What is LIFE CARE CENTER OF PUYALLUP's CMS rating?

LIFE CARE CENTER OF PUYALLUP has a five-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does LIFE CARE CENTER OF PUYALLUP have?

LIFE CARE CENTER OF PUYALLUP has 50 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at LIFE CARE CENTER OF PUYALLUP?

LIFE CARE CENTER OF PUYALLUP has a four-star staffing rating from CMS with 0.75 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is LIFE CARE CENTER OF PUYALLUP located?

LIFE CARE CENTER OF PUYALLUP is located in PUYALLUP, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does LIFE CARE CENTER OF PUYALLUP have?

LIFE CARE CENTER OF PUYALLUP has 102 certified beds.

Who owns LIFE CARE CENTER OF PUYALLUP?

LIFE CARE CENTER OF PUYALLUP is a for profit - limited liability company facility and is part of the LIFE CARE CENTERS OF AMERICA chain.

Is LIFE CARE CENTER OF PUYALLUP safe?

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

Do nurses at LIFE CARE CENTER OF PUYALLUP stick around?

LIFE CARE CENTER OF PUYALLUP has average staff turnover at 32%, which is typical for the nursing home industry.

Was LIFE CARE CENTER OF PUYALLUP ever fined?

Yes, LIFE CARE CENTER OF PUYALLUP has been fined $34,650 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is LIFE CARE CENTER OF PUYALLUP on any federal watch list?

No, LIFE CARE CENTER OF PUYALLUP is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at LIFE CARE CENTER OF PUYALLUP?

Medicare inspectors have found 50 deficiencies at LIFE CARE CENTER OF PUYALLUP: 48 moderate, 2 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting LIFE CARE CENTER OF PUYALLUP?

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

How does LIFE CARE CENTER OF PUYALLUP compare to other nursing homes?

LIFE CARE CENTER OF PUYALLUP has a 5-star overall rating, placing it above average compared to other nursing homes in WA. Higher-rated facilities typically have better inspection results and staffing levels.

LIFE CARE CENTER OF PUYALLUP

Name: LIFE CARE CENTER OF PUYALLUP
Address: 511 10TH AVENUE SOUTHEAST, PUYALLUP, WA, 98372, US
Telephone: (253) 845-7566
Rating: 5.0

511 10TH AVENUE SOUTHEAST, PUYALLUP, WA 98372 · (253) 845-7566

For profit - Limited Liability company 102 Beds LIFE CARE CENTERS OF AMERICA Data: November 2025

Trust Grade

75/100

#23 of 190 in WA

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Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Life Care Center of Puyallup has received a Trust Grade of B, indicating that it is a good facility overall, but there may be areas for improvement. The nursing home ranks #23 out of 190 facilities in Washington, placing it in the top half, and #2 out of 21 in Pierce County, suggesting it is one of the better local options available. Unfortunately, the facility's trend is worsening, with the number of reported issues increasing from 7 in 2024 to 13 in 2025. Staffing is a strength, with a rating of 4 out of 5 stars and a turnover rate of 32%, which is significantly lower than the state average of 46%, indicating experienced staff who are familiar with the residents. However, the facility has faced $34,650 in fines, which is average and raises some concerns about compliance. Additionally, there have been specific incidents of concern, including failures in infection control practices that could put residents at risk for healthcare-associated infections, as well as a lack of privacy for residents with catheter bags, potentially affecting their dignity. While there are strengths in staffing and overall care, families should be aware of the increasing number of issues and the specific concerns noted in inspections.

Trust Score: B
In Washington: #23/190
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 32% turnover. Near Washington's 48% average. Typical for the industry.
Penalties: $34,650 in fines. Lower than most Washington facilities. Relatively clean record.
Skilled Nurses: Each resident gets 44 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
Violations: 50 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★★

5.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★★★☆

4.0

Inspection Score

↔

Stable

2024: 7 issues

2025: 13 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (32%)
16 points below Washington average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Staff Turnover: 32%

13pts below Washington avg (46%)

Typical for the industry

Federal Fines: $34,650

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: LIFE CARE CENTERS OF AMERICA

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 50 deficiencies on record

Jul 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create a comprehensive care plan for 2 of 3 residents (Residents 1 and 2) reviewed for urinary incontinence. This failure placed the residents at risk for unmet needs, skin impairments, feelings of discomfort and a decreased quality of life.Findings included.Resident 1Review of the admission minimum data set (MDS, a required assessment tool), dated 06/18/2025, showed Resident 1 admitted on [DATE] with diagnoses to include hip fracture with surgical repair, weakness, difficulty walking, and need for assistance with personal care. The MDS showed Resident 1 was always incontinent (had lack of voluntary control) of bowel and bladder.Review of the comprehensive care plan, last reviewed 07/09/2025, showed incontinence was not listed, nor were goals or interventions in the care plan to address Resident 1's incontinence. Resident 2Review of the admission MDS, dated [DATE], showed Resident 2 admitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), overactive bladder, and need for assistance with personal care. The MDS showed Resident 2 was frequently incontinent of bladder.Review of a facility document titled, Admission/readmission Collection Tool - V 6, dated 05/20/2025, showed Resident 2 was incontinent of bladder.Review of the discharge MDS, dated [DATE], showed Resident 2 discharged from the facility on 06/02/2025.Review of the comprehensive care plan, last reviewed 07/09/2025, showed that Resident 2's incontinence was not included in their care plan until 06/02/2025, the date that Resident 2 discharged .During interview on 07/09/2025 at 3:36 PM, Staff A, Director of Nursing Services (DNS), stated that Residents 1 and 2 should have had care plans in place for incontinence as soon as the need for care in that area was identified - via the admission nursing assessment and/or the MDS.Reference WAC 388-97-1020(1), (2)(a)(b).

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to routinely monitor and assess the status of skin impairments for 2 of 3 residents (Residents 1 and 2) reviewed for pressure injuries. This failure placed the residents at risk for worsening of pressure wounds, lack of appropriate treatment, medical complications and a decreased quality of life.Findings included.Resident 1Review of the admission minimum data set (MDS, a required assessment tool), dated 06/18/2025, showed that Resident 1 admitted on [DATE] with diagnoses to include hip fracture with surgical repair, weakness, difficulty walking, and need for assistance with personal care. The MDS further showed that Resident 1 had a stage 1 pressure injury (the initial stage of a pressure ulcer, characterized by non-blanchable [does not fade or turn white when pressure is applied] redness of intact skin, usually over a bony prominence) over the sacrum (large triangular bone at the bottom of the spine).Review of the care plan, dated 06/16/2025, showed that Resident 1 was at risk for pressure related skin injury related to impaired mobility and incontinence (poor bladder and bowel control).Review of the facility document titled, Admission/readmission Collection Tool - V 6, dated 06/16/2025, showed that Resident 1 had non-blanchable redness to sacrum. There were no measurements documented.Review of the active and discontinued physician orders, on 07/09/2025, showed Resident 1 did not have a treatment or monitoring order for the stage 1 pressure injury over the sacrum.Review of the medical record showed no additional documentation, after Resident 1's admission date, to show that the stage 1 pressure injury had been monitored, and no documentation of it's worsening or improvement.Resident 2Review of the admission minimum data set (MDS, a required assessment tool), dated 05/23/2025, showed that Resident 2 was admitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized muscle weakness, and need for assistance with personal care. The MDS further showed that Resident 2 had moisture-associated skin damage (MASD, skin inflammation and erosion caused by prolonged exposure to moisture such as urine) to the gluteal folds (the crease that separates the buttocks from the thighs).Review of the care plan, dated 05/20/2025, showed that Resident 2 was at risk for pressure related skin injury related to impaired mobility and incontinence.Review of a facility document titled, Admission/readmission Collection Tool - V 6, dated 05/20/2025, showed Resident 2 also had a small open area to their gluteal cleft (the deep [NAME] located between the buttocks).Review of a facility document titled, Wound Observation Tool - V 4, dated 05/21/2025, showed Resident 2's gluteal cleft open area measured 1.5 centimeters (cm) long by 1 cm wide.Review of the facility document titled, Weekly Skin Integrity Data Collection - V 2, dated 05/23/2025, showed Resident 2 had a Small size opening on the left gluteal cleft. There were no measurements documented.Review of the medical record showed no additional documentation, after 05/23/2025, to show that Resident 2's gluteal cleft open area had been monitored, and no documentation of it's worsening or improvement.During interview on 07/09/2025 at 3:36 PM, Staff A, Director of Nursing Services (DNS), stated there should have been orders for monitoring Resident 1 and 2's skin impairments, and there should have been assessments completed weekly, to include documentation of measurements and description of wound appearance. Staff A, DNS, further stated that it was their expectation that weekly assessments be completed until open areas heal, at which point there should be documentation that the areas were resolved. Reference WAC 388-97-1060 (3)(b).

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement treatment and/or monitoring orders for skin impairments (damaged skin) for 2 of 3 residents (Residents 2 and 3) reviewed for skin impairments. This failure placed the residents at risk for worsening wounds and other skin conditions, infection, and re-hospitalization. Findings included . Resident 2 Review of the admission minimum data set (MDS, a required assessment tool), dated 05/08/2025, showed that Resident 2 admitted on [DATE] with diagnoses to include falls, right lower leg laceration (a tear or cut in the skin), difficulty walking, generalized weakness and need for assistance with personal care. The Care Area Assessment (CAA) Summary, linked to the MDS, for pressure ulcer/injury showed, [Resident 2] has laceration on RLE. Wound was sutured in the hospital. [Resident 2] was then transferred here for ongoing care and rehab. Review of the hospital discharge/transfer orders, dated 05/06/2025, showed that the facility was to follow current wound care recommendations, to treat Resident 2's right leg laceration. Review of the nursing admission evaluation, dated 05/06/2025, showed that Resident 2 had a right shin laceration, with 15 stitches, measuring 9 centimeters (cm) by 7 cm. Review of the treatment administration record (TAR), dated May 2025, showed that there were no treatment or monitoring orders, for Resident 2's right leg laceration, implemented until 05/17/2025 - 11 days after Resident 2 admitted to the facility. Resident 3 Review of the admission MDS, dated [DATE], showed that Resident 3 was admitted on [DATE] with multiple medical diagnoses. Review of the nursing admission evaluation, dated 05/27/2025, showed that Resident 3 had a large bruise to their right upper shoulder, and bruises on both arms. Review of the TAR, dated June 2025, showed that there were no treatment or monitoring orders, for Resident 3's bruises, implemented until 06/10/2025 - 14 days after Resident 3 admitted to the facility. In interview on 06/18/2025 at 3:00 PM, Staff A, Director of Nursing Services (DNS), stated that their expectation was that upon admission, the resident should have had a full-body skin assessment. If the resident was noted to have any skin impairments, including bruises, staff should have contacted the medical provider (doctor, nurse practitioner) and requested treatment and/or monitoring orders. Staff A, DNS, further stated that Resident 2 should have had orders to, at the least, monitor their right leg laceration daily, and Resident 3 should have had orders to monitor their bruises. Reference WAC 388-97-1060(1) .

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to identify an allegation of abuse and failed to report the allegation to the State Agency with the required timeframe for 1 of 3 sampled residents (Resident 1) reviewed for reporting alleged violations. These failures placed the resident at risk for ongoing abuse/neglect, unmet needs and a decreased quality of life. Findings included . Review of the electronic medical record (EMR) showed that Resident 1 admitted to the facility on [DATE] with diagnoses to include hemiplegia (a medical condition characterized by paralysis or severe weakness on one side of the body), muscle weakness, difficulty walking, and need for assistance with personal care. Review of a facility grievance form, dated 04/21/2025 at 8:00 AM, written by Staff C, Speech Language Pathologist (SLP, a health professional who evaluates, diagnoses, and treats communication and swallowing disorders), showed that Resident 1 reported that the previous night, a staff member refused to give them their bed remote control, and pushed them in their shoulder. Resident 1 reported feeling that the staff member was mad at them. Review of the facility incident report log, dated April 2025, showed that there was an allegation of abuse logged for Resident 1 on 04/22/2025, and an investigation into the allegation initiated the same day. Review of the online State Agency reporting confirmation, dated 04/22/2025 at 4:50 PM, showed that the facility reported Resident 1's allegation of abuse to the State Agency. The facility reported the allegation to the State Agency approximately 33 hours after the resident voiced the allegation to facility staff. During interview on 04/28/2025 at 1:28 PM, Staff C, SLP, stated that they spoke with Resident 1 on the morning of 04/21/2025, and Resident 1 reported the allegation to them. Staff C, SLP, then stated they discussed the allegation with their supervisor who instructed them to write it down on a grievance form, which they did, and dropped it into the grievance box (a receptacle near the social services office used to securely collect the forms). During interview on 04/28/2025 at 1:30 PM, Staff B, Director of Nursing Services (DNS), stated that they did not know why the allegation was not called in to the State Agency immediately. Staff B, DNS, stated that the grievance form was sitting on their desk the morning of 04/22/2025, at which time it was identified as an allegation of abuse and reported. During interview on 04/28/2025 at 1:55 PM, Staff A, Administrator, stated that Resident 1's allegation should not have been left to a grievance form. It should have been reported to the State Agency within 2 hours as an allegation of abuse. Reference WAC 388-97-0640 (5)(a) .

Feb 2025 9 deficiencies

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to develop comprehensive care plans to include all provided nursing services for 2 of 19 sampled residents (Residents 10 and 80) when reviewed for care planning. This failure placed residents at risk for not receiving needed care, a decline in condition, and a diminished quality of life. Findings included . Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses of paraplegia (inability to move lower limbs), diabetes (too much sugar in the blood), and a pressure ulcer to the lower back. Resident 10 was able to make needs known. During an interview on 02/24/2025 at 10:07 AM, Resident 10 stated they had a pressure ulcer and facility staff were treating it with the help of an outside wound provider. Review of the care plan, initiated 04/07/2020, showed no focus area for Resident 10's pressure ulcer, no intervention for nursing staff to treat the pressure ulcer, and no intervention for an outside wound provider to assist with treatment. During an interview on 02/27/2025 at 11:37 AM, Staff C, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated residents with a pressure ulcer should have a care plan focus area and interventions on what nursing care was being provided to treat the wound. Staff C stated Resident 10 did not have a focus area for the care of their pressure ulcer and this did not meet expectations. During an interview on 02/27/2025 at 1:05 PM, Staff B, Director of Nursing Services (DNS), stated residents with skin issues, such as a pressure ulcer, should have a care plan focus area addressing the care of the wound. Staff B stated Resident 10's lack of care plan for their pressure ulcer did not meet expectation. Resident 80 Review of the EHR showed Resident 80 was admitted to the facility on [DATE] with diagnoses to include hydrocephalus (build-up of fluid in the brain), dysphagia (difficulty swallowing) and respiratory failure. Resident 80 was able to communicate needs. Observation on 02/25/2025 at 11:04 AM, showed Resident 80 in their bed watching TV. There was a medical pole near the bed that was holding a feeding pump machine (a machine that pumps formula into artificial feeding tube). There was unopen can of soda pop on the over bed table and chocolates by the TV. Resident 80 stated they got the tube feeding at nighttime only. Review of the provider's orders, dated 01/08/2025, showed Resident 80 had an order for regular diet with puree texture. Review of the care plan focus area for nutrition and weight fluctuation, revised on 12/12/2024, showed a diet intervention of nothing by mouth (NPO). During an interview on 02/26/2025 at 2:08 PM, Staff B, DNS, stated when the orders were changed the nurse should update the care plan to current diet and NPO status. Staff B stated Resident 80's care plan was inaccurate and did not meet expectations. Reference WAC 388-97-1020 (1), (2)(a)(b) .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 75 Review of the quarterly minimum data set (MDS, a required assessment tool), dated 01/16/2025, showed Resident 75 readmitted on [DATE] with multiple diagnoses to include stroke, muscle weakness, cancer, dementia, neurogenic bladder (a loss of bladder control due to damage in the brain, spinal cord, or nerves), anxiety and depression. The MDS showed the resident had a foley catheter (a thin flexible tube inserted into the bladder through the urethra to drain urine) and was dependent on staff for assistance with activities of daily living (ADLs). Review of Resident 75's provider's order summary, dated 07/02/2024, showed for licensed staff to place an indwelling (foley) catheter 16 French (FR, diameter size of the catheter) and to change for infection, obstruction or when closed system was compromised as needed related to the resident's neuromuscular dysfunction of the bladder. Review of Resident 75's care plan, revised on 11/14/2024, showed the resident had a catheter 16 FR for their neurogenic bladder. Interventions included for licensed staff to observe and report to the provider for signs and symptoms of urinary tract infection to included cloudiness, foul smelling urine and deepening of urine color. Review of Resident 75's EHR clinical notes, dated 02/11/2025, showed a Licensed Nurse (LN) had documented the resident's family member was concerned with the appearance of the resident's urine and the family reported the resident complained of abdominal pain to them. A follow-up clinical note, on 02/12/2025, showed a LN documented the resident's foley catheter was clogged and changed during the shift with a 14 FR. During an interview and observation on 02/26/2025 at 9:07 AM, Staff E, LPN, was asked whether they had assessed Resident 75's foley catheter and if it was the correct size that the provider had ordered. Staff E explained to the resident they were there to conduct an assessment and check their foley catheter. The size of the foley catheter was revealed to be 14 FR and not 16 FR as indicated in the provider's orders. Staff E stated they were unaware that the resident had the 14 FR foley catheter. During an interview on 02/26/2024 at 9:28 AM, Staff B, DNS, stated it was their expectation the LN would have placed the correct size foley catheter as per the provider's order if the resident required it to be changed. Resident 72 Review of the EHR showed Resident 72 readmitted to the facility on [DATE] with diagnoses that included anxiety disorder, psychotic disorder, and depression. The annual MDS, dated [DATE], showed Resident 72 received antipsychotic and antidepressant medications and was able to make needs known. Review of the provider's order dated 11/16/2024 showed Resident 72 was prescribed to have orthostatic blood pressures (BP) obtained and monitored monthly every 30 days. Review of Resident 72's MAR of ordered monthly orthostatic BP showed the following: ---December 2024 MAR documentation on 12/17/2024 showed the area to document BP for lying and sitting had incomplete results, a BP result of 151/77 did not show what the position it was taken, and there was no BP documented for standing. ---January 2025 MAR documentation on 01/16/2025 showed the area to document BP for lying showed NA (not applicable), the BP result for sitting was incomplete, a BP result of 141/74 did not show what position the BP was taken, and there was no BP documented for standing. ---February 2025 MAR documentation on 02/15/2025 showed the area to document BP for lying and sitting had incomplete results, a BP result of 160/74 did not show what position the BP was taken, and there was no BP documented for standing. During an interview on 02/26/2025 at 10:25 AM, Staff C, LPN/UCC, stated Resident 72's December MAR orthostatic BP documentation on 12/17/2024 had incomplete results for lying and sitting, BP result of 151/77 did not indicate what position it was taken, and it did not have a standing BP documented. Staff C stated Resident 72's January and February MAR orthostatic BP documentation on 01/16/2025 and 02/15/2025 had NA (not applicable) documented for lying BP and/or had incomplete BP documented, BP results documented did not indicate position they were taken, and no standing BP was documented. During an interview on 02/26/2025 at 12:21 PM, Staff B, DNS, stated orthostatic BP were to be obtained while a resident was lying, sitting, and standing per provider's order and documented in the resident's MAR. Staff B stated Resident 72's orthostatic BP MAR documentation for December 2024, January 2025, and February 2025 were missing appropriate documentation and did not meet expectations. Based on observation, interview, and record review, the facility failed to obtain and/or follow provider's orders (Resident 1, 72, and 6), failed to monitor medication side effects (Resident 6), and failed to provide catheter care per professional standards (Resident 75) for 4 of 19 sampled residents (Residents 1, 75, 72, and 6) reviewed for professional standards of care and services. These failures placed residents at risk of avoidable fall injury, unintended medication side effects, medical complications, and a diminished quality of life. Findings included . Resident 1 Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses to include Crohn's disease of small intestine (bowel disease), autistic disorder (affects how people interact with others, communicate, learn, and behave), and dementia (decline in memory, thinking, reasoning, and judgment). Resident 1 was unable to make needs known. Review of the provider's orders showed Resident 1 was to have orthostatic blood pressure (blood pressure reading in different positions) measured while laying and sitting every month. Review showed Resident 1 was prescribed midodrine (treats low blood pressure that causes severe dizziness and fainting) and was to be held when systolic blood pressure (top number of blood pressure reading) was greater than 130. Review of the November 2024, December 2024, and January 2025 medication administration record (MAR) showed Resident 1's orthostatic blood pressure reading for sitting were labeled NA. Review of the February 2025 MAR showed Resident 1 had NA recorded for both laying and sitting orthostatic blood pressure reading. Review of the December 2024 MAR showed Resident 1's midodrine was provided outside the provider's parameters for 10 of 93 opportunities. Review of the January 2025 MAR showed Resident 1's midodrine was provided outside the provider's parameters for 4 of 93 opportunities. Review of the February 2025 MAR showed Resident 1's midodrine was provided outside the provider's parameters for 14 of 78 opportunities. During an interview on 02/27/2025 at 11:37 AM, Staff C, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated the expectation was for nursing staff to follow provider's orders. Staff C stated Resident 1 was not provided orthostatic blood pressure monitoring per provider's orders and this did not meet expectation. Staff C stated Resident 1's midodrine was provided outside provider's parameters, this constituted a medication error, and it did not meet expectation. During an interview on 02/27/2025 at 1:05 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was for nursing staff to follow provider's orders. Staff B stated Resident 1's lack of orthostatic blood pressure monitoring and midodrine provided outside of parameters did not meet expectation. Resident 6 Review of the EHR showed Resident 6 was admitted to the facility on [DATE] with diagnoses to include fracture of sacrum (bone at the end of the spine), diabetes (high blood sugar) and dementia (loss of memory, and thinking abilities). Resident 6 was able to communicate needs. Review of the provider order, dated 12/20/2024, showed Resident 6 was taking quetiapine (a mind-altering medication). Review of the abnormal involuntary movement scale (AIMS, a test that shows abnormal movements when taking mind-altering medications), dated 12/23/2024, showed the test was not completed. Review of the EHR did not showed documentation of orthostatic blood pressures for Resident 6. During an interview on 02/26/2025 at 9:50 AM, Staff B, DNS, stated the process for monitoring adverse side effects for mind-altering medications was to complete AIMS test and take orthostatic blood pressures. Staff B stated Resident 6's monitoring of adverse side effects did not meet expectations. Reference WAC 388-97-1620 (2)(b)(i)(ii), (6)(b)(i) .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 61 Review of the EHR showed Resident 61 admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (a disease that causes painful inflammation of the joints), respiratory failure, and heart failure. Resident 61 was able to make needs known. Review of the admission minimum data set assessment (MDS), an assessment tool, dated 12/05/2024 showed Resident 61 had upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) impairments on both sides. Resident 61 required substantial/maximal assistance with personal hygiene. Observation and interview on 02/24/2025 at 2:24 PM showed Resident 61 laid in bed and both feet exposed from under the covers and had thick, long toenails. Resident 61 stated they told staff they wanted to see a podiatrist (a person who treats the feet and their ailments) and was told they would be put on a list to be seen but still had not been. During a follow-up interview on 02/25/2024 at 12:32 PM, Resident 61 stated the last time they had their toenails trimmed was about two or three months ago by their family member; however, now their nails were too thick, and family did not want to attempt to cut them because they did not want to hurt them. Review of the referral binder located at the nurse's station showed a document titled, Referrals, dated February 2025, which did not have Resident 61's name on the list to be seen by the podiatrist. During an interview on 02/26/2025 at 11:02 AM, Staff C, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated residents that needed to be seen by a podiatrist got put on a list to be seen and the podiatrist came once a month. Staff C stated Resident 61's name was not on the current podiatry list in the referral binder at this time. Staff C stated Resident 61's toenails were long and thick and should have been cut by a podiatrist. During an interview on 02/26/2025 at 11:53 AM, Staff B, DNS, stated they were aware Resident 61's toenails were long and thick. Staff B stated Resident 61's toenails should have been cut by a podiatrist prior to now and this did not meet expectations. Reference WAC 388-97 -1060 (2)(c) Based on observation, interview, and record review, the facility failed to provide the necessary grooming services to maintain hygiene for 2 of 4 sampled residents (Residents 49 and 61) when reviewed for activities of daily living. This failure placed the residents at risk of feelings of indignity, decreased social interaction, and diminished quality of life. Findings included . Resident 49 Review of the electronic health record (EHR) showed Resident 49 was admitted to the facility on [DATE] with diagnoses to include right humerus (upper arm bone) fracture, diabetes (high blood sugar) and depression. Resident 49 was able to communicate needs. During an interview on 02/24/2025 at 11:47 AM, Resident 49 stated they liked to shave, but the facility did not offer to help. Observation on 02/25/2025 at 11:22 AM, showed Resident 49 sat in the wheelchair in their room with facial hair about an inch long. Review of the care plan focus area on self-performance, revised on 12/31/2024, showed Resident 49 required one staff assistance with personal hygiene. There was no specific instructions or directives about shaving in the care plan. During an interview on 02/26/2025 at 11:58 AM, Staff F, Certified Nursing Assistant (CNA), stated they offered shaving to resident, and the shower CNA did it. During an interview on 02/26/2025 at 12:01 PM, Staff G, CNA, who was assigned duties to provide showers, stated they offered shaving, but the CNA on the floor should also provide them. During an interview on 02/26/2025 at 2:04 PM, Staff B, Director of Nursing Services (DNS), stated the process was for staff to offer and shave the residents. Staff B stated Resident 49's lack of shaving did not meet expectations.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure the necessary interventions were in place for residents with a history of a fractured humerus (a bone in the upper arm) for 1 of 2 sampled residents (Resident 75) when reviewed for positioning and mobility. The facility also failed to consistently monitor and document bowel movements and implement the bowel program as needed for 2 of 7 sampled residents (Residents 6 and 49) when reviewed for bowel protocol. These failures placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Findings included . <Position/Mobility> Resident 75 Review of the quarterly minimum data set (MDS), a required assessment tool, dated 01/16/2025, showed Resident 75 readmitted on [DATE] with multiple diagnoses to include stroke, muscle weakness, cancer, dementia, anxiety and depression. The electronic health record (EHR) showed the resident had a history of a left humerus fracture and was dependent on staff for assistance with activities of daily living (ADLs). Review of Resident 75's care plan, revised on 11/08/2024, had impaired mobility and ADLs deficit and required assistance related to a history of a left humerus fracture and stoke with left side weakness. Interventions included for staff to always apply a sling (a device that supports and immobilizes an injured body part) to the resident's left arm, do not pull-on left arm, reposition, and may apply pillow for comfort. Observation on 02/22/2025 at 1:59 PM showed Resident 75 asleep in their bed. Observation showed a sign affixed to the wall behind the bed which showed, Don't pull left arm. No sling was observed being worn by the resident or their left arm positioned on a pillow. During an interview on 02/26/2025 at 9:07 AM, Staff E, Licensed Practical Nurse (LPN), stated the resident had the sling order discontinued on 02/03/2024 and they no longer applied the left shoulder sling. Review of Resident 75's EHR showed a provider's order to wear a sling, dated 11/19/2024, and was discontinued on 02/03/2025. The order showed the licensed staff had documented the sling was applied for the resident to wear to the left shoulder for a history of fracture and to wear when out of bed for comfort. An additional provider's order dated 02/03/2025 showed the left shoulder sling was to be applied when the resident was out of bed and for comfort as necessary (PRN); however, the order was not transcribed into the medication administration record (MAR) for the licensed staff to apply as per the provider's order. Review of Resident 75's MAR for February 2025 showed the PRN shoulder sling order was not transcribed into the resident's MAR until 02/26/2025 for the licensed staff to apply as ordered. During an interview on 02/26/2025 at 10:04 AM, Staff B, Director of Nursing Services (DNS), stated Resident 75's daughter wanted the resident to wear their left shoulder sling; however, they stated the resident frequently refused, so the order was changed from every shift to as necessary. Staff B was then informed the PRN sling order had not been transcribed yet into the MAR for the licensed staff to apply as necessary. Staff B was then observed to access the resident's EHR to update the order correctly into Resident 75's MAR. <Bowel Management> Resident 6 Review of the EHR showed Resident 6 was admitted to the facility on [DATE] with diagnoses to include fracture of sacrum (bone at the end of the spine), diabetes (high blood sugar) and dementia (loss of memory, and thinking abilities). Resident 6 was able to communicate needs. During an interview on 02/24/2025 at 10:23 AM, Resident 6 stated, I have bad constipation. They don't give me anything. Review of EHR's bowel documentation showed Resident 6 did not have bowel movements on 02/13/2025 through 02/16/2025 (four days). Review of the provider's orders showed Resident 6 had an order a medication for constipation to be administered when there were no bowel movements after three days. Review of the MAR for February 2025 showed no administration record for the constipation medication for the dates 02/15/2025 or 02/16/2025. Resident 49 Review of the EHR showed Resident 49 was admitted to the facility on [DATE] with diagnoses to include right humerus (upper arm bone) fracture, diabetes (high blood sugar) and depression. Resident 49 was able to communicate needs. Review of the EHR bowel documentation showed Resident 49 did not have bowel movements on 02/14/2025 through 02/17/2025 (four days). Review of the provider's orders showed Resident 49 had order a constipation medication to be administered when there were no bowel movements after three days. Review of the MAR for February 2025 showed Resident 49 had no administration the constipation medication for the dates of 02/16/2025 or 02/17/2025. During an interview on 02/25/2025 at 12:25 PM, Staff F, Certified Nursing Assistant, stated the process was to document the bowel movements in the record. During an interview on 02/26/2025 at 9:44 AM, Staff B, DNS, stated the system flagged for staff to follow up when there was no bowel movements documented and Licensed Nurses were to implement the bowel protocol. Staff B stated that Residents 6 and 49's lack of constipation medications after three days of constipation did not meet expectations. Reference WAC 388-97-1060(1) .

