Does VALLEY VIEW SKILLED NURSING AND REHABILITATION have any serious inspection findings?

Yes, VALLEY VIEW SKILLED NURSING AND REHABILITATION has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 83 total deficiencies from recent inspections.

What are the staffing levels at VALLEY VIEW SKILLED NURSING AND REHABILITATION?

VALLEY VIEW SKILLED NURSING AND REHABILITATION has a three-star staffing rating from CMS with 0.97 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

How many beds does VALLEY VIEW SKILLED NURSING AND REHABILITATION have?

VALLEY VIEW SKILLED NURSING AND REHABILITATION has 136 certified beds.

Who owns VALLEY VIEW SKILLED NURSING AND REHABILITATION?

VALLEY VIEW SKILLED NURSING AND REHABILITATION is a for profit - corporation facility and is part of the VERTICAL HEALTH SERVICES chain.

VALLEY VIEW SKILLED NURSING AND REHABILITATION

Name: VALLEY VIEW SKILLED NURSING AND REHABILITATION
Address: 4430 TALBOT ROAD SOUTH, RENTON, WA, 98055, US
Telephone: (425) 226-7500
Rating: 2.0

4430 TALBOT ROAD SOUTH, RENTON, WA 98055 · (425) 226-7500

For profit - Corporation 136 Beds VERTICAL HEALTH SERVICES Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

1/100

#158 of 190 in WA

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Last Inspection: December 2024

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

Overview

Valley View Skilled Nursing and Rehabilitation has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. Ranking #158 out of 190 facilities in Washington means they are in the bottom half, and at #40 out of 46 in King County, only five local options are better. While the facility is showing improvement, reducing issues from 25 in 2024 to just 1 in 2025, it still has a high number of deficiencies, with 83 total issues found during inspections. Staffing is a relative strength with a 3/5 star rating and a turnover rate of 35%, which is better than the state average, while RN coverage is good, exceeding that of 77% of facilities in the state. However, there have been critical incidents, including failure to provide CPR to an unresponsive resident and improper monitoring of residents' care needs, raising serious concerns about safety and quality of care.

Trust Score: F
In Washington: #158/190
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 35% turnover. Near Washington's 48% average. Typical for the industry.
Penalties: $70,502 in fines. Lower than most Washington facilities. Relatively clean record.
Skilled Nurses: Each resident gets 58 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
Violations: 83 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 25 issues

2025: 1 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (35%)
13 points below Washington average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Washington average (3.2)

Below average - review inspection findings carefully

Staff Turnover: 35%

10pts below Washington avg (46%)

Typical for the industry

Federal Fines: $70,502

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: VERTICAL HEALTH SERVICES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 83 deficiencies on record

2 life-threatening 3 actual harm

May 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

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 prepare and serve food under sanitary conditions for 1 of 4 nursing units (West One Unit) observed during mealtime. Failure to cover food items, secure lids of the dirty wash rag bin, ensure staff distributed and served food under sanitary conditions, and maintained a clean/sanitary meal cart placed residents at risk of acquiring food-borne illnesses and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Food Preparation and Service, revised April 2019, the food and nutrition services employees would prepare and serve food in a manner that complied with safe food handling practices. The policy showed appropriate measures were used to prevent food contamination and that both the food and nutrition services staff and the nursing services personnel would adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness including washing their hands before serving food to residents and when handling food trays. <Uncovered Food and Bin> Observation of the meal preparation in the kitchen on 05/09/2025 at 11:33 AM for lunch service showed the plated ready-to-eat green salad and desserts for [NAME] One Unit were left uncovered when they were placed on resident meal trays for distribution. There were small, black insects observed flying around the kitchen area next to the uncovered food. In an interview on 05/09/2025 at 11:34 AM, Staff H (Clinical Dietician) stated the facility was experiencing infestation issues of small, flying insects and had ongoing services from a pest control company. On 05/09/2025 at 11:45 AM, a bin of wet, dirty wash rags was observed sitting next to the hand washing sink without a lid/cover. There were small, black insects observed flying around the uncovered bin. In an interview on 05/09/2025 at 11:46 AM, Staff D (Dietary Manager) stated the facility was dealing with fruit flies [a small fly or insect] issues. Staff D stated it was important to ensure wet and dirty bins had lids and remained covered because fruit flies love wet and dirty stuff and could cause food-borne illnesses. Staff D stated the kitchen staff should have, but did not cover the dirty bin. Observation on 05/09/2025 at 12:29 PM showed Staff E (Certified Nursing Assistant - CNA) parked the meal tray cart between room [ROOM NUMBER] and the soiled linen room in [NAME] One Unit, took a meal tray out, and walked down the hallway to room [ROOM NUMBER] with the salad bowl and dessert plate left uncovered. There were several rooms on isolation (Transmission-Based Precautions) along the hallway passed over by Staff E with the food left uncovered. In a joint interview on 05/09/2025 at 12:31 PM with Staff's E, F, and G (CNAs), Staff G stated the salads and desserts usually came uncovered from the kitchen to the nursing units for meal service. Staff F stated the observation noted was not the first time it [uncovered food] happened. <Hand Hygiene> Observation and interview on 05/09/2025 at 12:26 PM showed Staff E brought a meal tray to room [ROOM NUMBER]-B, set the tray on the overbed table, touched the bed controller, assisted the resident to sit up and position in bed to eat, came out of the room, took another tray out from the meal cart, and brought it to room [ROOM NUMBER] without performing hand hygiene between residents. In an interview on 05/09/2025 at 12:28 PM, Staff E stated hand hygiene was important to prevent cross-contamination during meal service and to avoid the spread of infection from room to room. Staff E stated they should perform proper hand hygiene while serving the meal trays in between residents but they forgot. <Meal Tray Cart> Observation on 05/09/2025 at 12:12 PM showed the meal cart used for lunch service was parked by room [ROOM NUMBER]; the cart was dirty with dried up liquid spills and brownish sediments that lined the bottom of the cart. In an interview on 05/09/2025 at 12:37 PM, Staff A (Administrator) confirmed that the meal cart was dirty. Staff A stated they expected the dietary staff to keep the meal cart clean and sanitary for food safety. REFERENCE: WAC 388-97-1100(3), -2980. .

