician's orders or anything on the TAR for the cleaning of the humidifier reservoir for Resident 51. On 12/16/2024 at 12:08 PM, Staff L, Unit Manager said for Resident 51 said they could not locate orders or directions on the TAR for cleaning the CPAP reservoir, there should be orders, and it should be on the TAR. <Failure to store CPAP to prevent contamination/infection> On 12/09/2024 at 4:13 PM and 12/10/2024 at 8:42 AM, observed CPAP machine and mask on Resident 51's bedside table, mask was not in plastic bag and was resting on the tabletop. On 12/11/2024 at 12:33 PM, observed CPAP machine and mask on Resident 51's bedside table, mask was not in plastic bag and was resting on top of a radio that was on tabletop. On 12/12/2024 at 12:23 PM, Staff F, Infection Preventionist/LPN, said her expectation was for CPAP masks be wiped down daily and stored in a plastic bag at bedside after cleaning. Staff F said it did not meet expectations that Resident 51's mask was stored uncovered on the tabletop. On 12/12/2024 at 12:40 PM, Staff B, DNS, said CPAP masks should be stored in a sealed bag or container to prevent infection. Reference WAC 388-97-1320 (1)(a)(c),(2)(a)(b) .

. Based on observation and interview, the facility failed to ensure visibly dirty/soiled bed linen was removed and clean linen provided for 1 of 2 residents (Resident 97) reviewed for environment. This failure placed the resident at risk of feeling unclean, undignified, for potential infections and diminished self-worth. Findings included . A progress note, dated 10/18/2023 at 12:14 PM, documented Resident 97 had a new open area to their left ear. On 10/23/2023 at 2:08 PM, Resident 97 was observed in a left side-lying position in bed, with the left side of their head/face laying directly on the mattress without a pillow. Multiple dime and quarter sized brownish/red stains were noted on the fitted sheet clustered around Resident 97's head. Additionally, two large dry brown stains were observed on the right top side of the fitted sheet and continued off the edge of the mattress towards the floor. On 10/24/2023 at 9:54 AM and 11:18 AM, and 10/25/2023 at 12:22 PM, Resident 97's soiled bedding had not been changed. The cluster of dime and quarter sized reddish brown stains were still present on the fitted sheet around the resident's head, as were the two large dried brown stains on the right side of the fitted sheet that continued over the edge of the mattress. On 10/25/2023 at 1:04 PM, Staff B, Director of Nursing (DNS), said residents' bedding is changed routinely weekly on their shower day and as needed if dirty or soiled. On 10/25/2023 at 1:18 PM, Staff B, confirmed there was a cluster of blood stains on the fitted sheet around Resident 97's head and two large dried brown stains on right side of the sheet. Staff B said direct care staff should have identified the sheet/bedding was soiled and changed it. Reference WAC 388-97-0880 (1)(2) .

. Based on observation, interview and record review, the facility failed to ensure care plans (CPs) were reviewed, revised and accurately reflected resident care needs for 3 of 25 sampled residents (Resident 97, 73, and 100) reviewed for care plans. This placed residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 97's activities of daily living CP, revised 10/09/2023, showed the resident received a mechanical soft diet with thin liquids. Resident 97's chewing and swallowing difficulty CP, revised 10/19/2023, showed staff were to provide a mechanical soft diet with thickened liquids. Physician orders for Resident 97 showed an order, dated 02/20/2023, for a mechanical soft diet with thin liquids. Resident 97's activities of daily living CP, revised 10/09/2023, showed the resident had the following restorative programs (nursing interventions that promote the residents' ability to adapt and adjust to living as independently and safely as possible): 1) Active range of motion (ROM) utilizing motorized therapeutic cycle on level one for 15 minutes, five times per week. 2) Active ROM program to both upper extremities using a yellow elastic band, one set of 10 repetitions five days a week. 3) An ambulation program to walk 50 feet two times, three to six times a week. On 10/26/2023 at 8:44 AM, Staff B, Director of Nursing Services, said the chewing and swallowing CP was inaccurate and needed to be revised. On 10/27/2023 at 8:46 AM, Staff B said Resident 97 was no longer capable of participating in the programs and the CP needed to be revised. 2) Resident 73's activities CP, revised 10/26/2023, showed a goal that the resident would participate in activities of choice (Specify) times per week with direction to staff to encourage Resident 73's participation by (Specify). Resident 73's high risk for falls CP, revised 10/26/2023, showed staff were directed to ensure the resident was wearing appropriate footwear and describe correct client footwear i.e., brown leather shoes, tartan bedroom slippers, black non-skid socks when ambulating or mobilizing in w/c. On 10/27/2023 at 8:31 AM, Staff B said Resident 73's activities and fall risk CPs were incomplete and needed to be revised with resident specific goals and interventions. 3) Resident 100's urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) CP, revised 10/23/2023, showed no diagnosis, justification or indication for use was provided. On 10/27/2023 at 8:57 AM, Staff B explained Resident 100's catheter was discontinued by the facility but was unable to urinate and was referred to urology. Staff B said the CP needed to be updated/revised to reflect the resident's urinary retention and referral to urology. Reference WAC 388-97-1060 (3)(f) .

. Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 25 sampled residents (Residents 97 & 100) reviewed. The failure to follow and/or clarify physicians' orders when indicated and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs. Findings included . 1) Resident 97's physician orders showed an order, dated 02/20/2023, for oxycodone (narcotic pain medication) every six hours, as needed, for pain. Resident 97's October 2023 Medication Administration Record (MAR) showed the resident was medicated with oxycodone on 10/02/2023 at 5:28 PM and 10/04/2023 at 4:06 PM for a pain level of zero. Resident 97's physician orders showed an order, dated 10/15/2023, to administer oxycodone liquid concentrate every two hours, as needed, for pain or difficulty breathing and directed staff to notify hospice after two doses. Resident 97's October 2023 MAR showed the resident was medicated with oxycodone on 10/16/2023 at 9:15 PM and 10/23/2023 at 9:19 AM for pain level of zero. Additionally, from 10/15/2023 through 10/26/2023 the resident received 26 doses of oxycodone. Review of Resident 97's electronic health record showed no documentation or indication hospice was notified after Resident 97 received two doses of oxycodone as ordered or that the resident had difficulty breathing on 10/16/2023 or 10/23/2023 when they were medicated for a pain level of zero. On 10/27/2023 at 8:49 AM, Staff B, Director of Nursing Services (DNS), said facility nurses should not have administered as needed oxycodone when Resident 97 reported she had no pain. When asked if there was any documentation that the resident had difficulty breathing or that nursing notified hospice after two doses of oxycodone as ordered, Staff B stated, No. Staff B said the order was confusing and should have been clarified. Resident 97 had an order, dated 02/18/2023, to administer a blood pressure medication every morning, with direction to hold the medication if their systolic blood pressure was less than 100 or diastolic blood pressure (DBP) was less than 60. Resident 97's October 2023 MAR showed facility nurses administered the medication when the resident's DBP was less than 60 on the following occasions: 10/01/2023 with a DBP of 51; 10/07/2023 with a DBP of 58; and on 10/08/2023 with a DBP of 53. On 10/27/2023 at 8:48 AM, Staff B, DNS said on the above referenced occasions facility nurses should have held the medication as ordered but failed to do so. 2) Resident 100 had an order for Thrombo-Embolic Deterrent hose (TED, compression stockings), dated 06/14/2023, with direction to apply the TED hose every morning and remove them at bedtime. On 10/23/2023 at 3:16 PM, 10/25/23 at 12:33 PM and 10/26/2023 at 2:21 PM, Resident 100 was observed in bed wearing her personal socks. On 10/26/2023 at 2:21 PM, Resident 100 indicated she could not recall the last time staff applied her TED hose and said she did not think she had a pair anymore. Resident 100's October 2023 Treatment Administration Record (TAR) showed on each of the above referenced occasions, facility nurses signed that they had applied Resident 100's TED hose as ordered. On 10/26/2023 at 3:39 PM, Staff B, DNS, said it was the expectation that nurses follow physicians' orders and only sign for tasks they completed or validated as complete. At 3:51 PM, Staff B, DNS, indicated Resident 100's TED hose had not been applied. Staff B reviewed Resident 100's TAR and indicated the nurse signed for a task they did not complete. Reference WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i) .

**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 assessed for catheter removal as soon as possible, had a documented justification for ongoing catheter use if removal was contraindicated, or were referred to urology for evaluation in the absence of a documented justification. Additionally, the facility failed to ensure catheter care and management was provided in a manner that minimized the risk for complications and catheter related urinary tract infections for 1 of 2 residents (Resident 97) reviewed for urinary catheters. These failures placed residents at risk for catheter associated urinary tract infections and other potential negative health complications/outcomes. Findings included . Per the Centers for Disease Control Guideline for Prevention of Catheter-associated Urinary Tract Infections 2009, catheter tubing must be placed in a manner to promote an unobstructed flow of urine, from the bladder into the collection bag. Resident 97's admission Minimum Data Set (an assessment tool) showed the resident did not require the use of a urinary catheter. Resident 97's electronic health record (EHR) showed Resident 97 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 97's re-admission nursing assessment, dated 02/17/2023, showed the resident re-admitted with an indwelling urinary catheter in place and did not document justification for use. Resident 97's catheter care plan, initiated 02/17/2023, documented Resident 97 had an indwelling catheter placed at the hospital due to urinary retention. Staff were directed to assess for potential removal of catheter per physician orders. A hospital nurses note for Resident 97, dated 02/15/2023, documented the resident had a post void bladder scan that showed 360 milliliters of urine remained in their bladder and an indwelling urinary catheter was placed at that time. A hospital physician note for Resident 97, dated 02/15/2023, documented Resident 97 would need a follow-up urology appointment after discharge. Resident 97's EHR did not show documentation or indication that a follow-up urology appointment was scheduled for the resident or that the facility attempted to discontinue the catheter after re-admission to the facility. A facility nurse's note for Resident 97, dated 10/13/2023 at 1:55 PM, documented there was a concern related to Resident 97 having an indwelling catheter since February 2023 for urinary retention. The note indicated the resident had a hospice referral pending and stated a diagnosis of neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problem) or obstructive uropathy (blockage of urine flow) was recommended for continued use of the catheter. A nurses' note for Resident 97, dated 10/14/2023 at 12:17 PM, documented, Ok to add diagnosis of obstructive uropathy. The note did not indicate how the resident was determined to have obstructive uropathy (through imaging, physical examination at bedside, etc.). On 10/26/2023 at 4:13 PM, Staff B, Director of Nursing, was asked for documentation to support the justification for Resident 97's catheter use, that the resident was referred to and seen by urology and/or documentation of the test/assessment that was performed to determine the resident had obstructive uropathy. Staff B indicated he needed to look through the resident's record. No further documentation was provided. On 10/23/2023 at 2:08 PM, Resident 97's catheter drainage bag was observed hanging from the bedframe without a dignity cover. Resident 97's bed was in the low position and the drainage bag was pinched between the bottom bar of the bed frame and the floor. On 10/24/2023 at 9:54 AM and 11:18 AM, Resident 97's urinary drainage bag was observed attached to the right side of the bedframe without a dignity bag and resting on the floor. On 10/25/2023 at 12:22 PM Resident 97's urinary drainage bag was observed attached to the right side of the bedframe without a dignity bag and resting on the floor. At 1:13 PM, Staff O, Licensed Practical Nurse, confirmed Resident 97's urinary drainage bag was resting on the floor on the right side of the bed. Staff O said drainage bags should not contact the floor because it was unsanitary and placed the resident at risk for contracting a urinary tract infection. Reference WAC 388-97-1060(3)(c) .

. Based on observation, interview and record review, the facility failed to provide adaptive equipment with meals, for 1 of 1 resident (Resident 100) reviewed and who required assistance. Failure to provide adaptive equipment placed residents at risk for decreased independence with self-feeding, poor meal intake, and diminished quality of life. Findings included . Resident 100's activities of daily living care plan, revised 10/23/2023, showed staff were directed to provide light-weight silverware with built up handles (makes silverware easier to grasp) for all meals. On 10/23/2023 at 11:58 AM, Staff N, Certified Nursing Assistant (CNA) delivered Resident 100's lunch tray, positioned her in bed and exited the room. Observation of the tray showed Resident 100 was not provided silverware with built-up handles as they were assessed to require. At 12:52 PM, Resident 100 said there were attachments for the silverware in her top drawer of her bedside table that staff were to apply to the handles of her silverware. She indicated they were effective in improving her ability to handle silverware independently. Resident 100 then clarified and stated, When I get them. At at 12:54 PM, Staff N, CNA, said Resident 100 had cushions in her top drawer that staff applied to Resident 100's silverware handles that made them wider. When asked if she applied the cushions to Resident 100's silverware when she delivered the resident's lunch tray Staff N stated, No. On 10/25/2023 at 12:26 PM, Resident 100 was observed in bed resting with her eyes closed. Her lunch tray was observed sitting on her overbed table. Observation of the tray showed no cushions were applied to her silverware handles. On 10/26/2023 at 12:31 PM, Resident 100 was observed attempting to eat with standard silverware. Resident 100 said the cushions had not been applied for any meal in several days. At 3:46 PM, Resident 100 told Staff B, Director of Nursing (DNS), that staff had not been applying the cushions to her silverware. Staff B indicated he would follow-up with facility staff. At 3:48 PM, Staff B, DNS, confirmed that per Resident 100's plan of care staff were to provide silverware with built-up handles for all meals and said staff were expected to follow and implement that plan. Reference WAC 388-97-1140 (2) .