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure fall mats were in place to minimize the risk for injury during a fall for 1 of 4 sampled residents (Residents 75) when reviewed for accident hazards. This failure placed residents at risk for potential injury, negative outcomes and decreased quality of life. Findings included . Review of a facility's policy titled, Fall Management, dated 09/25/2024, showed the facility would assess the resident upon admission/readmission, quarterly, with change in condition and with any fall event for any fall risks and would identify appropriate interventions to minimize the risk of injury related to falls. In addition, the policy included for staff to implement interventions to include adequate supervision, and use assistive devices, consistent with resident needs, goals, care plan and current professional standards of practice. Review of the quarterly minimum data set (MDS), a required assessment tool, dated 01/16/2025, showed Resident 75 readmitted on [DATE] with multiple diagnoses to include stroke, muscle weakness, cancer, dementia, anxiety and depression. The MDS showed the resident was able to make needs known and was dependent on staff for assistance with activities of daily living (ADLs). Review of the facility's incident report log showed Resident 75 had falls on 11/03/2024 and 12/17/2024. Review of Resident 75's witness reports for fall incidents on 11/03/2024 and 12/17/2024 showed the fall scene investigation reports of drawings of the post fall scene, whereas the aide drew the area and position in which the resident was found (i.e. face down, on back, right of left side, position of the arms and legs, furniture, equipment and devices nearby). The document showed no falls mat were in place or documented in the report. Review of Resident 75's care plan, revised 08/04/2024, showed the resident had falls related to impaired mobility, weakness, and stoke with left sided weakness. Interventions included for staff to place the bed into lowest position and add floor mats at the side of the bed when asleep. Review of a multiple facility documents titled Fall Risk Evaluation, dated 04/22/2024, 07/01/2024, 07/29/2024, 11/03/2024, 12/20/2024, showed the facility staff had conducted several fall assessments and indicated Resident 75 was at a high risk for falls. During an interview on 02/26/2025 at 9:15 AM, Staff E, Licensed Practical Nurse (LPN), stated they did not see any fall mats being used for Resident 75. Staff E stated if the resident had a care plan intervention for mats to be in place for falls then it should be in place and on the floor next to the resident's bed while they slept. Observation on 02/26/2025 at 12:14 PM, showed Resident 75 asleep in bed. The bed was observed to be positioned at normal height and no fall mats were observed next to the resident's bed or within the room. During an interview and observation on 02/26/2025 at 12:22 PM, Staff D, Certified Nurse Aide (CNA), stated they would check to see if Resident 75's care plan/[NAME] required the resident's bed to be placed into a low position and if floor mats were needed while the resident was asleep. Staff D was then observed to review Resident 75's electronic health record (care plan/[NAME]). Staff D stated they noted the resident's bed was to be in a low position and floor mats were required while the resident slept. Staff D stated they would contact the maintenance staff to get the floor mats placed at the side of the resident's bed. During an interview on 02/26/2025 at 1:00 PM, Staff B, Director of Nursing Services (DNS), was asked about the missing falls mat not being used in Resident 75's room while they slept. Staff B stated the fall mats were remove earlier because they were frayed, and the facility had ordered new mats. During an interview on 02/26/2025 at 1:38 PM, Staff A, Administrator (ADM), stated their expectation would be if the interventions were on Resident 75's care plan then the fall mats should be in place. Reference WAC 388-97-1060(3)(g) .

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide pain management to adequately control residents pain for 1 of 6 sampled residents (Resident 3) when reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 3 admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), paraplegia (inability to move lower limbs), and anxiety. Resident 3 was able to make needs known. During an interview on 02/24/2025 at 11:09 AM, Resident 3 stated the facility staff would provide pain medication, but sometimes it did not control their pain. Resident 3 stated they would ask facility staff for additional pain medication but would be told by staff they could not have more yet. Review of Resident 3's January 2025 medication administration record (MAR) showed Resident 3 was prescribed two over the counter (OTC) pain medications and one narcotic pain medication. Review showed all three pain medications were as needed (PRN) and had no parameters for nursing staff to follow for which pain medication to be provided based on the resident's pain level. Further review of the January 2025 MAR showed Resident 3 received one OTC pain medication for pain levels 7 to 8, one OTC pain medication was unused, and the narcotic pain medication was used for pain levels 6 to 8. Review of the February 2025 MAR showed Resident 3 received one OTC pain medication for pain levels 4 to 8, one OTC pain medication was unused, and the narcotic pain medication was used for pain levels of 5. During an interview on 02/27/2025 at 11:37 AM, Staff C, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated when more than one PRN pain medication was prescribed it was up to nursing judgement on which to provide. Staff C stated providers would sometimes provide parameters for PRN pain medications and other times would not. During an interview on 02/27/2025 at 1:05 PM, Staff B, Director of Nursing Services (DNS), stated PRN pain medications should include a pain scale parameter to inform nursing staff which medication to provide. Staff B stated Resident 3's PRN pain medications did not have these parameters, and this did not meet expectation. Reference WAC 388-97-1060 (1) .

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 4 hallways (300 hallway) reviewed for Environment. Failure to ensure Resident 21's and 72's wheelchair armrests were in good repair placed residents at risk for injury, medical complications, and decrease quality of life. Findings included . Resident 21 Review of the electronic health record (EHR) showed Resident 21 readmitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar levels), heart failure, and muscle weakness. It showed Resident 71 utilized a manual wheelchair for mobility and was able to make needs known. Observation and interview on 02/24/2025 at 12:25 PM, showed Resident 21's wheelchair left armrest had cracked/torn vinyl with exposed beige material underneath (not a cleanable surface). Resident 21 stated the left armrest was rough to the touch and they would not put their arm on the armrest if they did not have a long-sleeved shirt on. Resident 21 stated staff had seen them in their wheelchair; however, they had not offered to fix or replace the armrest. During an interview on 02/27/2025 at 12:15 PM, Staff H, Registered Nurse (RN), stated Resident 21's wheelchair left armrests were cracked/torn, rough to the touch, and was not a cleanable surface. Staff H stated Resident 21's wheelchair issue was not logged from 01/02/2025 through 02/27/2025 in the 300 and 400 hall maintenance binder log and should have been. Staff H stated the armrest needed to be fixed or replaced. During an interview on 02/27/2025 at 12:30 PM, Staff A, Administrator, stated Resident 21's wheelchair left armrest was cracked/torn, rough to the touch, and not a cleanable surface. Staff A stated Resident 21's wheelchair issue was not logged in the maintenance book and should have been. Staff A stated Resident 21's wheelchair condition did not meet expectations. Resident 72 Review of the EHR showed Resident 72 readmitted to the facility on [DATE] with diagnoses to include diabetes, heart failure, and muscle weakness. It showed Resident 72 utilized a manual wheelchair for mobility and was able to make needs known. Observation and interview on 02/24/2025 at 11:40 AM showed Resident 72's wheelchair right armrest had cracked/torn vinyl with exposed beige material underneath (not a cleanable surface) and the left armrest was not stable when Resident 72 placed their arm or hand on it (wobbly). Resident 72 stated they had told staff about the wobbly left armrest and the cracked/torn right armrest quite a while ago but did not recall who. During an interview on 02/27/2025 at 11:57 AM, Staff H, RN, stated Resident 72's wheelchair right armrest was cracked/torn, rough to the touch, and was not a cleanable surface. Staff H stated Resident 72's left armrest was slightly loose/wobbly and may be missing a screw underneath the armrest. Staff H stated Resident 72's wheelchair issues were not logged from 01/02/2025 through 02/27/2025 in the 300 and 400 hall maintenance binder log and should have been. Staff H stated Resident 72's wheelchair armrests needed to be fixed and/or replaced. During an interview on 02/27/2025 at 12:22 PM, Staff A, Administrator, stated the process was for equipment/wheelchairs with issues were logged in the maintenance book/binder and if needed should be referred to therapy to fix and/or be replace. Staff A stated the condition of Resident 72's wheelchair armrests did not meet expectations. Reference WAC 388-97-0880 .

MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide written notification of the reason for transfer to the hospital to the resident and/or resident representative for 3 of 4 sampled residents (Residents 21, 54, and 72) reviewed for hospitalization. This failure placed the residents at risk for not knowing rights regarding transfer and discharge from the facility and diminished protection from being inappropriately discharged . Findings included . Resident 21 Review of the electronic health record (EHR) showed Resident 21 initially admitted to the facility on [DATE] with diagnoses that included heart failure, kidney failure, and diabetes (high blood sugar levels). Resident 21 was able to make needs known. Review of Resident 21's EHR showed a transfer to the hospital on [DATE] and on 12/19/2024. The EHR did not show a notice of transfer was provided to Resident 21 or their representative for either of their transfers to the hospital. During an interview on 02/26/2025 at 10:15 AM, Staff C, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated Resident 21, or their representative, did not receive a written notice of transfer; however, they were informed verbally for transfers to the hospital on [DATE] and on 12/19/2024. Resident 54 Review of the EHR showed Resident 54 initially admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, and respiratory failure. Resident 54 was able to make needs known. Review of Resident 54's EHR showed a transfer to the hospital on [DATE]. The EHR did not show a notice of transfer was provided to Resident 54 or their representative. During an interview on 02/26/2025 at 10:04 AM, Staff C, LPN/UCC, stated Resident 54 was informed verbally for transfer to the hospital on [DATE] and was not provided a written notification. Resident 72 Review of the EHR showed Resident 72 initially admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes. Resident 72 was able to make needs known. Review of Resident 54's EHR showed a transfer to the hospital on [DATE] and on 08/05/2024. The EHR did not show a notice of transfer was provided to Resident 72 or their representative for either of their transfers to the hospital. During an interview on 02/26/2025 at 9:42 AM, Staff C, LPN/UCC, stated Resident 72, or their representative, did not receive a written notice of transfer; however, they were informed verbally for transfers to the hospital on [DATE] and on 08/05/2024. During an interview on 02/27/2025 at 1:31 PM, Staff A, Administrator, stated the expectation was for the nurses to complete an interact transfer form and provide a written Nursing Home Transfer or Discharge Notice form to the resident and/or their responsible party for transfers to the hospital. Staff A stated a copy of the form should be sent to the hospital with the resident and a copy should go to Medical Records to be scanned into the resident's EHR. Reference WAC 388-97-0120 (2)(a-d) .

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

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. Based on observation and interview, the facility failed to ensure the survey results were posted in a place readily accessible to all residents and to post notices regarding the availability of the survey reports in areas that were prominent. These failures prevented residents and resident representatives the opportunity to use past survey results to evaluate the quality of care provided by the facility. Findings included . During a group interview on 02/25/2025 at 1:18 PM, Residents 10 and 41, both cognitively alert, stated they did not know survey results were available for their review nor where the survey results were located. Observations on 02/25/2025-02/26/2025 showed a binder labeled State Survey Results on a small corner table in the conference room on the 100-hall. The facility had 4 hallways where residents resided. Observation showed no notices about the availability or location of the binder throughout the resident-occupied areas. During an interview on 02/26/2025 at 11:36 AM, Staff J, Licensed Practical Nurse (LPN), stated the survey book was usually kept at the nurse's station or in the social services office. During an interview on 02/26/2025 at 11:38 AM, Staff K, Receptionist, stated they thought the survey book was located at the front desk but stated they needed to check with the Administrator. During an interview on 02/26/2025 at 11:40 AM, Staff A, Administrator (ADM), stated the binder was in the conference room with signage on the door so residents could have privacy viewing the results. Staff A stated there were no additional signs in the facility informing residents/visitors of the binder's location. Reference: WAC 388-97-0480 .

Jan 2024 7 deficiencies

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable), and/or the Notice of Medicare Non-Coverage (NOMNC) was provided and completed as required for 2 of 3 residents (Residents 34 and 66) reviewed for Beneficiary Notification. These failures placed residents at risk of not upholding their right to make informed choices about further treatment or services as required by the Medicare Program and of not being informed of their appeal rights prior to the end of Medicare covered services. Findings included . Resident 34 Review of Resident 34's SNF ABN dated 10/03/2023 showed, Options: Check only one box. We can't choose a box for you, portion of the form was left blank regarding whether the resident wanted to get the care listed on the form. This form did not show a check mark for which of the three available options the resident wanted, making the form incomplete. During an interview on 01/08/2024 at 11:17 AM, Staff E, Business Office Manager (BOM), stated that Resident 34's SNF ABN dated 10/03/2023 should have been completed to include a checkmark in the Options section of the form. During an interview on 01/08/2024 at 11:36 AM, Staff A, Administrator, stated that one of the options on Resident 34's SNF ABN dated 10/03/2024 should have been checked and that this did not meet expectations. Resident 66 Review of Resident 66's SNF ABN form and NOMNC form both dated 12/13/2023 showed that they were not signed by Resident 66 or the resident's legal power of attorney (POA, allowed to act on the behalf of someone). The SNF ABN form showed, Verbal - [name] - POA, handwritten on the Signature of Patient or Authorized Representative line and had a checkmark on the box Option 3. No other documentation was noted on the form. The NOMNC form showed, Verbal - [name] - POA, handwritten on the Signature of Patient or Authorized Representative line and under this line were two signatures with the date of 12/13/2023 written beside the signature; however, there were no titles to show who the signatures belonged to. During an interview on 01/08/2024 at 11:17 AM, Staff E, BOM, stated that Resident 66's SNF ABN and NOMNC forms dated 12/13/2023 did not meet expectation because the forms should have been mailed to the POA and the letters returned and uploaded into the resident's electronic health record (EHR) and that did not happen. Additionally, Staff E stated that Resident 66's SNF ABN options box on the form should not have been checked by staff and should have been mailed to the POA to complete the form. During an interview on 01/08/2024 at 11:36 AM, Staff A, Administrator, stated that Resident 66's SNF ABN and NOMNC forms both dated 12/13/2023 did not meet expectations and should have been mailed out to have Resident 66 and/or POA complete the forms. Reference WAC 388-97-0300 (1)(e), (5), (6) .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide safe, sanitary, and homelike environment in 1 of 4 hallways (200 hallway) reviewed for Environment. Failure to ensure Resident 32's and 50's bathrooms and Resident 32's wheelchair break handles were sanitary and in good repair placed residents at risk for injury, medical complications, and decrease quality of life. Findings included . Resident 32 Observations on 01/03/2024 at 12:13 PM, 01/03/2024 at 3:50 PM, 01/05/2024 at 2:20 PM, and 01/08/2024 at 9:54 AM showed Resident 32's wheelchair had loose, frayed tape wrapped around both break handles (these were not cleanable surfaces), and a black rubber cover was missing from the top of the left break handle leaving metal exposed. Additionally, Resident 32's bathroom showed loose floor baseboards falling forward from the cracked and paint chipped lower walls around the toilet floor area. During an interview on 01/05/2024 at 2:20 PM, Resident 32 stated that the tape on the wheelchair break handles and the poor condition of the bathroom had been that way for a while and staff were aware. Review of the admission Minimum Data Set assessment (MDS) showed that Resident 32 admitted to the facility on [DATE] with diagnoses to include a broken left lower leg, muscle weakness, and difficulty in walking. It further showed that Resident 32 utilized a wheelchair and walker for mobility and was able to make needs known. During an interview on 01/08/2024 at 10:25 AM S,taff H, Certified Nursing Assistant (CNA), stated that it looked like Resident 32's wheelchair needed new break handles because the frayed tape on both break handles were not cleanable surfaces, and the right break was missing rubber on the top of the handle. Staff H stated that Resident 32's bathroom floor baseboards were coming loose from the wall and the cracked paint chipped lower walls around the toilet needed to be fixed. Staff H further stated that Resident 32's wheelchair break handles and bathroom issues were not logged in the December 2023 or January 2024 Maintenance Log binder located at the nurses' station and they should have been. During an interview on 01/08/2024 at 10:56 AM, Staff A, Administrator, stated that Resident 32's taped wheelchair breaks were not cleanable surfaces, and the right wheelchair break handle needed a rubber top. Staff A stated that the loose baseboards and walls in Resident 32's bathroom needed repair. Staff A further stated that Resident 32's issues in need of repair were not logged in the December 2023 or January 2024 Maintenance Log and should have been. Resident 50 During an interview on 01/03/2024 at 3:19 PM, Resident 50 stated, The bathroom is disgusting. Resident 50 stated that the flooring around the toilet was puckering and lifting in areas and stained brown behind the toilet where the flooring was separated from the wall. Observations on 01/03/2024 at 3:19 PM, 01/05/2024 at 2:14 PM, and 01/08/2024 at 10:10 AM showed Resident 50's bathroom linoleum floor had puckering/lifted areas to the right and left side of the toilet, and loose baseboards. Additionally, the flooring was separated from the wall about one inch away from the baseboard which showed brownish stained flooring exposed in front of the baseboard behind the toilet. Review of the admission MDS dated [DATE] showed that Resident 50 readmitted to the facility on [DATE] with diagnoses to include arthritis, muscle weakness, and difficulty in waling. It further showed that Resident 32 utilized a wheelchair and walker for mobility and was able to make needs known. During an interview on 01/08/2024 at 10:14 AM, Staff H, CNA, stated that Resident 50's bathroom floor puckered in places around the toilet, baseboards were loose, the wall was cracked in the corner areas, the linoleum was separated from the wall about an inch with underneath flooring that was discolored with a rust like color of which all needed to be fixed. During an interview on 01/08/2024 at 10:54 AM, Staff A, Administrator, stated that Resident 50's bathroom needed repair. Reference WAC 388-97-0880(1) .

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement identified mental health interventions for 1 of 2 residents (Resident 47) when reviewed for PASRR. This failure placed residents at risk of not receiving needed mental health interventions, an increase in avoidable behaviors, and a diminished quality of life. Findings included . Review of Resident 47's electronic health record (EHR) showed a Pre-admission Screening and Resident Review Level 2 (PASRR, an assessment to determine appropriateness of placements and needed mental health interventions) was completed on 10/24/2023. Further review of Resident 47's EHR did not show that the interventions identified on the PASRR Level 2 were incorporated into Resident 47's plan of care. During an interview on 01/09/2024 at 9:48 AM, Staff G, Social Services Assistant, stated that the Social Services Department arranged PASRR Level 2 for residents that were assessed to require one and would then incorporate the identified interventions into the resident's plan of care. Staff G further stated that Resident 47's PASRR Level 2 interventions were not incorporated into the resident's plan of care. During an interview on 01/09/2024 at 9:54 AM, Staff A, Administrator, stated that the Social Services Department was responsible for arranging and implementing PASRR Level 2 and that identified interventions should be incorporated into the resident's plan of care as soon as possible. Staff A stated that Resident 47's lack of PASRR Level 2 interventions in the plan of care did not meet expectation. Reference WAC 388-97-1915 (4) .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 25 During an interview on 01/03/2024 Resident 25 stated, I am on fluid restriction of 40 ounces [1182.941 milliliters (ml)] every day. During an interview and observation on 01/05/2024 at 11:39 AM, Resident 25 stated that staff filled their personal water bottle [NAME] with ice because they liked to chew on ice. Resident 25's water bottle [NAME] showed it held 24 ounces (710 ml), and there was a plastic water bottle of 16.9 fluid ounces that was two thirds filled with water on the overbed table. Additionally, Resident 25 stated that they received fluids from the kitchen with meals; however, they were not sure if staff kept track of how much they consumed during mealtime and on their own during the day. Review of the significant change in status MDS dated [DATE] showed that Resident 25 admitted on [DATE] with diagnoses that included heart failure and kidney failure. Additionally, it showed Resident 25 received dialysis (treatment to filter wastes and water from the blood) services. Review of the [NAME] (care directives) on 01/04/2024 showed that there was no directive documented for fluid restrictions for Resident 25. Review of Resident 25's dialysis care plan on 01/04/2024 showed that the resident had an intervention for Fluid restriction as ordered. However, there were no details documented of the amount of fluids to be provided in a 24 hour period. Review of the January 2024 MAR from 01/01/2024 - 01/07/2024 showed a physician order dated 08/17/2023 that Resident 25 was prescribed fluid restriction of 1500 ml per day from Dietary: (960 ml /24 hours) Breakfast 360 ml, lunch 240 ml, and dinner 360 ml. From Nursing: (540 ml /24 hours) Days 180 ml, Evening 180 ml, Nights 180 ml every shift, document amount consumed, may have ice chips. Documentation showed some fluids provided by nursing; however, it did not show Dietary fluids provided during meals. Continued review of Resident 25's January 2024 MAR showed that fluid intake was to be documented in mls for day, evening, and night shifts. However, zero ml were documented for day shift on 01/03/2024 and zero ml on night shifts from 01/01/2024 - 01/06/2024. Also, documentation showed 580 mls provided on 01/05/2024 (40 mls over the parameters), 560 mls on 01/06/2024 (20 mls over the parameters), 810 mls on 01/07/2024 (270 mls over the parameters). During an interview on 01/08/2024 at 1:50 PM, Staff D, Certified Nursing Assistant (CNA), stated that they knew when a resident was on fluid restrictions because it would be in the resident's [NAME]. Staff D looked in Resident 25's [NAME] and stated that Resident 25 was not on fluid restrictions and that they provided ice for Resident 25 and did not keep track of fluid intake. During an interview on 01/08/2024 at 2:27 PM, Staff C, RCM, stated that Resident 25 was on fluid restriction and fluid intake should be documented by the licensed nurses in the MAR for fluid intake during medication administration each shift and by the nursing assistants under tasks in the computer system. Staff C stated that Resident 25 had no documentation of fluid intake during meals nor was fluid restriction documented in the resident's [NAME] and it should have been. During an interview on 01/08/2024 at 4:34 PM, after looking at Resident 25's EHR regarding Resident 25's fluid restriction and fluid intake monitoring and documentation, Staff B, DNS, stated that the documentation for Resident 25 did not meet expectations. Reference WAC 388-97-1060 (3)(h) Based on observation, interview and record review, the facility failed to implement the registered dieticians and providers recommendations for significant weight loss in a timely manner, ensure interventions were in place to prevent continued weight loss and/or monitor and accurately document fluid restrictions (a diet which limits the amount of daily fluid intake) per physician's orders for 2 of 2 residents (Residents 6 and 25) when reviewed for Nutrition. These failures placed the residents at risk for unmet needs, continued weight loss, medical complications, and a diminished quality of life. Findings included . Resident 6 Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 11/06/2023 showed that Resident 6 admitted on [DATE] with diagnoses to include multiple sclerosis (a chronic progressive disease involving damage to the nerve cells and spinal cord that results in numbness, impairment of speech and muscular coordination and severe fatigue), urinary tract infection, chronic pain, constipation, and anxiety. The MDS further showed that Resident 6 was able to make needs known and the clinical record showed the resident required assistance and encouragement with intake to meet daily requirements. Review of Resident 6's electronic health record (EHR) dated 12/12/2023 showed a Registered Dietitian (RD) assessment which documented the following quarterly nutrition note summary and recommendations: Resident 6 had been noted with a decrease in intake over the last month. Weights were reviewed and [resident] with a significant weight loss. No weight was obtained in December [2023] and will have staff obtain to confirm. In addition, the note indicated that the RD would trial health shakes (118 milliliters (mls) twice a day for weight maintenance and satiety (completely satisfied with food) and to continue to monitor weights and intake (mls) consumed. Review of Resident 6's weights showed the following weights and dates: 09/02/2023 at 177.5 pounds (lbs.) and 11/06/2023 at 152.8 lbs. This was a 24.7 lbs. decrease in two months. Review of Resident 6's December 2023 and January 2024 Medication Administration Record (MAR) and/or Treatment Administration Record (TAR) on 01/03/2024 showed no order for Health Shakes. In addition, the resident's EHR showed no additional weights were obtained after 11/06/2023. Review of Resident 6's care plan reviewed on 01/03/2024 showed a focus area initiated on 06/08/2023 that the resident was at risk for weight fluctuation related to current health status. The goal showed that the resident will not have significant weight gain/loss through next review date. During an interview on 01/05/2024 at 1:22 PM, Staff C, Residential Care Manager (RCM), stated that the expectation would be to hold an interdisciplinary team (IDT) meeting to discuss the RD's evaluation/recommendations and implement them. Staff C further stated that the recommendations for Resident 6 were not implemented but should have been. During an interview on 01/05/2024 at 1:45 PM, Staff B, Director of Nursing Services (DNS), stated that Resident 6's RD recommendations were not implemented but should have been. .

