**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete testing for COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) per federal guidelines for 8 of 10 staff (Staff A, B, C, D, F, G, I, J) during a COVID-19 outbreak. This failure increased the likelihood for delayed identification, diagnosis and treatment of COVID-19. In addition, the facility failed to implement their respiratory protection program in a timely manner for 4 of 10 staff (Staff A, B, D, H) every year within 12 months of the date of the last fit test. The respirator program consisted of fit testing procedures (a medical evaluation, fit testing and training on the use and wearing of a respiratory mask) of the N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for staff. This failed practice potentially resulted in transmission of the COVID-19 virus. Findings included . A COVID-19 outbreak began in the facility on 12/10/2024 and ended on 01/06/2025. The outbreak involved 10 residents and five staff, who tested positive for COVID-19. Review of the 06/24/2024 Centers for Disease Control and Prevention (CDC's) Infection Control Guidance: SARS-CoV-2, showed asymptomatic residents and staff with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If testing identifies additional infections, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. Review of the Washington State Department of Health guidance titled, Respiratory Protection Program for Long-Term Care Facilities, showed the respiratory protection program is the facility's plan on how to provide respiratory protection for the staff. A respirator medical evaluation was required to determine whether it was safe for staff to use respirators. After staff received their written recommendation stating they could use a respirator, they must complete the facility's respirator training before their first use of the respirator. The training needed to be done every 12 months. Respirator fit testing was done initially (upon hire or transfer) and then every year, within 12 months of the date of the last fit test. Review of staff testing records for COVID-19 and work assignment records during the outbreak between 12/10/2024 to 01/06/2025 showed the following: Staff A, Nursing Assistant (NA) - tested on [DATE], 12/16/2024, 12/30/2024 Work assignment records showed Staff A worked on 12/16/2024, 12/17/2024, 12/18/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, 01/02/2025, 01/03/2025, and 01/06/2025. Staff B, NA - Work assignment records showed they worked on 12/11/2024 and 12/12/2024, however they were not tested until 12/13/2024. Staff C, NA - tested on [DATE], 12/16/2024, 12/24/2024, 12/31/2024 Work assignment records showed Staff C worked on 12/12/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/30/2024, 12/31/2024, 01/01/2025, 01/02/2025, and 01/06/2025 Staff D, Registered Nurse - tested on [DATE], 12/19/2024, 12/30/2024 Work assignment records showed Staff D worked on 12/12/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/23/2024, 12/24/2024, 12/26/2024, 12/30/2024, 12/31/2024, 01/01/2025, 01/02/2025, 01/04/2025, and 01/06/2025 Staff F, Licensed Practical Nurse - tested on [DATE], 12/18/2024 Work assignment records showed Staff F worked on 12/11/2024, 12/12/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/30/2024, 12/31/2024, 01/01/2025, 01/02/2025, and 01/06/2025. Staff G, NA - tested on [DATE], 12/12/2024, 01/06/2025 Work assignment sheets showed Staff G worked on 12/11/2024, 12/12/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, 12/31/2024, 01/01/2025, 01/02/2025, 01/05/2025, and 01/06/2025 Staff I, Dietary Aide - tested on [DATE], 01/01/2025 Work assignment sheets showed Staff I worked on 12/11/2024, 12/12/2024, 12/13/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/21/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/31/2024, 01/01/2025, 01/02/2025, 01/03/2025, 01/04/2025, and 01/05/2025 Staff J, [NAME] - tested on [DATE], 12/25/2024, 01/04/2025 Work assignment sheets showed Staff J worked on 12/12/2024, 12/13/2024, 12/14/2024, 12/15/2024, 12/16/2024, 12/19/2024, 12/20/2024, 12/21/2024, 12/22/2024, 12/26/2024, 12/29/2024, 01/01/2025, 01/04/2025, 01/05/2025, and 01/06/2025 Review of residents' records showed there were no documented COVID-19 testing results for 29 of 29 residents in the facility during the COVID-19 outbreak. Review of staff fit testing records showed the following: Staff A - no fit testing performed since 11/30/2023 Staff B - no fit testing performed since 11/28/2023 Staff D - no fit testing performed since 12/01/2023 Staff H, Housekeeper - no fit testing performed since date of hire on 11/12/2024 On 01/10/2025 at 11:00 AM, Staff K, Director of Nursing, stated COVID-19 testing for residents and staff was to have been done twice weekly during the outbreak. On 01/10/2025 at 1:45 PM, Staff L, Administrator stated they and Staff K tested positive for COVID-19 at the beginning of the outbreak so the leadership at the facility was inconsistent during that time. Staff L stated they were aware resident testing for COVID-19 was being performed by staff despite being unable to provide any documented testing. They stated they believed testing on residents was done on 12/10/2024, 12/15/2024, 12/20/2024, 12/26/2024, 01/01/2025, and 01/06/2025. Reference (WAC) 388-97-1320(1)(a)(2)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was a completed Physician's Order for Life-Sustaining Treatment [POLST] (a form which instructed medical staff what treatment the resident wished to have done in the event they are seriously ill, or their heart stopped beating for 1 of 2 sampled residents (Resident 6) reviewed for Advance Directives. This failure placed the resident at risk for not having their wishes and choices regarding end-of life care honored. Findings included . <Resident 6> The [DATE] admission assessment documented Resident 6 admitted to the facility on [DATE] and was cognitively intact to make decisions regarding their care. Review of the [DATE] care plan documented Resident 6 made their own health care decisions and a POLST was in their medical record. Review of Resident 6's medical record found no documentation of a completed POLST form or other documentation that showed education and/or conversation had occurred related to the resident's wishes for cardiopulmonary resuscitation (CPR) in the event their heart stopped beating, or other treatment they wished to have if they became seriously ill. In addition, review of the white facility POLST binder located at the nurse's station found the admission record form documented Resident 6 was a full code (would receive CPR), but no completed POLST form for the resident was in the binder. On [DATE] at 2:44 PM, Resident 6 was observed in their room lying in bed, watching television. When asked if anyone at the facility had discussed what their preference for CPR would be in the event their heart stopped, Resident 6 stated they had never filled out a POLST form, and nobody had discussed that with them since they had been at the facility. In an interview on [DATE] at 4:40 PM, Staff A, Administrator, stated the POLST usually came with resident's paperwork when they admitted to the facility, and it was followed until the facility discussed it with the resident and completed a new one. When informed Resident 6 did not have a completed POLST, Staff A stated they would follow-up and see if any notes had been made or if Medical Records had any other additional documentation. In an interview on [DATE] at 5:05 PM, Staff B, Director of Nursing, stated they reviewed Resident 6's record and the facility POLST binder and confirmed a POLST had not been done and was being completed now. Reference (WAC): 388-97-0230 (3)(c)(i-ii), 0300 (1)(b)(3)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a Notification of Medicare Non-Coverage (NOMNC) two days prior to a planned discharge, as required, for 1 of 3 residents (Resident 136) reviewed for liability notices. This failure prevented the resident from exercising the right to appeal and dispute the termination of Medicare covered services. Findings included . According to their medical record, Resident 136 was admitted to the facility on [DATE] and discharged on 10/30/2024. Per the admission assessment, dated 10/28/2024, Resident 136 had diagnoses which included Myocardial Infarction (MI, a heart attack) and a recent Coronary Artery Bypass (open heart surgery.) Resident 136 was alert, oriented and able to make their needs known. A progress note, dated 10/28/2024 at 12:54 PM, documented the resident was going to be discharged on 10/30/2024. In a further review of Resident 136's record, no NOMNC form was found. During an interview at 11/15/2024 at 4:40 PM, Staff B, Director of Nursing, verified that the required notice was not given for Resident 136, and it should have been. Reference: WAC 388-97-0300 (1)(e)

Based on interview and record review, the facility failed to ensure a resident's medical record contained documentation of a hospital transfer and/or that the receiving hospital had received information of the resident's condition, for 1 of 2 sampled residents (Resident 31), reviewed for hospitalization. This failure placed the resident at risk for a delay in treatment and unmet care needs. Findings included . <Resident 31> The 11/04/2024 discharge assessment documented Resident 31 had cognitive impairment and had diagnoses which included malnutrition and a fractured left leg. Review of Resident 31's record showed a transfer form dated 11/04/2024 which documented the resident needed a proxy to make decisions and was being transferred to the hospital to be evaluated for unresponsiveness. Aside from the resident's diagnoses, date of birth , full name, reason for the transfer, and name of the hospital the resident was being sent to, the form was blank and did not include any other additional information, such as the resident's care needs, treatments, or status prior to being sent. A nursing progress note dated 11/04/2024 at 3:19 PM documented the hospital had been called to inquire about the resident's status, and had been told the resident was being admitted and would be placed on comfort care. Additional record review found no documentation that stated the resident was being transferred to the hospital or the reason/events that occurred that necessitated the transfer, or that information had been communicated to the receiving hospital. In an interview on 11/17/2024 at 10:35 AM, Staff C, Registered Nurse, stated when a resident was transferred to the hospital, a transfer form was filled out, the hospital was called to notify them of the resident's status, and a progress note was made in the resident's chart. After review of Resident 31's record, Staff C confirmed no progress note had been made and the transfer form had not been completely filled out. In an interview on 11/17/2024 at 10:55 AM, Staff B, Director of Nursing, confirmed the transfer process and documentation expectations as stated by Staff C. Staff B then reviewed Resident 31's record and confirmed the documentation had not been done and the transfer form was not thoroughly completed. Reference (WAC) 388-97-0120(2)(a)

Based on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they were hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 1 of 2 sampled residents (Resident 31), reviewed for hospitalization. This failure placed the resident at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included <Resident 31> The 11/04/2024 discharge assessment documented Resident 31 had cognitive impairment and had diagnoses which included malnutrition and a fractured left leg. Review of Resident 31's record showed a transfer form dated 11/04/2024 which documented the resident was being transferred to the hospital to be evaluated for unresponsiveness. Additional record review found no documentation that the resident and/or resident representative had been provided the required bed hold notice. In an interview on 11/17/2024 at 10:42 AM, Staff C, Registered Nurse, stated bed hold notices were done at the time of the resident being transferred to the hospital and if the resident was being transferred emergently, then the notice was done within 24 hours. In an interview on 11/17/2024 at 10:55 AM, Staff B, Director of Nursing, stated bed hold notices were included in the admission packet documentation, but a notice also needed to be completed at the time of transfer to the hospital or as soon as possible if the transfer was of an emergent nature. After review of Resident 31's record, Staff B confirmed a bed hold notice had not been done. Reference (WAC) 388-97-1020 (4)