. Based on interview and record review, the facility failed to designate a member of their inter-disciplinary team (IDT) who would be responsible for working with hospice representatives to ensure effective coordination of care between the facility and hospice staff, for 1 of 1 resident (Resident 97) reviewed for hospice services. Additionally, the facility failed to obtain a copy of the resident's hospice plan of care, which identified what services were to be provided, and which delineated hospice/facility responsibilities. These failures detracted from establishing a system by which consistent communication between the facility and hospice staff occurred and placed the residents at risk for not for receiving necessary care and services. Findings included . Review of the facility's hospice program policy, revised July 2017, showed the facility would designate a member from their IDT to coordinate care with the hospice provider. The designee would be responsible for obtaining the most recent hospice plan of care and the names and contact information for hospice personnel involved with the resident. Review of the facility's Hospice Services Agreement, dated 12/01/2016, showed a hospice plan of care would include an assessment of each hospice resident's needs, and an identification of services to be provided, including the frequency of such services. Resident 97's physician's orders showed she was referred for hospice services on 10/12/2023. A hospice physician admission note for Resident 97 showed hospice services were initiated on 10/14/2023 for a diagnosis of protein calorie malnutrition. Review of Resident 97's electronic health record (EHR) did not show a hospice care plan was present, nor was there any documentation from the hospice provider that indicated what services they would be provide or at what frequency. Review of the facility's hospice program document showed the section identifying the IDT member designated to coordinate hospice care was left blank. On 10/25/2023 at 1:06 PM, when asked who the facility's designated hospice coordinator was, Staff O, Licensed Practical Nurse, indicated there was not one. Staff O then explained that hospice documentation was not located in Resident 97's EHR, but instead could be found under a hospice tab in her paper chart. Hospice coordination of care paperwork, dated 10/14/2023, was found in the resident's paper chart under the hospice tab. The document indicated the facility would be provided a hospice plan of care and physician certification of terminal illness, following the resident's admission to hospice services. Further review showed neither document was present. Review of the Hospice and Palliative Care Log in Sheet, showed no hospice personnel had signed in since the admitting hospice nurse on 10/14/2023. On 10/25/2023 at 1:11 PM, when asked what services hospice was providing for Resident 97 and if any hospice personnel had been in since her admission to services on 10/14/2023 Staff O, said he did not know. On 10/26/2023 at 9:44 AM, Staff B, Director of Nursing, confirmed the facility did not: have a designated ITD member responsible for coordinating hospice care; have a copy of Resident 97's hospice plan of care; know what services hospice was providing or at what frequency; know who Resident 97's hospice nurse/case manager was; and did not know if any hospice personnel had seen the resident since their admission to services on 10/14/2023. Reference WAC 388-97-1060 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to offer the pneumococcal vaccine to 1 of 5 sampled residents (Resident 93) reviewed for pneumonia vaccinations. This failure placed residents at risk for developing pneumonia with potential negative outcomes. Findings included . Resident 93 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and congestive heart failure. The quarterly Minimum Data Set, an assessment tool, dated 07/13/2023, documented the resident was severely cognitively impaired. The facility's Pneumococcal Vaccine policy, revised 07/2017, documented, Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. Resident 93's electronic health record (EHR) did not document the resident's pneumococcal vaccine status. The EHR did not document whether the resident was offered or received a pneumococcal vaccine. On 10/26/2023 at 1:39 PM, Staff G, Social Services Director, said typically consents for immunizations, including pneumococcal immunization, were received during quarterly care conferences. Staff G was unable to provide documentation that consent was received during previous care conferences for the resident. At 2:36 PM, Staff F, Infection Preventionist and Licensed Practical Nurse, stated, Social services is responsible for getting consents for vaccinations. Staff F said the facility was aware of inadequate documentation for offered/declined vaccinations. Staff F said education was provided upon vaccination refusal but was not always documented. On 10/27/2023 at 12:15 PM, Staff A, Administrator/Registered Nurse, said she expects residents to be vaccinated per facility's policies. Reference WAC 388-97-1340 (1), (2), (3) .

. Based on interview and record review, the facility failed to ensure resident choices regarding bathing frequency were honored for 4 of 4 residents (Residents 33, 100, 73 and 19) reviewed for choices related to bathing. The facility's failure to accommodate resident preferences related to frequency of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, decreased self-worth, and diminished quality of life. Findings included . 1)On 10/23/2023 at 3:58 PM, Resident 33 said they were supposed to be showered weekly on Mondays but felt facility staff did not consistently do so. Review of resident 33's comprehensive care plan showed their desired bathing frequency was not identified. Resident 33's September and October 2023 bathing records showed from 09/01/2023 through 10/25/2023, the resident was offered/provided bathing on three (09/11/2023, 09/25/2023 and 10/02/2023) of eight opportunities. On 10/27/2023 at 12:15 PM, Staff B, Director of Nursing (DNS), said it was the expectation that residents' bathing preferences be honored and acknowledged Resident 33's had not been. 2) On 10/23/2023 at 3:16 PM, Resident 100 said they were scheduled to be bathed once a week on Fridays, but staff sometimes did not show up. Review of Resident 100's comprehensive care plan showed the resident's desired bathing frequency was not identified. Review of Resident 100's September and October 2023 bathing records showed from 09/01/2023 through 10/25/2023, the resident was offered/provided bathing on five (09/01/2023, 9/22/2023, 09/29/2023, 10/06/2023 and 10/13/2023) of eight opportunities. On 10/27/2023 at 12:15 PM, when asked if Resident 100 was provided bathing weekly per their bathing preference Staff B, stated, No. 3) On 10/23/2023 at 3:36 PM, Resident 73 said they were scheduled for one shower a week which was acceptable but reported staff failed to consistently show up to provide it. Review of Resident 73's comprehensive care plan showed the resident's desired bathing frequency was not identified. Review of Resident 73's September and October 2023 bathing records showed from 09/01/2023 through 10/25/2023, the resident was offered/provided bathing on five (9/01/2023, 09/22/2023, 09/29/2023, 10/06/2023 and 10/13/2023) of eight opportunities. On 10/27/2023 at 12:27 PM, when asked if Resident 73 was provided bathing weekly per their bathing preference Staff B, stated, No. 4) On 10/23/2023 at 2:19 PM, Resident 19 said she was supposed to be bathed once a week, but staff frequently failed to show up to provide it. Review of Resident 19's comprehensive care plan showed the resident's desired bathing frequency was not identified. Review of Resident 19's September and October 2023 bathing records showed from 09/01/2023 through 10/25/2023, the resident was offered/provided bathing on five (9/11/2023, 09/18/2023, 09/25/2023, 10/03/2023 and 10/10/2023) of eight opportunities. On 10/27/2023 at 12:27 PM, when asked if Resident 19 was provided bathing weekly per their bathing preference Staff B, DNS, stated, No. Reference WAC 388-97-0900(1)-(4) .

Based on interview and record review, the facility failed to ensure resident admission and annual Minimum Data Sets (MDS, an assessment tool) were completed within the required timeframes for 8 of 11 sampled residents (Residents 1, 37, 26, 49, 43, 75, 33 & 94) reviewed for resident assessments. Failure to complete admission and annual assessments within the required timeframes, placed residents at risk for a delay in identification of care needs and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS's) showed annual assessments must be completed no later than the assessment reference date (ARD) plus14 calendar days and admission assessments must be completed no later than the admission date plus13 days. 1) Resident 1's electronic health record (EHR) showed an annual MDS had an ARD of 08/10/2023. Review of the annual MDS completion date showed it was not completed until 10/08/2023, 59 days after the ARD. On 10/26/2023 at 1:44 PM, Staff E, MDS Director, said Resident 1's 08/10/2023 annual MDS assessment was completed late. 2) Resident 37's EHR showed an annual MDS had an ARD of 08/11/2023. Review of the annual MDS completion date showed it was not completed until 10/12/2023, 62 days after the ARD. On 10/26/2023 at 1:45 PM, Staff E said Resident 37's 08/10/2023 annual MDS assessment was completed late. 3) Resident 26's EHR showed an admission MDS had an ARD of 06/13/2023. Review of the admission MDS completion date showed it was not completed until 08/21/2023, 70 days after the ARD. On 10/26/2023 at 1:47 PM, Staff E said Resident 26's 06/13/2023 admission MDS assessment was completed late. 4) Resident 49's EHR showed an annual MDS had an ARD of 09/01/2023. Review of the annual MDS completion date showed it was not completed until 10/25/2023, 39 days after the ARD. On 10/26/2023 at 1:49 PM, Staff E said Resident 49's 09/01/2023 annual MDS assessment was completed late. 5) Resident 43's EHR showed an admission MDS had an ARD of 12/19/2022. Review of the admission MDS completion date showed it was not completed until 02/04/2023, 48 days after the ARD. On 10/26/2023 at 1:46 PM, Staff E said Resident 43's 12/19/2022 admission MDS assessment was completed late. 6) Resident 75's EHR showed an annual MDS had an ARD of 09/15/2023. Review of the annual MDS on 10/26/2023, showed it was not completed. On 10/26/2023 at 1:51 PM, Staff E said Resident 75's 09/15/2023 annual MDS assessment was late. 7) Resident 33's EHR showed an annual MDS had an ARD of 09/07/2023. Review of the annual MDS on 10/26/2023, showed it was not completed. On 10/26/2023 at 1:52 PM, Staff E said Resident 33's 09/07/2023 annual MDS assessment was late. 8) Resident 94's EHR showed an admission MDS had an ARD of 06/12/2023. Review of the admission MDS completion date showed it was not completed until 08/19/2023, 69 days after the ARD. On 10/26/2023 at 1:54 PM, Staff E said Resident 94's 06/12/2023 admission MDS assessment was completed late. Reference WAC 388-97-1000(5)(a) .