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consistently conduct and document pre and post dialysis (treatment to filter wastes and water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 resident (Resident 25) reviewed for Dialysis. This failure had the potential to place the resident at risk for unmet care needs and medical complications. Findings included . Review of the facility's policy and procedure titled, Hemodialysis [procedure where a dialysis machine is used to clean the blood] Offsite Policy, revision dated 04/17/2023 showed that the facility should provide ongoing assessment of the resident's condition and monitoring for complications, before and after dialysis treatments received at a certified dialysis facility. It further showed that there should be ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Observation and interview on 01/05/2024 at 9:21 AM showed Resident 25 sat in a wheelchair, right arm fistula (a site to access body for dialysis treatment) was visible. Resident 25 stated that they were provided one Gabapentin capsule [used to treat diabetic neuropathy/nerve pain] and two Sevelamer Carbonate [used to treat kidney disease for people on dialysis] tablets in an envelope to take while at dialysis. Review of the significant change in status Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 25 admitted on [DATE] with diagnoses that included heart failure and kidney failure. Additionally, it showed Resident 25 received dialysis services. Review of Resident 25's physician orders on 01/04/2024 showed the following: -Order dated 08/16/2023 showed to assess dialysis access site for thrill [feeling for vibration]/bruit [listen for blood flow] and monitor for bleeding every shift for dialysis care. -Order dated 01/03/2024 showed to complete the Pre-Dialysis Assessment Communication form and ensure it was sent to dialysis with the resident for pick up time at 10:00 AM. Verify dialysis bag was sent with patient and sack meal one time a day every Tuesday, Thursday, Saturday for dialysis communication. -Order dated 01/03/2024 showed to Complete the Post-Dialysis Assessment form after resident returned from dialysis at around 4:00 PM. Ensure resident returns from dialysis with the Pre-Dialysis Assessment. Call the Dialysis center if not returned with the resident or no weight obtained. Record return dry weight in the evening every Tuesday, Thursday, Saturday for dialysis return related to kidney disease. Review of the January 2024 MAR from 01/01/2024 - 01/07/2024 showed that Resident 25 had documentation of being provided one Gabapentin capsule at 12:00 PM on 01/02/2024, 01/04/2024, 01/06/2024, and two Sevelamer Carbonate tablets daily at 12:00 PM on 01/02/2024 through 01/07/2024. However, this documentation did not show that the resident was absent from facility with medication even though Resident 25 was at dialysis on the dates of 01/02/2024, 01/04/2024, and 01/06/2024. Review of six Pre/Post Dialysis Communication forms from 12/23/2023 through 01/06/2024 showed blank areas in Resident 25's forms that included if medications were given to the resident to take to dialysis, pre dialysis assessments, documentation to be completed by the dialysis center, and post dialysis assessments. During an interview on 01/09/2024 at 9:47 AM, Staff C, Resident Care Manager (RCM), stated that Resident 25's Pre/Post Dialysis Communication forms from 12/23/2023 through 01/06/2024 were not filled out completely. Staff C stated that portions of the forms were missing documentation that should have been completed including the resident's name on the forms, medications taken to dialysis by the resident, pre and post assessments, and documentation that was to be completed by the dialysis center. During an interview on 01/09/2024 at 11:18 AM, after looking at Resident 25's Pre/Post Dialysis Communication forms from 12/23/2023 through 01/06/2024, Staff B, Director of Nursing Services, stated that the forms needed to be filled out completely and this did not meet expectations. Reference WAC 388-97-1900(1), (6)(a-c) .

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to cover resident catheter bags to maintain dignity for 2 of 2 residents (Residents 20 and 47) reviewed for dignity. This failure placed residents at risk of depressed mood, feelings of worthlessness, and a diminished quality of life. Findings included . Resident 20 Observation on 01/03/2024 at 9:24 AM showed Resident 20 laid in bed with a catheter bag hanging from the bottom of the frame. Observation showed that there was no privacy cover on the catheter bag and urine was visible. Observation on 01/03/2024 at 11:55 AM showed Resident 20 sat in a wheelchair in the dining room during meal service with a catheter bag hanging from the bottom of the wheelchair. Observation showed that there was no privacy cover on the catheter bag and urine was visible. Observations on 01/04/2024 at 10:47 AM and 01/05/2024 at 10:10 AM showed Resident 20 laid in bed with a catheter bag hanging from the bottom of the frame. Observation showed that there was no privacy cover on the catheter bag and urine was visible. Resident 47 Observation on 01/03/2024 at 12:22 PM showed Resident 47 moving with facility staff down the hallway using a walker. Observation showed that Resident 47's catheter bag was attached to the walker, did not have a privacy cover, and urine was visible. Observations on 01/04/2024 at 10:57 AM and 01/05/2024 at 10:09 AM showed Resident 47 sitting on the edge of their bed with their walker next to the bed. Observation showed Resident 47's catheter bag attached to the walker, did not have a privacy cover, and urine was visible. During an interview on 01/05/2024 at 10:15 AM, Staff F, Registered Nurse, stated that resident catheter bags should be covered to prevent the urine being visible to maintain resident dignity. Staff F further stated that Resident 20's catheter bag was uncovered, and urine was visible from the hallway. Staff F stated that Resident 47's catheter bag was uncovered and hung from the resident's walker. During an interview on 01/09/2024 at 9:28 AM, Staff B, Director of Nursing Services, stated that catheter bags should be covered and urine not visible to maintain resident dignity. Staff B stated that Residents 20 and 47's lack of catheter bag covers did not meet expectation. Reference WAC 388-97-0180(1-4) .

CONCERN (E)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 11 Review of the significant change in status MDS dated [DATE] showed that Resident 11 admitted on [DATE] with diagnoses that included a broken hip and stroke. Additionally, it showed Resident 11 did not receive non-medication intervention for pain. Review of Resident 11's MAR dated December 2023 showed a provider order dated 07/26/2023 for staff to administer Acetaminophen every six hours as need for pain or fever. An entry showed that the LN administered the medication on 12/25/2023; however, no non-pharmacological interventions were documented within Resident 11's MAR or clinical record. During an interview on 01/09/2024 at 10:47 AM, Staff C, RCM, stated that Resident 11 should have had non-pharmacological interventions offered/provided and documented prior to being given as needed Acetaminophen on 12/25/2023. Resident 25 Review of the significant change in status MDS dated [DATE] showed that Resident 25 admitted on [DATE] with diagnoses that included kidney failure and arthritis. Additionally, it showed Resident 25 did not receive non-medication intervention for pain. Review of Resident 25's MAR dated January 2024 showed a provider order dated 08/16/2023 for staff to administer Oxycodone-Acetaminophen (used to treat moderate to severe pain) every eight hours as needed for moderated to severe pain. Entries showed that LNs had administered the pain medication on 01/04/2024, 01/05/2024, and 01/06/2024; however, no non-pharmacological interventions were documented within Resident 25's MAR or clinical record. During an interview on 01/09/2024 at 11:35 AM, Staff B, Director of Nursing Services, stated that the expectation was that residents were assessed and provided non-pharmacological interventions prior to being provided as needed pain medications. Additionally, after looking at Resident 25's January's 2024 MAR and EHR, Staff B stated they were unable locate documentation that non-pharmacological interventions were offered/provided prior to Resident 25 receiving Oxycodone-Acetaminophen as needed pain medication and this did not meet expectations. Reference WAC 388-97-1060(3)(k)(i) Based on interview and record review, the facility failed to ensure freedom from unnecessary pain medication for 3 of 5 residents (Residents 55, 11 and 25) and ensure that providers orders (heart rate parameters) were followed prior to the administration of medication for 1 of 5 residents (Resident 55) reviewed for unnecessary medication. These failures placed the residents at risk for side-effects related to the medication, medical complications, and a diminished quality of life. Findings included . Review of a document titled, Pain Assessment and Management, dated 09/12/2023 showed that the facility, will address/treat the underlying causes of the pain, to the extent possible. In addition, the document showed that the staff were to develop and implement both non-pharmacological and pharmacological interventions/approaches to pain management. Review of a document titled, Administration of Medication, dated 08/24/2023 showed that the facility will ensure medications are administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms. In addition, the document showed that staff who were responsible for medication administration would adhere to the 10 Rights of Medication Administration to include the correct assessment and to note the resident's history and any parameters around drug administration. Blood Pressure Parameters Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 10/13/2023, showed that Resident 55 admitted on [DATE] with diagnoses to included heart disease, high blood pressure, arthritis, and depression. In addition, the resident's electronic health record (EHR) showed a diagnosis of chronic pain syndrome. The MDS further showed that the resident was able to make needs known. Review of the Medication Administration Record (MAR) dated December 2023 and January 2024 for Resident 55 showed a provider's order dated 04/11/2023 an order for Furosemide (a diuretic medication used to eliminate excessive fluid within the body) and for the Licensed Nurses (LNs) to check the residents blood pressure and heart rate prior to the administration of the medication. Parameters were ordered to hold the medication for blood pressures (systolic) less than 100 and for a pulse rate less than 60 and staff were to notify the provider and write a progress note. Review of Resident 55's December 2023 MAR showed that on December 1, 4, 15, and 18 the LN had documented that the medication furosemide was administered to the resident for a heart rate below 60/minute. Review of the MAR for January 2024 again showed that the LN had administered furosemide on 01/03/2024 for a heart rate below 60/minute. No documentation showed that the provider was notified, or an entry was made into the resident's progress (clinical) notes for the resident's low heart rate. Review of the MAR dated December 2023 and January 2024 for Resident 55 showed that the provider had ordered the medication metoprolol (a medication used lower blood pressure and heart rate) to be administered and to hold if the residents blood pressure (systolic) was below 100 or if the heart rate was below 50/minute. Review of the December 2023 MAR showed that the LN had administered the medication on 12/18/2023 for a recorded heart of 48/minute. During an interview on 01/05/2024 at 10:00 AM, when asked what needed to be done prior to administering the medication metoprolol, Staff C, Residential Care Manager (RCM), stated that it would be the expectation that the LN would first ensure that the provider's ordered parameters were followed and not administer the medication if it was below the ordered rate. Non-Pharmacological Interventions Resident 55 Review of the MAR dated December 2023 and January 2024 for Resident 55 showed a providers order dated 05/03/2023 for staff to administer Hydrocodone-Acetaminophen (a medication used to treat moderate to severe pain) every four hours as needed for pain and an additional order dated 04/11/2023 for the LNs to administer acetaminophen (a medication used to treat mild to moderate pain) every 4 hours as needed for pain. An entry showed that the LNs had administered the pain medication hydrocodone on 12/14/2023 as directed; however, no non-pharmacological interventions was documented within Resident 60's MAR or clinical record. During an interview on 01/05/2024 at 10:00 AM, when asked what needed to be done prior to administering pain medication, Staff C, RCM stated that it would be the expectation that the LN would first attempt to provide non-pharmacological interventions first such as repositioning or massage and/or distraction prior to administering pain medication. .

Nov 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident, or the resident's responsible party, of new medications ordered to be administered for three of four residents (Residents 1, 3 and 4) reviewed for notification of changes. This failure prevented the resident and/or resident's representatives from being included in their plans of care and decision-making processes. Findings included . RESIDENT 1 Review of the electronic health record (EHR) showed that Resident 1 admitted to the facility on [DATE] and had another individual designated, as their responsible party, to make healthcare decisions. Review of a progress note, dated 11/06/2023, showed that an Advanced Registered Nurse Practitioner (ARNP) had seen Resident 1 that day, and ordered a new medication to be started to treat an infection. Review of the November 2023 medication administration record (MAR) showed that the medication was administered beginning the evening of 11/06/2023. Review of additional progress notes, and other documentation throughout the EHR, did not show that Resident 1, or their designated responsible party, had been informed of the new medication being started. In interview, on 11/28/2023 at 2:45 PM, Resident 1's responsible party stated that they had not been informed, by the facility, of the new medication having been ordered, and no one had discussed starting the new medication, with them, prior to it being administered. RESIDENT 3 Review of the EHR showed that Resident 3 admitted to the facility on [DATE] and had another individual designated, as their responsible party, to make healthcare decisions. Review of a progress note, dated 11/28/2023, showed that a new medication had been ordered for Resident 3, to treat an infection. Review of the November 2023 medication administration record showed that the medication was administered, to Resident 3, beginning 11/29/2023. Further review of the progress notes showed no notes documenting that Resident 3's responsible party was notified of the new medication. In interview on 11/29/2023 at 2:32 PM, Staff A, Resident Care Manager (RCM), stated that staff were expected to notify the resident, or the resident's responsibly party of any new medications, orders, treatments or changes in condition. Staff A, RCM, further stated that they did not believe they contacted Resident 3's responsible party for the new medication ordered on 11/28/2023. RESIDENT 4 Review of the EHR showed that Resident 4 admitted to the facility on [DATE] and they were their own responsible party to make healthcare decisions. Review of a progress note, dated 11/17/2023, showed that a new medication had been ordered for Resident 4, to treat an infection. Review of the November 2023 medication administration record showed that the medication was administered, to Resident 4, beginning the morning of 11/18/2023. Further review of the progress notes showed no notes documenting that Resident 4 had been notified of the new medication. In interview on 11/29/2023 at 2:29 PM, Resident 4 stated that they had just gotten over an infection and were doing better. Resident 4 stated they did not know if they had gotten any new medications or treatments to help treat the infection. In interview on 11/29/2023 at 2:40 PM, Staff B, Director of Nursing Services, stated that when a new medication was started, the staff were expected to speak to the resident, if they were able to understand, as well as the resident's responsible party. Staff B, DNS, further stated that they were not able to find documentation of notification, related to the new medication, for Residents 1, 3 or 4. Reference WAC 388-97-0320 (1)(c) .

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that care was provided in accordance with physician orders when lab work was not collected as ordered for one of three (Resident 1) residents reviewed for quality of care. This failure placed the resident at risk for medical complications, deterioration of condition and unmet needs. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including osteomyelitis, a bone infection of the foot and ankle. The Minimum Data Set, an assessment tool, dated 03/20/2023, documented Resident 1 was alert and oriented, and required extensive assistance with activities of daily living. An order dated 03/16/2023 called for labwork to be drawn weekly, every Wednesday, to follow Resident 1's response to medications given to treat the bone infection. A subsequent order, dated 04/11/2023, also ordered weekly labs to be done on Wednesdays to review Resident 1's status while under treatment for the infection. Review of Resident 1's clinical record showed documentation that labs were collected on 03/22/2023 and 04/13/2023. On 04/21/2023 at 8:01 AM, Collateral Contact 1 said they were told the facility was supposed to collect weekly labs because of the antibiotics ordered to treat Resident 1's bone infection, but that Resident 1 did not believe the labs were being done weekly. On 05/03/2023 at 4:25 PM, Staff C, a Licensed Practical Nurse (LPN), when asked about Resident 1's weekly labs, said it would not surprise him if some of the labs had been missed as there had been more temporary staff working who may not have been aware. On 05/23/2023 at 5:10 PM, Staff A, the facility Administrator, and Staff B, a Registered Nurse and the Director of Nursing Services (DNS), determined that lab results for 03/29/2023, 04/05/2023, and 04/19/2023 were not located in Resident 1's chart. On 05/23/2023 at 5:10 PM, when asked, Staff B said the expectation is that labs would be collected as ordered and followed-up on as necessary; if refusals were encountered, then it would be documented, the provider would be notified, a reattempt would be made and followed-up as necessary. Reference WAC 388-97-1060(1) .

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to implement a discharge plan that included conveyance of all special precautions and instructions for ongoing care to the receiving facility for one of three residents (Resident 1) reviewed for discharge planning. This failure placed the resident at risk for unmet needs and risk of harm to Resident 1 when their status deteriorated and was transferred to a higher level of care. Findings included . Review of the facility's Transfers and Discharges Policy, revised 08/16/2022, documented, when the facility transfers or discharges a resident the facility must ensure the transfer or discharge is documented and appropriate information is communicated to the receiving health care institution or provider, including all special instructions or precautions for ongoing care as appropriate. Resident 1 was admitted to the facility on [DATE] for rehabilitation following surgery on the digestive system, and was admitted with a urinary catheter and an ostomy (surgical relocation of the end of the colon). The Minimum Data Set, a comprehensive assessment tool, dated 12/26/2022, documented Resident 1 was alert and oriented and required assistance with activities of daily living. Review of progress notes in Resident 1's record included multiple observations of hematuria (blood-tinged or red-colored urine), on the days immediately prior to discharge. Observations were documented on: 01/12/2023 at 11:57 PM, Foley catheter patent and continues to have episodes of hematuria. Resident on Macrobid for UTI (urinary tract infection). 01/11/2023 at 8:52 PM, episodes of hematuria continues. Advanced Registered Nurse Practitioner continued Macrobid for 3 days. 01/09/2023 at 4:39 PM, episodes of hematuria continues. MD ordered to recheck urinalysis in 2 days if hematuria persists. MD ordered Macrobid two times a day for 5 days related to UTI. Resident 1 had been placed on Macrobid, a medication to treat a UTI, on two occasions prior to discharge: on 01/02/2023 for five days, and again on 01/09/2023 for three days. Review of the 01/13/2023 Discharge Summary Information documented Resident 1 had a catheter and an ostomy. The document did not describe hematuria, or relay information regarding the resident's recent UTI or treatment. Under the section entitled Nursing (course of treatment, including complications), the area was blank. On 01/30/2023 at 9:51 AM, Collateral Contact (CC) 1, Licensed Practical Nurse (LPN) and staff member of the receiving facility, stated when Resident 1 arrived, the resident's urinary catheter collection bag was full of bloody urine, the resident was diaphoretic (sweaty), had a low blood pressure, and said they felt ill. CC1 said they did not receive report from the facility before the resident arrived, and were not told the resident had a UTI recently, had blood in their urine, and was not feeling well. CC1 said Resident 1 was sent to the hospital for evaluation after their arrival. On 01/30/2023 at 1:50 PM, when asked about discharges, Staff C, a Registered Nurse (RN) and floor nurse in the short-term care area, said the floor nurses don't have anything to do with discharges, the Resident Care Managers (RCMs) do the discharges. Staff C said the RCMs do the skin assessments, do the note, everything. The only thing the floor nurses do is count the meds and go over them, and if there are narcotics, they have the RCM sign them off that they're taking them to be given to the resident/family when they discharge. On 01/30/2023 at 2:08 PM, when asked about discharges, Staff D, LPN and floor nurse in the long-term care hall, said most of the discharges are done from the short-term hall but the RCM does the paperwork. The floor nurse will count the meds and give them to the RCM. Staff D said any nurse can do the discharge note but usually the RCM does all of it. On 01/30/2023 at 2:36 PM, when asked who gives the report to the receiving facility when discharging a resident, Staff E, LPN and RCM for the 100 and 200 halls-the short-term area, said they (the RCM) never talked to anyone, that Social Services did that. Staff E said their job was to make sure the resident/receiving facility had the medications and the paperwork. On 01/30/2023 at 2:36 PM, when asked who does the discharge skin assessments, Staff E said no one did. Staff E said the residents were assessed weekly, so the Discharge Summary just referred to the last one that was done. On 01/30/2023 at 3:39 PM, Staff B, Registered Nurse and interim Director of Nursing Services, said the expectation was that Staff E, the RCM, would call the receiving facility to give a nurse-to-nurse report on the day of transfer, and a skin assessment was done the day the resident left the facility. On 02/28/2023 at 2:16 PM, Staff B said information such as blood in Resident 1's urinary catheter and treatment for the UTI should have been conveyed to the receiving facility. Staff B was not able to locate documentation the information had been conveyed to the receiving facility. On 02/28/2023 at 3:15 PM, Staff A was not aware that discharge skin assessments and verbal report to receiving facilities were not typically done during the discharge process as reported by nursing staff. Reference WAC 388-97-0080 (7)(c) .

Oct 2022 27 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to inform resident(s) in advance of the risks and benefits associated with proposed psychotropic medication treatment (medications capable of affecting the mind, emotions, and behavior) and obtain the resident's/resident's representatives consent for proposed psychotropic drugs prior to administering them for 1 of 5 residents reviewed (Resident 39) for unnecessary medications. This failure detracted from the resident's/resident's representatives' ability to make informed decisions regarding psychotropic medication use and precluded them from having the opportunity to decline the proposed treatment. Findings included . According to the facility's Psychotropic Medication Informed Consent Policy, revised 10/04/2022, facility staff should inform the resident and/or resident representative of the initiation, indication for use (i.e., specific diagnosis and documented condition), and the risks/benefits associated with use of psychotropic medications. The medication should not be started until after approved by the resident and, if appropriate, his/her family and/or representative(s). RESIDENT 39 Review of Resident 39's Physician's orders (POs) showed the following psychotropic medication orders: a 09/27/2022 order for lorazepam (an antianxiety medication) every eight hours for anxiety/agitation, hold if drowsy or sedated; and a 09/08/2022 order for nuplazid (an antipsychotic) daily for agitation/anxiety. Review of Resident 39's September and October 2022 Medication Administration Records (MARs) showed Resident 39 had been administered both the nuplazid and lorazepam daily since the order dates. Review of Resident 39's Electronic Health Record (EHR) showed a Psychoactive Medication Informed Consent (PMIC) forms for multiple psychotropic medications that were discontinued, but no PMICs were present for the use of lorazepam or nuplazid. During an interview on 10/10/2022 at 10:00 AM, Staff B, Director of Nursing Services, stated that a PMIC was not obtained from the resident/resident's representative for the use of nuplazid and lorazepam, and acknowledged facility nurses were administering both medications. Reference WAC 388-97-0260; -0300 (3)(a) .

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to have rooms set up for easy access to a light fixture located over the bed for three of six residents (Residents 265, 266 and 39) reviewed for environment and accommodation of need. Failure to ensure a pull cord/string was attached to light fixtures for easy accessibility to turn off and on, placed residents at risk for unmet needs, accidents, increased dependence on staff and a diminished quality of life. Findings included . Review of the facility's policy and procedure titled, Plant Operations - General Policy, dated 07/28/2022, showed, A safe, clean, and structurally sound environment shall be achieved in the facility through the development and implementation of the Plan Operations Program, the development and training of personnel, and the evaluation of goals in the department to assure correlation with the goals of the facility. It further showed that internal and external lighting was to be maintained along with repairs and alterations. RESIDENT 264 Observations on 10/03/2022 at 10:22 AM showed Resident 264's light fixture over the resident's bed had no pull cord/string long enough for the resident to have easy access to turn on and off the light. Observation and interview on 10/04/2022 at 11:08 AM showed a short string of metal balls attached to the light fixture placed above the bed that was about two inches long. Resident 264 stated, I was able to turn on the light by leaning up against the wall and reach up to grab to pull the light on, but it was not easy to do. Resident 264 stated staff were aware of the light fixture issue. During an interview on 10/05/2022 at 8:10 AM Staff P, Certified Nursing Assistant (CNA)/Agency, stated that Resident 264's light fixture over the bed did not have a string and should have one attached for easy access. Additionally, Staff P stated that Resident 264 had mentioned yesterday [10/04/2022] that there was no string attached to the light fixture, and that he had forgot to document in the maintenance clip board to get it fixed; however, he would follow up. During an interview on 10/05/2022 at 8:17 AM Staff A, Administrator, stated that Resident 264's light over the bed needed an extension or new pull cord to make it more accessible for the resident and that this did not meet expectations. RESIDENT 266 During an interview on 10/03/2022 at 11:01 AM Resident 266 stated, that the resident was unable to use the light above the bed since being at the facility because it needed a string attached to be able to reach and use it. Resident 266 stated that the resident had to turn on the call light/call bell and have staff turn the light fixture on or off when needed. Multiple observations on 10/03/2022, 10/04/2022, and 10/05/2022 showed that Resident 266's light fixture over the resident's head of the bed had a short string of metal balls attached to the light fixture not within reach for resident's use. During an interview on 10/05/2022 at 8:21 AM Staff P, CNA/Agency, stated that there was no string attached to the light fixture located over Resident 266's head of the bed to be able to turn the light on and off. Staff P further stated that it needed to be fixed. During an interview on 10/05/2022 at 8:33 AM Staff A, Administrator, stated that Resident 266's light fixture was missing an extension cord/pull cord for accessibility and did not meet expectations and needed to be fixed. RESIDENT 39 Observation on 10/03/2022 at 1:45 PM and 10/05/2022 at 9:38 AM, showed Resident 39's overbed light was missing the pull cord needed to turn the light on and off. During an observation and interview on 10/07/2022 at 7:33 AM, Staff U, Certified Nursing Assistant, was providing one to one supervision of Resident 39 and confirmed the absence of Resident 39's overbed light cord. During an interview on 10/07/2022 at 2:13 PM, Staff B, Director of Nursing Services, stated that all overbed lights should have pull cords long enough to be reached by residents, so they could turn their light on and off independently. Reference WAC 388-97-0860(2) .