Based on observation, interview and record review, the facility failed to ensure that 1 of 2 sampled residents (Resident 5) had current and complete oxygen orders for respiratory care. This failure placed the resident at risk for respiratory complications and a diminished quality of life. Findings included . <Resident 5> Per the 08/08/2024 quarterly assessment, Resident 5 was moderately cognitively impaired, had chronic obstructive pulmonary disease (COPD: a progressive lung disease that blocks air flow and makes it difficult to breathe) and heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During an observation on 11/12/2024 at 3:03 PM, Resident 5 was sitting in their room with the oxygen concentrator (a device that converted room air to oxygen) placed next to their bed. The concentrator was on and administering oxygen at 3.5 litres (L) per minute, but the nasal cannula was draped over the top of the concentrator and was not being worn by the resident. During an observation on 11/14/2024 at 3:18 PM, Resident 5 was sitting in their room wearing their nasal cannula with the oxygen concentrator flowing at 2 L per minute. A review of Resident 5's medication administration records (MARS) from 07/01/2024 to 11/14/2024 found no documentation that the physician had ordered oxygen. A review of Resident 5's care plan, dated 04/24/2024, found no respiratory care plan had been implemented nor were there any interventions in place that informed nursing staff what the resident's care needs were related to the COPD. A review of the Physician-Nursing Communication Book from 07/18/2024 to 11/16/2024 found no documentation related to Resident 5's respiratory status/care needs. A review of the progress notes from 10/01/2024 through 11/16/2024 documented on 10/16/2024 at 9:41 AM, Resident 5 complained of being short of breath and oxygen was administed at 2 L per minute via nasal cannula. In an interview on 11/16/2024 at 11:44 AM, when asked if they used oxygen, Resident 5 stated they had difficulty with their breathing at times and used oxygen when that occurred. In an interview on 11/16/2024 at 3:34 PM, Staff D, Nursing Assistant, stated for at least a month, Resident 5 had expressed being short of breath at times, and when that happened, Resident 5 requested their oxygen saturation level to be checked and oxygen administered. In an interview on 11/16/2024 at 4:07 PM, Staff C, Registered Nurse, stated that Resident 5 has required supplemental oxygen for approximately one month. Staff C confirmed that Resident 5 did not have physician orders related to oxygen prior to 11/15/2024. Reference (WAC): 388-97-1060(3)(j)(vi)

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate certifications necessary to carry out the functions of nutritional services for 30 residents. Specifically, the facility failed to ensure Staff E, Dietary Manager, had the required certification. This failure placed the residents at risk for unmet nutritional needs and a diminished quality of life. Findings included . A review of staff credentials showed that Staff E, Dietary Manager, did not have the required certification to serve as the dietary manager. In an interview on 11/14/2024 at 9:55 AM, Staff E confirmed that they had not finished completing the required training, and did not have the credentials for their role as a dietary manager. In an interview on 11/17/2024 at 12:20 PM, Staff A, Administrator, stated the facility did not have a full time Registered Dietician. When asked if Staff E had the certification required for a Dietary Manager, Staff A confirmed Staff E had not finished completing the training and did not have the certification. Reference (WAC): 388-97-1160(1)

Based on observation, interview, and record review the facility failed to store, discard and distribute food in accordance with professional standards for food safety for 1 of 1 facility kitchens reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised 01/18/2023, showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be consumed or discarded as directed by the food manufacturer's use-by-date. During a kitchen observation on 11/12/2024 at 10:31 AM, the produce refrigerator contained three extra-large bags of shredded iceberg lettuce that was brownish, wilted and soggy. The bags of lettuce were labeled with the used-by date of 10/24/2024. In an observation of the dry storage room on 11/12/2024 at 10:43 AM, a bag of opened crispy fried onions was undated and a 10-quart sealed container (less than 4 quarts full) of flour was labeled with an expiration date of 08/06/2024. In an observation on 11/12/2024 at 11:00 AM, a second refrigerator in the common area of the kitchen showed the following items were unlabeled and undated: large, sealed container of diced pineapples, a full pitcher of orange juice, and a half a bag of BBQ riblets. There was also a large box of prepackaged boiled eggs in the refrigerator that was labeled with an expiration date of 10/10/2024. In an observation on 11/12/2024 at 11:06 AM, the kitchen freezer contained a half of bag of unlabeled and undated sausage patties. In an observation and interview on 11/12/2024 at 11:15 AM, the nourishment refrigerator contained three cups of milk that had mold on the lids labeled with an expiration date of 10/14/2024 and an opened commercial pumpkin pie with no label or date. Staff E, Dietary Manager, acknowledged that the food and drink items should have been labeled, dated and discarded by the expiration date. Staff E stated that it was important to provide a label, date and to discard expired food items to make sure residents do not become ill. Reference (WAC) 388-97-1120 (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to notify the resident's representative of changes in condition in a timely manner for 1 of 3 residents (Resident 1) reviewed for notification of changes. The failure to notify the representative placed the resident at risk of not having them involved in the health care decision making process for timely care and services. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included right hip fracture with surgical repair and dementia. Review of Resident 1's comprehensive assessment, dated 04/24/2024, showed they were rarely/never understood and had short and long term memory issues. Review of Resident 1's plan of care, revised on 04/23/2024, showed they required extensive staff assistance with turning in bed, personal hygiene, dressing, transfers; and was totally dependent on staff for eating and toilet use. In addition, the plan of care showed Resident 1 was at risk for falls. On 05/24/2024 at 1:15 PM Staff B, Administrator, stated on 05/01/2024 they witnessed Resident 1 stand up from their wheelchair and got their left leg caught on the footrest, causing them to fall to the floor hitting their head. Staff B stated the resident's skin tear to the left lower leg truly happened at that time. On 05/30/2024 at 9:20 AM, Resident 1's representative stated they were notified by facility staff on 05/06/2024 (five days later) of the resident's fall and subsequent injury to their left lower leg. The representative stated they were concerned they were not being told by staff of the severity of the resident's injury. On 05/29/2024 at 8:30 AM Staff D, Registered Nurse (RN), stated they had not called Resident 1's representative following the resident's fall with injury on 05/01/2024. Staff D had assisted Resident 1 following the fall on 05/01/2024. On 05/29/2024 at 8:48 AM Staff C, RN, stated they had not called Resident 1's representative following the resident's fall with injury on 05/01/2024. Staff C was the charge nurse at the time of the fall. Reference (WAC)388-97-0320(1)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure an incident of neglect was reported to the State Survey Agency, as required, for 1 of 1 resident (Resident 1) reviewed for neglect. Failure to report a worsening wound on Resident 1's left lower leg due to a lack of timely staff assessments and delay in receiving medical treatment placed all residents at risk for continued neglect and poor quality of care. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, undated, showed neglect was the failure of the facility to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Staff were to report the incident immediately any allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property to applicable state and other agencies, including State Survey Agencies. Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included right hip fracture with surgical repair and dementia. Review of Resident 1's comprehensive assessment, dated 04/24/2024, showed they were rarely/never understood and had short and long term memory issues. Review of Resident 1's plan of care, revised on 04/23/2024, showed they required extensive staff assistance with turning in bed, personal hygiene, dressing, transfers; and was totally dependent on staff for eating and toilet use. In addition, the plan of care showed Resident 1 was at risk for falls. Progress Notes (PNs), dated 05/06/2024, showed Staff F, Director of Nursing, was first made aware on 05/06/2024 (five days later) that Resident 1 had a fall on 05/01/2024 after getting out of their wheelchair (w/c) hitting the outside of their left lower leg on the footrest of the w/c potentially causing a skin tear. Review of Progress Notes showed there was no documentation Resident 1 had fallen in the facility with injury prior to 05/06/2024 and no assessment of the skin tear to the left lower leg. The skin tear on 05/06/2024 measured 1.0 by 0.5 by 0.2 inches with the deepest open area on the top, then proceeded to get shallower on the bottom of the skin tear. Progress Notes, dated 05/10/2024 at 5:57 PM, showed the left lower leg skin tear had increased redness, pain, swelling with slough (dead cells that accumulated in the wound which contributed to a delay in wound healing and prevented an accurate assessment) in 100% of the wound bed. The wound had increased in size to 2.0 by 1.0 by 0.5 inches. The on-call provider was notified and gave orders to culture the wound, antibiotic therapy every eight hours for five days, and begin treatment using Aquacel (wound dressing). Later at 6:23 PM on 05/10/2024 showed there was wound drainage. Progress Notes, dated 05/13/2024 at 10:37 AM, showed the culture obtained from the resident's wound showed a contagious, bacterial infection resistant to many antibiotics. On 05/20/2024 at 2:44 PM, Staff A, Licensed Practical Nurse/Infection Control Preventionist, stated that despite staff being aware of the resident's fall on 05/01/2024 and subsequent injury there was no documentation/assessments in the resident's medical record until 05/06/2024. At that time Staff E, Nursing Assistant, brought Resident 1 to Staff A's office so the left lower leg wound could be assessed. Staff A stated when they first saw Resident 1's open wound on 05/06/2024 there was redness and swelling from the left outer ankle to the left outer knee. Despite the failure of staff to assess Resident 1's skin tear at the time of the fall on 05/01/2024 until 05/06/2024, and no prescribed treatment orders being obtained until 05/10/2024, review of the facility State Reporting Log showed no reporting of staff neglect as required. Refer to F684 for further information. Reference (WAC) 388-97-0640(6)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to conduct a thorough investigation in a timely manner for 1 of 3 residents (Resident 1) reviewed for falls. Failure to conduct a thorough investigation to identify the root cause and all contributing factors related to Resident 1's fall placed residents at risk for ineffective care planning interventions to prevent further falls with injury. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property, undated, showed staff was to review and investigate all allegations of abuse, neglect, exploitation, injuries of unknown source and misappropriation of resident property. Staff were to complete investigation summaries and final outcome summaries. Staff was to analyze the occurrences to determine what changes were needed to prevent further occurrences. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included right hip fracture with surgical repair and dementia. Review of Resident 1's comprehensive assessment, dated 04/24/2024, showed they were rarely/never understood and had short and long term memory issues. Review of Resident 1's plan of care, revised on 04/23/2024, showed they required extensive staff assistance with turning in bed, personal hygiene, dressing, transfers; and was totally dependent on staff for eating and toilet use. In addition, the plan of care showed Resident 1 was at risk for falls. Progress Notes (PNs), dated 05/06/2024, showed Staff F, Director of Nursing, was first made aware on 05/06/2024 (five days later) that Resident 1 had a fall on 05/01/2024 after getting out of their wheelchair (w/c) hitting the outside of their left lower leg on the footrest of the w/c potentially causing a skin tear. Review of Progress Notes showed there was no documentation Resident 1 had fallen in the facility with injury prior to 05/06/2024. The skin tear on 05/06/2024 measured 1.0 by 0.5 by 0.2 inches with the deepest open area on the top, then proceeded to get shallower on the bottom of the skin tear. Review of the facility investigation report, dated 05/06/2024 at 3:58 PM (five days following the resident's fall), showed Resident 1 had gotten up from their wheelchair unassisted in the hallway near the kitchen door and was walking when they fell on the floor hitting their head. Resident 1 sustained a skin tear to their left lower leg measuring 1.0 by 0.5 by 0.2 inches. The resident hit their left lower leg on the footrest. They were given a new wheelchair and new footrests with no sharp edges. The resident was unable to state the reason why they fell due to severe cognitive impairments. Staff B, Administrator, stated at the exit conference on 05/24/2024 at 1:15 PM, that they had witnessed Resident 1's fall on 05/01/2024. Staff B stated Resident 1 sustained the skin tear injury to their outer, left, lower leg at the time of that fall when their leg got caught on the footrest of their wheelchair. The resident was wearing sweat pants at the time of the fall. Despite Resident 1 sustaining an injury following their fall on 05/01/2024 a facility investigation and preventative interventions were not initiated by staff until 05/06/2024. Refer to F684 for further information. Reference (WAC) 388-97-0640(6)(a)(b) This is a repeat deficiency from the Statement of Deficiencies dated 12/05/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to serve meals that were at a safe temperature for 2 of 7 residents (Residents 1 and 2) reviewed for food temperatures. This failed practice placed residents at risk for decreased nutritional intake and food borne illness. Findings included . Review of the facility policy titled, Preventing Foodborne Illness - Food Handling, revised in July 2014, showed food temperatures would be monitored at designated intervals throughout the day and documented according to state-specific requirements. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included a serious illness that attacked the resident's nervous system, causing weakness and muscle paralysis. Review of the resident's comprehensive assessment, dated 03/09/2024, showed they had no cognitive deficits and required staff assistance with activities of daily living, including eating. On 04/26/2024 at 10:30 AM, Resident 1, stated that the food served to them in their room was cold and they had complained of cold food several times. On 04/26/2024 Resident 1's food tray was brought to their room at 12:50 PM by Staff A, Nursing Assistant. It was the last tray to be taken off the food cart (unheated) in the south hallway. The food cart had arrived to the hallway from the kitchen at 12:35 PM. The noon meal consisted of two fish fillets, mixed vegetables, and a lettuce salad. Staff A proceeded to assist Resident 1 with the meal. Upon questioning by the investigator Resident 1 stated the food items were cold. There was no attempt by Staff A to return the tray to the kitchen for reheating or offer an alternative menu. The investigator, with Resident 1's permission, took the plate of food to the kitchen and requested Staff B, Cook, to check the food temperatures. The temperature of the fish was 88 degrees Farenheit (F) and the mixed vegetables were 80 degrees F. Staff B stated the temperature of the fish had been 168 degrees F and the vegetables had been 158 degrees F at the steam table prior to serving. The plate of food was reheated in the microwave to appropriate temperatures and returned to Resident 1. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses which included respiratory disease. Review of Resident 2's comprehensive assessment, dated 03/05/2024, showed they had moderate cognitive deficits. On 04/26/2024 at 10:25 AM, Resident 2, stated their food was always cold. They ate in their room for all meals, and resided on the south hallway. Review of the facility food temperature monitoring forms between 04/01/2024 to 04/25/2024, showed they were documented on two different forms, Cooling Temperature Log (form designated for recording temperatures every two hours during the cooling cycle), and Food Substitution Log (form designated for recording substiuted food items). Despite food temperatures to be taken at every meal the first documented temperature was on 04/22/2024 and only certain food items had documented temperatures. The two forms utilized by staff were incomplete and there were no documented food temperatures between 04/01/2024 to 04/21/2024 taken by kitchen staff. On 05/01/2024 at 10:20 AM, Staff C, Food Service Manager, stated the facility had not been using the correct form regarding monitoring food temperatures since 03/01/2024, when the facility kitchen transitioned to the existing corporation. Reference (WAC) 388-97-1100(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure sufficient nursing staff were available to respond to call lights timely and to meet the care needs of 8 of 15 residents (Residents 3,1,4,5,6,2,7,8) reviewed for sufficient nursing staff. This failure resulted in feeling of frustration and vulnerability, diminished quality of life and unmet care needs of the residents. Findings included . <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses which included diabetes and cellulitis (bacterial skin infection that caused redness, swelling and pain in the affected area). Review of Resident 3's comprehensive assessment, dated 02/16/2024, showed they had no cognitive deficits. Review of Resident 3's plan of care, dated 11/15/2023, showed they required extensive assistance by staff for transfers, turning from side to side and bathing. Review of physician's orders, dated 04/19/2024, showed showers were to be given to Resident 3 every Tuesday, Wednesday, Friday, and Saturday. Review of Progress Notes, dated 04/26/2024 at 8:08 PM, showed Resident 3 returned from the wound clinic. The resident's representative stated antibiotic therapy was ordered for 10 days to treat an infection to the right foot. Review of bathing records between 04/01/2024 to 05/01 2024, showed Resident 3 was showered on 04/02/2024, 04/05/2024, 04/09/2024, 04/12/2024, 04/16/2024, 04/23/2024, 04/28/2024 and 05/01/2024. Despite the physician ordered showers of four times weekly on 04/19/2024 the resident only received three showers during that 12 day period of time. On 04/30/2024 at 3:25 PM, Resident 3's representative (RR), stated during a telephone interview that the resident had many concerns. Recently Resident 3 was only getting one shower per week. On 04/29/2024 the resident was left sitting in urine for over an hour during dinner due to the facility being short staffed. Thirty to 45 minutes was the average time for the resident's call light to be answered by staff. There would be only one Nursing Assistant (NA) for 28 or more residents on the evening shift. Staff D, Licensed Practical Nurse, came out of their office but really did not help on the floor as observed by the RR. The RR stated they changed Resident 3's brief frequently when they visited. The RR stated, the entire place has gone downhill. On 05/01/2024 at 10:20 AM, Resident 3 was observed seated in a recliner in their room. They kept a note pad of events occurring during the day. Resident 3, stated not enough staff, not doing what they told me they would do. It gets worse as the time goes on. According to the physician and wound clinic Resident 3 was supposed to get showers every other day. The resident stated they had never refused a shower, they [staff] tell me they'll do it and then it doesn't get done. The resident stated they had gone five to seven days without a shower. Call lights had been an issue as sometimes the resident had not had their call light answered by staff for 1.5 hours, which caused them to urinate in their brief. The resident stated, can take awhile to get care .sometimes they say I got a shower when I didn't. The resident stated, after obtaining information from their note pad, that they had received showers in April 2024 on 04/12/2024 at 10:05 AM, 04/16/2024 at 3:15 PM, 04/21/2024 at 4:05 PM, 04/28/2024 at 10:00 AM and 04/30/2024 at 3:25 PM. On 05/01/2024 at 10:40 AM, Anonymous Staff E (ASE), stated it had been really difficult and they never took breaks. Anonymous Staff E stated NA staff just learned that week Resident 3 was supposed to get showers ever other day. Resident 3 took 45 minutes to complete a shower. Many times the evening shift did not get their showers completed. When one NA was at lunch and the other two NAs were in a resident's room it took quite awhile for call lights to be answered. On 04/22/2024 there were no NAs scheduled for the evening shift. Anonymous Staff E stated they felt like they were being forced to work that evening shift (04/22/2024) after working all day. They had no options as they would have been abandoning residents had they not worked. Additionally, ASE stated there were too many residents that required two staff to assist with transfers. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included a serious illness that attacked the resident's nervous system, causing weakness and muscle paralysis. Review of the resident's comprehensive assessment, dated 03/09/2024, showed they had no cognitive deficits and required staff assistance with activities of daily living, including eating. Review of Resident 1's April 2024 bathing records showed they were showered on 04/04/2024, 04/10/2024, 04/11/2024, 04/18/2024, 04/25/2024, and 04/29/2024. On 04/24/2024 at 5:30 PM, Resident 1's family member, stated during a telephone interview that the resident had not gotten a shower for eight days. They stated the service provided by staff at the facility was better two months ago than it was currently. Staff was not answering the resident's call light timely and sometimes it took 1.5 hours to get staff assistance. On 04/24/2024 at 6:58 PM, Resident 1, stated it generally took over 30 minutes for staff to respond to their call lights. On the weekends it could take two hours and the worst time was between 5:00 to 9:00 PM. Resident 1 stated prior to that week they had only received showers once weekly instead of twice weekly. Often on the evening shift there were only two NAs and they were feeding residents so no staff were on the floor assisting residents. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses which included depression and bone disease. Review of Resident 4's comprehensive assessment, dated 02/01/2024, showed they had no cognitive deficits. Review of Resident 4's plan of care, dated 04/14/2022, showed they required limited assistance by one staff for bathing, turning in bed, dressing, personal hygiene and transfers; and extensive assistance by one staff for toileting. On 04/26/2024 at 10:05 AM, Resident 4, stated sometimes there was only one NA on the floor on the evening shift. The call light response time used to be five to 10 minutes, now it could be 20 to 25 minutes. Resident 4 stated they often had to wait for staff to be changed following a urinary incontinency episode. <Resident 5> Review of the medical record showed Resident 5 was admitted to the facility with diagnoses which included Parkinson's disease (progressive disorder that affected the nervous system and the parts of the body controlled by the nerves). Review of Resident 5's comprehensive assessment, dated 02/05/2024, showed they had no cognitive impairments. Review of Resident 5's plan of care, dated 03/17/2023, showed they required extensive assistance by one staff for bathing and personal hygiene; extensive assistance by two staff for turning in bed, toileting, dressing; and was dependent on two staff for transfers using a mechanical lift (device used for residents who were unable to assist with transferring in and out of a bed, wheelchair or shower chair). Review of Resident 5's April 2024 bathing records showed they were showered by staff on 04/08/2024, and had received bed baths on 04/15/2024 and 04/29/2024. On 05/01/2024 at 3:00 PM, Resident 5, stated that staff used the excuse they were too busy to be bothered by me. Resident 5 stated sometimes their call light did not get answered for 1.5 hours. They stated it had been several hours since they had their disposable brief changed that day. They stated they were incontinent of urine and stool. On 05/01/2024 at 3:10 PM two caregivers were observed changing the resident's disposable brief which was wet with urine and had stool. <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses which included stroke with left sided weakness. Review of Resident 6's comprehensive assessment, dated 02/25/2024 showed the resident had no cognitive impairments. Review of Resident 6's plan of care, dated 10/12/2023, showed the resident required total staff assistance with bathing, turning in bed, personal hygiene, dressing, toilet use; and a mechanical lift was utilized by two staff for transfers. On 04/26/2024 at 10:15 AM, Resident 6, stated it took over 30 minutes to get their call light answered by staff and they usually needed to have their disposable brief changed. The resident kept track of the time by looking at the clock on the wall across from their bed. <Resident 2> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses which included a respiratory disease which required the use of oxygen therapy. Review of Resident 7's comprehensive assessment, dated 03/05/2024, showed they had moderate cognitive impairment. Review of a Progress Note by the interdisciplinary team, dated 04/24/2024, showed Resident 2 required stand by assistance by staff with turning in bed, transfers, walking using a walker; and staff supervision with toileting, and dressing. Resident 2 was alert and oriented and able to make their needs known. On 04/26/2024 at 10:25 AM, Resident 2, stated the facility needed more help. The resident's call light was not answered for one hour that week which caused them to wet their bed. Resident 2 stated that had happened more than once. They stated that either on 04/25/2024 or 04/24/2024 they put their call light on at 4:00 PM and staff did not respond until 5:45 PM. <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility on [DATE] with diagnoses which included stroke. Review of Resident 7's comprehensive assessment, dated 02/27/2024, showed severe cognitive impairment. Review of Resident 7's plan of care, dated 02/27/2024, showed they required total staff assistance with bathing, personal hygiene, dressing; and extensive staff assistance with turning in bed, eating, transfers and toileting. Review of Resident 7's April 2024 bathing records showed they received showers on 04/03/2024, 04/06/2024, 04/14/2024 and 04/25/2024. <Resident 8> Review of the medical record showed Resident 8 was admitted to the facility on [DATE] with diagnoses which included diabetes. Review of Resident 8's comprehensive assessment, dated 04/16/2024, showed they had severe cognitive deficits. Review of Resident 8's plan of care, dated 04/05/2024, showed