Dec 2024 23 deficiencies

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to implement their Grievance policy for 1 of 2 residents (Resident 1) reviewed for grievance reporting. The failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievance resolution delayed or incomplete, feelings of frustration, and a diminished quality of life. Findings included . <Facility Policy> Review of a facility policy titled, Resident and Family Grievances, revised March 14, 2023, showed residents may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished regarding their Long Term Care (LTC) facility stay. The staff member receiving the grievance would record the nature and specifics of the grievance on the designated grievance form or assist the resident to complete the form. The grievance form would be forwarded to the grievance official as soon as practicable. The grievance official or designee would keep the resident appropriately apprised of progress towards resolution of the grievances. In accordance with the resident's right to obtain a written decision regarding their grievance the grievance official would issue a written decision on the grievance to the resident at the conclusion of the investigation. <Resident 1> According to the 09/23/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 1 could be understood and could understand others. Resident 1 was dependent on staff for lower body dressing and required substantial assistance with upper body dressing and personal hygiene. Resident 1 required set up assistance for eating and oral hygiene due to medically complex conditions including heart failure, morbid obesity and back pain. In an observation and interview on 12/08/2024 at 9:00 AM, Resident 1 stated their Grabber Reacher (an assistive device/tool) was missing for the past 4 days on 12/4/2024. Resident 1 stated the Grabber Reacher was in their room and then it just disappeared. Resident 1 stated they needed the Grabber Reacher, as they could not reach things around their bed without the tool. Resident 1 stated they reported this to the nursing staff and staff helped to look around the room for the item but Resident 1 did not hear from anyone about the missing item and did not receive a replacement. In an observation and interview on 12/13/2024 at 11:58 AM, Resident 1 stated they finally heard back from staff on their missing Grabber Reacher after the surveyors interviewed Resident 1 about their grievance. The facility provided Resident 1 with a new Grabber Reacher but the one received was not the right one. The Grabber Reacher Resident 1 received was too small and did not grab items all the way around like their previous one. Resident 1 stated staff were aware the replacement Grabber Reacher was not the right one. In an interview with Staff F (Resident Care Manager) on 12/12/2024 at 12:41 PM, Staff F stated they did not receive a grievance form for Resident 1's missing Grabber Reacher. Staff F stated their expectation was for care staff to report this to the nurse. Staff F also stated that anyone could fill out a grievance report and a form should have been filled out. Staff F stated they would help to fill the grievance form out if a resident could not fill one out for themselves. Staff F stated the grievance report was important as the facility was the resident's home and the grievance process was important so residents could feel like they were not being ignored. In an interview with Staff F on 12/13/2024 at 12:08 PM, Staff F stated they did not know the replacement Grabber Reacher was too small for Resident 1 and will order another one for them. Staff F stated they do not always document on grievance forms, as they try to just resolve the issue themselves. Staff F stated they would fill out a grievance form now for Resident 1's missing Grabber Reacher, 9 days after the grievance was reported to staff. In an interview on 12/13/2024 at 9:54 AM Staff B (Director of Nursing) stated staff knew where the green grievances forms were kept. Staff B stated they expected staff to fill a grievance form out upon report of a grievance. Documentation of the grievance and investigation should be kept on the green grievance form so the facility could track what was done, this would also create an acknowledgement with the resident about the resolution. REFERENCE: WAC 388-97-0460. .