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician order (PO) and implement a skin integrity assessment for the use of seatbelt for one of one resident (Resident 55) reviewed for Restraints. This failure placed the resident at risk for injury, unmet needs, and a diminished quality of life. Findings included . Review of the facility policy titled Physical Restraint Use, reviewed 09/12/2022, showed A physician's order is required for the use of the specific type of restraint. The order should include the specific type of restraint, the condition and, or medical symptom that warrants restraint use. Review of the Resident 55's annual Minimum Data Set (MDS, a required assessment tool) dated 03/28/2022 and quarterly MDS dated [DATE] showed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis to include paraplegia (paralysis of the legs and lower body), a cognitive communication deficit and was using a restraint. Review of Resident 55's Electronic Health Record (EHR) and paper medical record on 10/04/2022 showed no PO or skin integrity assessment for use of a seatbelt. Review of Resident 55's care plan dated 07/20/2018 showed that the resident used a seatbelt on the lap while sitting up in a wheelchair as a restraint to decrease risk for falls, injury and for proper body positioning while in the wheelchair. Observations on 10/03/2022 at 9:32 AM, 10/04/2022 at 10:05 AM, and 10/10/2022 at 8:44 AM showed Resident 55 sitting in a wheelchair with a seatbelt attached to the wheelchair and across the resident's lap. During an interview on 10/05/2022 at 9:08 AM, Staff N, Certified Nursing Assistant Certified (CNA), stated that Resident 55 used a seat belt when they were up in a wheelchair to help from falling out of the wheelchair. Staff N further stated that she was trained to put the seatbelt on and off the resident. Staff N also stated that she usually looked at the skin around the seatbelt and would notify the nurse if there was any redness around the seatbelt area. During an interview on 10/05/2022 at 11:00 AM, Staff K, License Practical Nurse (LPN) Resident Care Manager (RCM), stated that the Resident was assessed for the use of a seat belt due to the resident independently moving their body and would fall out of the wheelchair when sitting up. Staff K additionally stated that the physician was aware of the seatbelt use; however, she could not find a PO for the seatbelt in the resident's medical chart. When ask about skin integrity assessment documentation, Staff K stated that there was no documentation for skin integrity under and around the seatbelt in the resident's medical record. Additionally, Staff K stated that a skin integrity assessment and a PO for the use of a seat belt should have been in place; however, they were not. During an interview on 10/6/2022 at 10:40 AM, Staff B, Director of Nursing (DNS), stated that it was her expectation that a PO was in place for the use of a seatbelt as a restraint as well as staff documentation on skin integrity for the use of a seatbelt as a restraint. Staff B also stated that there was not a PO in the Resident 55's medical chart for the use of a seatbelt as a restraint or skin integrity documentation in the resident's medical record for the use of a seatbelt as a restraint. Reference WAC 388-97-0620 .

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to timely initiate and thoroughly investigate allegations of abuse and misappropriation for 1 of 2 residents (Residents 56) who were reviewed. The facility's failure to identify and interview the residents who were present visiting when Resident 56 was slapped and had their arm twisted by Resident 39, detracted from the ability to get thorough account of what transpired and precluded staff from determining what psychosocial affect, if any, witnessing the assault had on them. These failures placed residents at risk for unidentified psychosocial harm, feelings of fear, and unmet care needs. Additionally, failure to investigate an allegation of misappropriation for greater than 30 days after it was reported to facility management, resulted in the inability to pinpoint when the resident's belonging went missing and who might have been involved. Findings included . ABUSE RESIDENT 56 Review of the facility's Incident Reporting Log (IRL) showed a 09/04/2022 resident to resident incident was logged for Resident 56. Review of the facility's investigation showed a group of residents were in the hallway visiting with each other near the nurse's cart. The group included Resident 56 and Resident 39. According to the investigation Staff LL, Licensed Practical Nurse, then observed Resident 39 grab and twist Resident 56's arm and slap her. Staff LL immediately separated the residents. Staff LL documented that Resident 56's arm was red, but they denied any pain and their range of motion was intact. Review of Resident 56's electronic health record (EHR) showed the following nurses notes: 09/04/2022 9:05 PM, Resident placed on alert status for being involved in resident-to-resident altercation. Another resident slapped this resident on the arm and twisted her wrist. They were sitting in the hallway with another resident talking to each other when this happened. Residents were immediately separated. This resident's wrist was red but that soon resolved; and a 09/05/2022 2:21 PM note that read, Resident has 0 c/o [complaint of] pain in her arms or wrists from incident where she had been assaulted by another resident yesterday. 0 bruising, swelling or redness noted. Review of the Interdisciplinary teams (IDT) investigation summary showed they thought the incident was related to Resident 39's dementia and Parkinson's disease with recent development of psychosis. The IDT stated that the root cause was an escalation in Resident 39's delusions and the resident was placed on 1:1 monitoring. On 10/03/2022 Resident 39 was observed in a wheelchair in their room with a staff member providing 1:1. Resident 39 was calm but would not respond to questioning. Further review of the investigation showed there was no indication why it was concluded that Resident 39's delusions were the cause of the event, as there was no documentation to support the resident had delusions at the time, and if the resident did, what the delusion were. The investigation failed to identify the other residents who were present and visiting and failed to include interviews with them as to what was happening or being said just before Resident 39 grabbed and slapped Resident 56. Additionally, there was no indication the other residents who witnessed the event were assessed for potential psychosocial harm. During a telephone interview on 10/12/2022 at 10:28 AM, when asked who the other residents were that were present and what they indicated was being said just prior to Resident 39 grabbing Resident 56 Staff B, Director of Nursing Services, stated she did not know. Staff B then confirmed to perform a thorough investigation, all witnesses should be interviewed, and all facts obtained and considered, and that the other residents who were present, should have been assessed for potential psychosocial harm and/or fear of Resident 39, but acknowledged this did not occur. MISAPPROPRIATION RESIDENT 56 During an interview on 10/03/2022 at 1:14 PM, Resident 56 explained about a month or so prior, her ear lobes were sore, so she removed a pair of earrings, cleaned them, and placed them in a collectors' shot glass on the shelf. When Resident 56 went to put the earrings on the next day, she found the shot glass and earrings were gone. Resident 56 stated she immediately went and reported the missing earrings to the (former) Administrator. Resident 56 stated she had not heard anything in about a week, so she filled out a blue card (concern form) and turned it in directly to the (former) Administrator. Resident 56 stated that again, no one came to ask about the earrings, so she notified the new Administer, Staff A. Review of the facility's IRL and Grievance log showed no entries related Resident 56's missing earrings. During an interview on 10/06/2022 at 11:25 AM, Staff A, Administrator, confirmed Resident 56 had reported the missing earrings. Staff A stated that he called the missing earrings into the state and initiated an investigation, and while speaking with the social worker, they came a cross the 08/24/2022 concern form Resident 56 had completed related to the missing earrings. It had not been logged on either log and there was no indication an investigation had been initiated prior to Staff A calling it in to the state and initiating one on 09/23/2022. Staff A stated he had left messages for both of Resident 56's daughters, to identify which one purchased the earrings, and the price but had not received a call back. Staff A acknowledged that investigations initiated this long after an event occurred, were more difficult determine what occurred. Reference WAC 388-97-0640 (6)(b)

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 4 of 25 sampled residents (Residents 56, 24, 39 and 5) whose Minimum Data Set assessments (MDS) were reviewed. Failure to accurately assess residents' Pre-admission Screening and Resident Review (PASRR) Level II status', placed residents at risk for unidentified and/or unmet mental health needs. Findings included . RESIDENT 56 Resident 56 admitted to the facility on [DATE]. Review of Resident 56's 12/27/2018 Level I PASRR showed the resident was assessed with serious mental illness indicators and exhibited serous functional limitations such as substantial difficulty interacting appropriately and communicating effectively with others. It was determined that a Level II PASRR referral was required. Review of Resident 56's Electronic Health Record (EHR) showed a 01/03/2019 PASRR Notice of Determination which determined the resident had a mental health diagnosis as defined by federal regulations and required specialized behavioral health services. A 01/03/2018 Level II PASRR Initial Psychiatric Evaluation Summary was completed, and treatment plan recommendations were provided to the facility. Review of Resident 56's comprehensive care plan (CP) showed PASRR Level II CP, revised 09/26/2022, that identified the resident was a Level II PASRR for psychiatric diagnoses of depression, anxiety and an unspecified neurocognitive disorder. Review of Resident 56's 10/04/2021 and 09/10/2022 Annual MDSs showed staff coded the resident was not considered by the state Level II PASRR process, to have serious mental illness and/or intellectual disability or a related condition. During an interview on 10/10/2022 at 8:44 AM, Staff B, Director of Nursing Services, stated that the MDSs were inaccurately coded and needed to be corrected. RESIDENT 24 Resident 24 admitted to the facility on [DATE]. Review of Resident 24's 07/24/2018 Level I PASRR showed the resident was assessed with serious mental illness indicators and determined that a Level II PASRR referral was required due to a significant change in condition. Review of Resident 24's EHR showed a 07/26/2018 PASRR Notice of Determination which determined the resident had a mental health diagnosis as defined by federal regulations and did require Level II specialized services. A 07/26/2018 Level II PASRR Initial Psychiatric Evaluation Summary was completed, and treatment plan recommendations were provided to the facility. Review of Resident 24's comprehensive CP showed a PASRR Level II CP, with a target date of 01/29/2022, that identified the resident was a Level II PASRR. Review of Resident 24's 02/23/2022 Annual MDS showed staff coded the resident was not considered by the state Level II PASRR process, to have serious mental illness and/or intellectual disability or a related condition. During an interview on 10/10/2022 at 8:44 AM, Staff B, stated that the MDSs were inaccurately coded and needed to be corrected. RESIDENT 39 Resident 39 admitted to the facility on [DATE]. Review of Resident 39's EHR showed a 09/15/2017 PASRR Notice of Determination which determined the resident had mental health diagnoses as defined by federal regulations and required Level II specialized services. A 09/15/2017 Level II PASRR Initial Psychiatric Evaluation Summary was completed, and treatment recommendations were provided to the facility. Review of Resident 39's comprehensive CP showed a PASRR Level II CP, with a target date of 12/07/2022, that identified the resident was a Level II PASRR. Further review of Resident 39's EHR showed facility staff completed a new Level I PASRR on 06/29/2022 which showed the resident was assessed with serious mental illness indicators including bipolar disorder and anxiety disorder, and and that a Level II PASRR referral was not required. Staff documented under additional comments Updated to reflect current diagnoses. No rationale was provided as how nursing home staff determined Resident 39's Level II (who was determined by state evaluators to be a level II ) could or should be terminated. Additionally, the resident had not discharged from the facility since the state evalautors determined the resident met the criteria of a Level II. Review of Resident 39's 11/10/2021 Annual and 08/24/2022 Significant Change MDSs showed staff coded the resident was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. During an interview on 10/10/2022 at 8:44 AM, Staff B, stated that the MDSs were inaccurately coded and needed to be corrected. RESIDENT 5 Review of Resident 5's EHR showed a 01/22/2021 PASRR Notice of Determination which determined the resident had mental health diagnoses as defined by federal regulations and required Level II specialized services. A 01/22/2021 Level II PASRR Initial Psychiatric Evaluation Summary was completed, and treatment recommendations were provided to the facility. Review of Resident 5's comprehensive CP showed a PASRR Level II CP, revised 08/05/2022, that identified the resident was a Level II PASRR and directed staff to arrange referrals as indicated by PASRR level 2 findings Review of Resident 5's 10/04/2021 Significant Change and 07/25/2022 Annual MDSs showed staff coded the resident was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. During an interview on 10/10/2022 at 8:44 AM, Staff B, stated that the MDSs were inaccurately coded and needed to be corrected. Reference WAC 388-97-1000 (1)(b) .

CONCERN (D)

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

Deficiency F0646 (Tag F0646)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the state mental health authority after a significant change in the mental condition for 1 of 5 residents (Resident 39) reviewed for unnecessary medications. The failure to follow the state Preadmission Screening and Resident Review (PASRR) program requirements, such as ensuring residents with serious mental illness (SMI) were referred to the state mental health authority after a significant change in the mental or physical condition, placed residents at risk for delayed provision of mental health services, unmet mental health care needs and a diminished quality of life. Findings included . RESIDENT 39 Resident 39 admitted to the facility on [DATE]. According to the 08/24/2022 Significant Change Minimum Data Set assessment (MDS) the resident was severely cognitively impaired, had diagnoses of depression, anxiety, and bipolar disorders, experienced an acute onset mental status change, delusions, verbal, and physical behaviors that affected others and placed the resident at risk for physical injury. Staff then assessed that Resident 39's behaviors were worse than the prior assessment. Review of Resident 39s Physician's orders (POs) showed the following orders for psychotropic medications: a 09/27/2022 order for lorazepam (an antianxiety medication) every eight hours for anxiety/agitation, hold if drowsy or sedated; and a 09/08/2022 order for nuplazid (an antipsychotic) daily for agitation/anxiety. Review of Resident 39's Electronic Health Record (EHR) showed a 09/15/2017 PASRR Notice of Determination which assessed Resident 39 had mental health diagnoses as defined by federal regulation and required specialized behavioral health services; and a 09/15/2017 Level II PASRR Initial Psychiatric Evaluation Summary that identified the resident had major depressive disorder, unspecified anxiety disorder and probable Major Vascular Neurocognitive Disorder, and a specified treatment plan with recommendations was provided to the facility. Further review of Resident 39's EHR and paper medical record, showed no documentation or indication Resident 39 was referred to the state mental health authority, as required, after the resident was identified on 08/24/2022 with a significant change in their mental and/or physical condition. During an interview on 10/10/2022 at 10:59 AM, Staff E, Social Services Director, stated that residents with SMI who had significant changes in their mental and/or physical condition, were to be referred to the county PASRR evaluator, but was unsure if that had occurred. During an interview on 10/10/2022 at 10:00 AM, Staff B, Director of Nursing Services, stated that it did not appear that Resident 39 was referred to the state mental health authority after the facility identified a significant change in the resident's mental health. Reference WA 388-97-1975 (7) .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 2 of sample residents (Residents 24 and 39) reviewed. The facilities' failure to follow and/or clarify Physician's Orders (POs) when indicated, and to only sign for tasks they completed or validated were complete, placed residents at risk for medication errors, delays in treatment, unmet care needs, and potential negative outcomes. Findings included . RESIDENT 24 Review of Resident 24 POs showed a 02/17/2022 order for a suprapubic indwelling catheter to straight drainage. Size 18 French (F), change for leakage or obstruction (no more than one time a month without notifying MD) as needed; and a 06/19/2022 order to monitor the 14 F suprapubic catheter, for leakage every shift, notify physician if any problems. Review of Resident 24 August, September, and October 2022 Medication Administration Records (MARs) and Treatment Administration Records (TARs) showed nursing signed they replaced the resident's 18 F catheter on 08/02/2022 and 08/27/2022 and had not replaced it since. However, facility nurses were also signing three times a day that they monitored Resident 24's 14 F catheter for leaks. During an interview on 10/10/2022 at 9:35 AM Staff B, Director of Nursing Services, confirmed that facility nurses could not have placed a 18 F catheter as ordered and monitored a 14 F catheter for leaks. Staff B stated facility nurses should have identified the conflicting orders and clarified them. Review of Resident 24 POs showed a 09/23/2022 order to place the resident's catheter tube and drainage bag on the left leg. Observations on 10/07/2022 at 2:03 PM and 10/10/2022 at 9:43 AM, showed Resident 24's catheter tubing was run down the right leg, not left as ordered. Review of the October 2022 TAR however, showed on 10/07/2022 and 10/10/2022 facility nurses signed that they ensured the resident's catheter tubing was on the right leg. During an observation and interview on 10/10/2022 at 9:50 AM, Staff B observed Resident 24 and confirmed the catheter tubing was on the resident's right leg and the nurses had signed for a task they did not complete or validate was completed. Review of Resident 24 POs showed a 04/30/2022 order to apply TED hose (compression stockings) in the AM and to remove at bedtime. Observations on 10/03/2022 at 2:34 PM, 10/5/2022 at 2:57 PM, 10/07/2022 at 2:03 PM, and 10/10/2022 at 9:43 AM, showed Resident 24 had dark blue or black dress socks and their TED hose had not been applied. Review of Resident 24's October 2022 TAR showed facility nurses signed on the first three days that they applied Resident 24's TED hose as ordered. The TAR was not checked on 10/10/2022. During an observation and interview on 10/10/2022 at 9:50 AM, Staff B observed Resident 24, and confirmed their TED hose had not been applied and facility nurses had signed for tasks they did not complete. Review of Resident 24 POs showed a 02/17/2022 order for a 18 F suprapubic indwelling catheter to be change for leakage or obstruction no more than one time a month without notifying the physician. Review of Resident 24's MARs showed the last two times the resident catheter was changed was on 08/02/2022 and 08/27/2022, when facility nurses signed the changed the resident's 18 F catheter. On 10/10/2022 at 9:50 AM, Resident 24 was fully dressed so Staff B was unable to validate the size of catheter Resident 24 had in place. In a telephone interview on 10/12/2022 at 11:33 AM, Staff B stated that Resident 24's catheter was a 14 F catheter and acknowledged facility nurses failed use an 18 F catheter as ordered. RESIDENT 39 Review of Resident 39's POs showed the resident had a 08/18/2022 order for Miralax (a laxative) as needed if no bowel movement (BM) times three day. Review of Resident 39's September 2022 MAR showed a facility nurse administered the resident as needed Miralax on 09/05/2022 at 5:01 PM. Review of Resident 39's bowel monitor showed the resident had a large bowel movement (BM) on 09/05/2022 at 6:47 AM. During an interview on 10/05/2022 at 12:48 PM, Staff K, Unit Care Coordinator, stated that the resident's Miralax should not have been administered as the resident had a BM earlier on the same day, and acknowledged the nurse failed to follow the PO. Reference WAC 388-97-1620 (2)(b)(ii)

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure a resident's ability to participate in activities of daily living did not diminish for one of one sampled resident (Resident 47) reviewed for activities of daily living (ADLs) and therapy services. The facility failure to provide assistance with ADLs and continued therapy services for the resident, placed the resident at risk for an avoidable decline, and a diminished quality of life. Findings included . Review of a document titled, Activities of Daily Living (ADLs) dated 08/22/2022 showed that the resident will receive assistance as needed to complete ADLs, and any change in the ability to perform ADLs will be documented and reported to the Licensed Nurse (LNs). In addition, the document showed that based on the comprehensive assessment of the resident, the facility must ensure that the resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices. Furthermore, the documented showed that the facility must provide the necessary care and services to ensure that a resident's abilities in ADLs do not diminish. Review of Resident 47's admission Minimum Data Set assessment (MDS) dated [DATE] showed the resident admitted on [DATE] with multiple diagnoses to included heart and kidney disease, Parkinson's Disease (a degenerative disorder of the central nervous system that mainly affects the motor system), abnormalities of gait (walk), mobility, and muscle weakness. In addition, the MDS showed that the resident was able to make needs known. During an interview on 10/03/2022 at 10:34 AM, when asked about whether the resident was getting better or had decline with ADLs since admission to the facility, Resident 47 stated, No, I'm getting weaker. I need therapy. Review of Resident 47's care plan revised on 07/12/2022 showed that Resident 47 was to have ADL Assistance and Therapy services needed to maintain or attain highest level of function. Interventions included assistance with mobility and ADLs as needed. During an interview on 10/05/2022 at 1:27 PM, Staff EE, Director of Rehabilitation Services, stated that the resident had been discontinued after achieving the highest level of abilities on 07/04/2022. Staff EE also stated that the resident would be re-evaluated if any decline was shown. Review of 47's electronic health record (EHR) showed multiple entries of LNs documentation that the resident was receiving physical and occupational therapy (PT/OT). On 07/05/2022 at 3:46 PM it showed the LNs had documented, .working with PT/OT to increase functional mobility and strengthening; on 07/26/2022 at 1:31 PM, staff documented, working with therapy services,; on 08/25/2022 at 1:55 PM, staff documented continuing to work with therapy to meet goals; on 08/30/2022 at 10:25 AM, staff documented, resident has weakness and is receiving therapy services for muscle strengthening. In addition, a note on 09/12/2022 at 9:50 AM, showed that a LN had documented, continues to work with therapy for strengthening. Review of Resident 47's EHR, document titled, Monthly Summary, dated 08/23/2022 and 09/23/2022 showed the resident's muscle tone limitations and location as described as, Weakened lower extremities. During an interview with Staff FF, Restorative Therapy/Certified Nursing Assistant, (RT/CNA) on 10/05/2022 at 1:40 PM stated that she did not have Resident 47 on her list to provide any restorative program to the resident at the facility. During an interview on 10/05/2022 at 1:50 PM, Staff B, Director of Nursing Services, (DNS) stated that the resident was supposed to go home after therapy; however, the resident's spouse was unable to care for the resident at home because they needed a lot of ADL care that the spouse could not provide. In addition, Staff B, stated the facility had dropped the ball on this one, because there were a lot of changes in staff such as the resident care managers and that the resident should have been re-evaluated, especially if there was a decline in strength and mobility. Reference (WAC) 388-97-1060(2)(a) .

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide assistive devices and/or proper treatment to maintain hearing abilities for 1 of 1 resident reviewed for hearing. This failure placed the resident at risk for frustration, social isolation, unmet care needs and diminished quality of life. Findings included . RESIDENT 24 Resident 24 admitted to the facility on [DATE]. According to the 08/04/2022 Quarterly Minimum Data Set (MDS, an assessment tool) the resident was cognitively impaired, could sometimes understand and be understood in conversation, had difficulty hearing, and did not have hearing aids or other hearing appliances. Review of Resident 24's comprehensive care plan (CP) revealed the following: A Resident has hearing aids CP, initiated 06/14/2022, that directed staff to store hearing aids in nurses cart when not in use; and an Activities of Daily Living CP with an intervention, initiated on 05/19/2022, that directed staff to put in hearing aids in the morning and take off at bedtime and give to floor nurse, hearing aids will be left in the cart overnight. Observations on 10/03/2022 at 2:34 PM and 10/05/2022 at 9:13 AM and 11:47 AM showed Resident 24 did not have their hearing aids in place. During an observation and interview on 10/07/2022 at 2:03 PM, Resident 24 was observed siting in his wheelchair in the front lobby. While greeting Resident 24 and approaching from the resident's left side, the resident called out What in a elevated voice and maneuvered the wheelchair around so their right ear was toward (the speaker) and indicated it was the good ear. When asked why the hearing aides were not in place Staff 24 stated, Someone kiped em, Right out of my drawer. During an interview on 10/07/2022 at 2:11 PM, when Resident 24 was asked if they wanted their hearing aids in if located (CP indicated they were locked in the nurse's cart) the resident who appeared agitated stated, You're GD right. Review of Resident 24's electronic health record (EHR) showed a 05/18/2022 order for the resident to: Wear hearing aid, on AM and off at bedtime. This order was discontinued on 06/18/2022. Further review of the EHR showed no indication why. During an observation interview on 10/10/2022 at 09:50 AM, Staff B, Director of Nursing Services validated Resident 24's hearing aides were not in place and stated that staff should be assisting the resident to apply them. On 10/13/2022 at 4:41 PM, an email was received from Staff B which stated that Resident 24's hearing aides were not found in the nurse's cart and the facility was in the process of getting them replaced. Reference WAC 388-97-1060(3)(a)