they required extensive staff assistance with all activities of daily living. Review of the April 2024 bathing records showed Resident 8 received showers on 04/04/2024, 04/25/2024, 04/29/2024 and one bed bath on 04/05/2024. <Staff Interviews> Anonymous Staff F (ASF) On 04/26/2024 at 8:30 AM, ASF, stated the facility was short handed 90 percent of the time. On 04/22/2024 two NAs, that had worked the dayshift, had to stay over on the evening shift as there were no scheduled NAs assigned to work. The facility was chronically understaffed. Resident 1 only got a shower once weekly despite the resident's request to have two showers weekly. Additionally, ASF stated, call lights were on forever. Anonymous Staff G (ASG) On 04/29/2024 at 12:14 PM, ASG, stated during a telephone interview that they were unable to take any breaks if there were only two NAs assigned to care for residents, which occurred twice last week. They stated that staffing had not been very good. Anonymous Staff G stated Staff D never got on the floor to assist with resident care. They stated they try to give showers but residents end up getting bed baths instead due to staffing issues. Anonymous Staff H (ASH) On 04/30/2024 at 3:55 PM, ASH, stated during a telephone interview that staffing was the worst. They stated Staff I, Administrator, was aware there was only one Licensed Nurse (LN) and one NA on the evening shift. The evening shift was not getting their showers done, they had several assigned showers per evening. Instead of a shower the resident might only get a bed bath due to staffing issues. Anonymous Staff H stated, we are not fulfilling our jobs .call lights were on forever. One resident was dying that week and there was not enough staff to spend any time with them. Residents had eaten in their beds due to low staffing. Administrative staff knew there was inadequate numbers of staff and they did nothing about it. Anonymous Staff H stated they had requested additional help several times. They had asked for help from Staff D when a new resident was admitted to the facility and Staff D had never been out helping. Additionally, ASH stated they rarely got a lunch break. Anonymous Staff J (ASJ) On 04/30/2024 at 4:08 AM, ASJ, stated during a telephone interview that on the evening shift of 04/29/2024 (a Monday) they had approached administrative staff and informed them they would not accept the medication cart until another NA was assigned to work (at that time there was only one LN and one NA). The daily assignment sheet had been out for staff to view all weekend. Anonymous Staff J stated Staff I knew about the staffing since 04/26/2024 but could not get to it. They stated they had worked an additional three hours the previous Sunday to get the work done. Anonymous Staff J stated Staff D stated they would help on the floor, but more often that not their office door was closed. Staff D would state they were too busy doing their own work. Call lights were not being answered timely and showers were not getting done. There were not enough staff with two NAs scheduled to work. Anonymous Staff K (ASK) On 05/01/2024 at 8:15 AM, ASK, stated most of last week there were only two NAs working and one LN. Some night shifts there was only one NA. Anonymous Staff K stated, pretty short handed this past month, There was not enough staff on the evening shift to do showers and frequently bed baths were given instead. Call lights could be on for an hour. Staff D was asked on one occasion to help on the floor but they stated they were on their lunch break and slammed the door. On 04/26/2024 at 9:15 AM, Staff I, stated they had previously identified issues with staffing and call lights especially on the evening shift. Staff I stated they were aware on 04/18/2024 they had no NA staff scheduled for the evening shift of 04/22/2024, as staff was on vacation and college students could not work due to final exams. They stated two NAs who had worked the dayshift on 04/22/2024 also worked the evening shift along with the Director of Nursing. Review of the Resident Council Minutes, dated 03/24/2024, showed residents had complained of long call light wait times over 20 minutes, not enough NAs and over working the NA staff. Review of the Resident Council Minutes, dated 04/10/2024, showed several residents complained about long call light wait times over 20 minutes. Review of facility records between 04/12/2024 to 04/26/2024 showed there was an average of 26.43 residents in the facility. Additionally, there were seven residents who required a mechanical lift for transfers using two staff and five residents who required two staff to assist with transfers. Review of the facility Admission/Discharge form for April 2024 showed there were seven residents admitted to the facility and five discharges. On 05/01/2024 at 3:30 PM Staff I verified there was a new admission that day and three additional admissions coming during the remainder of the week. Reference (WAC) 388-97-1080(1),1090(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of potential abuse was reported immediately to the facility Administration as required for 1 of 3 residents (Resident 2), reviewed for abuse. Failure to report an incident of potential abuse placed Resident 2 and other residents in the facility at risk for additional abuse. Findings included . Per the quarterly assessment dated [DATE], Resident 2 had diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety and depression and was able to make their needs known. Review of the facility's policy for prevention and reporting allegations of abuse dated 08/2022, showed all alleged violations are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse. The center acknowledges the definition of abuse as a willful infliction of intimidation or punishment resulting in pain or mental anguish. Review of a facility investigation by Staff B, Director of Nursing, showed notification of the incident of potential abuse between Staff A, Administrator, and Resident 2 that occurred on 12/01/2023 at 1:30 PM, had not been reported to Staff B until 12/05/2023. During an interview on 12/05/2023 at 2:50 PM Staff C, Registered Nurse, stated they would report any suspicion of abuse or neglect to the Administrator or Director of Nursing and call the State Agency. During an interview on 12/05/2023 at 5:10 PM, Staff B confirmed the investigation was not complete, failed to rule out potential abuse and not reported to administrative staff until 12/05/2023. Reference WAC 388-97-0640(6)(a)(b)(c)

Based on interview and record review, the facility failed to ensure a resident received consistent showers for 1 of 3 dependent sampled residents (Resident 1), reviewed for activities of daily living. This failure placed the resident at risk for poor hygiene. Findings included . Review of Resident 1's comprehensive assessment, dated 11/17/2023, they required assistance with activities of daily living, including transferring, dressing, personal hygiene, and bathing. Review of Resident 1's bathing documentation dated 11/11/2023 through 12/04/2023, showed the resident received showers on 11/11/2023, and 11/18/2023 (once weekly). Resident 1 did not receive a shower from 11/19/2023 through 11/28/2023 (ten days). During an interview on 12/05/2023 at 10:21 AM, Resident 1 stated they received a shower only twice in November 2023 and that was upsetting to them. The resident stated they would like at least two showers per week. During an interview on 12/05/2023 at 11:00 AM, Staff C, Nursing Assistant, stated showers were given twice weekly and refusals were charted in the electronic medical record (EMR). During an interview on 12/05/2023 at 5:10 PM, Staff B, Director of Nursing, stated showers needed to be given twice weekly and refusals charted in the EMR. Staff B found no other documentation on Resident 1's showers. Reference: (WAC) 388-97-1060(2)(c)

Based on interviews and record review the facility failed to implement their respiratory protection program for fit testing procedures which included a medical evaluation, fit testing (a 20 to 30 minute procedure to ensure a proper seal between the respirator face piece and the staff member's face) and training on the use and wearing of the respirator mask) of the N95 respirator mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for staff. The facility had not implemented the respiratory protection program for 53 of 53 staff initially upon date of hire or transfer and then every year within 12 months of the date of the last fit test. A COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak began in the facility on 10/30/2023 with one staff testing positive for COVID-19. At the end of the investigation on 11/09/2023 there were four residents and nine staff that had tested positive. This failed practice potentially resulted in the transmission of the COVID-19 virus. Findings included . Review of the facility's policy titled, Respiratory Program Policy & Procedure, updated in November 2022, showed every staff member of the facility who must wear an N95 or other filtering facepiece respirator will be provided with a medical evaluation before they are allowed to use the respirator. All staff required to wear filtering facepiece respirators must pass an initial fit test before using their respirator. Annual fit testing is to be completed. After passing a fit test each staff member will be trained on proper use and issued a respirator. Review of the Washington State Department of Health guidance titled, Respiratory Protection Program for Long-Term Care Facilities, showed the respiratory protection program is the facility's plan on how to provide respiratory protection for the staff. A respirator medical evaluation is required to determine whether it is safe for staff to use respirators. After staff receive their written recommendation stating they can use a respirator, they must complete the facility's respirator training before their first use of the respirator. The training needs to be done every 12 months. Respirator fit testing is done initially (upon hire or transfer) and then every year, within 12 months of the date of the last fit test. On 11/09/2023 at 11:25 AM Staff A, Registered Nurse/Interim Infection Control Preventionist (ICP), stated staff had not completed the respirator protection program as required. The former ICP had resigned their position the end of September 2023 or first week of October 2023 and it never got completed. Reference (WAC) 388-97-1320(2)(a) This is a repeat deficiency from the Statement of Deficiencies dated 07/25/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure sufficient preparation for a safe and orderly discharge home for 1 of 3 residents (Resident 1), reviewed for discharge to home. Resident 1 was discharged home without current referrals for in-home caregivers and home health for wound management and therapy services, supplies for diabetic testing, incontinent supplies, phone service, evaluation of the resident's home, and no assessment by staff to Resident 1 was able to perform blood sugar testing and administration of insulin. This placed Resident 1 at risk for medical complications, unmet care needs and a diminished quality of life. Findings included . <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses which included below knee amputation to the left lower leg, Stage IV pressure ulcer (full-thickness skin and tissue loss to the extent where bone was visible) to the tailbone, Stage II pressure ulcer (partial-thickness loss of skin presenting as a shallow open ulcer) to the right heel, stroke, foot drop to the right foot (difficulty lifting the front part of the foot), peripheral neuropathy (occurs when the nerves located outside the brain and spinal cord are damaged, often causing weakness, numbness and pain), diabetes and circulatory disease. Review of Resident 1's comprehensive assessment, dated 08/04/2023, showed they had no cognitive impairments; required extensive assistance by two staff for turning in bed, transfers, toilet use, dressing; supervision with one person assistance with personal hygiene; dependent on two staff for bathing; independent with set up for eating and occasionally incontinent of urine and always incontinent of bowel. Review of a physician assessment from the hospital wound healing center dated 08/30/2023, showed that in addition to the pressure ulcers to Resident 1's tailbone and right heel there were Stage II pressure ulcers to the left, front area of the amputation site below the knee, left amputation site above the knee and the right great toe. Progress Notes dated 08/17/2023, showed Social Services met with the resident to discuss potential for discharge as Resident 1 was requesting to discharge from the facility and return home (approximately 140 miles from facility) the next week. The resident still required assistance with activities of daily living and on-going wound care. Social Services was to initiate referral discharge orders and home health services. The resident's discharge was anticipated early the next week. Progress Notes dated 09/06/2023 at 3:13 PM, showed the resident had cataract surgery to their right eye. Progress Notes dated 09/08/2023 at 12:19 PM, showed Resident 1 was to be discharged on 09/11/2023 and a medical transport company would be taking them home. A physician's appointment was scheduled for the following day (09/12/2023). Progress Notes dated 9/11/23 at 12:25 PM, showed a phone would be delivered by mail to Resident 1's home. On 09/11/2023 at 1:25 PM the resident was discharged home. Review of Resident 1's Medication Administration