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview the facility failed to ensure missing narcotics were reported to the State Survey Agency (SSA) within the required timeframe for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to complete required reporting of missing resident narcotics placed the residents at risk for further misappropriation of resident narcotic medications and the potential for uncontrolled pain. These failures placed the facility at risk for possible diversion of controlled substances. Findings included . <Policy> Review of the facility policy titled, Controlled Medication Storage, dated 01/2024, controlled substances were subject to special record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. The policy showed any discrepancies in controlled substance medication counts would be investigated by the Director of Nursing and every reasonable effort would be made to reconcile the discrepancies. According to a facility policy titled, Incidents and Accidents, revised 01/2023, the facility would meet regulatory requirements for analysis and reporting of incidents. The policy showed incidents of misappropriation would be managed and reported according to the facility's abuse prevention policy. <Nursing Home Guidelines Purple Book> According to the Sixth Edition Nursing Home Guidelines Purple Book, dated October 2015, immediate telephone reporting was required when misappropriation of resident property had occurred. The Purple Book' showed it was the Nursing Homes responsibility to report all misappropriated resident property. <East 2 Narcotic Ledger> Observation and record review on 12/09/2024 at 3:13 PM of the East 2 narcotic lock box and ledger showed page 83 with 30 tablets remaining transferred to page 101. Review of page 101 showed the starting count as 29 tablets, 1 tablet missing from the remaining balance from page 83. Page 96 showed 14 tablets remaining with the whole page crossed off and no card of medications in the lock box for page 96. Page 99 showed 20 tablets remaining with the page crossed off and transferred to page 99 written in, balanced transferred to unit box was left blank, and no card of medications was in the lock box. Page 103 showed 20 tablets remaining with the whole page crossed off and no card of medications in the lock box for page 103. Page 111 and 112 was missing from the East 2 narcotic ledger, the pages were ripped out. In an interview on 12/09/2024 at 3:13 PM Staff I (Licensed Practical Nurse) stated they reported the missing narcotics to Staff F (Resident Care Manager) when counting off with the night nurse on 11/08/2024 and Staff F reconciled the narcotic count in the ledger. Staff I stated Staff B (Director of Nursing) was also notified of the missing narcotics. In an interview on 12/09/2024 at 3:15 PM Staff B stated they were notified of the missing narcotics and the pages torn out, pages 111 and 112, in the East 2 narcotic ledger by Staff I on 11/11/2024. Staff B stated they did not report the missing narcotics or the missing pages in the narcotic ledger to the SSA. In an interview on 12/11/2024 at 9:53 AM Staff B stated they did not know they needed to report the resident missing narcotics and missing narcotic ledger pages to the SSA at the time of the misappropriation but had reviewed the purple book guidelines and understood they should have. Staff B stated it was important to report missing narcotics to ensure a thorough investigation, prevent any further misappropriation of resident's narcotic medications, and prevent diversion of controlled substances within the facility. Refer to F610 - Thorough Investigation Refer to F755 - Pharmacy Procedures REFERENCE: WAC 399-97-0640(5)(a). .