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision, thorough investigations to determine the circumstances, potential physiological and environmental factors contributing to resident falls, and identification and implementation of resident specific interventions to prevent reoccurrence for two of eight residents (Residents 39 and 24) reviewed for accidents. Failure to thoroughly assess the underlying causes of falls, identify, and implement interventions, including adequate supervision and/or assistive devices, contributed to a pattern of repeated falls and placed residents at risk for continued accidents, injuries and decreased quality of life. Findings included . RESIDENT 39 Resident 39 admitted to the facility on [DATE]. According to the 08/24/2022 Significant Change Minimum Data Set (MDS, an assessment tool), the resident had severe cognitive impairment, diagnoses of anxiety, depressive and bipolar disorders, received antianxiety, antidepressant and opioid medications, was unsteady and required staff assistance to stabilize when walking, and had two or more non-injury falls and one injury fall since the prior assessment. Review of facility's August 2022 Incident Reporting Log (IRL) showed the following falls were logged for Resident 39: 08/17/2022 at 1:28 AM; 08/17/2022 at 08:45 AM; 08/17/2022 at 10:00; and 08/18/2022 at 07:00 AM Review of Resident 39's August 2022 Physician's order' showed the following psychotropic medication orders, a 11/15/2019 order for Amitriptyline (an antidepressant), and had a new 08/15/2022 order for Buspar (an antianxiety medication) twice daily. Review of Resident 39's Medication Administration Record (MAR) showed the resident began receiving the Buspar twice daily on 08/16/2022. Fall 1 According to the facility's fall investigation for the 08/17/2022 at 1:28 AM fall, Resident 39 was heard yelling help. Staff entered Resident 39's room and observed the resident seated on the bathroom floor with their back against the wall across from the toilet and had been incontinent of bowel and bladder. Staff assisted the resident to the standing position, cleaned and changed and placed into their wheelchair. Review of the investigative documents showed the resident was oriented only to self and denied any pain or injury. The investigation did not identify what, if any, interventions were put into place to prevent reoccurrence. Review of the attached 08/17/2022 fall assessment showed the resident was assessed to be confused. Under the heading Systolic Blood Pressure [SBP] and Vitals which directed staff to measure the resident's SBP while lying, sitting, and standing (Orthostatic blood pressures, assesses for orthostatic hypotension which can cause dizziness or lightheadedness and possibly fainting and is a common side effect of psychotropic medications). Staff checked the box that stated, No drop in pressure noted. However, review of the incident investigation and Resident 39 electronic health record (EHR) and paper chart, showed no documentation or indication that staff obtained orthostatic blood pressures. Review of the two attached Certified Nursing Assistant (CNA) statements showed Resident 39 was confused and had ambulated to the bathroom without the use of their walker, which was observed positioned next to the resident's bed at the time of the fall. Contrary to the Licensed Nurse's (LN) incident description, both CNA statements stated that Resident 39 had pain and was hungry. The presence of or location of Resident 39's reported pain was not addressed in the investigation, nor was the reported hunger. Review of the attached 08/17/2022 Pain Evaluation Tool showed it was blank. However, review of Resident 39's August 2022 Medication Administration Record (MAR) showed the nurse administered Tylenol on 08/17/2022 at 2:20 AM, less than one hour after the fall. Additionally, a new order for was obtained on 08/17/2022 at 11:13 AM for Vicodin (an opioid analgesic) as needed for back pain. Fall 2 According to the facility's fall investigation for the 08/17/2022 at 8:45 AM fall, Resident 39 was heard yelling for help from the bathroom, when staff reached the room, the resident was observed sitting on the floor in front of the sink. Resident 39 was assessed to be alert and oriented times four (to person, place, time and situation), without injury and reported that they had lost balance while trying to stand at the toilet. Review of the attached 08/17/2022 12:20 PM Pain Evaluation Tool showed staff documented no complaint of pain. No fall assessment was attached to this investigation. The investigation did identify what, if any, interventions were put into place to prevent reoccurrence, showed indication staff assessed the resident for orthostatic hypotension considering they were started on Buspar the day prior, 08/16/2022 and had subsequently fallen twice. Additionally, there was no explanation given related to the resident being assessed as confused and only alert to self at 2:00 AM and was alert and oriented times four. Review of Resident 39's EHR showed the resident was seen by the Physician on 08/17/2022 at 11:13 AM and ordered the Vicodin for back pain, decreased the resident's Tamsulosin (medication used to treat enlarged prostate) and discontinued the resident's amitriptyline. Although these changes were not identified in the fall investigation. Fall 3 According to the facility's fall investigation for the 08/17/2022 at 10:00 PM fall, Resident 39 was found sitting on the floor against the bed. Under Immediate action taken staff documented the resident was assisted back to bed. The nurse assessed the resident was alert and oriented times three and sustained a laceration to the back of the head. The investigation did not have an attached pain or fall assessment, nor did it identify what, if any, interventions were put into place to prevent reoccurrence. There was no documentation or indication the nurse evaluated the resident for orthostatic hypotension or consideration whether the resident newly implemented order for Buspar main be contributing to the resident's falls. Additionally, although the nurse assessed Resident 39 to be alert and oriented times three, an attached CNA statement stated that the resident was very confused 3rd fall in under 24 hours. Fall 4 According to the facility's fall investigation for the 08/18/2022 at 7:00 AM fall, Resident 39 was found sitting on the fall mat next to the bed, leaning against the bed with legs stretched out in front. Under Immediate Action the nursed documented Resident 39 was assisted to a wheelchair and brought out to the hallway for close supervision. The resident was assessed to be alert only to self and without injury. Two 08/18/2022 Fall Risk Evaluations (FRE) by different authors were attached to the fall investigation. Each showed staff checked the box that indicated Resident 39 had no drop in SBP when checked for orthostatic hypotension. However, review of the incident investigation and Resident 39 EHR and paper chart, showed no documentation or indication that staff obtained orthostatic blood pressures. The following summary of Resident 39's four falls was attached to each fall investigation under notes. During total investigation, which ended up with 4 falls in a 24-hour period it was discovered that the resident had started a new psychotropic medication which has known potential side effect of dizziness. The medication was stopped. Other interventions have been to keep resident within sight of staff at the nurses' station or medication cart to avoid any further falls. No signs of abuse or neglect were found. All falls were met with quick response and interventions. The facility's investigative summary did not identify or address that the first three fall investigations failed to identify any intervention to prevent reoccurrence, the contradictory nurses' assessments of the resident's cognition and presence/absence of pain. Additionally, the summary did not identify what interventions the facility allegedly implemented or when. Nor, was there an explanation as to why it took four falls to discover the resident was on a new psychotropic medication, when the resident was on alert for the initiation of that medication. During a telephone interview on 10/12/2022 at 10:28 AM, Staff B, Director of Nursing, acknowledged facility nurses had conflicting and /or inaccurate assessments of Resident 39 cognition on their fall investigations, that no interventions were identifed and there's no indication any were implemented to prevent reoccurence of falls, until after Resident 39's fourth fall. Staff B further acknowledged that Resident 39 was on alert for the start of Buspar, thus, nurses should have been monitoring and documenting to the presence or absence of adverse side effects, but failed to do so, potentially contributing to the delayed (discovery) that the resident was receiving a new psychotropic medication. RESIDENT 24 Review of facility's August 2022 IRL showed the resident had a fall on 08/27/2022 at 4:20 AM. Review of the facility's fall investigation showed the resident was found on the fall mat next to the bed. The resident was alert but confused and unable to provide an account of events. Assessment revealed some bleeding from Resident 24 suprapubic catheter site, the physician was notified, and the resident's suprapubic catheter was changed. The investigation concluded that the resident likely stepped on the urinary catheter tubing and tripped, resulting in the fall. The investigation identified an intervention of ensure catheter drainage bag is located on side of bed which the resident egresses [exits] In the conclusion staff documented the intervention put in place is valid. Review of Resident 24 comprehensive care plan showed ensuring the resident's catheter tubing was located on the side of the bed used to exit, had not been care planned or added to the resident's plan of care. Additionally, observations on 10/03/2022 at 2:34 PM and 10/5/2022 at 2:57 PM showed the left side of Resident 24's bed was against the wall and according to the resident's falls care plan had been 04/09/2021. During a telephone interview on 10/12/2022 at 10:28 AM, Staff B confirmed that Resident 24's bed was against the wall on the left side, thus, their catheter tubing was already only able to be attached on the side the resident exited and was not an appropriate or effective intervention. Additionally, Staff B acknowledged the identified intervention was never added to Resident 24 plan of care. Reference WAC 388-97-1060(3)(g) .

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act on and/or consistently follow the consultant pharmacist's Medication Regimen Review (MRR) recommendations in a timely manner and maintain MRR documentation for two of five residents (Resident 8 and 39) reviewed for unnecessary medication use. These failures placed the residents at risk for not having all MRR documentation in the medical record, experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of the facility's policy and procedure titled, Pharmacy Services and Medication Regimen Review, dated 08/25/2022, showed, The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. Also, The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. It further showed, Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. Additionally, it showed, The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. RESIDENT 8 Review of the annual Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 8 originally admitted to the facility on [DATE]. It further showed that Resident 8 had diagnoses to include heart failure, kidney disease, depression, and psychotic disorder. Review of Resident 8's pharmacy form titled, Consultation Report, dated 03/18/2022 showed a pharmacist's recommendation for, [Resident 8] receives quetiapine [an antipsychotic medication] without monitoring of postural BP's [blood pressure (BP) drops when rising from sitting or lying down]. It further showed, Please monitor orthostatic blood pressures [blood pressure and heart rate taken while lying, sitting and standing] periodically. This form did not show a provider's signature and date nor if the provider agreed or disagreed with the recommendation. Review of Resident 8's physician order dated 03/26/2022 showed that the resident was prescribed to have orthostatic BPs monthly in the evening every 30 days for use of an antipsychotic medication and results were to be documented in the vital signs tab in the resident's electronic health records (EHR). Review of Resident 8's EHR on 10/06/2022 showed no monthly orthostatic BPs were documented in the resident's vital signs tab or in the Resident's Medication Administration Records (MARs) for the months of March, April, May, June, August, or September 2022. Review of Resident 8's pharmacy form titled, Consultation Report, dated 04/21/2022 showed a pharmacist's recommendation for, [Resident 8] receives doxycycline [antibiotic medication use to treat infection] and MVI [multi-vitamin] with minerals at 0800 [8:00 AM]. It further showed, Please consider space by at least 2 hours [to not provide both medications at the same time, instead provide two hours apart]. This form did not show a provider's signature and date nor if the provider agreed or disagreed with the recommendation. Review of Resident 8's April and May 2022 MARs on 10/06/2022 showed that both doxycycline and MVI with minerals continued to be administered to Resident 8 at 8:00 AM for 19 days after the pharmacist recommendation on 04/21/2022 was to space the medications at least two hours apart. During an interview on 10/10/2022 at 8:32 AM Staff R, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated that pharmacist's recommendations were usually faxed and/or placed in the providers box for review, the provider would note the document/form and if agreed would provide new orders and if not would write a rationale on the form which should be in the resident's paper chart. Staff R stated that Resident 8's pharmacist's recommendations for monitoring of postural BP's and spacing antibiotic and MVI with minerals medications by two hours apart should have been followed/implemented, provider notified, and provider's documentation for the pharmacist notification form should have been in Resident 8's paper chart. During an interview on 10/10/2022 at 10:15 AM, Staff B, Director of Nursing Services (DNS), stated that pharmacist's recommendations should be followed up within a week and provider notified, provider should sign the recommendation form to show if agree or disagree and if disagree the provider should document rationale. Staff B stated that the MRR documentation should be in the resident's paper chart or in the pharmacy binder. Staff B stated that expectations were not met regarding Resident 8's pharmacy recommendations [on 03/18/2022 and 04/21/2022], the provider should have been provided the pharmacist recommendations and show provider's documentation in Resident 8's paper chart. RESIDENT 39 Review of Resident 39's 08/24/2022 Significant Change MDS, the resident was severely cognitively impaired, had diagnoses of Parkinson's disease, bipolar and anxiety disorder, and experienced an acute onset mental status change and delusions during the assessment period. Review of Resident 39's 09/22/2022 pharmacy Consultation Report, showed the pharmacist identified Resident 39 received nuplazid (an antipsychotic medication) with a supporting diagnosis of anxiety. According to the pharmacist This supporting diagnosis will result in a survey citation. This agent is specifically for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. Please change the diagnosis to Parkinson's Disease Psychosis. Review of Resident 39's Physician's orders (PO) on 10/10/2022 showed the supporting diagnosis for the use of nuplazid, remained agitation/anxiety. During an interview on 10/10/2023 at 3:23 PM, Staff B, Director of Nursing Services, stated that the 09/23/2022 pharmacy recommendations should have been completed withing seven days of receiving the recommendation, but acknowledged that did not occur. Resident 39's 08/19/2022 pharmacy Consultation Report showed the pharmacist was performing a medication review to identify medications that may contribute to falls and documented that Propranolol (a cardiac medication), may cause slow heart rate, low blood pressure and contributed to falls. The pharmacist recommended parameters to hold the medication if the residents heart rate was less than 60 or the systolic blood pressure was less than 90. Review of Resident 39's POs showed the recommended propranolol hold parameters were not added to the propranolol order until 09/22/2022, 30 days after the recommendation was received. During an interview on 10/10/2023 at 3:23 PM, Staff B, stated that the recommendation should have been carried out within a week, but was not. Additionally, Resident 39's 08/19/2022 pharmacy Consultation Report, showed the pharmacist documented that Tamsulosin (a medication used to treat benign prostatic hyperplasia, BPH) may cause low blood pressure and dizziness but the effect may be lessened if administered with food. A recommendation was made to administer the Tamsulosin 30 minutes after the same meal daily. Review of Resident 39's POs showed no direction had been added to the Tamsulosin order directing staff to administer the medication 30 minutes after dinner daily. During an interview on 10/10/2023 at 3:23 PM, Staff B, DNS, stated that the pharmacy recommendations should have been processed already, but were not. Reference WAC 388-97-1300 (1)(c)(iv), (4)(c) .

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and maintain a current care plan in collaboration with hospice, to identify what services were to be provided and a delineation of hospice responsibilities and to have a system by which consistent communication between the facility and hospice staff occurred for one of one resident (Resident 31) reviewed for Hospice. This failure placed the resident at risk for not receiving necessary care and services and a diminished quality of life. Findings included . According to the facility's Hospice Coordination of Care policy, dated August 2022, showed The facility provides hospice care under a written agreement and must ensure that each resident's written plan of care includes both the recent hospice plan of care and a description of the services furnished by the LTC (Long Term Care) facility to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. Procedure .If the resident/responsible party chooses to receive hospice services, the attending physician must write an order referring the resident to hospice. The facility's interdisciplinary team, hospice and the resident/responsible party collaborate to develop the resident's plan of care. The facility will continue to meet the resident's personal care and nursing needs per the care plan and in collaboration with hospice personnel. Review of the quarterly Minimum Data Set assessment(MDS) dated [DATE] showed that Resident 31 readmitted on [DATE] with diagnoses to include kidney cancer, chronic kidney disease and diabetes. The MDS further showed that Resident 31 was able to make needs known. Review of an additional significant change MDS dated [DATE] showed that Resident 31 agreed to hospice services. Review of Resident 31's Electronic Health Record (EHR) showed no physician order for hospice nor hospice care plan were present. Additional review of Resident 31's paper chart showed no physician order for hospice nor hospice care plan were present. The last documented communication from hospice was dated August 2022. During an interview and joint record review on 10/06/2022 at 10:45 AM, Staff K, Registered Nurse / Unit Care Coordinator (RN/UCC) stated, the documents that are required for hospice residents included a physician order, separate care plan, hospice communication notes and medication orders. Staff K was unable to locate a physician order or care plan in the paper chart or EHR. Staff K did locate hospice chart notes; however, the most recent note was dated August 2022. During an interview on 10/06/2022 at 11:04 AM, Staff B, Director of Nursing (DNS), stated that it was her expectation that the facility would obtain a physician order, medication orders, hospice chart notes and an individualized care plan relating to hospice for all residents receiving hospice services. Reference WAC 388-97-1060 (1) .

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 17 Review of Resident 17's paper chart on 10/03/2022 showed no AD. Additional review of the EHR on 10/05/2022 showed no AD. During an interview on 10/06/2022 at 10:40 AM with Staff E, SSD, they stated that AD should have been addressed at admission, the first care conference, and quarterly care conferences thereafter. Staff E confirmed that there was no documentation of AD in the paper chart or EHR. Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c) RESIDENT 19 Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's admission agreement, dated 12/28/2021, showed that Resident 19 had executed an AD prior to admission to the facility and would provide the facility with a copy. Review of Resident 19's EHR and paper chart on 10/04/2022 at 12:08 PM, revealed no AD documents. On 10/05/2022 at 11:56 AM, Staff E, stated that the facility did not obtain a copy of the AD for Resident 19 and the facility did not review ADs with Resident 19 after admission. RESIDENT 62 Review of Resident 62's admission agreement, dated 02/25/2021, showed Resident 62 had not executed an AD prior to admission and had received information from the facility about ADs. Review of Resident 62's EHR and paper chart, on 10/04/2022 at 12:10 PM, showed no AD documents. Review of Resident 62's Care Plan showed Resident has ADs POLST. Review of Resident 62's annual social service note, dated 09/16/2022, showed ADs reviewed: full code with full treatment. On 10/05/2022 at 12:02 PM, Staff E, stated that the facility staff had thought the POLST was an AD, and they reviewed the POLST quarterly. Staff E stated that the facility did not review or follow up on ADs for Resident 62. The facility only reviewed the POLST form. RESIDENT 31 Review of Resident 31's EHR and paper chart on 10/05/2022 at 1:44 PM showed no AD for health care. Review of Resident 31's social service assessment dated [DATE] showed an area for AD, but it was not completed RESIDENT 63 Review of Resident 63's EHR on 10/03/2022 at 10:04 AM showed no AD. Review of Resident 63's paper chart on 10/06/2022 at 1:02 PM showed no AD. During an interview on 10/07/2022 at 11:23 AM, Staff E, SSD, stated that she had not discussed Resident 63's AD. During an interview on 10/10/2022 at 9:47 AM, Staff A, Administrator, stated that the facility reviewed ADs with residents through the admission packet. Staff A further stated that his expectation was that social services would request ADs from residents and provide information to residents regarding establishing an AD. RESIDENT 8 Review of Resident 8's EHR and paper chart on 10/03/2022 at 1:49 PM showed no AD for health care. During an interview on 10/04/2022 at 11:29 AM, when asked if the resident had an AD, Resident 8 stated that the resident did not recall being asked by staff about an AD and was not sure if the facility had any documents or not. During an interview on 10/05/2022 at 10:43 AM Staff E, SSD, stated that originally, she thought that a POLST was an AD. Staff E stated that Resident 8's AD should have been in the resident's paper chart; however, she knew that Resident 8 did not have an AD at this time and just had a POLST. Additionally, Staff E stated that she was unable to locate documentation that Resident 8 or responsible party was provided information/education on establishing an AD and there should have been. During an interview on 10/05/2022 at 12:41 PM Staff A, Administrator, stated that AD information was asked for upon admission and that social services were to obtain AD and follow up as needed. Staff A stated that ADs were periodically reviewed quarterly during care conferences and if there was a change of condition. Additionally, Staff A stated that they were looking for Resident 8's AD documentation and would provide when found. This documentation was not provided for review. Based on interview and record review, the facility failed to determine if residents had advanced directives (AD), and if not, determine whether the residents wished to formulate advanced directives for 9 of 9 residents (Residents 30, 47, 8, 55, 19, 62, 31, 63, and 17) reviewed for Advanced Directives. This failure denied the residents the opportunity to direct their health care in the event if they were to become unable to make decisions or communicate their health care preferences. Findings included . PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) .a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an AD. If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. Review of the facility's policy and procedure titled, Advance Directives and Advance Care Planning, dated 09/30/2022 showed that each time the resident is admitted to the facility, quarterly and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning information . The social services director or designee should document in the medical records and assist as needed with updating the documents that need revision in accordance with state and federal requirements. RESIDENT 30 Review of Resident 30's electronic health records (EHR) and paper chart on 10/03/2022 at 11:02 AM showed no advance directive for health care. RESIDENT 47 Review of Resident 47's EHR and paper chart on 10/03/2022 at 12:42 AM showed no advance directive for health care. During an interview on 10/05/2022 at 11:42 AM Staff E, Social Services Director (SSD), stated that she thought a POLST was an AD. .

CONCERN (E)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to provide Notices of Medicare Non-Coverage (NOMNC) at least two calendar days before Medicare services ended for 1 of 3 residents (Residents 215) reviewed. In addition the facility failed to issue and/or accurately complete Advanced Beneficiary Notices (ABNs, a notification that lists services that Medicare is not expected to pay for, along with the estimated costs of those services, so beneficiaries could decide if they wished to continue receiving the services and assume financial liability), for 2 of 3 residents (Resident 214 and 215) whose Medicare stay ended, but remained in the facility. These failures precluded residents from exercising their right to appeal and/or placed the residents at risk for not having adequate information to make financial decisions related to their continued stay in the facility. Findings included . RESIDENT 215 According to the Skilled Nursing Facility (SNF) Beneficiary Protections Notification Review form completed by facility staff on 10/05/2022, Resident 215's skilled services started on 04/12/2022 and ended on 05/23/2022, after which Resident 215 remained in the facility. Review of Resident 215's NOMNC showed it identified the resident's last covered day (LCD) as 05/23/2022, but review of the signature page revealed that it was unsigned and undated. During an interview on 10/05/2022 at 11:29 AM, Staff V, Business Office Manager, confirmed the NOMNC was unsigned and undated. Review of the ABN issued on 05/18/2022 showed the facility believed the resident's care no longer met Medicare coverage requirements. Under the heading Reason Medicare May Not Pay staff documented You need only routine nursing/supportive care. For the estimated costs for continuing the current skilled care, staff listed the room and board daily rate, rather than the estimated cost to continue the skilled services that were to be discontinued. Further review of the 05/18/2022 ABN showed Resident 215 selected Option 1, which instructed the facility that Resident 215 wanted to continue the current skilled services and provided the facility the following direction, You may ask to be paid now, but I also want Medicare to be billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare does not pay, I am responsible for the payment. During an interview on 10/05/2022 at 11:29 AM, when asked for documentation to support the facility attempted to bill Medicare as directed by the resident, Staff V indicated the facility did not attempt to bill Medicare and explained that the resident was trying to select that they wanted room and board, but because the facility erroneously listed room and board as the care no longer likely to be covered rather than the skilled services that were ending, Resident 215 accidently selected option 1 thinking they were selecting Room and Board. RESIDENT 214 According to the SNF Beneficiary Protections Notification Review form completed by facility staff on 10/05/2022, Resident 214's skilled services started on 02/25/2022 and ended on 04/10/2022, after which Resident 214 remained in the facility. Review of ABN in Resident 214's file showed no option had been selected and it was undated and unsigned. During an interview on 10/05/2022 at 11:24 AM, Staff V stated that the ABN was completed. Reference WAC 388-97-0300(1)(e),(5),(6) .

CONCERN (E)

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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 27 Review of Resident 27's admission MDS dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include left-side weakness due to stroke and dementia. The MDS further showed that Resident 27's hearing ability was assessed at minimal hearing and a hearing aid or device was used in the assessment. During an observation on 10/03/2022 at 11:32 AM Resident 27 was asleep with the television on and wearing bilateral hearing aids. During observations on 10/04/2022 at 1:00 PM and 10/05/2022 at 8:58 AM and 10/06/2022 at 10:58 AM Resident 27 was not wearing hearing aids in either ear; however, on 10/05/2022 hearing aids were observed on the bedside table. During an interview on 10/06/2022 at 1:45 PM, Staff C, Certified Nursing Assistant (CNA), stated she had not seen Resident 27 wearing hearing aids for over a week. Staff C further stated she believed Resident 27 ran over the hearing aids with the resident's wheelchair. When asked about observations of Resident 27 wearing hearing aids, Staff C stated the resident was wearing a different resident's hearing aids. During an interview on 10/06/2022 at 1:57 PM, Staff D, Registered Nurse (RN), stated Resident 27's hearing aids had been missing for months. Staff D stated one hearing aid was ran over by Resident 27's wheelchair about 4 months ago and was not sure what happened to the other. Staff D stated Resident 27 was wearing another resident's hearing aids until they realized they weren't Resident 27's. Additionally, Staff D said, I reported the lost hearing aids to the Resident Care Manager and Social Services Director, but I don't know what gets done after that. Review of a progress note dated 06/26/2022 showed that Resident 27 reported both hearing aids fell out in the dining room. Staff assisted Resident 27 in looking for the hearing aids but were unsuccessful. Review of the facility's grievance log, from April 2022 through September 2022, showed no grievance had been logged and/or initiated on behalf of Resident 27. During an interview and joint record review on 10/07/2022 at 11:21 AM, Staff E, Social Services Director (SSD), stated there was no documentation of Resident 27's missing hearing aids on the grievance sheet. Staff E reviewed progress notes in the electronic health record and stated that an investigation had been completed but was not written on a blue card which should have been filled out on behalf of Resident 27. Staff E stated that a blue card stated an investigation process and documented the investigation steps and findings. Staff E further stated that since a blue card was not completed the Administrator did not sign off and there was no resolution. Based on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, investigated, and timely resolved in response to residents' verbalization of concerns during resident council for four of four months reviewed, and for three of three residents (Residents 8, 27 and 56) reviewed for grievances and personal property. The facility's failure to initiate, log, investigate expressed concerns, timely resolve, and notify residents of the findings and actions taken to correct the concern(s), detracted from the facility's ability to identify care trends, and placed residents at risk for unresolved concerns, feeling unheard, frustrated, diminished self-worth and decreased quality of life. Additionally, the facility failed to maintain evidence demonstrating the result of all grievances for a minimum of three years as required. Findings included . According to the facility's Grievance Program (Concern and Comment) policy, revised 06/15/2022, the facility will post in prominent locations through the facility of the right to file grievances orally (meaning spoken), in writing or anonymously. Any associate can assist in the completion of a Concern and Comment form if a resident family member, or guest expresses a concern or comment. Resolve the concern, if possible. If resolution is not possible at that time, explain to the individual that another staff member will be assigned to investigate the concern and will contact them in a timely manner. All concerns are to be reported to the supervisor on duty who will contact the Executive Director, Director of Nursing and/or other personnel as needed. Maintain a recordkeeping system of all complaints reported via the Concern and Comment Program or any other means of reporting that includes date received; summary statement of the resident's grievance; steps taken to investigate the grievance; a summary of pertinent findings or conclusions regarding the concerns; a statement about whether the grievance was confirmed or not; any corrective action taken by the facility; and date the written decision was issued. Follow up with the resident or family to communicate resolution or explanation and ensure the issue was handled to the resident's or family's satisfaction. Maintain evidence demonstrating the result of all grievances for no less than three years from the issuance of the decision. All grievances and Concern & Comment, reports would be reviewed and addressed in a timely and appropriate manner and that concerned individuals would feel that some type of resolution had been communicated, achieved, and maintained. RESIDENT 8 Review of the annual Minimum Data Set (MDS, a required assessment tool) dated 07/25/2022 showed that Resident 8 readmitted to the facility on [DATE] from an acute hospital. During an interview on 10/03/2022 at 9:41 AM, Resident 8 stated that the resident had personal clothing go missing that included pants, shirts, T-shirts and shoes. Resident 8 stated that family and staff were aware; however, nothing had been done about it. Review of the facility's Grievance log dated from 04/05/2022 through 09/07/2022 showed no grievance logged for Resident 8 related to missing personal items. Review of Resident 8's inventory list dated 08/26/2021 included/showed that the resident had two shirts, one pair of slacks, 28 undershirts, 14 underwear, four sweatpants, and six shorts. During an interview on 10/05/2022 at 9:19 AM, after looking in Resident 8's room, Staff S, Certified Nursing Assistant (NAC)/Agency, stated that Resident 8 had three white T-shirts labeled with the resident's name and one long sleeve button up plaid shirt labeled with an X, of which Resident 8 stated that the shirt did not belong to the resident. In continued interview, Staff S then went to the laundry room and spoke to Staff T, Environmental Services Director, to enquire about Resident 8's missing clothing items. Staff T stated that she was aware that Resident 8 had some concerns about clothing not coming back from laundry which was an ongoing issue; however, Resident 8's labeled clothing was returned after laundered. Staff T stated that Resident 8 probably did not have all clothing labeled when admitted and Resident 8 had not wanted to look at the unlabeled clothing rack. Staff T further stated that she did not fill out a Concern and Comment card in the last six months; however, she had filled one out for Resident 8 in the past for missing clothing. During an interview on 10/05/2022 at 10:15 AM Staff E, Social Services Director, stated that there were no grievances logged in 2022 to date regarding missing clothing for Resident 8 and she did not have access to previous logs; however, the Administrator should have them. Additionally, Staff E recalled that Resident 8 had complained of missing clothing and Staff E had spoken to Resident 8's family member who had complained via phone about having to bring in more clothing due to Resident 8 missing clothing items. Staff E stated that they did not fill out a Concern and Comment card related to missing clothing items for Resident 8, and they should have. During an interview on 10/05/2022 at 10:55 AM, Staff A, Administrator, stated that a blue card [Concern and Comment/grievance card] should have been filled out, logged, and investigated for Resident 8's missing clothing items, and that this did not meet expectations. Staff A further stated that he was not aware of where the 2021 Grievance log was located; however, he would provide it when found. During a follow-up interview on 10/06/2022 at 9:35 AM Staff A stated that he was unable to locate the 2021 Grievance log and it should be maintained. RESIDENT COUNCIL May Resident Council 2022 Review of the May Resident Council minutes showed Resident 46 reported that when housekeepers are off sick or on vacation, resident rooms do not get cleaned. Review of the facility's Grievance log showed no grievance was logged for Resident 46's verbalized complaint/concern. During an interview on 10/10/2022 at 09:02 AM, Staff B, Director of Nursing Services (DNS), stated that a grievance should have been generated for Resident 46, but was not. June Resident Council 2022 Review of the June Resident Council minutes showed the Council stated that resident needed to be offered a washcloth every morning to wash their face, needed to get their teeth brushed, bedding needed to be changed more frequently and residents still did not like agency (staff). It was not identified in the minutes who or how many of the resident's present were having problems with the provision of morning care, bedding changes, agency staff, or identify what the concerns with agency staff were. According to the council minutes six facility staff members attended the meeting including Staff B, DNS. Review of the facility's Grievance log showed there was a 07/01/2022 grievance logged for Resident Council for Concerns about morning ADLs [Activities of Daily Living] which was requested but not provided. July Resident Council 2022 The July Resident Council was canceled due to isolation precautions in the facility, no minutes to review. August Resident Council 2022 Review of the August Resident Council minutes showed Resident 56 reported nurses' aides were not changing linen when residents were showered and some residents were told that they were independent, when that should not matter. Under Miscellaneous Concerns or Comments it was documented that the flags in front of the building needed to be changed; Resident 56 asked about getting shower aides to strip residents' beds, housekeeping to wipe the beds down, the nurses' aides to apply fresh linen; and that residents who are unable to get up, should be given provided a washcloth so they can wash their face. This was a repeat request previously requested during the June 2022 Resident Council. The minutes did not identify which resident(s) voiced concerns about the need to change the flags in front of the building, not being provided a wash rag to wash their face; or whether other residents were having difficulty getting their linen changed (as alleged by Resident 56), what the alleged time was between linen changes and whether their linen was soiled/ dirty. According to the council minutes five facility staff members attended the meeting including Staff B, Director of Nursing Services Review of the facility's Grievance log showed no grievances were logged for the concerns voiced by residents in the August 2022 Resident Council. During an interview on 10/10/2022 at 9:06 AM, Staff B stated staff should have initiated grievances on each residents behalf, but failed to do so. September Resident Council 2022 Review of the September Resident Council minutes showed for discussion of new business and care issues an unidentified resident(s) reported concerns about showers, Aides don't have enough time to get people up and can't give showers. Under the heading Miscellaneous concerns and comments Resident 56 asked about evening showers and Staff A, Administrator, indicated it was a possibility, but in the meantime if the resident(s) needed a shower they could have their aide give them one at night. The minutes did not identify who or how many residents voiced concerns about not being assisted up in the morning, had missed showers, how long they had without a shower, or what effect it had on them. According to the council minutes two facility staff members were listed as present at the meeting, as well as Staff A, Administrator, for a portion of the meeting. Review of the facility's Grievance log showed no grievances were logged addressing the care concerns residents voiced during the meeting. During an interview on 10/10/2022 at 09:08, when asked which residents reported not receiving showers, how long allegedly went without being bathed, and what psychosocial effect it had, if any, each resident. Staff B indicated she did not know and acknowledged an individual grievance should have been initiated for each resident who verbalized a concern as each residents' experience may be different (e.g., one may have not been bathed for a month and feel embarrassed or depressed and another may have only missed one of three scheduled showers in a week) as will their response to the alleged events. RESIDENT 56 During an observation and interview on 10/03/2022 at 01:26 PM, Resident 56 was observed without dentures. The resident stated that their dentures had been missing for over a year. Resident 56 said she had informed staff and the housekeeper (could not recall name but indicated she had recently passed) helped look for the dentures over several days but were unable to find them. Resident 56 stated they were informed insurance would pay for new ones but hadn't heard anything since. The resident also stated that they recently spoke with the new Administrator (Staff A) about getting new dentures made. Review of Resident 56's Activities of Daily Living care plan, revised 09/26/2022, showed the resident has dentures/does own oral care/denture management and personal hygiene. This confirmed the resident had dentures. Review of Resident 56's electronic health record (EHR) revealed no documentation or indication Resident 56's dentures were missing. Review of the facility's 2022 Incident log and Grievance log showed no entry related Resident 56's missing dentures. During an interview on 10/06/2022 at 11/25/2022, Staff A, Administrator, confirmed there was a housekeeper that recently passed, and that he had been informed by Resident 56 of their missing dentures and indicated the resident had been placed on the dental list for the next visit. When asked if he initiated a grievance for Resident 56, Staff A, stated, No but acknowledged a grievance form should have been initiated. Reference WAC 388-97-0460 .