. Based on interview and record review, the facility failed to ensure resident quarterly Minimum Data Sets (MDS, an assessment tool) were completed within 14 days of the assessment reference date (ARD) as required for 9 of 11 residents (Residents 1, 37, 26, 49, 43, 75, 33, 90 & 94) reviewed for resident assessments. Failure to timely complete resident quarterly assessments, placed residents at risk for a delay in identification of care needs and/or unmet care needs. Findings included . Review of the Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS's), showed quarterly assessments must be completed no later than the ARD plus 14 calendar days. 1) Resident 1's electronic health record (EHR) showed a quarterly MDS had an ARD of 05/10/2023. Review of the quarterly MDS completion date showed it was not completed until 07/16/2023, 69 days after the ARD. On 10/26/2023 at 1:44 PM, Staff E, MDS Director, said Resident 1's 05/10/2023 quarterly MDS assessment was completed late. 2) Resident 37's EHR showed a quarterly MDS had an ARD of 05/11/2023. Review of the quarterly MDS completion date showed it was not completed until 07/24/2023, 75 days after the ARD. On 10/26/2023 at 1:45 PM, Staff E said Resident 37's 05/11/2023 quarterly MDS assessment was completed late. 3) Resident 26's EHR showed a quarterly MDS had an ARD of 09/12/2023. Review of the quarterly MDS completion date showed it was not completed until 10/25/2023, 44 days after the ARD. On 10/26/2023 at 1:47 PM, Staff E said Resident 26's 09/12/2023 quarterly MDS assessment was completed late. 4) Resident 49's EHR showed a quarterly MDS had an ARD of 06/02/2023. Review of the quarterly MDS completion date showed it was not completed until 08/04/2023, 64 days after the ARD. On 10/26/2023 at 1:49 PM, Staff E said Resident 49's 06/02/2023 quarterly MDS assessment was completed late. 5) Resident 43's EHR showed a quarterly MDS had an ARD of 09/14/2023. Review of the quarterly MDS completion date showed it was not completed until 10/25/2023, 42 days after the ARD. On 10/26/2023 at 1:46 PM, Staff E said Resident 43's 09/14/2023 quarterly MDS assessment was completed late. 6) Resident 75's EHR showed a quarterly MDS had an ARD of 06/15/2023. Review of the quarterly MDS completion date showed it was not completed until 08/07/2023, 54 days after the ARD. On 10/26/2023 at 1:51 PM, Staff E said Resident 75's 06/15/2023 quarterly MDS assessment was completed late. 7) Resident 33's EHR showed a quarterly MDS had an ARD of 06/07/2023. Review of the quarterly MDS completion date showed it was not completed until 08/04/2023, 59 days after the ARD. On 10/26/2023 at 1:52 PM, Staff E said Resident 33's 06/07/2023 quarterly MDS assessment was completed late. 8) Resident 90's EHR showed a quarterly MDS had an ARD of 06/20/2023. Review of the quarterly MDS completion date showed it was not completed until 08/05/2023, 47 days after the ARD. On 10/26/2023 at 1:54 PM, Staff E said Resident 90's 06/20/2023 quarterly MDS assessment was completed late. 9) Resident 94's EHR showed a quarterly MDS had an ARD of 09/12/2023. Review of the quarterly MDS completion date showed it was not completed until 10/17/2023, 36 days after the ARD. On 10/26/2023 at 1:55 PM, Staff E said Resident 94's 09/12/2023 quarterly MDS assessment was completed late. Reference WAC 388-97-1000(5)(d) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include trimming residents' fingernails and toenails and providing assistance with eating for 3 of 4 dependent residents (Residents 100, 19 & 97) reviewed for ADL's. The failure to provide assistance with eating and nail care to dependent residents, placed them at risk for decreased intake, weight loss, poor hygiene, embarrassment, and a diminished quality of life. Findings included . <Assistance with Eating> 1) Review of Resident 100's quarterly Minimum Data Set (MDS, an assessment tool), dated 09/05/2023, showed the resident was cognitively intact and required extensive assistance with eating and personal hygiene. Resident 100's ADL care plan, revised 10/23/2023, showed the resident required one-person extensive assistance with meals. On 10/23/2023 at 11:58 AM, Staff N, Certified Nursing Assistant (CNA) delivered Resident 100's lunch tray, positioned her in bed and exited the room. Assistance with eating was not provided. On 10/25/2023 at 12:22 PM, Staff P, Hospitality Aide, delivered Resident 100's lunch tray, elevated the head of the resident's bed, removed the lid from the meal and exited the room. Assistance with eating was not provided. On 10/25/2023 at 1:16 PM, Staff O, Licensed Practical Nurse (LPN), said staff were expected to provide care as directed by residents' care plans, and explained staff should sit down and provide assistance with meals to residents who require it, at the time the tray is delivered. <Nail Care> On 10/23/2023 at 3:16 PM, Resident 100 reported staff had not provided toenail care for several months Resident 100's toes were observed with long, thick and untrimmed toenails. The toenail on Resident 100's third digit on the right foot curled around the end of the toe to the bottom of the toe. Resident 100's ADL care plan, revised 10/23/2023, did not show direction to staff to assist with nail care. Review of Resident 100's electronic health record (EHR) did not show orders or direction to staff indicating who should provide nail care or when. On 10/26/2023 at 3:46 PM, Staff B, Director of Nursing (DNS), indicated Resident 100's toenails were long, thick, untrimmed and required attention. 2) Review of Resident 19's quarterly MDS, dated [DATE], showed the resident was cognitively intact and required extensive assistance with personal hygiene. On 10/23/2023 at 2:37 PM, Resident 19 stated, My toenails need to be cut, they have not been for some time. Resident 19's toes were observed with long, untrimmed and uneven jagged edges. Resident 19's ADL care plan, revised 10/26/2023, did not show orders or direction to staff to assist with nail care. Review of Resident 19's EHR did not show orders or direction to staff indicating who should provide nail care or when. On 10/27/2023 at 9:26 AM, Staff B indicated Resident 19's toenails were, long thick, untrimmed, and required attention. 3) Review of Resident 97's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment and required extensive assistance with personal hygiene. On 10/25/2023 at 12:26 PM, Resident 97's toenails were observed to be long, untrimmed, and starting to curl around the end of her toes. Resident 97's fingernails were observed to long, untrimmed, and had dark debris under them. On 10/27/2023 at 9:24 AM, Staff B indicated Resident 19's toenails and fingernails were long and untrimmed and required attention. Reference WAC 388-97-1060(2)(C) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure residents received care and services as ordered for 4 of 7 residents (Residents 93, 31, 97 and 51) reviewed for bowel management. The failure to provide bowel care in accordance with the facility's bowel protocol and/or physician's orders placed residents at risk for constipation, pain/discomfort and other potential negative health outcomes. Findings included . The facility's Bowel Management Protocol, dated May 2018, documented that if a resident had had not produced a bowel movement after two days, nursing staff would initiate the bowel management protocol. On day three staff would offer Miralax (laxative) or bisacodyl (laxative) and these could be repeated the following day. If no bowel movement was produced on day four, staff would offer a bisacodyl suppository. If no bowel movement, on day five staff would offer an enema. 1) Resident 31 was admitted to the facility on [DATE]. The annual Minimum Data Set, (MDS, an assessment tool), dated 07/31/2023, documented Resident 31 was severely cognitively impaired. A physician's order, dated 06/29/2023, documented to give a bisacodyl tablet for constipation if resident did not have a bowel movement after two days. A physician's order, dated 06/29/2023, documented, bisacodyl suppository could be administered after 24 hours if no response to other medication. A physician's order, dated 11/30/2018, documented a fleet oil enema (mineral oil) could be administered 24 hours later if no bowel movement from the suppository. Resident 31's bowel record documented resident did not have bowel movements from 10/20/2023 through 10/26/2023, seven days without a bowel movement. On 10/26/2023 at 9:33 AM, Staff D, Licensed Practical Nurse (LPN), said after two days without bowel movements, the bowel protocol was to be started and the resident given a bisacodyl tablet. Staff D said if there was still no bowel movement after three days, then they would offer a bisacodyl suppository. Staff D said if there was no bowel movement after five days. then nursing staff would offer an enema. Staff D said Resident 31's last bowel movement was on 10/19/2023 and the bowel protocol should have been started. At 10:04 AM, Staff C, Unit Manager, said nursing staff are alerted to clinical needs of the resident in the computer system, including resident bowel movements. Staff C said staff use the less intrusive interventions first, starting after six shifts (48 hours) with no bowel movement. Staff C said staff would offer a bisacodyl tablet. Staff C said after another 24 hours with no bowel movements staff would offer a bisacodyl suppository. Staff C said if the resident had still not had a bowel movement after 24 hours, the resident would be offered an enema. Staff C reported Resident 31's last bowel movement was on 10/19/2023. Staff C said the bowel protocol should have been started for Resident 31. At 1:38 PM, Staff B, Director of Nursing Services (DNS), said the bowel protocol was started 24 hours without bowel movement and failure of non-pharmacological interventions. Staff B said on day three without a bowel movement, staff would offer Miralax or bisacodyl tablet. Staff B said after another 24 hours with no bowel movement, staff would offer a bisacodyl suppository. Staff B said if there was still no bowel movement within 24 hours after suppository, staff would offer an enema. Staff B said Resident 31's last bowel movement was on 10/19/2023. Staff B said Resident 31 should have had the bowel protocol offered. 3) Resident 51 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired. Resident 51's physician's order, dated 11/15/2021, documented to orally administer 17 grams of Miralax powder in 4-8oz of fluid, applesauce, or pudding and if no bowel movement, then to administer a fleet oil enema every 24 hours as needed and administer 5 MG of bisacodyl tablets orally, as needed. A 30-day bowel record report showed Resident 51 had a bowel movement on 09/25/2023 at 9:59 PM and did not have another bowel movement until 09/30/2023 at 1:59 PM, 134 hours between bowel movements. Resident 51's October 2023 Medication Administration Record (MAR) showed the bowel protocol was not initiated. 4) Resident 93 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired. Resident 93's physician's order, dated 07/04/2023, documented to orally administer 17 grams of Miralax powder in 4-8oz of fluid, applesauce, or pudding and if no bowel movement, then to administer a fleet oil enema every 24 hours as needed and administer 10 MG of bisacodyl tablets orally, as needed. A 30-day bowel record report showed Resident 93 had a bowel movement on 10/21/2023 at 9:59 PM and did not have another bowel movement until 10/26/2023 at 12:22 PM, 108 hours between bowel movements. Resident 93's October 2023 MAR showed the bowel protocol was not initiated. On 10/26/2023 at 10:38 AM, Staff C, Unit Manager and Registered Nurse, said after two days of no bowel movements, Miralax is administered. If no bowel movements 24 hours later, Bisacodyl Suppository is given. Staff C stated, Bowel protocol was not initiated. It should have been issued a few days ago. At 1:38 PM, Staff B, DNS/Registered Nurse, said bowel intervention should have been initiated. Staff B stated, Should have started it on the 24th. Reference WAC 388-97-1060 (1), (3)(c) 2) Resident 97 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 97 was severely cognitively impaired. Resident 97's physician's orders showed the resident had the following, as needed, bowel care orders: - Miralax every 24 hours, as needed, for laxative intervention - lactulose (a laxative) every eight hours, as needed, for constipation - bisacodyl tablet orally every 24 hours, as needed, for constipation - bisacodyl suppository every 24 hours, as needed, for constipation if oral bowel medication is ineffective; - fleet oil enema, every 24 hours, as needed, for constipation if oral bowel medication and suppository are ineffective. Resident 97's bowel care orders did not indicate which medication to use first, when, or how long a nurse should wait before administering the next medication if the first medication was ineffective. Resident 97's bowel record showed the resident went the following periods without a bowel movement: 09/20/2023 through 09/23/2023 (four days); 09/26/2023 through 10/06/2023 (nine days); and 10/11/2023 through 10/14/2023 (four days). On 10/26/2023 at 3:36 PM, when asked if facility nurses initiated the facility's bowel protocol and administered Miralax or a bisacodyl tablets on Resident 97's third day without a bowel movement, Staff B stated, No. Staff B also acknowledged that Resident 97's bowel care orders did not provide the same direction as the facility's bowel protocol and indicated they were confusing and should have been clarified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure residents received respiratory care in accordance with professional standards of practice and physicians' orders for 2 of 2 residents (Residents 97 & 100) reviewed for respiratory care. The facility's failure to ensure nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs) tubing and masks were cleaned and periodically changed, and a residents' peripheral oxygen saturation were monitored, as ordered to determine if administration of supplemental oxygen was indicated, placed residents at risk for unidentified and/or unmet respiratory needs and potential negative outcomes. Findings included . 1) Resident 97's quarterly Minimum Data Set (MDS), an assessment tool, dated 08/10/2023, showed the resident had no respiratory related diagnoses but required supplemental oxygen during the assessment period. Resident 97's physician's orders, dated 02/17/2023, showed an order to administer oxygen 1-4 liters per minute via nasal canula to keep oxygen saturation greater than 88 percent. Resident 97's October 2023 Medication Administration Record (MAR) showed facility nurses signed three times daily the order was carried out. The MAR did not include a place for nurses to document what Resident 97's oxygen saturation was or whether the resident was administered any supplemental oxygen. Resident 97's vital sign record for September and October 2023 showed Resident 97's oxygen saturation was checked once on the following days: 09/01/2023, 09/03/2023, 09/04/2023, 09/14/2023, 09/23/2023, 10/06/2023, 10/14/2023 and 10/20/2023. On 10/27/2023 at 8:54 AM, when asked how facility nurses determined if Resident 97 required supplemental oxygen without assessing the resident's oxygen saturation, Staff B, Director of Nursing Services (DNS), indicated they could not and stated, They would need three oxygen saturations [one for each shift] per day to carry out the order. Staff B acknowledged facility nurses failed to assess and monitor the resident's respiratory status as ordered and signed for a task they did not complete. 