Record showed a long-acting insulin (used to control blood sugars) was administered twice daily (morning and bedtime). In addition, a short acting insulin was administered routinely three times a day, and per sliding scale based on the resident's blood sugars taken four times daily. Following the resident's cataract surgery on 09/06/2023 an eye medication was ordered four times daily for 21 days to relieve swelling, redness, and itching; and a second eye medication was ordered four times daily for seven days to treat bacterial infections (needed to be administered until 09/12/2023). Review of facility documents (Discharge Orders, Medication Review Report), given to Resident 1 by staff upon their discharge from the facility, showed they were dated 08/17/2023 (25 days prior to the resident's discharge) with the only referral being an appointment on 09/12/2023 with a physician. Home Health was checked with therapy, wound care, and bathing assist but no agency name or telephone number listed. The discharge orders were signed by the physician on 08/17/2023 and the resident signed the documents on 09/08/2023. As the Medication Review Report was dated 08/17/2023 the eye medication ordered following cataract surgery on 09/06/2023 was not listed as part of Resident 1's medications. In addition, there was no documentation as to the times the medications were being administered and when the last dose was given prior to discharge. During a telephone interview with Resident 1 on 10/01/2023 at 7:19 PM, they stated the original discharge date was 08/17/2023, however the resident did not know why the delay occurred. Resident 1 stated there was supposed to be caregivers and wound care set up prior to their discharge but that did not happen. Resident 1 stated their friend was at their home upon their arrival on 09/11/2023, however the friend was not a caregiver. Facility staff told the resident a cell phone would arrive the next day via the mail, however the mail had not yet been delivered at the time of the interview with the resident (20 days later). The resident stated they had not been in their home for a year due to hospitalizations and being a resident in nursing homes. The resident stated they were administering their own insulin; however, it was very difficult to see even after the cataract surgery to the right eye. Resident 1 stated just at the time that discharge planning was supposed to occur in August the facility Social Services had to take their vacation time prior to leaving their job the end of August, which left Staff A, Medical Records, to take over the discharge planning. The resident stated the biggest problem for them was not having any caregivers to provide care until 09/18/2023 (seven days following discharge). Collateral Contact (CC) A, Clinic Registered Nurse, stated during a telephone interview on 09/28/2023 at 9:32 AM, they met Resident 1 during their physician appointment on 09/12/2023. They arrived to the appointment in a patient gown; no underwear; no wheelchair cushion and had open pressure ulcers to the tailbone, right heel and amputated leg. The tailbone wound did not have a dressing in place. The resident did not have a phone thus was unable to make appointments. They had not resided in their home for a year due to medical issues requiring hospital and nursing home care. Resident 1 had resided in a nursing home approximately 140 miles away from their home since 07/2023. Upon being discharged on 09/11/2023 from that facility to home by a medical transport company they dropped the resident off at the front door and left. No home health (wound care and therapy) or caregiver services had been recently established for Resident 1 prior to their discharge. The previous referral for home health had been sent by the facility on 08/17/2023. Home Health had closed the resident's case as they were not aware of the facility discharge date and were unable to contact the resident. A referral for caregiver services was also sent by facility staff in August but the case was closed due to the inability to contact the resident and unknown discharge date . Resident 1 had informed CC A they had not checked their blood sugar (ordered by facility physician to be done four times daily) since discharge as they had no testing strips. The resident had a nonworking telephone in their home. Collateral Contact B, supervisor for the home health agency, stated during a telephone interview on 10/02/2023 at 8:46 AM, they had received a referral from the facility regarding Resident 1 on 08/29/2023 for wound care and therapy services. When they attempted to call the resident, they did not have a working number. On 09/05/2023 a home health staff member drove to the resident's home to determine services and they found the house was vacant, thus they closed the resident's case. During a telephone interview on 09/29/2023 at 12:33 PM with CC C, supervisor for the caregiver service agency, showed they were contacted by the facility on 08/24/23 regarding providing services to Resident 1. Despite three attempts to call the resident with messages being left CC B never heard from them. It was not until 09/13/2023 when they received a telephone call from CC A requesting services for the resident. Collateral Contact C stated they visited Resident 1 in their home on [DATE] and found them seated in a wheelchair with nothing on from the waist down as there were no incontinent supplies. They stated it was difficult to walk through the house due to the number of boxes on the floor, and even more difficult for the resident as they were in a wheelchair. In addition, there was a significant problem with mouse droppings found throughout the kitchen and in the garage area where there was a strong offensive odor. The resident's friend was attempting to clean the resident after incontinency episodes. Collateral Contact C stated on 09/15/23 they received a telephone call from the friend stating they had not signed up for this, referring to providing personal care to the resident. The friend also stated during personal care they had gotten stool in the open wound on the resident's tailbone. Staff A stated during an interview on 10/02/2023 at 12:15 PM, they had worked on Resident 1's discharge plan after the former Social Services Director had vacated their position in August 2023. Staff A stated Resident 1 had informed them they had not resided in their home for an entire year. The resident had a preferred agency for caregiver services. Staff A stated they were not sure when the initial referral had been sent to the caregiver agency, and no updates regarding the resident's discharge had been made by facility staff. Staff A stated no home health referral had been made relative to the resident's open wounds as that would be done following their medical appointment on 09/12/2023. A cell phone was going to be mailed to their home. Staff B, Director of Nursing, stated on 10/02/2023 at 01:05 PM, that Resident 1 had stated to staff they knew how to give their own insulin and do blood sugar checks. Despite the resident not administering insulin and doing blood sugar checks for a year and their vision problems, staff had not evaluated the resident to determine if they were able to do those procedures accurately and safely. In addition, despite the resident (who lived alone at home) not residing in their home for a year Staff B stated an evaluation of the resident's home had not been done to determine if it was safe for the resident. Reference (WAC) 388-97-0120(4)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 1 of 1 sampled resident (Resident 330), reviewed for dialysis. In addition, the facility failed to process a medication order from the dialysis center timely for Resident 330, which resulted in a delay in the medication being administered. These failures placed the residents at risk for unmet care needs and medical complications. Findings included . The 08/02/2023 admission assessment showed Resident 330 was cognitively intact to make decisions regarding cares, had medically complex conditions, and diagnoses which included kidney disease, and diabetes (a disease caused by the inability of the body to convert the food we eat into sugar needed for the cells to use as energy). In addition, the assessment showed the resident received dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys stopped working properly). Review of the 04/29/2019 agreement between the facility and the dialysis center showed care of residents receiving dialysis was to be coordinated between the facility and the dialysis center, to ensure continuity of care and the resident's well-being. The facility dialysis policy showed the facility must ensure that residents who required dialysis received services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The policy instructed the facility to coordinate with the dialysis center that erythropoietin medication was administered at the dialysis center. The policy further stated nursing needed to define how provider orders would be communicated between nursing staff at the dialysis center and the facility. Review of the dialysis care plan showed interventions were implemented on 07/27/2023. The care plan instructed nursing to coordinate care with dialysis center and physician. A care plan was added on 08/01/2023 for an infection associated with Resident 330's central venous catheter (a long flexible tube that is inserted into a vein to deliver medication). An intervention to give the antibiotics at dialysis was not entered until 08/13/2023. Review of Resident 330's discharge paperwork from the hospital dated 07/26/2023 showed two medications were prescribed (Epoetin, a medication to treat anemia and Cefazolin, a medication used to treat infections). The Order Summary Report, dated 07/26/2023, showed the resident should have received the Epoetin on Monday, Wednesday and Friday and the Cefazolin on Monday and Wednesday at 5 PM, after dialysis, followed by a larger dose on Fridays. Review of the Medication Administration Record for July and August 2023 showed the above medications were not given in the facility. A progress note dated 08/02/2023 at 4:25 PM, stated a dialysis nurse called the facility and enquired if Resident 330 was receiving an antibiotic as their catheter had drained pus and was infected. The nurse from the facility denied giving the medication and stated Resident 330 was supposed to have received Cefazolin at the dialysis clinic. The dialysis nurse stated they never received the orders for the Cefazolin. The nurse from the facility asked if the clinic had received the orders from the hospital and the dialysis nurse denied getting the orders. A progress note dated 08/02/2023 at 16:45 stated a call was received from the dialysis nurse. The nurse called to enquire if Resident 330 was receiving their Epoetin injections. The facility nurse denied giving the injections and stated they were supposed to be given at dialysis. The dialysis nurse denied receiving the orders. During an interview on 08/17/2023 at 3:28 PM, Staff G, Registered Nurse, stated that a communication form was sent with the resident to dialysis and came back incomplete at times. Staff G stated they attempted to call the dialysis facility, but it was closed and would call the facility the next day. Staff G stated they were unsure what medications were given to Resident 330 at dialysis as the clinic has not communicated well. During an interview on 08/18/2023 at 4:59 PM, Registered Nurse (RN) from the dialysis clinic, Collateral Contact 1, stated that Resident 330 brought a communication form to the clinic one time. The RN stated the resident was discharged from the hospital on [DATE] and returned to their clinic on 07/26/2023. They stated they were unaware that Resident 330 was supposed to be receiving antibiotics until 08/09/2023. They explained that dialysis clinic received orders from their physician to start antibiotics and that Resident 330 was not receiving their Epoetin. The RN added that there was a communication gap between the facility and the clinic. During an interview on 08/18/2023 at 5:41 PM, Staff B, Director of Nursing stated they were unsure how the dialysis clinic knew what medications needed to be administered. Staff B stated they assumed that the hospital sent Resident 330's discharge paperwork to the dialysis clinic. Staff B added the facility did not send the dialysis clinic Resident 330's discharge paperwork. Staff B further added that the facility was unaware of the dialysis communication form until recently. Staff B provided two communication forms for Resident 330, one form was uncompleted. Reference: WAC 388-97-1900 (1), (6)(a-c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide wound management that met quality standards of care for 3 of 3 sampled residents, (Residents 5, 9 and 82) reviewed for wound care. The facility failed to follow provider orders for wound care, follow infection control standards during wound care, and fully document the wounds in the medical record. These failures placed the residents at risk of wound complications. Findings included . The facility's policy, Pressure Ulcer Prevention and Treatment dated 02/03/2023, showed skin should be assessed upon admission, weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk assessment (a scale used to determine the risk of skin breakdown). <Resident 82> According to an admission assessment, dated 05/13/2023, Resident 82 had a diagnosis of quadriplegia (paralysis affecting all four limbs) and used a wheelchair. The assessment further showed that the resident was alert, oriented