CONCERN (E)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 27 Review of Resident 27's admission MDS dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include left-side weakness due to stroke, dysphagia (difficulty swallowing), diabetes and dementia. The MDS further showed that Resident 27 was able to make needs known. Review of an additional discharge assessment MDS dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 27 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 27's medical record on 10/04/2022 showed no documentation that a written notice of transfer/discharge was provided to Resident 27 and/or their responsible party for the transfers to the hospital. RESIDENT 65 Review of Resident 65's admission MDS dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include urinary tract infection, failure to thrive and difficulty walking. Review of an additional discharge assessment MDS dated [DATE] showed that Resident 65 was transferred from the facility to the hospital on [DATE]. Review of Resident 65's medical record on 10/05/2022 showed no documentation that a written notice of transfer/discharge was provided to Resident 65 and/or their responsible party for the transfer to the hospital. During an interview on 10/06/2022 at 2:59 PM, Staff B, Director of Nursing Services (DNS), stated that Resident 65's lack of written notification of transfer did not meet her expectation. Reference WAC 388-97-0120 (2)(a-d), -0140(1)(a)(b)(c)(i-iii) Based on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party of discharges to the hospital for three of five residents (Residents 30, 27, and 65) reviewed for hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility and placed residents at risk for diminished protection from being inappropriately discharged . Findings included . RESIDENT 30 Review of the discharge assessment Minimum Data Set (MDS) dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 30 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 30's medical record on 10/04/2022 showed no documentation that a written notice of transfer/discharge was provided to Resident 30 and/or his responsible party for the transfers to the hospital on [DATE]. During an interview on 10/05/2022 at 11:38 AM, Staff E, Social Service Director (SSD), stated that she did not provide any written notification to the resident or the residents representative of the transfer and/or discharge to the hospital. Staff E further stated that it was the responsibility of the nursing staff to provide the written notification. During an interview on 10/05/2022 at 12:04 PM, Staff M, Infection Control Preventionist stated that the nurses verbally inform the resident or the resident's representative and no written documentation was provided to them. During an interview on 10/05/2022 at 12:21 PM, Staff B, Director of Nursing (DNS), stated that it would be her expectation that a written notification was provided to the resident and/or the resident's representative and ensure that written documentation was completed as per protocol.

CONCERN (E)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 27 Review of Resident 27's admission MDS dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include left-side weakness due to stroke, dysphagia (difficulty swallowing), diabetes and dementia. The MDS further showed that Resident 27 was able to make needs known. Review of an additional discharge assessment MDS dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 27 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 27's medical record on 10/04/2022 showed no documentation that a bed hold was provided to Resident 27 and/or their responsible party for the transfers to the hospital. During an interview on 10/05/2022 at 11:38 AM, Staff V, Business Office Manager (BOM) stated that she did not provide any bed hold to the resident or the resident's representative related to the transfer to the hospital. Staff V further stated that she did not believe bed holds were being done at this time as they do not have a Social Services Assistant. Additionally, Staff V stated in the past the nurse would provide the bed hold to the resident at the time of transfer and the Social Service Assistant would complete the follow-up. During an interview on 10/05/2022 at 12:05 PM, Staff K, Registered Nurse / Unit Care Coordinator (RN/UCC), stated bed holds are handled by either the Director or Nursing, Social Services, or Business Office and the nurse was responsible for contacting the family by phone; however, they did not provide anything in writing to the resident/resident representative. RESIDENT 65 Review of Resident 65's admission MDS dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include urinary tract infection, failure to thrive and difficulty walking. Review of an additional discharge assessment MDS dated [DATE] showed that Resident 65 was transferred from the facility to the hospital on [DATE]. Review of Resident 65's medical record on 10/05/2022 showed no documentation that a bed hold was provided to Resident 65 and/or their responsible party for the transfer to the hospital. During an interview on 10/06/2022 at 2:59 PM, Staff B, Director of Nursing services (DNS), stated I was just informed we have not been doing bed holds [ .] to the resident/representative upon transfers. This does not meet my expectation. The process should and will be that the nurse gives the bed hold packet to the resident upon transfer and notifies the family. Social Services will follow up the next day and also send notice. This information will be entered into the electronic health record. Reference WAC 388-97-0120 (4) Based on record review and interview, the facility failed to provide written bed hold notices at the time of transfer to the hospital for three of five residents (Residents 30, 27, and 65) reviewed for hospitalization. This failure placed residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of a document titled, Bed-Hold Policy, dated 08/16/2022 showed that the bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or if the resident goes on therapeutic leave of absence. In addition, the facility will provide written information of the nursing facility's policy on bed-hold periods and the resident's return to the facility to the resident or resident's representative to ensure that residents were made aware of the facility's bed-hold and reserve bed payment policy before and upon transfer to hospital or when taking a therapeutic leave of absence from the facility. RESIDENT 30 Review of Resident 30s admission Minimum Data Set assessment (MDS) dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include heart and kidney disease, and dementia. The MDS further showed that Resident 30 was able to make needs known. Review of an additional discharge assessment MDS dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 30 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 30's medical record on 10/04/2022 showed no documentation that a bed hold was provided to Resident 30 and/or their responsible party for the transfers to the hospital with an impending readmission on [DATE]. During an interview on 10/05/2022 at 11:38 AM, Staff V, Business Office Manager (BOM), stated that she did not provide any bed hold to the resident or the resident's representative related to the transfer to the hospital. Staff V further stated that we always hold the bed for the residents but have not been providing a bed hold to the resident or their representative.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 17 Review of Resident 17's paper chart and EHR on 10/06/2022 showed no care conference. During an interview on 10/06/2022 10:40 AM, Staff E, SSD, stated that care conferences were held within seven days of admission and quarterly thereafter, based upon the schedule of MDS. Staff E confirmed that there was no documentation of care conferences in the resident's chart, and stated they were either not done or not documented. Staff E further added this did not meet the expectation for care conference scheduling or documentation. Reference WAC 388-97-1020 (2)(c)(d)(f), 4(b), 5(b) RESIDENT 19 Resident 19 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (partial paralysis on one side of the body) and muscle weakness. Review of the MDS, dated [DATE], showed the resident was cognitively intact. An observation on 10/03/2022 at 11:45 AM showed Resident 19 with a brace on their right and left lower legs. Resident 19 stated that they wore the braces to hold their feet steady when they stood. Review of Resident 19's Physical Therapy Progress Note dated 09/15/2022, showed Resident 19 had bilateral (both sides of the body) ankle-foot orthosis (lower leg braces, AFOs). Review of Resident 19's Care Plan, dated 08/08/2022, showed no documentation of right and left lower leg braces. On 10/05/2022 at 10:14 AM, Staff Q, Certified Nursing Assistant, stated that Resident 19 had bilateral AFOs that supported Resident 19 when they stood. On 10/05/2022 at 11:27 AM, Staff B, DNS, stated that she would expect the Care Plan to include the AFOs. Staff B reviewed Resident 19's Care Plan dated 08/08/2022 and said there were no AFOs documented in the Care Plan and the Care Plan did not reflect Resident 19's current care needs. RESIDENT 63 During an interview on 10/03/2022 at 9:44 AM, Resident 63 stated they were unaware of their medication regimen, the reasons for taking the medications, and had not had a care conference to discuss these issues. Review of Resident 63's EHR showed no documentation of a care conference occurring. During an interview on 10/05/2022 at 10:40 AM, Staff E, Social Services Director (SSD), stated that care conferences were offered to residents on admission and then quarterly. Staff E also stated that residents were the driving force at care conferences and should be invited to care conferences. Staff E further stated that Resident 63 had not been offered a care conference. During an interview on 10/05/2022 at 11:57 AM, Staff B, DNS, stated that her expectation was for residents to be offered care conferences. Staff B also stated that Resident 63's lack of care conference did not meet her expectation. RESIDENT 8 During an interview on 10/03/2022 at 9:45 AM, Resident 8 stated that the resident did not remember going to a care conference. Review of the annual MDS dated [DATE] showed that Resident 8 originally admitted to the facility on [DATE]. Review of the progress note dated 04/24/2022 showed that Resident 8 and a family member had attended a care conference as well as Social Services and the Administrator on 04/24/2022. Review of Resident 8's progress note dated 03/23/2022 showed that a care conference was held with a family member to discuss resident care; however, it did not show that Resident 8 or any other staff members attended. During an interview on 10/05/2022 at 9:54 AM Staff E, Social Services Director, stated that Resident 8 had one care conference held on 03/22/2022; however, it did not show that Resident 8 had attended, and another care conference on 05/24/2022 that showed that Resident 8, a family member, and other staff members attended. Staff E stated that this did not meet expectations and that there should have been a formal care conference held when Resident 8 first admitted to the facility and every quarter thereafter. During an interview on 10/05/2022 at 2:13 PM, Staff B, Director of Nursing Services (DNS), stated that care conferences were to be held upon admission and then quarterly. Staff B stated that there should be documentation to show attempts to schedule a care conference and documented refusals. Additionally, Staff B stated that Resident 8's documented care conferences did not meet expectations. RESIDENT 266 During an interview on 10/03/2022 Resident 266 stated that the resident did not recall going to a care conference. Review of the admission MDS dated [DATE] showed that Resident 266 admitted to the facility on [DATE]. Review of Resident 266's electronic health Record (EHR) on 10/04/2022 showed no documentation that a care conference had occurred or if Resident 266 or responsible party were invited to participate in a care conference. During an interview on 10/05/2022 at 3:43 PM Staff X, Social Services Assistant (SSA), stated that residents and responsible party/family were invited to care conferences in person and/or by phone and would be documented in a progress note. Staff X stated that an initial care conference would be held within five days of admission. Staff X stated that Resident 266 did not have documentation to show that Resident 266 or family had been invited to a care conference. During an interview on 10/06/2022 at 8:38 AM after looking at Resident 266's EHR, Staff B, DNS, stated that Resident 266 did not have documentation to show that a care conference was held. Staff B stated that this did not meet expectations and that initial care conferences should take place seven to ten days from admission. Staff E stated that there should have been documentation to show why the delay in scheduling and/or conducting the care conference at a later date for Resident 266. Based on observation, interview and record review the facility failed ensure care plans were reviewed, revised, implemented and accurately reflected resident care needs and to ensure care planning meetings with the resident or responsible party were conducted timely for 10 of 21 sampled residents (Residents 24, 39, 56, 8, 266, 63, 9, 15, 7 and 17 ) who were reviewed for participation in care planning and whose care plans (CP) were reviewed. These failures placed residents at risk not having input in the development of their plan of care, unmet needs, and a diminished quality of life. Findings included . RESIDENT 24 Review of Resident 24's 06/14/2022 Resident has hearing aids care plan, the residents hearing aids would be stored in the nurse's cart when not in use. Review of Resident 24's Activities of Daily Living (ADLs) care plan, revised 03/14/2022, staff were directed to Put the resident's hearing aids in, in the morning, and to remove at bedtime and give them to floor nurse, to be kept in the nurse's cart overnight. Observations on 10/03/2022 at 2:34 PM, 10/05/2022 at 9:13 AM and 11:47 AM, and 10/07/2022 at 2:03 PM, showed Resident 24 did not have their hearing aids in place. During an observation interview on 10/10/2022 at 09:50 AM, Staff B, Director of Nursing Services, validated Resident 24's hearing aides were not in place and stated that staff should have been assisting the resident to apply them. Additionally, on 10/13/2022 at 4:41 PM, an email was received from Staff B which stated that Resident 24's hearing aides were not found in the nurse's cart. Review of Resident 24's ADL care plan, revised 03/14/2022, showed the resident has supra-pubic catheter prefers a LEG BAG . Additionally, a 07/10/2018 Suprapubic catheter care plan showed Resident prefers a leg bag. Observations on 10/03/2022 at 2:34 PM, 10/05/2022 at 9:13 AM and 11:47 AM, and 10/07/2022 at 2:03 PM, showed Resident 24's catheter was draining to a standard drainage bag. During an observation interview on 10/10/2022 at 09:50 AM, Staff B confirmed Resident 24 did not have a leg bag as care planned. Review of Resident 24's ADL care plan, revised 03/14/2022, showed direction to staff that the resident Wears TED hose [compression stockings] placed on in the morning and off at HS [bedtime]. Observations on 10/03/2022 at 2:34 PM, 10/05/2022 at 9:13 AM and 11:47 AM, and 10/07/2022 at 2:03 PM, showed Resident 24 was not wearing TED hose. During an observation interview on 10/10/2022 at 09:50 AM, Staff B confirmed Resident 24 did not have a leg bag as care planned. Review of Resident 24's diuretic therapy care plan, revised 03/14/2022, the resident received Lasix (a diuretic medication) to treat edema. Review of Resident 24's physicians' orders (POs) showed the resident did not receive Lasix. Resident 24's Lasix order was discontinued on 06/19/2018. During an interview on 10/10/2022 at 09:40 AM, Staff B stated that the care plan was inaccurate and needed to be revised. RESIDENT 39 Review of Resident 39's POs showed the resident received antianxiety and antipsychotic medications. Review of Resident 39 comprehensive care plan showed the resident's use of antianxiety and antipsychotic medications was not care planned. During an interview on 10/10/2022 at 10:02 AM, Staff B stated that the residents of antianxiety and antipsychotic medications should have been care planned as well as the target behaviors each medication was intended to treat. RESIDENT 56 Review of Resident 56's ADL care plan, revised 09/26/2022, showed the following: 1) Resident 56 needed Therapy Services needed to attain highest level of function. Review of Resident 56's electronic health record (EHR) showed the resident was not receiving therapy services. During an interview on 10/10/2022 at 9:00 AM, Staff B indicated the care plan needed to be revised. 2) Resident 56 had a yellow flag to w/c to alert staff that resident may go outside of facility in the front or on premises unsupervised. Observation on 10/06/2022 at 10:03 AM, showed Resident 56 did not have a yellow flag on the wheelchair. During an interview on 10/10/2022 at 9:00 AM, Staff B indicated the flag was likely on the resident's electric wheelchair, which needed to be fixed and that the flag should be moved to the current wheelchair, or the CP revised. 3) Resident 56 has dentures/does own oral care/denture management and personal hygiene. During an observation and interview on 10/03/2022 at 01:26 PM, Resident 56 was observed without dentures and the resident reported they had been missing for over a year. In an interview on 10/06/2022 at 11/25/2022, Staff A, Administrator, stated that Resident 56 had reported their missing dentures. During an interview on 10/10/2022 at 9:00 AM, Staff B indicated that the care plan needed to be revised to reflect the resident's missing dentures.

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents that were unable to carry out activities of daily living (ADL) received the ADL services for 8 of 12 residents (Residents 7, 15, 16, 48, 57, 61, 24 and 27) reviewed for activities of daily living. This failure placed the residents at risk for unmet care needs, skin breakdown and a diminished quality of life. Findings included . RESIDENT 7 Resident 7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated 07/14/2022, showed the resident was cognitively intact and required extensive assist with bed mobility, toileting, transfers, personal hygiene, and dressing. Review of Resident 7's [NAME] (care instructions for the nursing assistants) dated 09/30/2022, showed the resident was incontinent of bowel and bladder, required staff to clean and dry skin after each incontinence episode and offer turning and repositioning every 2 hours. On 10/05/2022 at 2:02 PM, Resident 7 stated that they had not received care on 10/05/2022 until approximately 11:00 AM. Resident 7 stated that they like to get up no later than 10 AM and did not like being in a wet bed. An observation on 10/06/2022 at 9:09 AM showed Resident 7 on their back in bed. At 10:29 AM Resident 7 was observed on their back in bed and stated that they had not received care that morning. Resident 7 was asked if their brief was wet. Resident 7 stated, I don't know if I am wet, I cannot feel it. On 10/06/2022 at 10:59 AM, during an observation of care with Resident 7, Staff W, Certified Nursing Assistant (CNA), stated that she had provided Resident 7 with a breakfast tray, but this was the first time she had provided care to Resident 7 since her shift started at 6:00 AM. Resident 7 was observed with a soiled brief soaked with urine. On 10/06/2022 at 12:45 PM, Staff W stated that she was aware of the [NAME] for Resident 7 but was unable to complete the care due to workload. On 10/06/2022 at 4:52 PM, Staff B, Director of Nursing Services (DNS), reviewed Resident 7's [NAME] and stated Resident 7 should have been turned every 2 hours and provided care after each incontinent episode. RESIDENT 15 Resident 15 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 15 was cognitively impaired and required extensive assistance with bed mobility, toileting, and personal hygiene. Review of Resident 15's [NAME] dated 08/05/2022, showed Resident 15 was always incontinent of bladder and bowel, required staff to clean and dry skin after each incontinent episode, check and change, apply skin protective cream after each incontinence, and turn and re-position every 2 hours. Review of Resident 15's Wound Observation Tool, dated 09/22/2022, showed that Resident 15 had recurring Moisture Associated Skin Damage (MASD, skin breakdown caused by prolonged exposure to moisture) to the right and left side of their buttocks. An observation on 10/06/2022 at 8:34 AM, showed Resident 15 on their back in bed. At 9:21 AM, Resident 15 was observed attempting to sit up in bed yelling out help. At 9:26 AM Resident 15 was observed on their back, trying to adjust themself in bed, calling out incoherently. Resident 15's room had a strong smell of urine. At 9:34 AM Resident 15 was observed on their back in bed, yelling help. During an observation on 10/06/2022 at 9:56 AM, Staff W, CNA, was observed providing incontinent care to Resident 15. The resident was rolled onto the left side, Resident 15's buttocks were red with open areas on the right and left side of their buttocks. Resident 15's briefs were soaked with urine and soiled. The draw sheet and fitted sheet were wet with a brown ring extending the entire length of the draw sheet. Staff W, CNA, stated that she was assigned to care for Resident 15, and this was the first time she provided care to Resident 15 since her shift started at 6:00 AM. On 10/06/2022 at 12:45 PM, Staff W, CNA, stated that she was aware of the [NAME] for Resident 15 but was unable to complete the care due to workload. On 10/06/2022 at 4:52 PM, Staff B, Director of Nursing Services (DNS), reviewed Resident 15's [NAME] and stated Resident 15 should have been turned every 2 hours and provided care after each incontinent episode. Staff B stated that the care Resident 15 received did not meet her expectation. RESIDENT 16 Resident 16 was admitted to the facility on [DATE]. Review of the MDS assessment, dated 07/25/2022, showed that Resident 16 was cognitively impaired and required extensive assistance for bed mobility, toileting, dressing and personal hygiene. Review of Resident 16's [NAME] dated 09/16/2022, showed Resident 16 was incontinent of bladder and bowel, on a check and change program, offer toileting before meals, and turn every 2 hours. Review of Resident 16's Weekly Skin Integrity assessment dated [DATE], showed Resident 16 had MASD to buttocks. An observation on 10/06/2022 at 8:34 AM, showed Resident 16 in bed on their back. At 9:21 AM and 9:34 AM Resident 16 was observed on their back in bed, eyes closed, head of the bed at 90 degrees, a breakfast tray on the overbed table in front of them and bacon lying on their chest. At 10:20 AM and 10:42 AM resident 16 was observed on their back in bed. During an observation on 10/06/2022 at 10:46 AM, Staff W, CNA and Staff Z, CNA, were observed providing incontinent care to Resident 16. The resident was rolled onto the left side, Resident 16's buttocks were red. Resident 16's briefs were soaked with urine and the urine had soaked through the draw sheet. Staff Z stated that she was assigned to care for Resident 16, and this was the first time she had provided incontinent care and/or turning to Resident 16 since her shift started at 6:00 AM. Staff Z stated that she did provide Resident 16 with a breakfast tray. On 10/06/2022 at 1:14 PM, Staff Z, stated that she is knowledgeable about the [NAME] for Resident 16, but is unable to complete the care timely due to her workload. Staff Z stated, no matter what I do I cannot get to them. On 10/06/2022 at 4:52 PM, Staff B, Director of Nursing Services (DNS), reviewed Resident 16's [NAME] and stated Resident 16 should have been turned every 2 hours and offered toileting. RESIDENT 61 Resident 61 was admitted to the facility on [DATE]. Review of the MDS assessment, dated 09/13/2022, showed Resident 61 was cognitively intact and required extensive assistance with bed mobility, dressing, personal hygiene, and toileting. Review of Resident 61's [NAME], dated 09/23/2022 showed Resident 61 required turning and re-positioning every 2 hours and check and change every 2 hours. Review of Resident 61's Wound Observation Tool, dated 10/03/2022, showed Resident 61 had a stage 4 pressure ulcer (wound caused by prolonged pressure) on their sacrum (area at base of spine) and required turning every 2 hours to prevent further skin breakdown. Review of Resident 61's Wound Observation Tool, dated 10/05/2022, showed Resident 61 had MASD on their buttocks and required turning every 2 hours to prevent further skin breakdown. On 10/06/2022 at 8:32 AM, Staff W, CNA, stated that she was assigned to care for Resident 61 and her shift started at 6:00 AM. Observations on 10/06/2022 at 8:34 AM, 9:20 AM, 9:34 AM, 10:20 AM and 11:07 AM showed Resident 61 on her back in bed with the head of the bed up at 90 degrees. On 10/06/2022 at 11:20 AM, Staff W, entered Resident 61's room and stated that this was the first time she had provided care to Resident 61 since her shift started at 6:00 AM. On 10/06/2022 at 12:45 PM, Staff W stated that she was aware of the [NAME] for Resident 61 but was unable to complete the care due to workload. On 10/06/2022 at 4:52 PM, Staff B, Director of Nursing Services (DNS), reviewed Resident 61's [NAME] and stated Resident 61 should have been turned every 2 hours. Staff B stated that Resident 61 had wounds and the lack of turning and repositioning would not help in the healing of the wounds. RESIDENT 48 Resident 48 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment, dated 09/01/2022, showed the resident was cognitively impaired and required extensive assistance with bed mobility, transfers, personal hygiene, dressing and toileting. Review of Resident 48's [NAME] dated 09/14/2022, showed that Resident 48 was to have toileting offered every 2 to 3 hours and was to be turned and repositioned every 2 hours. Review of Resident 48's Weekly Skin Integrity assessment, dated 10/02/2022, showed that Resident 48 had MASD to buttocks. Observations on 10/06/2022 at 8:33 AM, 9:49 AM, 10:20 AM, 10:42 AM, 11:08 AM, 11:31 AM and 12:12 PM, showed Resident 48 on her back in bed with the head of the bed up at 90 degrees. An observation on 10/06/2022 at 12:12 PM, showed Staff W, CNA, in Resident 48's room with linen supplies. Staff W stated that this was the first time she had provided care to Resident 48 since her shift started at 6:00 AM. Staff W stated that she had provided a breakfast tray to Resident 48 but had provided no care. Observation on 10/07/2022 from 10:24 AM to 11:41 AM showed Resident 48 stayed in the same position and that no staff entered the room to reposition or toilet the resident. Observation on 10/07/2022 at 12:43 PM showed that staff adjusted Resident 48's bed into an upright position for lunch. Observation on 10/07/2022 at 2:00 PM showed Resident 48 sitting upright in bed with no staff repositioning or toileting. On 10/06/2022 at 12:45 PM, Staff W stated that she was aware of the [NAME] for Resident 15 but was unable to complete the care due to workload. On 10/06/2022 at 4:52 PM, Staff B, Director of Nursing Services (DNS), reviewed Resident 48's [NAME] and stated Resident 48 should have been turned every 2 hours and offered toileting every 2-3 hours. Staff B stated that Resident 48 did not receive the care per their [NAME] and did not meet Staff B's expectation of care. During an interview on 10/07/2022 at 12:45, Staff Y, CNA stated the orders are to turn, reposition, and toilet the resident every two hours. Two staff members work as a team for the entire hallway and start their shift at 6:00 AM. On 10/07/2022, the first time Staff Y saw Resident 48 was at 11:15 AM to toilet and reposition. When asked if they were able to assist Resident 48 every two hours with toileting and repositioning, Staff Y replied it was dependent on the acuity of the rest of floor. They further stated it was not unusual to not be able to keep to the two-hour turn/toilet schedule. RESIDENT 57 Review of the quarterly MDS dated [DATE], showed that Resident 57 admitted on [DATE] with multiple diagnoses to include heart disease, arthritis, dementia (a disease that destroys memory and other important mental functions) and depression. Resident 57 had impaired memory and required extensive assistance (unable to do the task independently) for personal hygiene and bathing. During an interview on 10/04/2022 at 10:38 AM Resident 57 stated that they had only been receiving one shower per week although they were told by staff they would be able to receive a shower twice a week. Review of Resident 57's care plan showed that Resident 57 was scheduled to receive a shower every Tuesday and Friday. Review of the bathing flowsheets dated, 09/10/2022 through 10/10/2022, showed that Resident 57 had received six showers out of 10 potential opportunities for scheduled showers. No documentation of resident refusal was reflected in progress note or on flowsheet. During an interview on 10/05/2022 at 9:13 AM, Staff C, Certified Nursing Assistant (CNA), stated Resident 57 liked to shower twice per week; however, Resident 57 had not been receiving showers as scheduled due to refusing and then wanting a shower later in the week. During an interview on 10/10/2022 at 11:42 AM, Staff B, Director of Nursing Services (DNS), stated that Resident 57 had not received showers according to the bathing schedule. In addition, Staff B, DNS, further stated that her expectation was that all residents received showers according to their care planned preferences or document the residents' refusal. RESIDENT 27 Review of Resident 27's admission MDS dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include left-side weakness due to stroke, dysphagia (difficulty swallowing), diabetes and dementia. The MDS further showed that Resident 27 required extensive assistance for personal hygiene and bathing. Observation on 10/03/2022 at 1:53 PM showed Resident 27 lying in bed with food particles in their hair. Review of Resident 27's care plan showed that Resident 27 was scheduled to receive a shower every Wednesday. Review of the bathing task in the electronic health record showed between 09/10/2022 through 10/10/2022 that Resident 27 received showers on 09/28/2022, 10/05/2022 and 10/08/2022. During an interview on 10/10/2022 at 11:31 AM, Staff K, Registered Nurse / Unit Care Coordinator (RN/UCC) stated Resident 27 was scheduled to have a shower weekly however had only received three showers in the last 30 days. Staff K further stated this did not meet her expectation. If the resident was refusing the aide should tell nurse and the nurse should encourage the resident and document in progress notes. During an interview on 10/10/2022 at 11:42 AM, Staff B, Director of Nursing Services (DNS), stated Any resident not getting services that they are care planned for does not meet my expectations. I expect that the staff is following the care plan or documenting why they are unable to. Reference WAC 388-97--1060 (2)(c) RESIDENT 24 During an interview 10/03/2022 at 02:38 PM, Resident 24 indicated they were not being bathed frequently enough, indicating staff were only providing one shower a week and they wanted at least two showers a week. Review of Resident 24's 08/04/2022 Quarterly MDS showed the resident required extensive assistance with activities of daily living (ADLs) and was not bathed during the seven-day assessment period. Review of Resident 24's 07/10/2018 ADL care plan, showed the resident Prefers showers in AM scheduled Tuesday and Friday day shift. Review of Resident 24's bathing record for the 30 period of 09/05/2022- 10/05/2022, showed the resident was offered/provided bathing on 09/15/2022 - provided; 09/30/2022 - refused; and 10/04/2022 - provided. This showed Resident 24, who was dependent on staff for the provision of bathing, was only offered bathing on three occasions during a 30-day period. During an interview on 10/05/2022 at 12:42 PM, Staff K, Unit Care Coordinator, acknowledged the facility was not offering/providing Resident 24 bathing at their desired frequency or in accordance with the resident's plan of care. .