2) Resident 100's quarterly MDS, dated [DATE], showed the resident had an active diagnosis of respiratory failure. Resident 100 had a physician order, dated 07/18/2023, for Ipratropium/Albuterol Inhalation (inhaled medication that decreases airway inflammation) via nebulizer twice daily. On 10/23/2023 at 2:55 PM, Resident 100's nebulizer mask was observed to be oily and the mask and tubing were dated, 09/27/2023. Review of Resident 100's physicians orders did not show their were nebulizer maintenance orders in place. Resident 100's altered respiratory status care plan, revised 10/23/2023, showed there was no direction to staff to clean the nebulizer machine or to change/replace the resident nebulizer mask or tubing. On 10/23/2023 at 3:30 PM, Staff Q, Registered Nurse, confirmed Resident 100's nebulizer mask and tubing was dated 09/27/2023. On 10/26/2023 at 3:54 PM, Staff B, Director of Nursing Services, said nebulizer masks and tubing were to be changed weekly and this direction should have been included in Resident 100's orders and plan of care. Reference WAC 388-97-1060 (3)(j)(vi) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure sufficient staff to assess resident care needs, and to provide and supervise that care as evidenced by the failure to complete resident assessments within required time frames for 8 of 11 residents (Residents 1, 37, 26, 49, 43, 75, 33 & 94) reviewed, to honor resident preferences related to bathing frequency for 4 of 4 residents (Residents 33, 100, 73 and 19) reviewed for choices, and to provide assistance with activities of daily living (ADLs) for 3 of 4 dependent residents (Residents 100, 19 & 97) reviewed for ADLs. These failures placed residents at risk for poor hygiene, unidentified and unmet care needs, feelings of powerlessness, and decreased quality of life. Findings included . <Resident Assessments> On 10/26/2023 at 1:52 PM, when asked what was preventing the facility from completing resident assessments within the required time frames, Staff E, MDS (Minimum Data Set) Director, said it was staffing. Staff E explained the facility had two MDS nurses, herself and another that worked four days a week because they were in school. Staff E explained that both had to take leave at various times throughout the year and the facility did not have anyone to complete their work in their absence. On 10/27/2023 at 8:42 AM, Staff B, Director of Nursing (DNS) confirmed that both of the facility's MDS personnel had needed to take extended leave at times throughout the year and the facility was not able to replace them during their absence. <Bathing> On 10/27/2023 at 9:25 AM, Staff R, Scheduler, said the facility usually ran two shower aides per day, one on the Bay Unit and one on the [NAME] Unit. Staff R identified the shower aides as Staff S and Staff T. On 10/26/2023 at 8:29 AM, Staff S, Shower Aide, said she had 10 showers scheduled on her shift and indicated when they were fully staffed she was able to complete the showers as scheduled. Staff S said she had completed two showers so far that day but had been pulled to help with breakfast and residents who required two-person assistance with transfers. Staff S said she would likely not be able to complete the 10 showers that were scheduled for bathing that shift. Staff S said the aides on the floor were supposed to help complete bathing when the shower aides were pulled but usually were unable to because they were short staffed as well. Staff S indicated her and Staff T, shower aide, were frequently pulled to the floor. On 10/26/2023, Staff T, Bay unit Shower Aide was pulled to the floor and was not providing showers as scheduled. On 10/27/2023 Staff T called in sick. On 10/27/2023 at 8:40 AM, Staff W, Certified Nursing Assistant (CNA) and Staff X, CNA, were working on the Bay Unit. When asked if they would bathe the resident scheduled for showers that day, both stated that they would not have time. Review of the Facility's staffing from 09/01/2023 - 10/27/2023 (56 days) showed a shower aide was pulled from showers to work the floor 42 times. <Restorative and ADLs> On 10/27/2023 at 11:23 AM, when asked if there was anything preventing them from providing residents their restorative programs (A restorative program helps residents practice activities of daily living to improve, or at least maintain, overall functioning) at the frequency they were assessed to require, Staff V, Restorative Aide, stated, Staffing, that's the only thing. Staff V indicated the restorative aides get pulled to the floor occasionally to provide direct care, thus some programs would not get done. On 10/27/2023 at 11:23 AM, Staff U, Restorative Aide, said the biggest thing that prevented restorative programs from being completed was staffing. Review of the Facility's staffing from 09/01/2023- 10/27/2023 (56 days) showed a restorative aide was pulled from restorative duties to work the floor 28 times. On 10/27/2023 at 12:15 PM, when asked why he thought residents were not being bathed per their scheduled bath days Staff B, DNS, stated, In September we had some staffing issues. Refer to F561, F636, F638, F677, and F810 Reference WAC 388-97-1080(1), 1090 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 3 of 3 nourishment refrigerators (Bay Unit, Hydration Station, and [NAME] Unit). This failure placed residents at risk for cross-contamination and food borne illness. Findings included . <Bay Unit Refrigerator> On 10/23/2023 at 11:35 AM, the Bay Unit refrigerator, in the corner of Bay Dining Hall, was observed with an undated, unlabeled, and partially filled glass jar of Smuckers jelly, and 2 liter bottles of Sprite and Root Beer. At 11:35 AM, Staff J, Certified Nursing Assistant (CNA), stated, This all should have been dated here. <Hydration Station Refrigerator> On 10/27/2023 at 09:33 AM, the Hydration Station small refrigerator, was observed with an undated, unlabeled, and partially consumed glass jar of Smuckers jelly, and a jar of sweet chili sauce. In the same refrigerator unit, was an undated, and unlabeled small, orange, plastic container with unidentifiable contents of food. At 9:35 AM, Staff K, Licensed Practical Nurse (LPN), said items in the nourishment refrigerators are typically dated and labeled upon being placed there. Staff K acknowledged the items were not labeled or dated. <[NAME] Unit Refrigerator> On 10/27/2023 at 8:53 AM, [NAME] Unit refrigerator, was observed to contain an undated and unlabeled vintage cheese (16 oz) package with 1/3 package open to air.On 10/23/2023 at 10:43 AM, a container of vanilla pudding and applesauce were observed in the [NAME] unit refrigerator. Each container was labeled with a use by date of 10/22/2023. On 10/23/2023 at 10:45 AM, Staff I, Administrative Assistant, said the pudding and applesauce were past their use by dates and should have been discarded. Reference WAC 388-97-1100 (3) & 2980 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure infection control principles were followed related to management of urinary drainage bags, proper use of Personal Protective Equipment (PPE), appropriate infection control measures during COVID-19 (a disease which can be very contagious and spreads quickly and capable of progressing to severe symptoms including death) testing, and following transmission-based precautions (TBP) for COVID-19 virus for 4 of 8 sampled residents (97, 102, 10 & 311) reviewed for infection control measures related to urinary drainage bags, PPE, COVID-19 testing and TBP. These failures placed residents at risk for contracting COVID-19 and a diminished quality of life. Findings included . Facility policy entitled COVID-19 Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19, revised 10/23/2023, showed nurses should test one resident at a time. Nurses should wash their hands or use hand sanitizer before and/or after securing a sample for a COVID test. Nurses should always change gloves after securing a sample for a COVID test. Nurses should always wash their hands or use hand sanitizer when entering or exiting a resident's room. <Use of Personal Protective Equipment> Observation on 10/23/2023 at 12:09 PM, Staff G, Certified Nurse Assistant (CNA), entered room [ROOM NUMBER] with full PPE on, including a N95 mask (respiratory protective device designed for a close facial fit, efficient protection for airborne particles). Observation of the resident door with signage for Aerosol/Contact isolation. Staff G delivered a meal tray, removed all PPE except the N95 mask and sanitized her hands. Staff G entered room [ROOM NUMBER] with signage on the door for (aerosol/contact isolation) with full PPE and the same N95 mask. Staff G delivered a meal tray, removed all PPE except the N95 mask, exited the room and sanitized hands her hands. Observation and interview on 10/23/2023 at 12:14 PM, Staff G entered room [ROOM NUMBER] with signage for (aerosol/contact isolation) with full PPE and the same N95 mask. Staff G delivered a meal tray, removed all PPE, exited the room and removed the N95 mask. Staff G sanitized her hands and applied a new N95 mask. Staff G said N95 masks are to be changed between isolation rooms and she forgot to change her mask during meal delivery. Interview on 10/26/23 at 3:01 PM, Staff F, Infection Preventionist, said it is the expectation for staff to remove all PPE after leaving a resident room who is on droplet/contact precautions, disinfect hands and apply a new N95 mask. She stated staff did not follow their infection control policy. <COVID-19 Testing> Observation and interview on 10/23/23 at 10:32 AM, showed Staff H, Assistant Infection Control Nurse, performed COVID-19 testing on 2 residents who had tested negative for COVID-19. Staff H was observed testing two residents in the same room for COVID-19 and did not change gloves or wash hands between testing each resident. Staff H said she performs COVID-19 testing on residents all the time. Staff H said she does not change gloves or wash hands between residents because she completes the COVID-19 test for each resident with a separate hand. Interview on 10/23/2023 at 11:36 AM, Staff B, Director of Nursing Services (DNS), stated, I will address it. Staff B said that is not how COVID-19 testing is suppose to be done. <Resident 311> Resident 311 was admitted to the facility on [DATE]. Observation and interview on 10/23/2023 at 10:35 AM, showed Resident 311's door with signage for aerosol/contact precautions posted. Staff J, Restorative Aid, pushed Resident 311, seated in a wheelchair (w/c) from the resident's room to outside the room in the hallway with a surgical mask. Staff J said Resident 311 is on isolation for COVID exposure. Staff J said Resident 311 was brought out of her room during the day because her roommate requested Resident 311 be taken out of the room. Observation of Resident 311 on 10/23/2023 at 1:58 PM, showed Resident 311 seated in a w/c outside of her room with a mask off her nose, resting on the chin. Observation on 10/25/2023 at 9:24 AM, showed Resident 311 seated in a w/c outside of her room, in the hallway without a mask. Observation on 10/25/2023 11:17 AM, showed Resident 311 seated in a w/c outside of her room, in the hallway without a mask. Interview on 10/23/2023 at 12:15 PM, with Staff M, Registered Nurse (RN), said Resident 311 is on aerosol/contact precautions because her roommate tested positive for COVID-19. Staff M said Resident 311 is a high risk for falls and therefore brought out in the hallway for increased supervision to prevent falls. On 10/25/2023 at 4:29 PM, Staff F, Infection Preventionist, said the Local Health Jurisdiction (LHJ) advised the facility to keep all residents who tested positive for COVID in the same room. Staff F said roommates of COVID positive residents should not be in the hall without a mask because they have been exposed and should remain in their room. Staff F said she received guidance from the facility LHJ that Resident 311's door can be left open if she is 6 feet from the door because the resident is a high falls risk. <Management of Urinary Catheters> On 10/23/2023 at 2:08 PM, Resident 97's catheter drainage bag was observed without a dignity cover attached to the right side of her bedframe. Resident 97's bed was in the low position and the drainage bag pinched between the bottom bar of the bed frame and the floor. Observations on 10/24/2023 at 9:54 AM and 11:18 AM, showed Resident 97's urinary drainage bag attached to the right side of the bedframe without a dignity bag, resting on the floor. On 10/25/2023 at 12:22 PM, Resident 97's urinary drainage bag was observed attached to the right side of the bedframe without a dignity bag, resting on the floor. On 10/25/2023 at 1:13 PM, Staff O, Licensed Practical Nurse, said Resident 97's urinary drainage bag was resting on the floor on the right side of the bed. Staff O said drainage bags should not contact the floor because it was unsanitary and placed the resident at risk for contracting a urinary tract infection. Staff O said the urinary drainage bag could contaminated the floor with urine, which staff could unknowingly step in and track through the building. Reference WAC 388-97-1320 (2)(a)(5)(b) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure two out of 42 sampled residents (Resident (R) 95 and R111) were provided with choices regarding showers. R95 and R111 were dissatisfied with receiving one shower a week and communicated to staff that they wanted more showers. The facility failed to assess R95's and R111's preferences regarding desired frequency of showers and failed to make attempts to provide showers to accommodate their preferences. Findings include: Review of the Resident Self Determination and Participation policy dated February 2021 revealed, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life . Each resident is allowed to choose activities and schedule health care and healthcare providers, that are consistent with his or her interests . 