and did not have any skin breakdown. A review of the resident's progress notes showed numerous entries about the resident staying up in their wheelchair all day, refusing to reposition or lay down for pressure relief, or allow positioning off their right side when lying down. A comprehensive assessment, dated 07/12/2023, showed that the resident rejected care daily and now had 2 pressure ulcers. Weekly skin evaluations from 05/10/2023 through 5/26/2023 showed no skin breakdown. The skin evaluation on 06/07/2023 showed that there was a small open area above coccyx. The evaluation did not include a description, drainage or wound measurements. Skin evaluations on 06/14/2023, 06/28/2023 and 07/05/2023 showed additional and worsening skin breakdown, but no detailed description of wounds or drainage until the 07/05/2023 note. In addition, none of the skin evaluations showed any wound measurements. Neither of the notes from an outside wound care vendor, dated 06/27/2023 and 07/05/2023, showed descriptions of the wounds or drainage, or any measurements. No further documentation was found in the resident record that described the wound status. During an intervew on 08/15/2023 at 10:57 AM, Staff G, Registered Nurse, stated that they never measured wounds. During an interview on 08/17/2023 at 10:30 AM, Staff K, Nursing Assistant, stated that the nurse measured wounds on admission and occassionally after that. During an interview on 08/19/2023 at 11:27 AM, Staff B, Director of Nursing. stated that their staff should be documenting descriptions of wounds, any drainage and wound measurements weekly. They further reported that staff could verbally descibe the wound, but were not documenting those descriptions as they should. During an interview on 08/19/2023 at 1:24 PM, Staff B and Staff H, Resident Care Manager, acknowledged wound care measurements and wound descriptions were not consistently done. <Resident 5> According to the 07/20/2023 admission assessment, Resident 5 had a diagnosis of heart failure, a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen. The assessment further showed the resident had a surgical wound to the right lower leg. Review of the 08/13/2023 wound care order showed the surgical wound was to be cleansed with sterile water, an Aquacell dressing, an absorbent material that transformed into gel when contact was made with fluid, was to be placed onto the wound bed, covered with 4x4 gauze, then wrapped with rolled gauze and secured with Coban. On 08/15/2023 at 10:57 AM, an observation was made of the wound care and dressing change to right lower leg. Observation showed both lower legs were wrapped with gauze, had weeping edema, caused when swollen parts of the body leaked excess fluid through the skin, and multiple small superficial openings in the skin. There was a large, open surgical wound on the back of the right calf that was draining blood-tinged fluid. Staff G, Registered Nurse, removed the dressings from the resident's lower legs, retrieved a washcloth from a basin containing warm water and washcloths. then wiped down the skin on the left lower leg, changed gloves and reached back into the basin, removed another washcloth and wiped down the skin on the right lower leg around the wound. Staff G changed gloves before reaching back into the basin for wash cloths but did not change gloves or perform hand hygiene after removing the soiled dressings prior to retrieving the first wash cloth from the basin. After cleansing the legs, Staff G applied lotion to both lower legs and feet, and without changing gloves or performing hand hygiene, removed a gauze pad from a package containing multiple gauze pads. Staff G then separated the resident's toes by weaving the pad between them. During the treatment the resident's right lower leg was observed resting on the leg rest of the recliner, which caused the open wound to touch the leg rest. Without cleaning the wound, Staff G, placed a Hydrofera Blue dressing, an absorptive foam dressing, onto the wound bed, then covered the dressing with 4x4 gauze pad, and wrapped it with rolled gauze and secured it with Coban, a self-adhering bandage wrap. During an interview on 08/15/2023 at 11:40 AM, Staff G stated they did not clean the resident's right leg surgical wound during the wound care procedure, and they used the Hydrofera Blue dressing because the Aquacell dressing was not available. Staff G stated the Treatment Administration Record (TAR) informed the nursing staff how to care for the wound. During an interview on 08/18/2023 at 11:46 AM, Staff B, Director of Nursing, acknowledged the incorrect dressing was used at the time of the dressing change observation. <Resident 9> Per Resident 9's Braden skin assessment dated [DATE] showed the resident was at moderate risk for skin breakdown. Per the quarterly assessment dated [DATE], Resident 9 had diagnoses which included diabetes mellitus and history of a diabetic foot ulcer. The assessment also showed the resident needed assistance from staff for repositioning and turning in bed, and that the resident was identified as being at risk to develop pressure ulcers but did not have any at the time of the assessment. Review of the August 2023 Treatment Administration Record (TAR) showed an ongoing order for a weekly diabetic foot assessment, which instructed the nursing staff to notify the physician of any new areas of skin impairment. Documentation showed the assessments had been completed. Review of Total Body Skin Evaluation on 08/13/2023 showed Resident 9 had no skin issues. During an observation on 08/14/2023 at 11:49 AM, Resident 9 had a scab over a bony prominence on the top of their left foot and the outside of left foot. During an interview on 08/17/2023 at 4:34 PM, Staff I, Licensed Practical Nurse, stated skin assessments are completed weekly and documented in the medical record. Staff I accompanied surveyors to Resident 9's room to assess their left foot. Staff I stated they were unaware of the skin issue on Resident 9's left foot. Per review of Resident 9's medical record there was no documentation on skin issues to resident's left foot. During an interview on 08/17/2023 at 3:45 PM, Staff B, Director of Nursing, stated they expect nursing staff would assess skin daily during cares and report any new skin issues to management and the physician. Reference: WAC 388-97-1060(1)(3)(a)

Based on observation, interview, and record review, the facility failed to ensure processes for proper holding temperatures were maintained for prepared foods, between when they were prepared in the kitchen, and when the residents received the food, opened foods were labeled and/or dated as required for 1 of 3 refrigerators, expired food in 1 of 1 dry storage area. This failure placed residents served from the kitchen at risk for onsuming expired food. Findings included . During an initial tour of the kitchen on 08/13/2023 at 9:45 AM, the pantry revealed a bag of tortilla shells that were opened and had expired, there were multiple packages of tortilla shells that expired on 08/09/2023, three loaves of bread, a bag of rolls and a cake mix that was undated and had no received or expiration date. The freezer contained a turkey, chicken breasts and hashbrowns that had been opened with no opened date or discard date. During an interview on 08/13/2023 at 10:20 AM, Staff D, Cook, stated that anyone who opened a package should write the date on it immediately. Staff D stated that the bread and rolls were sent from the distributor without a date and the received date needed to be written on the packages when they arrived. Staff D threw away all items that had expired and had no opened or received date except for the bread. Staff D added that the bread had arrived on 08/12/2023 and they were going to write the date on it. During an observation on 08/14/2023 at 3:17 PM, the refrigerator in the dining area contained a package of blueberries that had mold, an orange in a bag that was brown and mushy, and both were undated, and yogurt that had expired on 08/02/2023. Staff B, Director of Nursing, verified the items listed were expired and threw them away. Staff B, stated that nursing and activities should have been checking expiration dates on the food and it should have been discarded. During an observation of meal service on 08/16/2023 at 11:43 AM, egg salad sandwiches were on the meal cart, ready to be served to the residents. The temperature of the egg salad was 51 degrees (normal temperature should be 41 degrees or below). Staff C, Dietary Manager, placed the sandwiches in the refrigerator to decrease the temperature. The caesar salad was 64 degrees and Staff C stated they would like it to be 45 degrees (normal temperature should be 41 degrees or below). Staff C stated the egg salad would have been served to the residents at 51 degrees and the aide needed education on temping the food prior to placing it on the cart. During an observation of meal service on 08/16/2023 at 12:10 PM, Staff C removed the egg salad from the refrigerator and the temperature was 51 degrees. Staff C decided to make more egg salad and the temperature was 50 degrees. The egg salad was served to the residents at 50 degrees. During an interview on 08/16/2023 at 1:15 PM, Staff C stated the temperature of the egg salad should have been 40 degrees or below and they should have put the egg salad in the freezer to bring the temperature down to the normal range prior to serving it to the residents. Staff C added the facility was looking into purchasing new carts that are insulated and have doors as the current carts were not insulated and had no doors. Reference: WAC 388-97-1100(3), 2980

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the requirements for a facility-initiated transfer or discharge notification for 1 of 1 sampled residents (Resident 1), emergently sent to the hospital. This placed the resident at risk of unmet care needs and a diminished quality of life. Findings included . Review of Resident 1's medical record showed they were admitted to the facility from the hospital on [DATE] with diagnoses which included diabetes, dementia (impaired ability to remember, think or make decisions that interfere with doing everyday activities) and schizoaffective disorder (mental illness that can affect thought, mood and behavior). Review of Resident 1's comprehensive assessment, dated 05/31/2023, showed the resident had moderate cognitive impairment, was independent with turning in bed, needed supervision of one staff for transfers/dressing/personal hygiene, and supervision with set up help by staff for eating and toilet use. Review of a 05/25/2023 progress note showed Resident 1 ambulated with a walker throughout the facility, and was able to transfer with supervision. The note also showed the resident had a good appetite, was continent of bowel and bladder, and was pleasant and cooperative. Review of a 07/12/2023 progress note showed Resident 1 was not participating in therapy, and was extremely impulsive and unsafe. Per the note, staff attempted to redirect the resident, but due to their impulsiveness it was difficult to do, and the resident exhibited yelling behaviors. Review of a 07/13/2023 progress note showed Resident 1 was forgetful which was complicated by behavioral disorders, was throwing things off the table in their room, which included a supplement drink at the face of a licensed nurse. The note also showed the resident now required maximum assistance with activities of daily living, verbal cueing to eat meals, and refused to allow their blood sugar to be checked to monitor their diabetes. Per a progress note on 07/14/2023 at 10:30 AM, Resident 1 was screaming loudly, hitting staff during personal care, and staff were unable to distract or converse with the resident for redirection or calming down. Per the record, on the same day at 10:36 AM, the physician was called regarding Resident 1's behaviors. The physician gave orders to send the resident to the emergency room for evaluation and treatment. The note showed three law enforcement staff arrived at the facility prior to the arrival of emergency medical staff, to assist staff with the resident. Per a progress note on 07/14/2023 at 10:49 AM, Staff C, Social Services Director (SSD), attempted to redirect Resident 1 due to their increased behaviors. The resident was screaming out that they had killed someone or yelling out for help, throwing items at staff, pulling out their hair and throwing themselves around in their bed. When the resident was up in a wheelchair they ran into walls and staff, and were unable to calm down. Staff C and Staff A, Administrator, provided two to one supervision to keep staff and the resident safe. Staff C stated during a telephone interview on 07/25/2023 at 11:05 AM, that despite Resident 1's long history of mental health issues their behaviors were manageable for several weeks following admission to the facility. Staff C stated they transferred Resident 1 to the hospital to have them stabilize their behaviors, as they no longer could meet the resident's needs. Review of the Nursing Home Transfer or Discharge Notice, dated 07/14/2023, showed the notice was given on 07/14/2023, as the transfer or discharge was necessary for Resident 1's welfare, and their needs could not be met in the facility. Despite the facility initiating a transfer/discharge of Resident 1 due to increased, uncontrollable behaviors, and inability of staff to meet their needs, there was no documentation in the resident's medical record by the resident's physician, as required, regarding the basis for the transfer or discharge. Reference (WAC) 388-97-0120(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on by the physician for 1 of 3 sampled residents (Resident 1), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications, medication-related adverse reactions, and a diminished quality of life. Findings included . Review of the facility policy titled, Medication Regimen Review and Reporting, dated 09/18, showed the facility follows up on the pharmacy recommendations to verify appropriate action has been taken. Recommendations shall be acted upon within 30 days. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document their rational of why the recommendation is rejected in the resident's medical record. Review of Resident 1's medical record showed they were admitted to the facility on [DATE] from the hospital with diagnoses which included dementia (impaired ability to remember, think or make decisions that interfere with doing everyday activities) and schizoaffective disorder (mental illness that can affect thought, mood and behavior). Review of physician's orders on 05/26/2023 showed they were receiving the following medications: Escitalopram Oxalate (used in the treatment of depression and anxiety). Haloperidol (used in the management of schizophrenia - a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Donepezil Hydrochloride (used in the treatment of dementia). Olanzapine (used to treat the symptoms of schizophrenia). Quetiapine (used in the treatment of schizophrenia, depression, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the Pharmacy Consultant Report, recommendation date of 05/26/2023, showed Resident 1 received two or more medications that were known to prolong the QT interval (a heart rhythm disorder that could potentially cause fast, chaotic heartbeats which could be life-threatening, whichn could be inherited or caused by a medication or condition). The pharmacy recommendation on that report was to reevaluate continued use of the above-listed medications, and to consider discontinuation of the Donezepil. Per the report, if those medications were to continue to be used, it was recommended the physician document an assessment of the risk versus benefit, showing that it continued to be a valid therapeutic intervention for Resident 1. Review of Resident 1's medical record showed that between 05/26/2023 to 07/14/2023 (the date the resident was discharged ), Donepezil Hydrochloride, Escitalopram Oxalate, Olanzapine and Quetiapine continued to be administered to the resident, despite the recommendation of the consulting pharmacy. Haloperidol was discontinued on 06/22/2023. There was no physician assessment of the risk versus benefit for the continued use of Donepezil Oxalate. Staff D, Primary Care Physician for the resident, stated on 07/24/2023 at 12:10 PM, that they continued the Donepezil, as they were not certain if the resident had dementia or not, however they did not document an assessment of the risks versus benefits. Staff B, Director of Nursing, stated on 07/24/2023 at 11:15 AM, that the physician did not document any assessment of the the risks versus benefits of the continued use of Donepezil Hydrochloride in Resident 1's medical record. Staff A, Administrator, stated on 07/24/2023 at 1:45 PM, that Resident 1's physician was not consistently following up on the recommendations made by the consulting pharmacist. Reference (WAC) 388-97-1300(4)(c)

Based on interview and record review, the facility failed to inform and/or obtain a choice in writing, related to continuing skilled services, for 2 of 3 sample residents (15, 17) of their potential liability for payment, related to Medicare coverage ending. This failure placed the residents/representatives at risk for not having adequate information to make financial decisions, related to a continued stay in the facility. Findings included . Resident 15 Record review showed that on 05/25/2021, the facility issued a Notice of Medicare Non-Coverage (NOMNOC), informing Resident 15 Skilled Nursing Services would end on 05/27/2021. Additional record review showed the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), was issued and signed by the resident. However, the facility failed to obtain the resident's choice related to continuing skilled nursing services, once Medicare payment ended. Resident 17 Record review showed that on 05/07/2021, the facility issued a NOMNOC, informing Resident 17 that Skilled Nursing Services would end on 06/08/2021. Additional record review showed the SNFABN was unsigned, not dated, and failed to document the resident's choice related to ongoing services. In an interview on 09/03/2021 at 10:31 AM, Staff A, Administrator, acknowledged the paperwork was incomplete. Reference: (WAC) 388-97-0300 (4)(a-c)

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 sample residents (22) reviewed for activities of daily living received consistent, adequate oral hygiene. This failure placed the resident at risk for diminished quality of life. Findings included . According to a 08/20/2021 admission assessment, Resident 22 was severely cognitively impaired and required extensive assistance with personal hygiene. Per review of an activities of daily living care plan initiated on 08/20/2021, the resident was totally dependent on staff for assistance with oral care. Review of documentation under the personal hygiene tab in the electronic record for 08/13/2021 - 09/07/2021 showed no refusals. On 08/31/2021 at 11:46 AM an electric toothbrush was observed in the resident's room. The toothbrush bristles were completely dried out and stiff. A regular toothbrush in an unopened wrapper was also observed in a container of other hygiene items. No other oral hygiene items were observed. Similar observations were made on 09/01/2021 at 2:14 PM, and 09/02/2021 at 9:32 AM. On 09/02/2021 at 9:58 AM, the resident's toothbrushes and teeth were observed with Staff B, Director of Nursing. Staff B confirmed both toothbrushes appeared to be unused. The resident's bottom teeth had large amounts of white build up around the edges, as well as pieces of food. The resident had only one upper tooth remaining. Staff B then proceeded to use the previously sealed toothbrush to brush the resident's teeth. The resident fully cooperated with the examination of her teeth, as well as the brushing, without any sign of refusal. Per Staff B residents' teeth were to brushed in the morning and at bedtime. Staff B added the resident sometimes refused oral care. In an interview on 09/01/2021 at 9:21 AM, Staff F, Nursing Assistant, stated oral hygiene was completed as part of morning care. Staff F added if residents refused, the refusal was documented under the personal hygiene tab in the electronic record. In an interview on 09/02/2021 at 11:22 AM, Staff K, Nursing Assistant stated the resident would often refuse oral hygiene and did not like the electric toothbrush the resident's family had brought in. Staff K added staff was going to get the resident one of the white toothbrushes the facility had and try that. The resident had been at the facility for over two weeks. Reference: WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to assess, monitor, and implement treatment for a skin injury for 1 of 2 sample residents (10) reviewed for skin conditions. This failure put the resident at risk for worsening of the injury. Findings included . In an interview on 08/26/2021 at 2:59 PM, Resident 10 stated that they had a wound on their lower leg. Per the resident, the wound had originally occurred in December 2020 and had healed and re-opened several times since. On 08/27/2021 at 9:28 AM a small gauze covering with a 2-3 inch spot of light color drainage was observed on the resident's right lower shin. Documentation from an outside wound clinic dated 06/14/2021 showed the resident had been discharged from their services with no further orders for wound care. Review of a 07/22/2021 provider note showed the resident had a chronic right shin wound with some new tearing of the epidermis [outer layer of skin]. Per the note the wound was to be kept moist with dressings changed twice weekly. No mention of the wound, or any wound care was in theshown resident's progress notes, Medication Administration Record (MAR) or Treatment Administration Record (TAR) for July 2021 through 08/10/2021. Documentation from an appointment with an outside provider on 08/11/2021 showed the resident had an open wound on the right lower leg, and a new referral to the wound clinic was needed. A progress note on 08/11/2021 referenced the outside appointment and wound clinic referral. Per the note, the resident currently had small open areas scattered on lower shin right leg, and had an open area for multiple weeks that had quickly resolved prior. It was unclear from the note when the areas were open, and when they had healed. No further mention of the status of the wounds was found in the resident's record until 08/31/2021, the day after the resident's wound clinic referral appointment. Review of the resident's August 2021 TAR showed treatments for the area were not implemented until 08/27/2021, over a month after the July provider note. In an interview on 09/01/2021 at 1:44 PM, Staff B, Director of Nursing, stated that nurses were expected to document the location of skin injuries and add them to the MAR/TAR so they could be monitored for signs and symptoms of infection. Staff B stated that she monitored wounds weekly and documented in the resident's progress notes. Per Staff B, the resident had reported their shin wounds had opened up again on 08/27/2021, so the facility obtained orders for dressing changes until the resident was seen at the wound clinic. When asked about the 07/22/2021 provider note referencing open areas and dressing changes, Staff B stated when she went in to assess the resident, the resident told her the areas had healed so she discontinued the dressing changes. The facility was unable to provide any documentation of the status of the resident's right shin area, or any treatments from around the time the provider noted open wounds on 07/22/2021 through 08/11/2021 when the resident was seen by the outside provider, or from 08/12/2021 - 08/30/2021 when the resident was seen by the wound clinic. 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 thoroughly assess a resident's increased wandering behaviors and evaluate the need for safety interventions for 1 of 1 sample residents (74) reviewed for wandering. This failure placed the resident at increased risk for elopement (leaving the premises unaccompanied, when assessed not to be safe to do so). Findings included . According to a 08/16/2021 admission assessment, Resident 74 admitted to the facility on [DATE], had diagnoses including encephalopathy (condition that affects brain function), and was severely cognitively impaired. Per review of a 08/14/2021 Wander Risk assessment, the resident had impaired cognition, was bed-bound or immobile, had no history of wandering and was determined not to be at risk for wandering. On 08/27/2021 at 11:31 AM the resident was observed sitting in a wheelchair across from the nurses station. The resident attempted to stand and was redirected by nearby staff to sit. At 11:42 AM that same day, the resident was observed in the hallway with Staff C, Staff Development Coordinator. The resident told Staff C they wanted to go outside. Staff C responded that they would take the resident outside in a minute and the resident should wait in the hallway for them. At 11:43 AM the resident was observed self-propelling in a wheelchair in the hallway to the front door. The resident attempted to open the door by pushing on the door handles. The resident then proceeded to repeatedly bang on the door handles to try and open the doors. Therapy staff and Staff B, Director of Nursing responded to the noise and intervened. On 08/31/2021 at 2:41 PM the resident was observed self-propelling in a wheelchair down the hall towards the dining room. On 09/01/2021 at 7:18 PM the resident was observed in their wheelchair at the front door attempting to open it. Staff S, Licensed Practical Nurse, was with the resident. Staff S redirected the resident back to their room to use the bathroom. At 7:33 PM the same day, the resident was observed propelling in the hallway. At 7:39 PM the resident self-propelled towards the end of the north hallway where there was an exit; no staff were visible. At 7:48 PM the resident approached Resident 15's doorway. Resident 15 began to yell out. Staff S responded, moved the resident away from the doorway and shortly after took the resident to their room. In an interview on 09/01/2021 at 9:21 AM, Staff F, Nursing Assistant, stated that the resident had asked where the highway two different times, but did not go looking for it. In an interview on 09/02/2021 at 11:18 AM, Staff S stated that the resident became restless and easily agitated in the evening, but did not usually wander or exit seek. In an interview on 09/01/2021 at 8:04 PM, Staff J, Registered Nurse, stated that the resident's behaviors included wandering, and that the resident did exit seek off and on. Staff J added the resident had recently been started on a new medication and their behaviors were improving a little. Per Staff J, the resident did not wear a wander guard (device worn by the resident that alarms when close to an exit), but stated that staff kept a close eye on the resident, and the doors at each exit had recently been locked and alarmed. On 09/02/2021 at 9:49 AM, Resident 74's wandering and exit seeking were discussed with