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure three of 21 sampled residents (Residents 5, 24, 39) reviewed, received care and services in accordance with professional standards of practice and residents' person-centered care plans. The failure to provide ongoing assessment and monitoring of identified non-pressure skin conditions (Residents 24, 5) and bowel care (Resident 39), placed residents at a risk for unidentified decline in skin conditions, delayed treatment, abdominal discomfort, unmet care needs and a diminished quality of life. Findings included . NON-PRESSURE SKIN RESIDENT 24 According to Resident 24's 09/23/2022 2:34 PM progress note, their right lower extremity (RLE) was assessed with 2 + weeping edema (swelling can become so severe that fluid will leak out directly from the skin) and open sores. The resident's provider was notified gave an order for Keflex (an antibiotic) and new treatment orders. Review of Resident 24's Physician's orders (POs) showed the following 09/23/2022 orders: Keflex (an antibiotic) three times a day for right lower extremity (RLE) cellulitis (skin infection) ties 10 days and clean wounds to RLE with normal saline and cover with a gauze dressing daily. According to Resident 24's October 2022 Treatment Administration Record (TAR), the resident's RLE continued to be dressed daily. Review of Resident 24's Weekly Skin Integrity Data Collection (WSIDC) showed a 09/23/2022 assessment that identified the resident had open area/wound and no further information was provided. The assessment did not identify the type, number or location of the wounds or any wound characteristics. Review of the 9/30/2022 WSIDC showed staff documented Resident 24 had a Rash and open area/wound but failed to identify the number, type, size, or location of the wounds/rash, or provide a description of their characteristics. Review of Resident 24 electronic health record (EHR) showed no documentation or indication how many RLE wounds Resident 24 had, their locations and sizes, amount of drainage, wound bed and peri-wound characteristics or response to treatment. During an interview on 10/10/2022 at 9:20 AM, Staff B, Director of Nursing Services, stated that it was the expectation that non-pressure skin issues be assessed by nursing weekly to include the type of wound, number, location, and size as well as characteristics of the wound like tissue type, character and amount of drainage, presence, or absence of signs/ symptoms of infection and response to treatment. During an interview on 10/10/2022 at 9:24 AM, when asked if there were any initial or weekly assessments for Resident 24's RLE wounds Staff B, stated, No. RESIDENT 5 According to Resident 5's 08/26/2022 2:05 PM progress note the resident was assessed by the nurse practitioner who wrote new treatment orders for Resident 5's scabbed abrasion to lower leg measuring 2.5 cm x 0.3 cm and open abrasion to top of right foot measuring 4 cm x 0.7 cm with no drainage. Review of Resident 5's POs showed a 08/26/2022 order to cleanse abrasions to the front of RLE and the top of the right foot with soap and water or normal saline, apply bacitracin (antibiotic ointment) and cover with dressing /bandage daily. Review of Resident 5's August, September and October 2022 TAR(s) showed Resident 5 still required and received daily dressing changes for abrasions/ wounds to the RLE. Review of Resident 5's WSIDC assessments showed on 08/29/2022 the resident was assessed with abrasions to the right lower extremity. The WSIDC did not include a description of the wounds, the presence or absence of drainage, peri-wound, or how the wounds were responding to the current treatment. Review of the subsequent WISDCs on 09/05/2022, 9/12/2022, 9/19/2022, 9/26/2022 (resident refused), 10/03/2022 (resident refused) and 10/10/2022 (Resident refused), showed no further mention or assessment of the abrasions to Resident 5's RLE. Review of Resident 5's EHR on 10/10/2022 showed no documentation or indication the facility had assessed the size, characteristics, or the response to treatment of the resident's wounds since 08/26/2022, a period of 45 days. During an interview on 10/10/2022 at 09:24 AM, when asked if there was any documentation to show the facility was performing weekly wound assessment on Resident 5 Staff B stated, No. BOWEL MANAGEMENT RESIDENT 39 Review of Resident 39's POs showed the resident had the following 08/18/2022 bowel care orders: Miralax (a laxative) as needed, if no bowel movement (BM) times three days; and Bisacodyl Suppository insert one rectally, as needed, for constipation if no results from Miralax. According to Resident 39's bowel monitor, the resident had no BM from 09/15/2022- 09/18/2022, four consecutive days. Review of Resident 39's September 2022 MAR showed facility nurses failed to administer the resident's Miralax 9/19/2022, the fifth day of no BM, During an interview on 10/05/2022 at 12:48 PM, when asked if facility nurses provided Resident 39 bowel care on the 3rd day of no BM as ordered Staff K, Unit Care Coordinator, stated, No. Reference WAC 388-97-1060(1) .

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure treatment and services were provided to increase, maintain and/or prevent decline in ROM and mobility for 2 of 4 residents (Residents 30 and 35) and 3 supplemental residents (Residents 20, 60 and 51) reviewed for limited Range of Motion (ROM) and restorative nursing services. The facility's failure to have a process in place that ensured timely processing, assessment, and implementation of restorative nursing programs, placed residents at risk for not maintaining gains made while on skilled therapy, functional decline, increased dependence on staff, contracture formation, pain, unmet care needs and diminished quality of life. Findings included . During an interview on 10/07/2022 at 1:48 PM, Staff FF, Restorative Aide (RA), explained that she was the only RA for the building currently and worked Monday through Friday 6:00 AM to 2:00 PM for 7.5 hours per day (minus a 30-minute lunch). Additionally, Staff FF reported she had dining room duty daily for the breakfast meal from 6:45 AM to 7:45 AM, leaving her 6.5 hours to complete all the residents scheduled Restorative Nursing Programs (RNPs). Staff FF indicated she was usually able to complete the programs because each day a few residents would refuse. RESIDENT 20 Review of the Restorative Referral Forms showed the therapy department referred Resident 20 for a RNP on 08/24/2022, but 47 days after the referral the RNP had not yet been processed or implemented. RESIDENT 60 Review of the Restorative Referral Forms showed the therapy department referred Resident 60 for a RNP on 08/31/2022, but 40 days after the referral the RNP had not yet been processed or implemented. RESIDENT 51 Review of the Restorative Referral Forms showed the therapy department referred Resident 51 for a RNP on 09/06/2022, but 34 days after the referral the RNP had not yet been processed or implemented. RESIDENT 35 Review of the Restorative Referral Forms showed the therapy department referred Resident 35 for a RNP on 09/27/2022, but 13 days after the referral the RNP had not yet been processed or implemented. RESIDENT 30 Review of the Restorative Referral Forms showed the therapy department referred Resident 30 for a RNP on an unknown date (date was left blank), but the program had not yet been processed or implemented. A copy of Resident 30's Physical Therapy discharge summary was requested, but not provided. During an interview on 10/07/2022 at 2:48 PM, Staff B stated that a reasonable timetable to review, process and implement therapy referrals for RNPs was A week. During an interview on 10/10/2022 at 9:15 AM, Staff B reviewed the above referenced referrals and indicated she was not aware of them but stated that the programs should have already been implemented but were not. Reference WAC 388-97-1060 (3)(d) .

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 31 Review of the quarterly MDS dated [DATE] showed that Resident 31 readmitted on [DATE] with diagnoses to include kidney cancer, chronic kidney disease and diabetes. The MDS further showed that Resident 31 was able to make needs known. Multiple observations on 10/05/2022 at 11:51 AM, 10/06/2022 at 10:06 AM, and on 10/07/2022 at 10:49 AM showed Resident 31 lying in bed with a water pitcher within reach on the overbed table. Review of the physician order dated 05/24/2022 showed that Resident 31 was prescribed a fluid restriction of 1500 ml per 24 hours. Review of the care plan dated 08/19/2022 showed no guidance documented to show how much fluids were to be provided by the nursing or the dietary departments and/or if the resident was able to be provided a water pitcher at the bedside. Review of Resident 31's MAR from 09/01/2021 through 10/03/2022 did not show totals of all fluids provided in a 24-hour period to be able to ensure that Resident 31's physician ordered fluid restriction had been followed as ordered. During an interview on 10/06/2022 at 9:23 AM, Staff Z, Nursing Assistant Certified (NAC), stated that she had taken care of Resident 31 before and did not think Resident 31 was on fluid restrictions. During an interview on 10/06/2022 at 9:28 AM Staff W, Nursing Assistant Certified (NAC), stated that there were no residents on the 300 hall on a fluid restrictions. During an interview on 10/06/2022 at 10:06 AM, Staff CC, Registered Nurse / Unit Care Coordinator (RN/UCC), stated that the care plan did show that Resident 31 was on fluid restrictions; however, there was no place on the MAR to document for a 24-hour period. Staff CC, stated that We should be documenting the total fluid intake in a 24-hour period from all sources and the amount of fluid intake consumed during meals. During an interview on 10/06/2022 at 2:59 PM, after looking at Resident 31's EHR, Staff B, DNS, stated that the MARs did not show totals of fluid that were provided, to include all of nursing, dietary, and fluid independently consumed in a 24-hour period. Additionally, Staff B, stated that Resident 31's fluid restriction monitoring and documentation did not meet her expectations. Based on observation, interview, and record review the facility failed to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders for two of two residents (Residents 266 and 31) reviewed for fluid restrictions. Additionally, the facility failed to obtain weekly weights per physician orders and to address/follow up on the Registered Dietician (RD) recommentations for one of nine residents (Resident 39) reviewed for nutrition. These failures placed the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of the facility's document titled, Fluid Restriction, undated, showed, When calculating fluid restrictions, the order should include the total amount per day and then be given during medication pass, and how much fluids will be given at each meal. It further showed, Nursing will keep a record of all liquids consumed each shift to include liquids that are consumed during meals. Additionally, it showed that liquids that needed to be included in fluid monitoring included any liquids given during medication pass, any liquid supplementation, and any liquids given at the bedside. RESIDENT 266 Observation and interview on 10/04/2022 at 8:45 AM, showed that Resident 266 had a breakfast tray on the overbed table with plate of food covered and a carton of milk of 236 milliliters (ml, a measurement of volume) and an eight-ounce cup of juice of 236 ml, for a total of 472 ml. There was also a covered water pitcher with a straw stuck in it on the overbed table. Resident 266 stated that the resident was aware of being on fluid restrictions; however, the resident was not sure of the amount they were able to drink. Review of the admission Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 266 admitted on [DATE] with diagnoses to include heart failure, respiratory failure, diabetes, and was able to make needs known. Review of Resident 266's physician order dated 09/20/2022 showed that Resident 266 was prescribed fluid restrictions and was to receive 2000 ml a day. Dietary was to provide 1000 ml in a 24-hour period and Nursing was to provide; Day shift = 400 ml; Evening shift = 400 ml; and Night shift = 200 ml. for congestive heart failure and the fluid consumed was to be documented. Observation on 10/05/2022 at 2:07 PM showed Resident 266 working with a physical therapist and there was a covered water pitcher with a straw stuck in it on the overbed table. During an interview on 10/05/2022 at 4:04 PM Staff AA, Certified Nursing Assistant, stated that residents on fluid restrictions should not be provided a water pitcher and that they [nursing assistants] had the ability to document meal intake and vital signs but not the resident's fluid intake in the computer system. Staff AA stated that she would write down on her personal notes/paper and verbally tell the nurse the amount a resident would drink if a resident was on fluid restrictions. In continued interview, Staff AA stated that Resident 266 was to receive 400 ml on her shift; however, she did not know how much the resident had during the day shift and would have to ask the nurse to find out. During an interview on 10/05/2022 at 4:26 PM, Staff R, Licensed Practical Nurse/Unit Care Coordinator, stated that a resident on fluid restriction should not have a water pitcher and that nursing assistants did not document fluid consumption; however, they needed to report to the nurse to know how much fluid to be given and how much fluid they provided. Staff R stated that fluid documentation was in the residents Medication Administration Record (MAR) and that totals of fluid consumed in a 24-hour period should be documented. After looking at Resident 266's electronic heath record (EHR), Staff R stated that Resident 266's MARs [September and October 2022] did not include totals of fluids consumed in a 24-hour period and only showed what fluid was provided by nursing and not for dietary fluids provided during meals. During an interview on 10/05/2022 at 4:51 PM after looking at Resident 266's EHR, Staff A, Director of Nursing Services, stated that the resident's MARs [September and October 2022] did not include totals of fluids consumed in a 24-hour period and it should have. Staff A stated that generally residents on fluid restrictions were not provided a water pitcher. Additionally, Staff A stated that the nursing assistants should have been documenting fluid consumption during meals; however, Staff A was unable to locate Resident 266's fluid intake documented during meals, and this did not meet expectations. RESIDENT 39 Resident 39 admitted to the facility on [DATE]. According to the 08/24/2022 significant change MDS, the resident experienced a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a prescribed weight loss regimen. Review of 8/12/2022 9:31 AM Nutrition/Dietary Note showed the resident was seen by the Registered Dietician (RD) for decreased oral intake status post COVID- 19 infection. Most recent weight was on 07/23/2022- 168.2 pounds (lbs.). Resident 39 acknowledged not feeling very hungry, not much appealed to him with an estimated intake of 27% of meals (weeks prior looking back 41%, 37%, 60%). Recommendations were made to increase frequency of weights from monthly to weekly, notify the Physician of the markedly decreased intake, and to restart health shakes 118 ml twice daily, and document amount accepted on the Medication administration Record (MAR). Review of Resident 39's August 2022 MAR showed the resident was started on health shakes twice daily on 8/15/2022 accepting approximately 50%. Review of Resident 39's weight flowsheet showed the resident weighed the following: 07/23/2022-168.2 lbs.; 08/22/2022-153 lbs. (a significant weight loss of -9.04% in one month.) Review of Resident 39's 08/23/2022 Rd note showed it was assessed the resident had inadequate intake related to decreased appetite from acute illness as evidenced by intake is less than needs. The plan was to monitor the effectiveness of the health shakes previously implemented, notify the Physician of the decreased appetite, and consider starting an appetite stimulant. On 8/29/2022 Resident 39's significant weight loss was validated, when the resident was weighed at 151.2 lbs., now showing a weight loss of 10.11% from the weight of 168.2 lbs. on 7/23/2022. to 151.2 lbs. Review of Resident 39's 8/30/2022 4:45 PM Weight Change Note showed facility staff identified the resident's significant weight loss and recommended starting Remeron as an appetite stimulant, to which the provider was agreeable, but wanted to wait two more weeks due to recent start of an antipsychotic medication. The plan was to continue to monitor oral intake, weekly weights, and re-approach the Remeron idea in mid-September 2022. Review of the weight flowsheet showed Resident 39's weight loss continued as follows: 09/05/2022- 150.6 lbs.; 09/12/2022- 146 lbs. (-4.6 lbs. in one week); 09/19/20922- 146.8; and 10/03/2022- 143.2 lbs. (- 3.6 lbs. in one week. Review of Resident 39 EHR showed staff did obtain the most of the resident's weekly weights. However, there was no indication staff were evaluating them, as there was no documentation to support staff identified or were aware of the resident's continued insidious weight loss. Additionally, no documentation was found to support that the plan to start Remeron as an appetite stimulant was revisited in mid-September as planned. No further nutrition assessments or mention of starting an appetite stimulant was found until 10/04/2022 (35 days later.) Review of Resident 39's 10/04/2022 10:26 AM Nutrition/Dietary Note assessed the following dementia has been increasingly worsening; has had psych consults with medication changes. NP [Nurse Practitioner] is aware of weight loss. Have discussed the possibility of starting Mirtazapine [as an appetite stimulant] with IDT [Interdisciplinary team], but provider wanting to give other psych medications time to be effective before adding more. Has house shake in place BID [two times daily], accepts maybe ~50% of each offering. Recommendations were made to offer a PM snack and doc % accepted in Medication Administration Record (MAR) and provide fortified cereal at breakfast. Review of Resident 39's EHR showed no order for fortified cereal at breakfast nor had a diet slip been filled out to notify the kitchen. Similarly, an order and/or direction to staff to offer a PM snack was not found. Review of the October MAR showed no documentation or indication the resident was ever offered or provided the PM snack as recommended. During an interview on 10/07/2022 at 11:38 AM, Staff B, Director of Nursing Services, acknowledged the facility failed to obtain the resident's 09/26/2022 weekly weight as ordered, and in the 35 days between nutrition assessments (8/30/2022 wt-151.2 lbs. and 10/03/2022 wt. 143.2 lbs.), Resident 39's lost another 5.29 % without assessment or intervention. During an interview on 10/07/2022 at 12:29PM, when asked if the 10/04/2022 RD recommendations to initiate a PM snack and to provide fortified cereal at breakfast, to increase caloric intake, had been carried out and/or implemented Staff B stated, No, I don't see them on the orders. Reference WAC 388-97-1060(3)(h) .