1. Review of the undated admission Record provided by the facility revealed R95 was admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/13/22 in the electronic medical record (EMR) under the MDS tab, revealed R95 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (score of 13 - 15 indicates intact cognition). It was very important for R95 to be able to choose between a tub bath, shower, bed bath, or sponge bath. R95 required assistance with activities of daily living (ADLs) such as extensive assistance with bed mobility, transfers, dressing and toilet use. R95 was dependent for bathing. Review of the Care Plan dated 07/01/21, in the electronic medical record (EMR) under the Care Plan tab revealed, [R95] has an ADL self-care performance deficit r/t [related to] fatigue, limited mobility, and Parkinson's. Care plan interventions included in pertinent part, Bathing/showering: 2 PA [personal assist] Hoyer [mechanical lift] with transfers in showers; 1-2 showers a week; offer bed bath if unable to give 2nd shower. Review of the undated Resident Shower Plan of Care for R95 provided by the facility and maintained in the bath book in the shower room, failed to identify preferred frequency of bathing. The section for Frequency was blank. During an interview 10/17/22 at 1:26 PM, R95 stated she would like to receive a shower daily; however, she received showers no more than once a week. R95 stated she told multiple nursing staff members that she wanted more showers and had been asking for more showers for a while. R95 stated the staff told her they were working on it, but nothing changed, and she continued to receive a maximum of one shower a week. R95 stated that prior to the Covid [coronavirus] outbreak, she received two showers per week. Review of bath records documented on the Daily Weights tables provided by the facility for August 2022 - October 2022 [through 10/19/22] revealed R95 received one or less showers per week: -August: R95 received showers on 08/22/22 and 08/29/22 for a total of two for the month. -September: R95 received showers on 09/12/22, 09/19/22, and on 09/26/22 for a total of three for the month. -October: R95 received showers on 10/03/22, 10/12/22, and on 10/17/22 for a total of three up through 10/19/22. During an interview on 10/18/22 at 2:23 PM, Registered Nursing Assistant (RNA), Staff DD, stated all the residents in the [NAME] Unit received one shower per week, according to the schedule posted in the shower room. Staff DD stated residents were showered every seven days unless the facility was short staffed and then they might wait an extra day or so. Staff DD stated the Certified Nursing Assistants (CNAs) did not give showers; there was a designated shower aide who showered the residents. Staff DD stated R95 was cooperative with care and could express her preferences and needs. During an interview on 10/18/22 at approximately 4:35 PM, the Director of Nursing (DON), Staff B, stated she did not know how bathing preferences were assessed and where this was documented, but she would find out. During an interview on 10/19/22 at 9:04 AM, Social Services Clinician (SSC), Staff FF, stated social services was not involved in assessing residents' preferences including the provision of showers/baths. Staff FF stated residents could bring up concerns such as bathing to social services and voice them in care conferences. During an interview on 10/19/22 at approximately 2:30 PM, Certified Nursing Assistant (CNA), Staff O, stated she was the shower aide for the [NAME] unit and gave all the residents on the unit (a total of 54 residents including R95) their showers. She stated she worked as a shower aide Sunday through Thursday and someone else gave showers on Fridays. Staff O stated she got pulled to provide CNA care to residents on Sundays at times but could usually make up the showers on Monday if they were not completed on Sunday. Staff O stated R95 received showers on Thursdays. Staff O stated all residents on [NAME] unit were scheduled for one shower per week; no residents were scheduled for more than one a week. Staff O stated a lot of residents would like to be showered more often than once a week, but it was not possible because there was not enough staff. Staff O stated she typically got pulled once or twice a week to work as a CNA on the floor. Staff O stated if she could not give a shower, she tried to provide a bed bath instead and this would be documented. Staff O stated, prior to Covid, residents received two showers per week. Staff O stated she did not ask residents how many showers a week they wanted when completing the Resident Shower Plan of Care. Staff O verified the shower records provided to the surveyor for three months were complete. During an interview on 10/20/22 at 12:48 PM, Registered Nurse/Unit Manager (RN/UM) Staff II, stated R95 had spoken with him about not getting enough showers. During an interview on 10/20/22 12:50 PM, Staff B, stated the resident's preferred frequency for showers should be documented on the Resident Shower Plan of Care. Staff B stated the shower aide completed this form and it should include residents' preferences for showers/baths. Staff B stated the facility could not provide more than one shower per week due to facility staffing problems. Staff B stated, We pull the bath aide if we have crisis staffing levels. Staff B stated the priority was for residents to be fed, clean, to receive medications and treatments, and to be hydrated prior to being bathed/showered. Staff B stated, We used to have more shower aides and indicated previously, residents received two showers per week. 2. Review of the undated admission Record provided by the facility revealed R111 was admitted to the facility on [DATE]. Review of the admission MDS with an ARD of 09/23/22 in the EMR under the MDS tab, revealed R111 had intact in cognition with a BIMS score of 15. It was very important for R111 to be able to choose between a tub bath, shower, bed bath, or sponge bath. R111 required assistance with activities of daily living (ADLs) such as extensive assistance with bed mobility, transfers, dressing and toilet use. R111 was dependent for bathing. Review of the Care Plan dated 09/16/22 in the EMR under the Care Plan tab, revealed a problem of The resident has an ADL self-care deficit r/t weakness and decreased mobility related to ataxia. Interventions included in pertinent part, Bathing/Showering: The resident requires assistance with bathing/showering 1- 2x (times)/week and as necessary.1-2 showers a week offer bed bath if unable to give 2nd Shower. Review of the Resident Shower Plan of Care provided by the facility and maintained in the bath book in the shower room, failed to identify preferred frequency of bathing. The section for Frequency was blank. In addition, the sections for Preferred Shower Day and Preferred Time of Day were blank. During an interview on 10/17/22 at 11:20 AM, R111 stated she had not resided in the facility very long. R111 stated she had no choices related to the provision of showers. R111 stated she had received one shower per week since she was admitted . R111 stated it was important for her to be showered more often, that she preferred a daily shower and she had notified staff of this. R111 stated she was told by nursing staff she could receive two showers a week, but that had not occurred. Review of bath records documented on the Daily Weights tables provided by the facility for September 2022 [from 09/16/22] - October 2022 [through 10/19/22] revealed R111 received one shower per week: -September: R111 received showers on 09/22/22 and 09/29/22 for a total of two from 09/16/22 through the end of the month. -October: R111 received showers on 10/06/22 and 10/13/22 for a total of two showers up through 10/19/22. During an interview on 10/18/22 at 2:10 PM, Staff DD, stated residents, including R111, were showered every seven days by the bath aide and verified the CNAs did not give showers. During an interview on 10/19/22 at 9:12 AM Staff GG, stated residents received one shower per week with a goal of two per week. If the second shower was not provided, a bed bath should be given instead. The Shower aide was responsible for documenting showers and bed baths and whether residents refused. Staff GG stated if all residents received one shower for the week, they could offer a bed bath in lieu of a second shower. Staff GG stated the shower aide got pulled to work as a CNA on the floor when staffing was short. The priority was providing food, fluids, turning residents, changing incontinence briefs and then showers came next. During an interview on 10/18/22 at approximately 2:35 PM, Staff O, stated R111 received showers on Thursdays. R111 was lenient as far at the time of day as long as she got it. Staff O stated, They [residents] are excited when I come and can shower them. Staff O verified she did not document how many showers a week a resident preferred on the Resident Shower Plan of Care form. Reference WAC 388-97-0900(1)-(4) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to notify one (Resident (R)106) of 42 sampled residents' physician of a change in condition. R106's physician was not notified of a significant weight loss. Findings include: Review of the Change in a Resident's Condition or Status Policy dated August 2017 revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., medication change, changes in level of care, billing/payments, resident rights, etc.) Review of the undated admission Record provided by the facility, revealed R106 was admitted to the facility on [DATE]; diagnoses in pertinent part included cerebral infarction (stroke), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure) and atherosclerotic heart disease. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/21/22 in the electronic medical record under the MDS tab, revealed R106 was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (13 - 15 indicates intact cognition). During an interview on 10/18/22 at 1:39 PM, R106 stated she was weak, tired, and wanted to rest. R106 stated she could no longer get out of bed, and she was not hungry or interested in eating. R106 stated she received shakes and water, and she did not want anything else. Review of the Weights tab in the EMR under the Vitals tab revealed the resident had experienced a significant weight loss (7.4% significant weight loss in one month between 09/06/22 and 10/07/22): 10/07/22 113.6 pounds (lbs) 09/20/22 116.0 lbs 09/06/22 122.8 lbs 08/30/22 122.6 lbs 08/23/22 123.6 lbs 08/16/22 122.5 lbs 08/11/22 122.6 lbs 08/02/22 123.1 lbs Review of the EMR revealed the most recent physician's visit was on 09/12/22. The Physician's Note dated 09/12/22, in the EMR under the Progress Notes tab was written prior to the occurrence of the resident's significant weight loss. R106's weight was documented as 122.8 pounds in the progress note. The note revealed, Stable weight and good appetite. Review of the Care Plan dated 10/03/22 in the EMR under the Care Plan tab revealed, Problem r/t [related to] history of weight loss, occasionally refuses supplements ordered (Does not like the taste of Ensure); 10/3/2022- Unintentional wt [weight] loss r/t poss [possible] measurement errors and/or low PO [oral] intake a/e/b [as evidenced by] wt [weight] loss noted (-6.5%, -8# [pounds], x [times]1/mos [month]). Intervention in pertinent part included: Monitor/record/report to RD [Registered Dietitian] and MD [Medical Doctor] PRN [as needed] . significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. A request was made on 10/20/22 for documentation showing R106's physician was notified of the significant weight loss. No documentation showing the physician was specifically notified of the significant weight loss was provided. In addition, Progress Notes were reviewed for 09/20/22 - 10/19/22 and there was no documentation to show the physician was notified of R106's weight loss. During an interview on 10/20/22 at 9:21 AM, the Registered Dietitian (RD), Staff D, stated he completed a quarterly nutrition assessment on 10/03/22 and noted the weight of 116 lbs at that time, but was not sure if the weight was accurate and had requested a reweigh. Staff D reviewed R106's meal intake records during the interview and stated her nutritional intake had declined and was currently poor. Staff D stated the weight of 113.6 pounds on 10/07/22 confirmed weight loss had occurred. Staff D stated there was no facility mechanism for notifying him of significant weight losses. Staff D stated he did not know what the notification mechanism was for notifying the physician of significant weight loss. During an interview on 10/20/22 at 12:37 PM, Registered Nurse/Unit Manager (RN/UM) Staff II, stated R106's condition began to deteriorate at the end of September 2022. An order for imaging was obtained and the resident was noted with a kidney stone. A procedure to address the kidney stone was initiated on 09/30/22. The pain from the kidney stone resolved after the procedure, but R106 became weak and started to have trouble swallowing. Staff II stated the physician was informed and an evaluation for speech therapy and then a chest x-ray was conducted showing a right lung infiltrate. Staff II stated the physician prescribed antibiotic medication and the resident's diet texture was downgraded. Staff II stated the physician was aware of the resident's poor intake; however, he verified there was no documentation to demonstrate the physician was notified of the resident's significant weight loss. Reference WAC 388-97-0320 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility policy review, the facility failed to ensure one Resident (R) R86 of three residents reviewed for the use of restraints was free from unnecessary restraints. A quarterly assessment and informed consent for the resident's use of a Merry [NAME] was not consistently obtained. Findings include: The facility's Restraint Free Environment Policy; dated 2022 read, in pertinent part, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints; and A Physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint. Review of R86's admission Record, dated 10/19/22 and found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses including Alzheimer's Disease. Review of R86's most recent Assessment and Consent for Safety Enabling Device, dated 03/15/22 and found in the EMR under the Assessments Tab, indicated the resident was assessed for her use of the Merry [NAME] on that date and informed consent was obtained for the use of the Merry [NAME] from the residents Responsible Party (RP) on that date. The assessment indicated, Merry [NAME] will prevent resident from falling and it will be used only after resident is fatigue(d) from walking so much (laps after laps around the halls). Review of R86's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/08/22, revealed the Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition and indicated the resident had both short and long-term memory deficits. The Restraints Section of the assessment indicated Chair prevents Rising was used daily for the resident during the assessment reference period. Review of R86's Order Summary Report, dated 10/19/22 and found in the EMR under the Orders Tab, indicated orders for the as needed use of a Merry [NAME] when the resident was showing signs of fatigue when walking. Review of R86's Mobility Care Plan, dated 10/19/22 and found in the EMR under the Care Plan Tab, read, PRN (as needed) use of Merry [NAME] when resident is showing signs of fatigue when walking with aide. R86 was not able to be interviewed due to her poor cognition. Observation of R86 revealed the resident was using the Merry [NAME] while wandering the halls on the secured unit on 10/17/22 at 3:15 PM and on 10/19/22 at 10:06 AM and again at 11:04 AM. The Merry [NAME] was being used appropriately during the observations with no safety concerns. During an interview with Registered Nurse /Unit Manager (RN/UM) Staff J on 10/19/22 at 2:25 PM, he stated the Merry [NAME] was considered a potential restraint and so an assessment of the Merry Walker, along with informed consent by the resident's responsible party needed to be done quarterly. He stated, Usually the initial assessment is done by therapy. After that the quarterly assessments should be done by nursing. During a follow-up interview with Staff J on 10/19/22 at 3:10 PM, he stated he was unable to locate a more recent assessment and informed consent for the use of R86's Merry Walker. He stated, We are supposed to do assessment with every care conference (quarterly). I will do one now. During an interview with the Director of Nursing (DON), Staff B on 10/19/22 at 4:38 PM, she confirmed any restraint in use for a resident, including R86's Merry Walker, was to be assessed and consent obtained quarterly. Staff B verified an assessment and consent had not been completed for the use of R86's Merry [NAME] since March of 2022. Reference WAC 388-97-0620(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure fluids were available between meals for 2 of 6 residents (Residents 85 and 51) reviewed for nutrition/ hydration. This failure placed the residents at risk of dehydration and a decreased quality of life. Findings included . RESIDENT 85 Resident 85 was admitted to the facility on [DATE]. Review of the 09/07/2022 quarterly Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively impaired and required extensive assistance with drinking. Review of Resident 85's care plan, dated 12/06/2021, showed the following interventions: encourage the resident to drink fluids of choice, recommended daily fluid intake 1600 ml every 24 hours and ensure the resident has access to nectar thickened liquids whenever possible. Review of Resident 85's 10/18/2022 Nutrition/Dietary note, showed Resident 85's fluid intake was less than one liter per day. Observations on 10/17/2022 at 9:55 AM, 11:34 AM, 1:25 PM, 2:22 PM and 10/18/2022 at 8:48 AM, 9:08 AM, 1:47 PM, 3:02 PM and 10/19/2022 at 9:02 AM, 9:13 AM, 9:29 AM, 11:02 AM, 11:30AM, showed no fluids offered to resident 85 and no fluids in Resident 85's room. RESIDENT 51 Resident 51 was admitted to the facility on [DATE]. Review of the 08/12/2022 quarterly MDS, showed the resident was cognitively impaired and required extensive assistance with drinking. Review of Resident 51's care plan, dated 05/25/2020, showed the following interventions: ensure resident has access to nectar thick fluids throughout day and encourage intake of water to support adequate hydration. Observations on 10/17/2022 at 11:09 AM, 11:23 AM,1:30 PM and 10/18/2022 at 8:50 AM 12:42 PM, 1:47 PM, 2:19 PM and 10/19/2022 at 8:46 AM, 9:14 AM, 9:27 AM, 11:02 AM, 11:19 AM, 11:50 AM and 4:09 PM showed no fluids offered or accessible to Resident 51. On 10/19/2022 at 12:16 PM, Staff S, Certified Nursing Assistant, stated that she did not offer any fluids to Resident 51 or Resident 85 between breakfast and lunch. She stated that usually the Hospitality Aide offered fluids, but the aide was new. On 10/19/2022 at 12:19 PM, Staff U, Hospitality Aide, stated that she had not given any fluids to Resident 85 or 51. She stated she was new to the unit and had not offered any fluids. On 10/19/2022 at 1:12 PM, Staff C, Nursing Services Assistant Director, stated that the Hospitality Aides usually provided fluids throughout the day. Staff C stated the Hospitality Aide was new and might not know. Reviewed the observations of no fluids offered or accessible throughout the day to Resident 51 and Resident 85 for the past three days with Staff C. Staff C stated that she would expect the nursing assistants to offer fluids when they provided care and/or checked on the residents and fluids should be accessible and offered throughout the day. Reference WAC 388-97-1060(3)(h) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure there was sufficient staffing resulting in showers not being provided as scheduled. This affected three out of three sampled dependent Residents (R46, R68, and R95) reviewed for activities of daily living (ADL). Findings include: 1.Review of R46's admission Record, dated 10/19/22 and found in the Electronic Medical Record (EMR) under the Profile tab, indicated the resident was admitted on [DATE]. R46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/22, revealed the Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition and indicated the resident had both short and long-term memory deficits. The assessment also indicated the resident required two plus staff members to physically assist R46 with bathing/showering. Review of R46's undated Activities of Daily Living (ADL) Care Plan, found in the EMR under the Care Plan Tab, indicated the resident had an ADL self-care performance deficit related to increased weakness and decreased mobility secondary to Alzheimer's Disease. Interventions included, BATHING/SHOWERING: 1 person assist 2x/week and as needed. Review of R46's Documentation Survey Reports, dated 06/01/22 through 10/19/22 and found in the EMR under the Tasks Tab, indicated the resident received showers on 06/15/22, 06/30/22, 07/06/22, 08/12/22, 08/16/22, 08/20/22, 08/30/22, 09/09/22, and 09/13/22. This reflected that R46 was showered a total of nine times out of 42 opportunities to be showered over a four-month period. R46 was not able to be interviewed due to her poor cognition. 2. Review of the undated admission Record provided by the facility revealed R95 was admitted to the facility on [DATE]. Review of the annual MDS with an ARD of 09/13/22 in the EMR under the MDS tab, revealed R95 was intact in cognition with a BIMS score of 15 out of 15 (score of 13 - 15 indicates intact cognition). R95 was dependent on staff for bathing. Review of the Care Plan dated 07/01/21, in the EMR under the Care Plan tab revealed, [R95] has an ADL self-care performance deficit r/t [related to] fatigue, limited mobility, and Parkinson's. Care plan interventions included in pertinent part, Bathing/showering: 2 PA [personal assist] Hoyer [mechanical lift] with transfers in showers; 1-2 showers a week; offer bed bath if unable to give 2nd shower. Review of bath records documented on the Daily Weights tables provided by the facility, for August 2022 - October 2022 [through 10/19/22] revealed R95 received less than one shower per week as follows: -August: R95 received showers on 08/22/22 and 08/29/22 for a total of two for the month. There was no documentation of showers between 08/01/22 - 08/22/22, a 21-day period. -September: R95 received showers on 09/12/22, 09/19/22, and on 09/26/22 for a total of three for the month. There was a 14-day gap between R95's shower on 08/29/22 and her next shower on 09/12/22. -October: R95 received showers on 10/03/22, 10/12/22, and on 10/17/22 for a total of three up through 10/19/22. There was a nine-day gap between R95's shower on 10/03/22 and her shower on 10/12/22. During an interview 10/17/22 at 1:26 PM, R95 stated she would like to receive more showers than she was provided. R95 stated she received a maximum of one shower a week. R95 stated that prior to the Covid [coronavirus] outbreak, she received two showers per week and her preference was for daily showers. During an interview on 10/18/22 at 2:23 PM, Registered Nursing Assistant (RNA), Staff DD, stated residents were showered every seven days unless the facility was short staffed and then they might wait an extra day or so. Staff DD stated the CNAs did not give showers; there was a designated shower aide who showered the residents. During an interview with Certified Nursing Assistant (CNA)/Shower Aide, Staff N on 10/19/22 at 11:16 AM, she indicated she was the full-time shower aide on the secured unit and unsecured unit. She stated, I try to split everything (showers) up by workload. Everyone on the unit I try to get showered once a week. Sometimes we are short staffed, and I have to work the floor and so I can't get them (residents) showered (once per week). Staff N stated she worked in the facility Monday through Friday and that is when showers were done on her units. She stated showers were not done on the weekend because there was no staff in the facility to shower residents on the weekend. During an interview on 10/20/22 at 12:48 PM, Registered Nurse/Unit Manager (RN/UM) Staff II, stated R95 had spoken with him about not getting enough showers. During an interview on 10/20/22 12:50 PM, with the Director of Nursing (DON), Staff B, stated the facility could not provide more than one shower per week due to facility staffing problems. Staff B stated, We pull the bath aide if we have crisis staffing levels. Staff B stated the priority was for residents to be fed, cleaned, to receive medications and treatments, and to be hydrated prior to being bathed/showered. Staff B stated, We used to have more shower aides and indicated previously, residents received two showers per week. 3. Review of 68's 08/18/2022 annual MDS, showed the resident was admitted on [DATE] , was cognitively intact and required physical assistance with bathing/showers. During an interview on 10/17/2022 at 10:05 AM, R68 shared concerns about only being bathed once a week and reported often choosing to stay in bed out of fear that she smelled and/or that someone else would smell her. The resident stated that she did get up and go to activities on shower days but indicated the facility did not have enough staff to provide bathing more frequently than once a week. Review of R68's care plan, dated 02/26/2022, showed that resident should be getting two showers each week. Review of R68's EMR documentation, located in the Task/ADL bathing tab showed that resident 68 received one shower a week for thirty days look back period 09/18/2022-10/17/2022. During an interview on 10/19/22 at 11:05 AM, Staff O, Shower Aide/ Certified Nursing Assistant (CNA), acknowledged that R68 was only provided one shower a week and indicated this was due to time restraints, Staff O stated that she was only able to provide each resident one shower a week. Refer to F-677. Reference WAC 388-97-1080(1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R66's 08/31/2022 quarterly MDS showed the resident was severely cognitively impaired, had diagnoses of post-traumatic stress disorder, psychotic disorder, anxiety disorder and depression, and received antipsychotic, antidepressant, and antianxiety medication on seven of seven days during the assessment period. Review of R66's Physician's orders (POs) showed the resident had a 08/12/2022 order for lorazepam (an antianxiety medication) 0.5 MG every eight hours as needed (PRN) for anxiety until 08/01/2023. Review of R66's EMR showed a 07/29/2022 pharmacist's Note To Attending Physician/Prescriber (NTAP) that read The resident receives the PRN psychotropic lorazepam 0.5 MG every 8 hours as needed for agitation/anxiety. CMS [Centers for Medicare and Medicaid Services] regulations require a 14 day stop date on all PRN psychotropics UNLESS the physician documents clinical rationale for continued use and provides a new duration of use. Review of the NTAP form showed the physician extended the duration of the PRN lorazepam for one year, through 08/01/2022, but the space provided to document the clinical rationale for continued PRN psychotropic therapy was left blank. During an interview on 10/20/2022 at 11:13 AM, Staff B stated, No the physician did not provide a clinical rationale for extending R66's PRN lorazepam beyond 14 days, as required. Review of R66's September and October 2022 MARs showed no documentation to support non-pharmacological interventions had been identified and/or attempted prior to the administration of R66's PRN lorazepam. During an interview on 10/20/2022 at 11:13 AM, when asked if there was any documentation or indication facility nurses attempted non-pharmacological interventions prior to administration of R66's PRN lorazepam Staff B stated, No. Reference WAC 388-97-1060(3)(k)(i) Based on facility policy review, interviews, and record review, the facility failed to ensure appropriate monitoring for two Residents (R) R24 and R66 of seven residents reviewed for unnecessary use of medication. Specific behaviors were not monitored related to the administration of antipsychotic and anxiolytic medication for R24 and R66 and non-pharmacological interventions were not attempted prior to the administration of as needed anxiolytic medication for R66. Findings include: The facility's Behavioral Assessment, Intervention and Monitoring Policy dated 03/2019 read, in pertinent part, When medications are prescribed for behavioral symptoms, documentation will include: a. rationale for use; b. potential underlying causes of the behavior; c. other approaches and interventions tried prior to the use of antipsychotic medications; d. potential risks and benefits of medications as discussed with the resident and/or family; e. specific target behaviors and expected outcomes; f. dosage; g. duration; h. monitoring for efficacy and adverse consequences; and i. plans(if applicable) for gradual dose reduction. 1.Record review revealed R24 was admitted to the facility on [DATE], according to the admission Record, dated 10/19/22 and found in the Electronic Medical Record (EMR) under the Profile tab, with diagnoses including frontotemporal neurocognitive disorder and dementia with behaviors. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/22/22, located in the EMR under the MDS tab indicated the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of four out of 15. The assessment additionally indicated R24 exhibited Other behaviors not directed toward others on one to three of the days during the assessment reference period. No other behaviors were noted on the assessment. Review of R24's Behavior/Mood Care Plan, dated 10/19/22 and found in the EMR under the Care Plan tab, indicated the resident exhibited behaviors including exposing his genitals in public areas or speaking inappropriately about his genitals. Interventions included the administration of antipsychotic medications and the monitoring of these behaviors each shift on the facility's behavior tracking forms. The care plan indicated if behaviors occurred staff was to document the intervention used and notify the licensed nurse of the behavior. Review of R24's Order Summary Report, dated 10/19/22 and found in the EMR under the Orders tab, indicated orders for Abilify (an antipsychotic medication) 5 milligrams (MG) by mouth each morning for dementia with behavioral disturbance. Review of R24's Medication Administration Records (MARs) dated 09/19/22 through 10/19/22 and found in the EMR under the Orders tab indicated R24 was receiving the Abilify as ordered. Review of R24's Behavior Tracking Documentation, dated 09/19/22 through 10/19/22 and found in the EMR under the Tasks tab, indicated the resident exhibited behaviors of exposing his genitals to others or speaking inappropriately about his genitals a total of six times during that time period. The behaviors were indicated by a check under the Yes category on the document. No specifics related to the behaviors, attempted interventions, or indication the licensed nurse was notified of the behaviors were noted on the document. R24's Progress Notes, dated 09/19/22 through 10/19/22 and found in the EMR under the Notes tab, indicated nothing related to the resident's above noted behaviors. There was no notation in the progress notes to indicate the licensed nurse was notified of the behaviors, any specifics related to the behaviors, or interventions provided when the behaviors occurred. During an interview with the Director of Nursing (DON), Staff B on 10/18/22 at 3:12 PM, she stated, All behaviors should be documented on the MAR by nurses and in POC (Point of Care/CNA [Certified Nursing Assistant] Documentation) by CNAs. During an interview with Registered Nurse/Unit Manager (RN/UM) Staff J on 10/18/22 at 3:28 PM, he stated resident behaviors were to be documented in the Progress Notes by nursing. He stated the CNAs were not able to document specifics related to behaviors or interventions in their charting (POC), so they were to answer Yes or No to indicate whether a behavior occurred, and if a behavior did occur the CNA was to notify the licensed nurse so that an assessment of the resident could be done, and a specific note could be written in the progress notes related to the behavior. During an interview with Staff B and the Assistant Director of Nursing (ADON) Staff C on 10/19/22 at 4:29 PM, Staff B stated, If a behavior occurs then staff should let the (licensed) nurse know, and an assessment and progress note should be completed. That is my expectation.