Staff B. Staff B stated that the resident had only recently completed a 14 day quarantine in their room, and just started moving about in the facility. Staff B added that the facility had recently locked the facility's exit doors after staff noticed an increase in the resident's wandering and exit seeking. Staff B confirmed the resident's wandering assessment and care plan had not been updated and should have been, and other safety interventions like a wander guard had not yet been implemented. Reference: WAC 388-87-1060 (3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ANTICOAGULATION CARE PLAN: RESIDENT 21 Per an admission assessment dated [DATE], Resident 21 had a diagnosis of chronic atrial fibrillation (an irregular heart rhythm, which places the person at increased risk of blood clots, heart attack and stroke). Their medications included Coumadin (an anticoagulant or blood-thinner). Per the Nursing 2022 Drug Handbook by Wolters Kluwer, pages 1532-1534, Coumadin could cause major or fatal bleeding. Patients should be regularly monitored for signs and symptoms of bleeding, such as bruising, bleeding gums, or blood in the urine or stool, and the provider should be notified immediately. In a review of the resident's record, the care plan did not include any mention of Coumadin, or any interventions to monitor for signs or symptoms of bleeding. Further review showed that the [NAME] (a document that shows the plan for the nursing assistants) did not mention Coumadin, or that the resident was at an increased risk for bleeding. In an interview on 09/08/2021 at 9:28 AM, Staff K , Nursing Assistant, said that if a resident was on blood thinners, it would be on the care plan and [NAME]. They further reported that the nursing assistants looked at the [NAME]. In an interview on 09/08/2021 at 10:03 AM, Staff I, Nursing Assistant, stated they weren't sure where it was documented, if a resident was on blood thinners. In an interview on 09/09/2021 at 9:07 AM, Staff F, Nursing Assistant, reported that you could tell if a resident was on blood thinners by the care plan. In an interview on 09/08/2021 at 2:49 PM, Staff J, Registered Nurse, stated that blood-thinners were found on the MAR (Medication Administration Record), doctor's orders, the [NAME] (so the nursing assistants were aware) and on the care plan. In an interview on 09/08/2021 at 11:07 AM, when asked where it was documented if a resident was on blood-thinners, Staff Q, Registered Nurse stated it was on the care plan and [NAME]. Additionally, they reported that the nursing assistant's would know about it from the [NAME]. When asked if that information was usually on the care plan, they said it should be. Reference : (WAC) 388-97-1020 (1),(2)(a)(b) Based on interview and record review, the facility failed to implement care plan interventions related to nutrition for 7 of 7 sample residents (7, 13, 19, 21, 22, 74, 174) reviewed for nutrition. Failure to consistently weigh residents placed the residents at risk for unidentified weight loss. In addition, the facility failed to include anticoagulant therapy (medication to decrease the risk of blood clots), in the comprehensive care plan for 1 of 5 sample residents (21), reviewed for medications. This failed practice placed the resident at risk for unrecognized bleeding and other possible complications. Findings included . NUTRITION CARE PLANS: According to the facility's Skin and Nutrition Outline policy, dated 10/2019, residents were to be weighed weekly for the first four weeks, and then monthly after that. RESIDENT 7 Resident 7's nutrition care plan included a 03/22/2021 intervention directing staff to weigh the resident per the facility weight protocol. Review of the resident's weight record on 09/07/2021 showed the resident weighed 126.4 pounds (lbs.) on 05/25/2021. No weights were documented in over three months since. RESIDENT 13 According to a 07/12/2021 nutrition care plan, Resident 13 was to be weighed per the facility weight protocol. Review of the resident's weight record showed the resident was weighed on 07/10/2021 when they admitted to the facility. The resident was not weighed again until 09/02/2021, nearly eight weeks later. RESIDENT 19 Review of Resident 19's nutrition care plan showed a 07/28/2021 intervention directing staff to weigh the resident per the facility weight protocol. Review of the resident's weight record showed the resident was weighed on 07/27/2021 when they admitted to the facility. No other weights were documented prior to the resident's discharge five weeks later on 09/01/2021. RESIDENT 21 According to Resident 21's 08/05/2021 nutrition care plan, staff were to weigh the resident weekly for four weeks and until stable, then monthly, or per facility protocol. Per review of the weight record, Resident 21 was weighed when they admitted to the facility on [DATE]. No other weights were documented prior to the resident discharging four weeks later on 09/02/2021. RESIDENT 22 Review of Resident 22's 08/15/2021 nutrition care plan showed an intervention to weigh the resident per the facility weight protocol, or as ordered No specific weight order was found in the resident's record. Per review of the resident's weight record, the resident was weighed when they admitted to the facility on [DATE]. The next documented weight was not until 09/02/2021, almost three weeks later. RESIDENT 74 According to an 08/11/2021 nutrition care plan, staff were to weigh Resident 74 weekly for four weeks and until stable, then monthly, or per the facility's policy. Review of the weight record showed the resident was weighed on 08/10/2021 when they admitted to the facility. The resident was not weighed again until over four weeks later on 09/02/2021. RESIDENT 174 Resident 174's 08/18/2021 nutrition care plan directed staff to weigh the resident per facility policy, or as ordered. No specific weight order was found in the resident's record. Per review of the weight record on 09/07/2021, the resident was weighed when they admitted to the facility on [DATE]. No other weights were documented for the three week period. In an interview on 09/02/2021 at 11:22 AM, Staff R, Nursing Assistant, stated that weights were done either daily, weekly, or monthly depending on the resident and then documented in the electronic weight record. When asked how staff knew when weights were needed for each specific resident, Staff R stated the frequency was noted in the electronic record. In an interview on 09/02/2021 at 11:44 AM, Staff N, Registered Dietician, stated residents were to be weighed daily for the first three days, then weekly for four weeks, then at least monthly. Staff N added she provided Staff B, Director of Nursing, a list of residents that were not being weighed per protocol and/or needed an updated weight each month. Per Staff N, the facility had been having some issues weighing residents per the policy related to staffing issues. In an interview on 09/03/2021 at 9:53 AM, Staff B confirmed Staff N had provided a list of residents who needed a current weight most recently on 08/19/2021. Refer to F692 for additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 8 Per an admission assessment dated [DATE], Resident 8 had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - obstructive lung disease) and an abdominal mass Per the record, the resident was admitted for hospice services on 06/01/2021. Further review of the record showed hospice documents from 06/01/2021 through 06/18/2021 scanned into the electronic medical record, but none since. A review of the progress notes back to the resident's admission showed no entries from hospice staff. Resident 5 Per the record, Resident 5 was admitted for hospice services on 11/16/2020. Further review of the record showed 3 hospice documents dated 11/17/2020, 12/03/2020 and 06/10/2021 scanned into the electronic medical record, for the 10 months they had been receiving hospice care. A review of the resident's progress notes from 05/01/2021 through 09/08/2021, showed no entries from hospice staff. In an interview on 09/08/2021 at 11:07 AM, Staff Q, Registered Nurse, was asked how staff would find out what happened during a hospice visit? Staff Q brought the surveyor to the nurses station, and demonstated removing a large binder, labeled with an outside hospice provider, from the shelf. When the surveyor looked through the binder with Staff Q, they stated that since the notes from Resident 5 and 8 were not there, they would just ask Staff B, Director of Nursing, any questions. The only documents found in the binder were on a former resident, who had passed 2 years prior. In an interview on 09/08/2021 at 2:49 PM, Staff J, Registered Nurse, stated that they would look for hospice information in the progress notes in the resident's chart, or just call hospice directly. The surveyor had requested copies of any hospice documents from Staff B for Resident 8 and Resident 5. Paper copies on Resident 8 were provided the following day, which included documents from 07/01/2021 and 07/29/2021 (which weren't found in the electronic medical record). The paper copy of a hospice note from 06/15/2021 on Resident 5 was provided near the end of survey. Per Staff B, they had to ask hospice to fax Resident 5's note over. No more recent documents for either resident were provided. Reference: (WAC) 388-97-1720 (1)(a)(i-iv)(b) Based on interview and record review, the facility failed to ensure resident medical records were complete and accurate, for 2 of 5 sample residents (14, 8), reviewed for unnecessary medications. Failure to ensure documentation of physician visits was available in the resident records, placed the residents at risk for unmet care needs, and incomplete information being considered when making medical decisions. Additionally, the facility failed to have hospice records readily available for 2 of 2 residents (5, 8) reviewed for Hospice services. This failure put the residents on Hospice at risk for unmet care needs due to inconsistent communication among caregivers. Findings included . Physician Visit Records Resident 14 Review of Resident 14's record showed no documentation of a physician visit at least every 60 days, as required, between 03/01/2021 - 09/08/2021. Resident 8 Review of Resident 8's record showed the resident admitted to the facility on [DATE]. There was no documentation of a physician visit within 30 days and at least every 60 days, as required after that, up through 09/08/2021. On 09/08/2021 at 10:30 AM, the resident's charts were reviewed with Staff A, Administrator, who confirmed there was inconsistent documentation of physician visits in the residents records during the previous 6 months. In an interview on 09/08/2021 at 10:41 AM, Staff P, Medical Director, stated that physician visits were completed at least every two weeks, and often times weekly. Staff P acknowledged the notes from these visits were not readily available in either resident's medical record and stated that it was due to a misunderstanding about how to move documents from one computer system to another. The Medical Director stated that the documentation for physician visits was located in Gehri-Med, which was a system the facility didn't use to maintain electronic health records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 4 of 5 residents (4, 8, 15, 21), reviewed for pneumococcal immunizations, received education addressing the risks versus benefits, or had the opportunity to receive or decline the vaccine. This failure placed residents at risk for not being able to make an informed decision regarding their immunizations. Findings included . Per the CDC guidelines (Pneumococcal Vaccine Timing for Adults, 2015), adults [AGE] years of age or older should receive doses of both the pnuemococcal conjugate (PCV13) and pneumococcal polysaccharide (PPSV23) vaccines, in a series, for prevention of pneumococcal disease. Resident 4 Review of the immunization record for Resident 4 showed the resident received a pneumococcal vaccine on 03/20/2020. No documentation regarding when, or if, the resident had received the other pneumococcal vaccine in the series was found. The resident was over [AGE] years old, and was a potential candidate for both vaccines. Resident 15 Review of Resident 15's immunization record showed the resident received a pneumococcal vaccine on 03/05/2020. The resident was potentially eligible for both vaccines. No further pneumococcal vaccination documentation was found. Resident 8 A review of the medical records for Resident 8 showed the resident/representative had refused consent for the pneumococcal vaccine. There was no documentation that risks versus benefits of the vaccine was given to the resident or representative. Additionally, there was no signed and dated declination document in the residents record. Resident 21 Review of the medical records for Resident 21 showed no documentation the resident had received either pneumococcal vaccinations, nor was there any documentation that the risks versus benefits of the immunization was explained to the resident. On 09/08/2021 at 10:53 AM documentation of the second pneumococcal vaccine for Resident 4 and Resident #15 was requested from Staff B, Director of Nursing, and none was provided In an interview on 09/09/2021 at 11:53 AM, Staff C, Staff Development Coordinator, stated that the facility hadn't provided written documentation to residents with information on the risks versus benefits of immunizations. Additionally, staff C stated that there were no declination forms obtainedfrom residents. Reference WAC 388-97-1340(1)(2)(3)