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review, the facility failed to have sufficient nursing staff to provide nursing services as determined by their assessments and care plans for 6 of 13 residents (Residents 7, 15, 16, 48, 56 and 61) reviewed for sufficient staffing. This failure placed the residents at risk of unmet care needs, skin breakdown, pain, and mental anguish. Findings included . RESIDENT OBSERVATION AND INTERVIEWS: Resident 7 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated 07/14/2022, showed the resident was cognitively intact and required extensive assist with bed mobility, toileting, transfers, personal hygiene, and dressing. Review of Resident 7's [NAME] (care instructions for the nursing assistants) dated 09/30/2022, showed the resident was incontinent of bowel and bladder, required staff to clean and dry skin after each incontinent and offer turning and repositioning every 2 hours. On 10/05/2022 at 2:02 PM, Resident 7 stated that they had not received care on 10/05/2022 until approximately 11:00 AM. Resident 7 stated that they like to get up no later than 10 AM and did not like being in a wet bed. Resident 7 stated that they were used to being wet, the facility was short staffed, and won't hire anyone else due to the budget. Resident 7 stated that their aide today was excellent, and it was not the aide's fault. Resident 7 stated that they were worried about the other patients that don't have the ability to speak. An observation on 10/06/2022 at 9:09 AM showed Resident 7 on his back in bed. At 10:29 AM the resident was observed on their back in bed. Resident 7 stated that they had not received care yet that morning and when asked if their briefs were wet, Resident 7 stated, I don't know if I am wet, I cannot feel it. An observation on 10/06/2022 at 10:59 AM, showed Resident 7 with soiled briefs soaked with urine. RESIDENT 15 Resident 15 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 15 was cognitively impaired and required extensive assistance with bed mobility, toileting, and personal hygiene. Review of Resident 15's [NAME] dated 08/05/2022, showed Resident 15 was always incontinent of bladder and bowel, required staff to clean and dry skin after each incontinent episode, check and change, apply skin protective cream after each incontinence, and turn and re-position every 2 hours. Review of Resident 15's Wound Observation Tool, dated 09/22/2022, showed that Resident 15 had recurring Moisture Associated Skin Damage (skin breakdown caused by prolonged exposure to moisture) to the right and left side of their buttocks. An observation on 10/06/2022 at 8:34 AM, showed Resident 15 on their back in bed. At 9:21 AM, Resident 15 was observed attempting to sit up in bed yelling out help. At 9:26 AM Resident 15 was observed on their back, trying to adjust themself in bed, calling out incoherently. Resident 15's room had a strong smell of urine. At 9:34 AM Resident 15 was observed on their back, yelling help. During an observation on 10/06/2022 at 9:56 AM, Staff W was observed providing incontinent care to Resident 15. The resident was rolled onto the left side, Resident 15's buttocks were red with open areas on the right and left side of their buttocks. Resident 15's briefs were soaked with urine and soiled. The draw sheet and fitted sheet were wet with a brown ring extending the entire length of the draw sheet. RESIDENT 16 Resident 16 was admitted to the facility on [DATE]. Review of the MDS assessment, dated 07/25/2022, showed that Resident 16 was cognitively impaired and required extensive assistance for bed mobility, toileting, dressing and personal hygiene. Review of Resident 16's [NAME] dated 09/16/2022, showed Resident 16 was incontinent of bladder and bowel, on a check and change program, offer toileting before meals, and turn every 2 hours. Review of Resident 16's Weekly Skin Integrity assessment dated [DATE], showed Resident 16 had MASD to buttocks. An observation on 10/06/2022 at 8:34 AM, showed Resident 16 in bed on their back. At 9:21 AM and 9:34 AM Resident 16 was observed with eyes closed, head of the bed at 90 degrees, a breakfast tray on the overbed table in front of them and bacon lying on Resident 16's chest. At 10:20 AM and 10:42 AM Resident 16 was observed on their back in bed. During an observation on 10/06/2022 at 10:46 AM, Staff W, CNA and Staff Z, CNA, were observed providing incontinent care to Resident 16. The resident was rolled onto the left side, Resident 16's buttocks were red. Resident 16's briefs were soaked with urine and the urine had soaked through the draw sheet. RESIDENT 48 Resident 48 was admitted to the facility on [DATE]. Review of the MDS, dated [DATE], showed the resident was cognitively impaired and required extensive assistance with bed mobility, transfers, personal hygiene, dressing and toileting. Review of Resident 48's [NAME] dated 09/14/2022, showed that Resident 48 was to have toileting offered every 2 to 3 hours and was to be turned and repositioned every 2 hours. Review of Resident 48's Weekly Skin Integrity assessment, dated 10/02/2022, showed that Resident 48 had MASD to buttocks. Observations on 10/06/2022 at 8:33 AM, 9:49 AM, 10:20 AM, 10:42 AM, 11:08 AM, 11:31 AM and 12:12 PM, showed Resident 48 on back in bed with the head of the bed up at 90 degrees. RESIDENT 61 Resident 61 was admitted to the facility on [DATE]. Review of the MDS assessment, dated 09/13/2022, showed Resident 61 was cognitively intact and required extensive assistance with bed mobility, dressing, personal hygiene, and toileting. Review of Resident 61's [NAME], dated 09/23/2022 showed Resident 61 required turning and re-positioning every 2 hours and check and change every 2 hours. Review of Resident 61's Wound Observation Tool, dated 10/03/2022, showed Resident 61 had a stage 4 pressure ulcer (wound caused by prolonged pressure) on their sacrum (area at base of spine) and required turning every two hours to prevent further skin breakdown. Review of Resident 61's Wound Observation Tool, dated 10/05/2022, showed Resident 61 had MASD on their buttocks and required turning every two hours to prevent further skin breakdown. Observations on 10/06/2022 at 8:34 AM, 9:20 AM, 9:34 AM, 10:20 AM and 11:07 AM showed Resident 61 lying on her back in bed with the head of the bed up at 90 degrees. STAFF INTERVIEWS On 10/06/2022 at 8:32 AM, Staff W, Certified Nursing Assistant (CNA) stated that she was assigned Residents 7, 15, 48 and 61. Staff W stated that her shift was 6:00 AM to 2:00 PM. On 10/06/2022 at 8:32 AM, Staff Z, CNA, stated that she was assigned Resident 16. Staff Z stated that her shift was 6:00 AM to 2:00 PM. On 10/06/2022 at 10:59 AM, during an observation of care with Resident 7, Staff W, stated that she had provided Resident 7 with a breakfast tray, but this was the first time she had provided care to Resident 7 since her shift started at 6:00 AM. On 10/06/2022 at 9:56 AM, during an observation of care with Resident 15, Staff W stated this was the first care she provided to Resident 15 since her shift started at 6:00 AM. On 10/06/2022 at 10:46 AM, Staff W and Staff Z were observed providing incontinent care to Resident 16. Staff Z stated that she was assigned to care for Resident 16, and this was the first time she provided care to Resident 16 since her shift started at 6:00 AM. Staff Z stated that she did provide Resident 16 with a breakfast tray. Staff W stated that she had not provided care to Resident 16 since the start of her shift at 6:00 AM. On 10/06/2022 at 11:20 AM, Staff W, entered Resident 61's room and stated that this was the first time she had provided care to Resident 61 since her shift started at 6:00 AM. An observation on 10/06/2022 at 12:12 PM, showed Staff W in Resident 48's room with linen supplies, closing the door., Staff W stated that this was the first time she had provided care to Resident 48 since her shift started at 6:00 AM. Staff W stated that she had provided a breakfast tray to Resident 48 but had provided no care. On 10/06/2022 at 12:45 PM, Staff W, CNA, stated that she was assigned 12 residents and was unable to complete the care of her assigned residents according to their [NAME], including Residents 7, 15,48 and 61 due to her workload. On 10/06/2022 at 12:47 PM, Staff Q, stated that she had the assignment that included Residents 7,15,16, 48 and 61 frequently. It was her permanent run. Staff Q stated that it was not possible to complete all the care tasks, according to the [NAME], in a timely manner. Staff Q stated that the care needs did not match the staff they have. On 10/06/2022 at 1:14 PM, Staff Z, CNA, stated that there was no way to complete the care for the residents she was assigned, including Resident 16 due to workload. Staff Z stated that she was aware of their needs on the [NAME] but no matter what she did she could not get to the residents, it was always the same. Staff Z stated that she had informed the Staffing Coordinator and was told that was what the Administrator and Director of Nursing wanted. Staff Z stated that the workload was more than the aides could handle. It was their everyday schedule and was not feasible. On 10/06/2022 at 2:06 PM, Staff GG, Staffing Coordinator, stated she was responsible for the nursing assistant assignments. Staff GG stated that the number of nursing assistants was based on census, and she took the number of residents and divided it by the number of nursing assistants. Staff GG stated that the nursing assistants had come to her daily and told her that the assignments that included Residents 7,15,16,48 and 61 were hard and they had to complete showers too. Staff GG stated that the nursing assistants had told her they could not get to the care according to the [NAME]. Staff GG stated that the nursing assistants came in crying, and she had notified the Director of Nursing and was told to rotate the aides' assignments but could not change the number of staff. Staff GG stated, I have requested more staff, it was denied, it is over budget. On 10/06/2022 at 4:52 PM, Staff B, Director of Nursing Services, stated that the nursing assistants' assignments were determined by dividing the number of residents by the number of staff. Staff B stated that she had not talked to them about assigning based on acuity because she did not think they would like that. When asked if anyone had spoken to her about the staffing assignments that included Residents 7,15,16,48 and 61, Staff B stated that four regular aides had come to her weeks before, she could not remember an exact date, and they had a roster that listed the residents on those assignments, their transfer status and level of assistance they required. Staff B stated that after speaking to the staff she believed they needed another nursing assistant to assist those assignments. Staff B stated she had another aide assigned but they had to be pulled for a 1:1 staffing assignment with a resident. Staff B stated she was aware the nursing assistants were having workload issues and they were asking for another nursing assistant. Review of the facility's Incident Summary dated 10/05/2022 and 10/06/2022, documented the facility's investigation into the lack of care and services provided for Resident 7, 15, 16, 48 and 61 on 10/05/2022 and 10/06/2022. The Incident Summary showed that insufficient staffing for the workload was the root cause. RESIDENT 56 During an interview on 10/04/2022 at 1:26 PM, while discussing how great the turnout in the dining room was for lunch, Resident 56 stated that it was because there is no dining room for dinner and no dining room for any meal on the weekends because there wasn't enough staff. During an interview on 10/10/2022 at 9:21 AM, when asked if the facility offered the dining room for dinner or on the weekends Staff B, DNS, stated, No and indicated due to staffing the facility kept dining rooms closed at those times. SHOWERS During an interview on 10/07/2022 at 1:25 PM, Staff JJ, Shower Aide, explained that she worked Monday - Friday 7.5 hours a day, but had lunch dining room duty from 11:15 AM -1:00 pm, which left her 5 hours and 45 minutes to complete the showers. Staff JJ stated she showers most of the residents who are Hoyer lifts and is supposed to complete 10 -13 showers a day, but one resident, due to their size, takes two hours. Additionally, Staff JJ shared that she gets pulled to work the floor on average once a month and pulled to do escorts three times a month. When asked if there was anything inhibiting her form providing showers the residents' desired frequency Staff JJ stated, Yes, staffing. During an interview on 10/10/2022 at 9:11 AM, when asked if she felt staffing had affected the provision of showers Staff B stated, At times. RESTORATIVE NURSING SERVICES During an interview on 10/07/2022 at 1:48 PM, Staff FF, Restorative Aide (RA), explained that she was the only RA for the building currently and worked Monday through Friday 6:00 AM to 2:00 PM for 7.5 hours per day. Additionally, Staff FF reported she has dining room duty daily for the breakfast meal from 6:45 AM to 7:45 AM, leaving her 6.5 hours to complete all the residents scheduled Restorative Nursing Programs (RNPs). Staff FF indicated she was usually able to complete the programs because each day a few residents would refuse. While going through the facility's Master RNP book, five therapy referrals for residents to start RNPs were found that had not been implemented. The referrals were 47,40, 34 and 13 days old, with the fifth being undated. During an interview on 10/07/2022 at 1:56 PM, Staff FF stated if the five residents with RNP referrals were added she would not be able to complete the programs. :Refer to F677 and F688 Reference WAC 388-97-1080 (1) .

CONCERN (E)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 17 Review of Resident 17's 08/01/2022 care plan showed directions that chronic pain will be below a 4/10 by next review period. Attempt and document NPI before giving pain medication EX: ice, rest, food, fluid, and re-positioning etc. Evaluate the effectiveness of pain interventions Review of orders on 10/05/2022 showed there were orders for acetaminophen tablet and oxycodone HCl Tablet 5 MG, as needed for pain. There were no orders for NPI before giving pain medications. Review of the September 2022 MAR showed that acetaminophen was given one time and oxycodone was given thirteen times. Further review of the September MAR showed no NPI listed before giving pain medication. Reference WAC 388-97-1060 (3)(k)(i) RESIDENT 266 Review of Resident 266's annual MDS dated [DATE] showed that the resident admitted on [DATE] with diagnoses to include heart failure, and kidney disease. Review of Resident 266's active physician orders, showed an order for Metoprolol Tartrate (a medication used to treat high blood pressure) with a start date of 09/21/2022, give 12.5 milligram (mg) by mouth once a day for high blood pressure and to hold the medication for a systolic blood pressure of below 110 or a heart rate of below 60. Also noted was an order for Lisinopril (a medication used to treat high blood pressure) with a start date of 09/21/2022, one tablet by mouth one time a day for high blood pressure, hold for systolic blood pressure below 110 or heart rate below 60. Review of the MAR from 09/20/2022 through 10/05/2022, showed that Metoprolol 12.5 mg had been administered to Resident 266 once daily. On 09/21/2022, 09/23/2022, 09/30/2022, 10/02/2022 and 10/4/2022 Resident 266's systolic blood pressure was below 110 but Metoprolol was not held. Review of the MAR from 09/20/2022 through 10/05/2022, showed that Lisinopril had been administered to Resident 266 once daily. On 09/29/2022, 10/01/2022, 10/02/2022 Resident 266's heart rate was noted to be below 60 but Lisinopril was not held. Review of a physician's order for oxycodone (a medication used to treat pain) with a start date of 09/21/2022 showed staff were to give one tablet by mouth every four hours as needed for pain and give two tablets by mouth every four hours as needed for pain. There were no instructions on when to give one or two tablets. There were also no orders to attempt NPI prior to administering this as needed pain medication. During an interview on 10/05/2022 at 9:15 AM, Staff G, Registered Nurse (RN), stated that if Resident 266's blood pressure was below 110 or heart rate below 60 the nurse would hold metoprolol and lisinopril. Staff G, RN, further stated that she determined whether to give Resident 266 one tablet or two tablets of oxycodone depending on the resident's request, and that she didn't see an order to try any NPI prior to administering. During an interview on 10/05/2022 at 12:43 PM, Staff R, Licensed Practical Nurse / Unit Care Coordinator (LPN/UCC) stated that the metoprolol and lisinopril should have been held when the blood pressure or pulse was out of parameters, but it was not held. During an interview on 10/05/2022 at 10:39 AM Staff B, DNS stated that her expectation was that the nurses hold the metoprolol and lisinopril if the residents systolic blood pressure and/or pulse were outside of the parameters. Staff B also stated that the order for oxycodone one or two tablets should have had parameters describing when to give one tablet and when to give two tablets. Staff B further stated that nurses should have been attempting NPI but there was not an order in the MAR for them and there should have been. Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for three of five residents (Residents 8, 266 and 17) reviewed for unnecessary medication use. Failure to provide non-pharmacological interventions (NPI, approaches, therapies, or treatments that do not involve drugs) prior to giving as needed pain medications and/or to ensure physician ordered medication parameters were in place and/or followed, placed the residents at risk for side-effects related to the medication, medical complications, and a diminished quality of life. Findings included . Review of the facility's policy and procedure titled, Pain Assessment and Management, dated 09/08/2022, showed, Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Also, it showed that the facility was to develop and implement both NPI and pharmacological interventions. RESIDENT 8 Review of the annual Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 8 readmitted to the facility on [DATE] with diagnoses to include heart failure, nerve damage, and a pressure sore on the right foot. Review of Resident 8's September 2022 Medication Administration Record (MAR) showed orders for as needed pain medications that included an order dated 03/11/2022 for acetaminophen (to treat minor aches and pains and reduce fever) two tablets every six hours as needed for pain or fever. It further showed, Attempt nonpharmacological intervention before giving pain medications, rest, repositioning, distraction, food, etc Documentation showed this was given on 09/28/2022 for a pain level of 6,; however, no NPI were documented as provided prior to administration. Continued review of Resident 8's September 2022 MAR showed an order dated 09/29/2022 for oxycodone HCI (a narcotic medication used to treat severe pain when other pain medicines did not work well enough or could not be tolerated) one tablet every eight hours as needed for pain. Documentation showed this was given on 09/25/2022 for a pain level of 8, 09/28/2022 for a pain level of 8, and on 09/29/2022 for a pain level of 7. However, no NPI were documented as provided prior to administration. Additionally, there were no pain level parameters documented as to which as needed pain medication was to be provided when Resident 8 complained of pain. During an interview on 10/05/2022 at 11:53 AM, Staff R, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated that Resident 8's September 2022 MAR did not have NPI documented as offered prior to administering as needed pain medications and/or if declined and there should have been. Additionally, Staff R stated that there should have been documented parameters for level of pain as to when to provide acetaminophen or oxycodone HCI and that was not done for Resident 8's as needed pain medications. During an interview on 10/05/2022 at 2:33 PM Staff B, Director of Nursing (DNS), stated that there should have been a progress note or documentation in Resident 8's September 2022 MAR for NPI provided or refused, prior to administering as needed pain medication. Additionally, Staff B stated that there should be pain level parameters for Resident 8's as needed pain medications and that they needed to get clarification for those orders to include plain level parameter from the provider. .

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 266 Review of Resident 266's annual MDS, dated [DATE], showed that the resident admitted on [DATE] with diagnoses to include anxiety and depression. Review of Resident 266's active PO, showed an order for alprazolam (an antianxiety medication) 0.5 MG every eight hours as needed (PRN) for anxiety with a start date of 09/26/2022 and a stop date after 14 Days. No NPI were documented prior to administering the medication for 12 administrations during the month of October. During an interview on 10/05/2022 at 9:15 AM, Staff G, Registered Nurse, stated that there should have been an order to try NPI before administering antianxiety and she did not see any of those ordered for Resident 266. During an interview on 10/05/2022 at 10:39 AM Staff B, DNS stated that her expectation was that the nurses offer NPI prior to administering any PRN pain or anxiety medication and that Resident 266 should have had orders in place but did not. Reference WAC 388-97-1060 (3)(k)(i) Based on interview and record review, the facility failed to monitor potential side effects related to psychotropic medications (a medication that affects behavior, mood, thoughts and/or perception) use, and/or to consistently monitor individualized target behaviors for three of five residents (Residents 8, 39, and 266) reviewed for unnecessary medication. In addition, the facility failed to conduct a gradual dose reduction (GDR) for one of five residents (Resident 8) reviewed. Failure to monitor blood vital signs (blood pressure and heart rate taken while lying, sitting, and standing) related to antipsychotic (AP) medication use, attempt a GDR, adequately monitor resident's behaviors, conduct an abnormal involuntary movement scale (AIMS, an assessment with a rating scale to measure involuntary movements) related to AP use, provide non-pharmacological interventions for an as needed psychotropic medication, placed residents at risk for adverse side effects, medical complications, and a decrease quality of life. Findings included . Review of the facility's policy and procedure titled, Psychotropic Medication Informed Consent Policy, revised on 10/04/2022, showed, Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. RESIDENT 8 Review of the annual Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 8 originally admitted to the facility on [DATE]. It further showed that Resident 8 had diagnoses to include heart failure, kidney disease, dementia, depression, and psychotic disorder. Additionally, this MDS showed that Resident 8 received antipsychotic medications. ORTHOSTATIC BP Review of the physician order dated 04/04/2022 showed that Resident 8 was prescribed quetiapine (an antipsychotic medication) twice a day for dementia with psychosis. Review of Resident 8's physician order dated 03/26/2022 showed that the resident was prescribed to have orthostatic blood pressures (BPs) monthly in the evening every 30 days for use of quetiapine and results were to be documented in the vital signs tab in the Electronic Health Record (EHR). Review of Resident 8's EHR on 10/06/2022 showed no monthly orthostatic BPs were documented in resident's vital signs tab or in the resident's Medication Administration Records (MARs) for the months of March, April, May, June, August, or September 2022. During an interview on 10/05/2022 at 11:19 AM Staff R, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated that Resident 8 did not have orthostatic BPs documented in the medical record per physician orders and this did not meet expectations. During an interview on 10/05/2022 at 2:24 PM, Staff B, Director of Nursing Services (DNS), stated that residents that received an antipsychotic medication should have orthostatic BPs conducted and documented monthly. Additionally, Staff B stated that Resident 8's orthostatic BP documentation did not meet expectations. GDR Review of Resident 8's EHR on 10/05/2022 showed Resident 8's physician order history for use of quetiapine (an AP medication) for dementia with psychosis, revealed that Resident 8's initial order dated 11/23/2021 for quetiapine 12.5 mg twice a day was provided until discontinued on 02/22/2022 (MDS tracking tool showed that Resident 8 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]). Further review showed an order dated 03/11/2022 for quetiapine 12.5 mg twice a day was provided until discontinued on 04/04/2022, and had another order dated 04/04/2022 for quetiapine 12.5 mg twice a day that was being provided as an active order. Review of Resident 8's Pharmacist Consultation Report dated 02/20/2022 showed that the pharmacist recommended, For the initial attempt at a gradual dose reduction (GDR), please reduce Seroquel [quetiapine] to 12.5 mg hs [at hour of sleep/bedtime]. It showed that the physician agreed with the recommendation and wanted it to be implemented as written. This form was signed and dated by the physician on 03/07/2022 (18 days after the pharmacist's recommendation). Review of Resident 8's psychosocial progress note dated 04/04/2022 showed that because Resident 8 had presented with target behavior symptoms multiple times, no GDR due at this time. It further showed that this paper progress note was signed by the provider on 04/05/2022 (24 days after readmitting to the facility on [DATE], 28 days after the provider agreed to a GDR on 03/07/2022, and 43 days after the pharmacist's recommendation for a GDR on 02/20/2022). Review of the psychosocial progress note dated 09/15/2022 showed that the interdisciplinary team (IDT) met to discuss Resident 8's current order for quetiapine 12.5 mg twice a day for dementia and psychosis and was due for GDR consideration. Additionally, it showed, Will SBAR [situation, background, assessment, recommendations form] to MD to recommend GDR as medication is probably not having much affect. Review of Resident 8's EHR and paper chart on 10/06/2022 showed no documentation that an SBAR was completed and/or provided to the provider. Additionally, Resident 8 continues to be provided quetiapine 12.5mg twice a day for dementia and psychosis. During an interview on 10/06/2022 at 4:26 PM after looking at Resident 8's EHR, Staff E, Social Services Director (SSD), stated that she was not able to see documentation as to when Resident 8 readmitted to the facility on [DATE], that the pharmacist consultation report dated 02/20/2022 for a GDR recommendation and the provider's agreement with the GDR on 03/07/2022 was not followed up on and documented upon Resident 8's readmission. Staff E stated that she was unable to explain why Resident 8's quetiapine order was discontinued on 04/04/2022 and then a new order for quetiapine with the same dose and time was created and implemented on 04/04/2022. Staff E stated that pharmacy recommendations for GDR should occur, and physician orders should be followed, and expectations were not met for Resident 8. During an interview on 10/06/2022 at 5:36 PM after reviewing Resident 8's EHR and paper chart, Staff B, DNS, stated that she did not know why Resident 8's quetiapine order was discontinued and reordered on 04/04/2022 with same dose and times. Staff B stated that an SBAR regarding Resident 8's request for a GDR should have been completed and given to the provider and there was no documentation to show that was done and this did not meet expectations. RESIDENT 39 Resident 39 admitted to the facility on [DATE]. According to the 08/24/2022 Significant Change MDS showed the resident was severely cognitively impaired, had diagnoses of dementia, Parkinson's disease, depression, anxiety, and bipolar disorder, experienced an acute onset mental status change with delusions and required the use of antidepressant and antianxiety medications during the assessment period. Review of Resident 39's physician's orders (POs) showed the following orders for psychotropic medications: a 09/27/2022 order for lorazepam (an antianxiety medication) every eight hours for anxiety/agitation, hold if drowsy or sedated; and a 09/08/2022 order for nuplazid (an antipsychotic) daily for agitation/anxiety. Review of Resident 39's comprehensive care plan (CP) showed a mood problem secondary to insomnia, depression and anxiety CP, revised 09/12/2022, that directed staff to: observe and report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions; observe and report to MD as needed acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating and habits; change in sleep patterns; diminished ability to concentrate; or change in psychomotor skills. The CP did not mention that the resident received antipsychotic and antianxiety medications or identify what target behaviors (TBs) each medication was intended to treat. The interventions did not include instruction to obtain monthly postural blood pressure/pulse or identify the common side effects associated with antianxiety medication use or associated antipsychotic use. Review of Resident 39's EHR showed the facility did not perform an AIMS test. Additionally, there was no documentation to support staff were obtaining monthly postural blood pressures. Review of Resident 39's October 2022 MAR and Treatment Administration Records (TAR) showed the resident was receiving lorazepam and nuplazid daily. Review of the TAR showed a 09/14/2022 behavior monitor that directed staff to monitor for agitation, exit seeking, restlessness, cursing, hitting, attempting to void on floor and document the number of times the behaviors were present on the shift (e.g., 3, would be 3 times) but there was no way to determine what behavior the resident had demonstrated (i.e., did the 3 represent voiding on the floor 3 times or hitting someone, which was also coded as a 3) Additionally, there was no indication what TBs the lorazepam was intended to treat versus the TBs the nuplazid was intended to treat. Further review of Resident 39's October 2022 MAR and TAR showed facility staff were not monitoring for adverse side effects associated with antipsychotic or antianxiety medication use. During an interview on 10/10/2022 at 10:02 AM, Staff B, DNS, stated that: each psychotropic medication should have the specific TB(s) it was intended to treat identified; each psychotropic medication should have a behavior monitor developed specific to it; adverse side effects specific to the psychotropic medications drug class, should be monitored via MAR/TAR; monthly postural blood pressures should be obtained, to rule out orthostatic hypotension; and that an AIMS test should be conducted at the time an antipsychotic medication was initiated but acknowledged this did not occur for Resident 39.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to implement an Infection Prevention and Control Program and ensure the collection of infection data, document analysis of infection control data, identify trends of infections and complete follow-up activities in response to trends for five of six months (May, June, July, August, and September of 2022) reviewed for infection control. These failures placed residents at risk for healthcare acquired infections, related complications, and a decreased quality of life. Findings included . Review of the document titled, Infection Prevention and Control Program (IPCP) and Plan, dated 09/20/2022 showed Goals of the Infection Prevention and Control Program were to reduce the risk of acquisition and transmission of healthcare-associated infections; Monitor for any occurrences of infection and implement appropriate control measures; identify and correct problems relating to infection prevention and control practices and optimize the treatment of infections while reducing the adverse events associated with antibiotic use through the implementation of the Antibiotic Stewardship Policies and Procedures. Further Review of the above-named document showed that the program included routine surveillance activities, data collection and analysis each month to identify infection prevention and control risks and included antibiotic stewardship activities. Record review of the facility's infection surveillance log for the months of May, June, July, August, and September 2022 showed a list of prescribed antibiotics for each month. It did not show antibiotic treatment start dates, stop dates, types of bacteria/organism, documentation of analysis for the data, identification of trending/tracking of infections and/or follow-up activities. During an interview on 10/05/2022 at 2:27 PM, Staff M, Licensed Practical Nurse/Infection Control Preventionist (LPN/ICP) stated that as part of the infection control and prevention plan, they would complete the infection control log daily to include mapping infections and complete analyses of that data monthly. Staff M further stated that this had not been completed for some time. During an interview on 10/07/2022 at 9:52 AM, Staff B, Director of Nursing Services (DNS), stated that since May of 2022 the Infection Prevention and Control Program to identify, track, trend and monitor infections had not really been implemented and it should have been. Refer to F881 for additional information. Reference WAC 388-97-1320 (1)(a)(2)(a) .

CONCERN (F)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of antibiotic resistance for one of five residents (Resident 7) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Record review of the facility policy titled Antibiotic Stewardship showed that it was the policy of the facility to maintain an Antibiotic Stewardship Program (ASP). This included the assessment of residents suspected of having an infection using McGeer criteria (a set of signs and symptoms that verify active infection) when considering initiation of antibiotics, review pharmacy data and the facilities antibiogram (a laboratory report on identified organisms) to discuss with providers and that an antibiotic time-out would be done at 72 hours after antibiotic initiation when each resident should be reassessed for consideration of antibiotic need. Review of an order dated 10/06/2022 showed Resident 7 started on cephalexin 500 milligram (mg, a unit of mass) one capsule by mouth every six hours for fever for seven days. Review of assessments and progress notes showed no documentation of evaluation of McGeer criteria prior to initiating antibiotic therapy. Review of Resident 7's electronic medical record on 10/10/2022 at 11:10 AM showed no further documentation related to antibiotic stewardship activities. During an interview on 10/05/2022 at 2:27 PM, Staff M, Licensed Practical Nurse/Infection Control Preventionist (LPN/ICP) stated that they would complete the infection control log daily, practice antibiotic stewardship, and use McGeer criteria to assess residents for antibiotic use. Staff M further stated that these activities had not been done for a while. During an interview on 10/07/2022 at 9:57 AM, Staff B, Director of Nursing Services, stated that the facility had a system for antibiotic stewardship, but it was not actively in place right now. No associated WAC .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• 32% turnover. Below Washington's 48% average. Good staff retention means consistent care.

Concerns

• 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
• $34,650 in fines. Higher than 94% of Washington facilities, suggesting repeated compliance issues.

Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

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About This Facility

What is Life Of Puyallup's CMS Rating?

CMS assigns LIFE CARE CENTER OF PUYALLUP an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Washington, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Life Of Puyallup Staffed?

CMS rates LIFE CARE CENTER OF PUYALLUP's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 32%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Life Of Puyallup?

State health inspectors documented 50 deficiencies at LIFE CARE CENTER OF PUYALLUP during 2022 to 2025. These included: 48 with potential for harm and 2 minor or isolated issues.

Who Owns and Operates Life Of Puyallup?

LIFE CARE CENTER OF PUYALLUP is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LIFE CARE CENTERS OF AMERICA, a chain that manages multiple nursing homes. With 102 certified beds and approximately 94 residents (about 92% occupancy), it is a mid-sized facility located in PUYALLUP, Washington.

How Does Life Of Puyallup Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, LIFE CARE CENTER OF PUYALLUP's overall rating (5 stars) is above the state average of 3.2, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Life Of Puyallup?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Life Of Puyallup Safe?

Based on CMS inspection data, LIFE CARE CENTER OF PUYALLUP has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Life Of Puyallup Stick Around?

LIFE CARE CENTER OF PUYALLUP has a staff turnover rate of 32%, which is about average for Washington nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Life Of Puyallup Ever Fined?

LIFE CARE CENTER OF PUYALLUP has been fined $34,650 across 1 penalty action. The Washington average is $33,425. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Life Of Puyallup on Any Federal Watch List?

LIFE CARE CENTER OF PUYALLUP is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 102
Avg. Residents: 94
Occupancy: 92.6%
Ownership: For profit - Limited Liability company
Chain: LIFE CARE CENTERS OF AMERICA
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
5-Star Rating: +40
50 Deficiencies: -10
Fines ($34,650): -5
Final Score: 75/100

Nearby Alternatives

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505324