Based on observations, interviews, and record review the facility failed to ensure a medication error rate of less than five percent. A total of three errors were made out of 27 opportunities during medication administration for two Residents (R) R65 and R85 of seven residents who were observed for medication administration. The facility's medication error rate was 11.11%. Findings include: The facility's Preparation and General Guidelines: Medication Administration-General Guidelines Policy dated 03/04/14 read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; and 7) Tablet Crushing/ Capsule Opening: Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines: Long-acting or enteric coated dosage forms should not be crushed; an alternative should be sought. Some long-acting capsules can be opened and administered (without crushing contents). Gloving is recommended to protect the nurse from exposure to contents of the capsule. Check with pharmacist before opening any capsules; and The need for crushing medications is indicated on the resident's orders and on the MAR (Medication Administration Record) so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety issues and alternatives, if appropriate, during medication regimen reviews. 1.Review of R65 current Physician Orders,located in the electronic medical record (EMR) under the Orders tab, revealed an order for Tamsulosin (for urinary retention) 0.4 milligram (mg) capsule, one capsule by mouth daily. The order indicated Do Not Crush. Observation on 10/18/22 at 8:45 AM revealed Registered Nurse (RN), Staff I was observed to open R65's Tamsulosin capsule and pour the contents in the medication cup along with the resident's other (crushed) medications. The medications were administered to R65 by mouth. During an interview with Staff I on 10/19/22 at 12:38 PM, she indicated she had spoken with the facility's pharmacist and was told the Tamsulosin capsules were not supposed to be opened. She stated, We are going to fix that. Review of the Pearson Nurse's Drug Guide, found at the nurse's station and used by facility for medication administration reference, indicated for Tamsulosin capsules do not crush, chew, or open. 2. Review of R85's current Order Summary Report, located in the EMR under the Orders tab, revealed orders for amantadine (antiviral) 100 mg by mouth daily and potassium chloride ER (extended release) 10 Milliequivalents (MEQ) daily. The orders indicated all medications were to be given whole in applesauce. Observation of Staff K on 10/19/22 at 8:28 AM revealed Staff K crushed R85's amantadine and potassium chloride along with all her other medications and administered them to the resident by mouth. Review of the Pearson Nurse's Drug Guide, found at the nurse's station and used by facility for medication administration reference, indicated the amantadine and the potassium chloride were not to be crushed. During an interview with Staff K on 10/19/22 at 9:49 AM, he indicated R85 had been recently having a hard time swallowing. He reviewed the resident's EMR and stated he could not find an order to crush the resident's medication. Staff K stated he was unsure of what medications could be crushed and what medications could not. During an interview with the Director of Nursing (DON) Staff B and the Assistant Director of Nursing (ADON), Staff C on 10/19/22 at 10:00 AM, both stated a crush order was needed if a resident's medications were to be crushed and long acting/extended release and enteric coated medications were not to be crushed. Reference WAC 388-97-1060(3)(k)(i) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, hospital record review, policy review, the facility failed to ensure one of three residents (Resident (R)53) reviewed for accidents received assistance with transportation after a failed attempt to obtain an x-ray. This created the potential for a delay in the resident's continued rehabilitation after sustaining multiple fractures and being on bedrest. Findings include: Review of the Transportation and appointment Communication policy dated October 2018 revealed, 1. The Transportation Manager (TM) schedules all appointments and drives for residents. 2. The Transportation Manager schedules staff transportation pickups/drop-offs with M&M transportation only. TM notifies the staffing office weekly if a staff member is required for appointments. The TM confirm appointments and transportation 1 week prior to appt . If the unit receives information regarding a cancelled appointment after hours, please email the TM [transportation manager]. Review of the undated admission Record provided by the facility, revealed R53 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/12/22 in the electronic medical record (EMR) under the MDS tab, revealed R53 was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (score of 13 - 15 indicates intact cognition). Review of the hospital Physician's Note dated 03/28/22 in the EMR under the Misc. [miscellaneous] tab, revealed R53 was hospitalized on [DATE] due to a fall with back pain. Diagnoses included closed odontoid fracture (break that occurs trough a specific part of the second vertebra bone in the neck) , multiple closed fractures of pelvis without disruption of pelvic ring, and a compression fracture of L4 (lumbar 4) vertebra. No surgical interventions were conducted, and the resident was discharged back to the facility on bed rest and with a cervical collar. Review of the Progress Notes from 09/29/22 - 10/18/22 in the EMR under the Progress Notes tab showed one entry related to the back and pelvis x-rays, Appointment with [name of facility] [NAME] [radiology] 09/30/22 @ 11:00 [AM] for lumbar, spine, pelvis. During an interview on 10/17/22 at 2:23 PM, R53 stated she had a fall in the bathroom (occurred on 03/27/22) and broke her back and her neck and had been on bedrest, for the most part, since the fall. R53 stated she had been cleared to be transferred by the mechanical lift into her wheelchair and could currently be up in the wheelchair for a couple of hours. R53 stated she had not been allowed to put her feet on the floor yet. R53 stated she had an appointment a few weeks ago to get x-rays which could clear her to start working on standing. R53 stated she was transported seven miles to the appointment to get the x-rays done, stating it was painful to be transported there and back and to be up in the chair that long. R53 stated when she arrived at the appointment, she was told they could not take the x-rays because a mechanical lift was needed to transfer her and the provider did not have a lift. R53 stated the appointment to obtain the x-rays had not been rescheduled. R53 stated, I have been waiting a long time, weeks. I need the x-rays. During an interview on 10/19/22 at 9:22 AM, Registered Nurse (RN), Staff GG, stated R53 had not been cleared yet for full mobility following her fall with multiple fractures. Staff GG stated it had been a long recovery for R53. Staff GG stated the facility had called ahead to ensure the radiology provider could transfer R53 with a lift to conduct the x-rays. Staff GG stated when R53 arrived to get the x-rays of the back and pelvis, she was told the x-rays could not be completed because there was no mechanical lift for transferring her. Staff GG could not find information to show the x-rays had been rescheduled. During an interview on 10/19/22 at 11:30 AM, the Administrative Assistant, Staff AA, stated she was responsible for setting up transportation. Staff AA stated Staff CC helped keep track of appointments/transportation for residents residing on [NAME] unit (where R53 resided). Staff AA stated she just recently heard about R53 needing to have the x-rays rescheduled. Staff AA stated she would ask the physician for an order and should be able to get her rescheduled quickly. Staff AA stated R53 was transported to the original appointment with the facility transportation on 09/30/22. Staff AA stated, Normally when they come back, I get a copy of what happened. I do not think I got any papers. Staff AA stated she had been on vacation for a week and was told when she returned from vacation that R53 could not be transferred by a lift at the appointment. During an interview on 10/19/22 at 1:27 PM Staff CC, on the [NAME] unit, stated R53 went to the x-ray appointment, and they could not do the x-rays because they did not have a lift. Staff CC stated she was not aware of the situation (the x-ray was not obtained) until 10/03/22. Staff CC stated, Today I made an appointment for the 26th (10/26/22). Staff CC stated she was not sure why there was a delay in rescheduling the appointment and transportation and further stated the appointment should have been rescheduled right away. Staff CC stated the necessary communication did not occur. Staff CC stated Staff AA was responsible for setting up the transportation. Staff CC stated it was her responsibility to send the referrals to Staff AA. Staff CC verified the x-rays were for the back and pelvis. During an interview on 10/20/22 at 12:14 PM, the Director of Nursing (DON), Staff B, stated Staff AA was the appointment coordinator. Staff B stated Staff AA needed information from nursing or the office that the appointment needed to get rescheduled. Staff AA stated the appointment should have been rescheduled right away. Staff B reviewed the EMR and stated she did not see a note regarding communication that the resident's x-ray was not completed. Staff B stated she also did not see a note from the radiology office. Staff B stated the facility sent the resident with an MD (medical doctor) visit packet and the radiology office should fill in any issues or orders which would then prompt the communication to get the appointment rescheduled. Staff B stated there was no paperwork from the visit. Staff B verified there was an appointment now scheduled for 10/26/22 to obtain the x-rays. Reference WAC 388-97-1060(1) .

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QA&A) committee that met at least quarterly and included the Medical Director or his/her designee. This failure detracted from the interdisciplinary effectiveness of the team. Findings included . During an interview on 10/20/2022 at 1:18 PM, Staff A, Administrator and Staff B, Director of Nursing Services, explained the facility's QA & A committee met a minimum of quarterly with the most recent meetings being held on 05/20/2022 and 08/19/2022. When asked to review the sign in list of attendees Staff B explained that several attendees attended the meeting from offsite and an email system was used to validate attendance, Staff B indicated she would check the system for documentation to validate the Medical Director or designees' attendance. During an interview on 10/20/2022 at 1:58 PM, Staff B indicated the facility did not have documentation to support the Medical Director or designee attended either of the past two quarterly QA & A meetings. Reference WAC 388-97-1760(1)(2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to ensure there was an appropriate rationale for the administration of antibiotics for one Resident (R ) R86 of a total of 42 residents reviewed in the sample. Findings include: The facility's Antibiotic Stewardship-Orders for Antibiotics Policy dated 12/2016 read, in pertinent part, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing; and 3. Appropriate indications for use of antibiotics include a. Criteria met for clinical definition of active infection or suspected sepsis; and b. pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Review of R86's admission Record, dated 10/19/22 and found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses including Alzheimer's Disease. Review of R86's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/08/22, revealed the Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition and indicated the resident had both short and long-term memory deficits. Review of R86's Order Summary Report, dated 10/19/22 and found in the EMR under the Orders Tab, indicated orders for Doxycycline (an antibiotic) 100 milligrams (mg) to be administered twice daily for seven days beginning on 10/13/22 for fever. R86 also had additional orders for a chest x-ray, COVID-19 test, urinalysis with culture and sensitivity, and complete blood count (CBC) with differential and Complete Metabolic Panel (CMP) related to her fever. Review of R86's Progress Notes, dated 10/13/22 and found in the EMR under the Progress Notes tab, read, Res (resident) with 99.9 tympanic temp [temperature], runny nose, cough, lungs clear, negative in house covid test Res [resident] eating well, taking fluids w/o (without) issues. Mentation unchanged w/ (with) possible sleepiness but difficult to assess w/ resident's inconsistent habits. Eating dinner currently. Labs drawn LFA (left forearm). Nasal swab completed. Second eve[evening] nurse to obtain UA (urinalysis) and place outside in lab box tonight. Review of R86's UA Results, COVID-19 results, chest x-ray, CBC, and CMP were reviewed. Results of all tests were negative. R86 was not able to be interviewed due to her poor cognition. During an interview with the Licensed Practical Nurse/Infection Preventionist (LPN/IP) Staff H on 10/19/22 at 1:27 PM, she indicated the facility followed the McGeer's Criteria for the identification of infection requiring treatment with antibiotics. She stated R86's symptoms did not meet the criteria for the administration of an antibiotic for her fever. Staff H stated, He (the physician) ordered the doxycycline almost immediately after urine was collected (to complete a urinalysis) due to the resident's fever. That is not normal practice around here, but we have changed providers a lot and we will be talking to providers about antibiotic stewardship. We discontinued the antibiotic once all the (test) results came back negative. Staff H indicated the physician who ordered antibiotics for R86's fever was not one of the facility's normal providers, and that the physician was covering for the facility's regular provider on the day the antibiotics were ordered. During an interview with the Director of Nursing (DON) Staff B and the Assistant Director of Nursing (ADON) Staff C on 10/19/22 at 4:35 PM, both stated the facility used McGeers criteria to guide the use of antibiotics for residents and their expectation was the criteria be met prior to the administration of any antibiotic. No Associated WAC .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide assistance with activities of daily living (ADLs) related to bathing and showers for 3 of 6 residents (Residents 68, 46 and 95) reviewed for ADLs and/or choices. This failure placed the residents at risk for unmet care needs, poor hygiene, skin breakdown, decrease quality of care and diminish quality of life. Findings included Review of facility policy titled Resident Showers, reviewed 10/18/2022, showed It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Resident 68 Review of Resident 68's 08/18/2022 annual Minimum Data Set (MDS, an assessment tool), showed the resident was admitted on [DATE] with diagnosis to include peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), hemiplegia and hemiparesis affecting right dominant side(paralysis and or weakness of partial or total body function on one side of the body), was cognitively intact and required physical assistance with bathing/showers. During an interview on 10/17/2022 at 10:05 AM, Resident 68 shared concerns about only being bathed once a week and reported often choosing to stay in bed out of fear that she smelled and/or that someone else would smell her. The resident stated that she did get up and go to activities on shower days, but indicated the facility did not have enough staff to provide bathing more frequently than once a week Review of Resident 68's care plan, dated 02/26/2022, showed that resident should be getting two showers each week. Review of Resident 68's electronic health record (EHR) documentation, located in the Task/ADL bathing tab showed that resident 68 recieved one shower a week for thirty days look back period 09/18/2022-10/17/2022. During an observation and interview on 10/19/2022 at 08:54 AM, Resident 68 was observed sitting up in a wheelchair next to the bed applying eye makeup. The resident stated that she was up in the wheelchair and very happy, because she received a shower, was clean, smelled good, and would now be attending BINGO later in the day. During an interview on 10/19/22 at 11:05 AM, Staff O, Shower Aide/ Certified Nursing Assistant (CNA), acknowledged that Resident 68 was only provided one shower a week and indicated this was due to time restraints, Staff O stated that she was only able to provide each resident one shower a week. During an interview on 10/18/22 02:35 PM, when asked if Resident 68 was consistently provided two showers a week in accordance with her personalized plan of care Staff B, DNS, stated No we are not meeting her shower needs per her care plan. 1.Review of Resident (R) 46's admission Record, dated 10/19/22 and found in the EMR under the Profile tab, indicated the resident was admitted on [DATE] with diagnoses including Alzheimer's Disease. R46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/22, revealed the Brief Interview for Mental Status (BIMS) assessment was not able to be completed due to the resident's poor cognition and indicated the resident had both short and long-term memory deficits. The assessment also indicated the resident required two plus staff members to physically assist R46 with bathing/showering. Review of R46's undated Activities of Daily Living (ADL) Care Plan, found in the EMR under the Care Plan Tab, indicated the resident had an ADL self-care performance deficit related to increased weakness and decreased mobility secondary to Alzheimer's Disease. Interventions included, BATHING/SHOWERING: 1 person assist 2x/week and as needed. Review of R46's Documentation Survey Reports, dated 06/01/22 through 10/19/22 and found in the EMR under the Tasks Tab, indicated the resident received showers on 06/15/22, 06/30/22, 07/06/22, 08/12/22, 08/16/22, 08/20/22, 08/30/22, 09/09/22, and 09/13/22. This reflected that R46 was showered a total of nine times out of 42 opportunities to be showered over a four-month period. R46 was not able to be interviewed due to her poor cognition. R46 was observed awake and wandering about the facility's secured unit on 10/17/22 at 2:15 PM, 10/18/22 at 09:20 AM and 2:05 PM, 10/19/22 at 11:04 AM and1:15 PM, and 10/20/22 at 8:49 AM. The resident appeared disheveled during all of the observations and her hair appeared oily and uncombed. During an interview with Certified Nursing Assistant (CNA)/Shower Aide, Staff N on 10/19/22 at 11:16 AM, she indicated she was the full-time shower aide on the secured unit as well as the unit immediately outside of the secured unit and stated, I try to split everything (showers) up by workload. Everyone on the unit I try to get showered once a week. Sometimes we are short staffed, and I have to work the floor and so I can't get them (residents) showered (once per week). Staff N stated she worked in the facility Monday through Friday and that is when showers were done on her units. She stated showers were not done on the weekend because there was no staff in the facility to shower residents on the weekend. Staff N stated she was very familiar with R46, and that the resident did not refuse showers. She stated, She (R46) is very pleasant to work with. During an interview with the Director of Nursing (DON), Staff B on 10/19/22 at 4:42 PM, she stated, Right now we have been trying to give at least one (shower) per week. Our goal is two. Staff B stated getting residents their showers per their care plans had been a challenge due to staffing issues since the beginning of the COVID-19 Pandemic. She indicated her expectation was that residents receive showers per their plan of care. 2.Review of the undated admission Record provided by the facility revealed R95 was admitted to the facility on [DATE]; diagnoses included in pertinent part end stage renal disease, diabetes mellitus, Parkinson's disease, congestive heart failure, and history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of the annual MDS with an ARD of 09/13/22 in the EMR under the MDS tab, revealed R95 was intact in cognition with a BIMS score of 15 out of 15 (score of 13 - 15 indicates intact cognition). R95 was dependent on staff for bathing. Review of the Care Plan dated 07/01/21, in the EMR under the Care Plan tab revealed, [R95] has an ADL self-care performance deficit r/t [related to] fatigue, limited mobility, and Parkinson's. Care plan interventions included in pertinent part, Bathing/showering: 2 PA [personal assist] Hoyer [mechanical lift] with transfers in showers; 1-2 showers a week; offer bed bath if unable to give 2nd shower. During an interview 10/17/22 at 1:26 PM, R95 stated she would like to receive more showers than she was provided. R95 stated she received a maximum of one shower a week. R95 stated that prior to the Covid [coronavirus] outbreak, she received two showers per week and her preference was for daily showers. Review of bath records documented on the Daily Weights tables provided by the facility, for August 2022 - October 2022 [through 10/19/22] revealed R95 received less than one shower per week as follows: -August: R95 received showers on 08/22/22 and 08/29/22 for a total of two for the month. There was no documentation of showers between 08/01/22 - 08/22/22, a 21-day period. -September: R95 received showers on 09/12/22, 09/19/22, and on 09/26/22 for a total of three for the month. There was a 14-day gap between R95's shower on 08/29/22 and her next shower on 09/12/22. -October: R95 received showers on 10/03/22, 10/12/22, and on 10/17/22 for a total of three up through 10/19/22. There was a nine-day gap between R95's shower on 10/03/22 and her shower on 10/12/22. During an interview on 10/18/22 at 2:23 PM, Registered Nursing Assistant (RNA), Staff DD, stated all the residents in the [NAME] Unit received one shower per week, according to the schedule posted in the shower room. Staff DD stated residents were showered every seven days unless the facility was short staffed and then they might wait an extra day or so. Staff DD stated the CNAs did not give showers; there was a designated shower aide who showered the residents. Staff DD stated R95 was cooperative with care. During an interview on 10/19/22 at approximately 2:30 PM, Staff O, stated she was the shower aide for the [NAME] unit and gave all the residents on the unit (a total of 54 residents including R95) their showers. She stated she worked as a shower aide Sunday through Thursday and someone else gave showers on Fridays. Staff O stated she got pulled to provide CNA care to residents on Sundays at times but could usually make up the showers on Monday if they were not completed on Sunday. Staff O stated R95 received showers on Sundays. Staff O stated all residents on [NAME] unit were scheduled for one shower per week. Staff O stated she typically got pulled once or twice a week to work as a CNA on the floor. Staff O stated if she could not give a shower, she tried to provide a bed bath instead and this would be documented. Staff O stated, prior to Covid, residents received two showers per week. Staff O verified the shower records provided to the surveyor for three months were complete. During an interview on 10/20/22 at 12:48 PM, Registered Nurse/Unit Manager (RN/UM) Staff II, stated R95 had spoken with him about not getting enough showers. During an interview on 10/20/22 12:50 PM, Staff B, stated the facility could not provide more than one shower per week due to facility staffing problems. Staff B stated, We pull the bath aide if we have crisis staffing levels. Staff B stated the priority was for residents to be fed, cleaned, to receive medications and treatments, and to be hydrated prior to being bathed/showered. Staff B stated, We used to have more shower aides and indicated previously, residents received two showers per week. Reference WAC 388-97-1060(2)(C) .

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of food borne illness to 108 of 111 residents (three residents received nutrition via feeding tubes). Specifically, the sanitizer solution did not register having any sanitizer present, a staff member failed to don a hairnet in the kitchen, and shakes were not properly dated. Findings include: Review of the Sanitation & Infection Control Food Safety policy dated January 2016 revealed All facilities will adhere to the food safety standards described in the HACCP [Hazard Analysis Critical Control Point] Food Safety Program Manual .Employees wear approved hair restraints . Labels for TCS [time/temperature control for safety] foods also must include time of storage. A use-by-date should be specified . Clearly labeled sanitizer of the proper concentration must be available and used to sanitize all food-contact surfaces of stationary equipment, i.e., work counter/tables. Sanitizer test strips must be used to ensure proper concentration. 1. The initial kitchen inspection was conducted on 10/17/22 from 9:24 AM - 10:13 AM with the Dietary Manager (DM), Staff E and the Executive Chef, Staff HH. The following concerns were observed: Staff were washing breakfast dishes in the commercial dish machine. Staff E stated it was a high temperature machine using hot water for sanitizing. The surveyor and Staff E looked for the manufacturer's data plate with the machine specifications. The data plate could not be found; Staff E called the Maintenance Director (MD), Staff G who entered the kitchen. Staff G wore his long hair in a ponytail that extended down his back. Staff G tried to find the manufacturer's data plate on the dish machine, looking around all sides of the machine, removing a stainless-steel panel, and crawling on the floor. Staff G looked for approximately 10 minutes for the name plate without a hair restraint in place while Staff E and the surveyor were in the dish room with him. The surveyor asked Staff G about wearing a hair restraint. Staff G stated he should have his hair covered and immediately left the dish room and returned wearing a hairnet. Observation in a reach in refrigerator located across from the dish room revealed there were 44, four-ounce cartons of Mighty Shakes located on two separate trays that were not dated. Staff E stated the shakes should be dated and could remain in the reach-in refrigerator for no more than 14 days before they needed to be disposed of. Staff E stated the shakes would be discarded because there were no dates on them. The label on one of the cartons of Mighty Shake was reviewed and the label indicated the shakes should be discarded no more than 14 days after being placed under refrigeration. Staff HH tested the concentration of the sanitizer in a bucket of wiping rag sanitizer solution with a quaternary ammonia test strip. The test strip did not noticeably change color (less than the first marker on the legend for 150 parts per million) which indicated an absence of sanitizer. Staff HH, was present and verified the absence of sanitizer in the solution. There were no other buckets of sanitizer in the kitchen indicating all staff had been using this bucket of solution to sanitize surfaces. Staff HH stated she would dump the solution and remix it. She stated she did not know when it had been mixed. 2. Review of the label of Oasis 146 Multi-Quat Sanitizer, the sanitizer used for the wiping rag buckets, indicated 200 - 400 ppm [parts per million] active quat [quaternary ammonia] was required for sanitizing. 3. During an interview on 10/19/22 at 8:33 AM, Staff E stated an Ecolab technician (dish machine service provider) came in on 10/17/22 and replaced the sanitizer dispenser. Staff E stated the dispenser was not mixing with water appropriately, contributing to the lack of sanitizer in the bucket checked during the initial kitchen inspection. Staff E stated the bucket of sanitizer solution needed to be changed almost every hour to maintain the correct sanitizer level. 4. During an interview on 10/20/22 at 9:57 AM, Staff E stated the kitchen staff had not used a log to monitor the concentration of the sanitizer solution but would going forward. Staff E stated he was not sure when the bucket of sanitizer solution had been mixed on 10/17/22. Staff E stated he had not noticed on 10/17/22 during the initial kitchen inspection that Staff G had not been wearing a hairnet. Staff E stated he was responsible for anyone coming into the kitchen and hair nets were located right inside the entrance door into the kitchen. Staff E verified that Staff G had long hair and was not wearing a hairnet. 5. During an interview on 10/20/22 at 10:50 AM, Staff G stated he should have put a hairnet on before coming into the kitchen on 10/17/22. Staff G stated he entered the kitchen through one of the doors that did not have hairnets available at the entrance. Staff G stated he knew where the hairnets were located. Reference WAC 388-97-1180(3), -2980 .