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, record review, and interview the facility failed to complete a thorough investigation of missing controlled substances (Narcotic Medications) for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to complete a thorough investigation placed residents at risk for uncontrolled pain, further misappropriation of resident narcotic medications, and possible staff diversion of controlled substances. Findings included . <Policy> According to a facility policy titled, Incidents and Accidents, revised 01/2023, the facility would complete incident reporting to ensure appropriate and immediate interventions were implemented and corrective actions were taken to prevent recurrence. The policy showed the facility would meet regulatory requirements for analysis and reporting of incidents. The policy showed the facility would complete an investigation for incidents that occurred on facility property and that involved a resident. Review of the facility policy titled, Controlled Medication Storage, dated 01/2024, controlled substances were subject to special record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. The policy showed any discrepancies in controlled substance medication counts would be investigated by the Director of Nursing and every reasonable effort would be made to reconcile the discrepancies. <East 2 Narcotic Ledger> In an observation and interview on 12/09/2024 at 3:13 PM discrepancies were found in the East 2 narcotic lock box and ledger. At this time Staff I (Licensed Practical Nurse) stated they reported the discrepancies to Staff B (Director of Nursing). In an interview on 12/09/2024 at 3:15 PM Staff B stated they were notified of the missing narcotics and the pages torn out, pages 111 and 112, in the East 2 narcotic ledger by Staff I on 11/11/2024. Staff B stated they had completed an investigation by doing a narcotic audit of the East 2 narcotic ledger. Staff B stated they did not come to a conclusion as to what happened to the missing narcotics or missing narcotic pages that were ripped out of the ledger. Staff B stated they instructed Staff F (Registerd Nurse-RN Manager) and staff H (RN Manager) to make a notation on each page that was incorrect so that it was corrected in the narcotic ledger for future nurses accepting the keys to that medication cart, but they did not check to ensure Staff F and Staff H made the notations. Staff B stated they ordered a pharmacy narcotic audit which was completed on 12/05/2024 and 12/06/2024. Staff B stated the pharmacist did not report any other discrepancies at the time of the audit. Review on 12/10/2024 of the facility's investigation of the missing narcotics and missing pages from the East 2 narcotic ledger received from Staff B showed only page 48 was identified to be missing 30 Milliliters (ml) of a liquid narcotic and pages 111 and 112 was torn out. The investigation showed they were unable to reconcile the 30 ml quantity missing on page 48 or the two missing pages, pages 111 and 112. In an interview on 12/11/2024 at 12:34 PM Staff B stated they missed the discrepancies found on pages 83, 96, 99, 101, and 103. Staff B stated they performed a narcotic audit on East 2 Narcotic Ledger by comparing only the cards of narcotics they had in the East 2 medication cart lock box to the assigned pages. Staff B stated they did not investigate page to page in the East 2 Narcotic Ledger as part of their narcotic audit but should have. Staff B stated they did locate page 96, and page 99 after the surveyor notified them but should have found these at the time of the initial investigation and narcotic audit on 11/08/2024. Refer to F609 - Reporting of Alleged Violations Refer to F755 - Pharmacy Procedures REFERENCE: WAC 388-97-0640(6)(a)(b)(c). .

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 39> Review of Resident 39's 08/28/2024 Discharge Return Anticipated MDS showed Resident 39 discharged to an acut...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 39> Review of Resident 39's 08/28/2024 Discharge Return Anticipated MDS showed Resident 39 discharged to an acute care hospital on [DATE]. Record review of Resident 39's health records showed no documentation staff provided the required written transfer notification for the transfer on 08/28/2024. In an interview on 12/13/2024 at 8:24 AM Staff E stated Resident 39 did not receive a written transfer notification for their transfer on 08/28/2024 but should have. Staff E stated it was important to provide written transfer notification for resident rights. REFERENCE: WAC 388-97-0120 (2)(a-d) <Resident 18> Review of Resident 18's 12/04/2024 Discharge Return Anticipated MDS showed Resident 18 discharged to an acute care hospital on [DATE]. Record review on 12/11/2024 showed no documentation staff provided the required written notification to Resident 18 and/or their representative regarding their discharge. In an interview on 12/12/2024 at 12:34 PM, Staff J (Regional Social Services Director) reviewed Resident 18's record and was unable to locate a written notification copy provided to Resident 18 during transferred to the hospital In an interview on 12/13/2024 at 10:34 AM, Staff B (Director of Nursing) stated it was important to provide a written transfer notification to ensure the resident or resident representative was informed of the reason for transfer and to ensure the transfer was in alignment with the resident's stated goals for care and preferences, but the facility did not follow the facility policy.Based on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 4 residents (Residents 65, 18, and 39) reviewed for hospitalizations and 1 supplemental resident (Resident 139) reviewed. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of a 09/01/2021 facility, Transfer and Discharge policy, showed for emergency transfers/discharges, the facility would provide a transfer notice as soon as practicable to the resident and their representative. <Resident 65> According to a 10/19/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 65 was discharged emergently to an acute care hospital on [DATE] with return anticipated. Record review showed Staff E (Director of Social Services) completed a Nursing Home Transfer or Discharge Notice on 10/19/2024 for Resident 65. On this form was a section to indicate to whom the notice was provided; and listed the resident or resident representative. Staff E documented in this section Resident 65 was sent to the emergency department and a copy of the form was, left at bedside. Resident 65 had no access to this form, which included their appeal rights, until after their return to the facility, six days later. In an interview on 12/13/2024 at 9:48 AM, Staff E stated the purpose of a transfer notice was to inform a resident of the reason they were being transferred to the hospital and included the resident's appeal rights in regards to a transfer and/or discharge from the facility. Staff E stated it was not their practice to provide the notice to a resident once they left the facility urgently. <Resident 139> According to a 11/20/2024 Discharge MDS, Resident 139 was discharged emergently to an acute care hospital on [DATE] with return anticipated. Record review showed Staff E completed a Nursing Home Transfer or Discharge Notice on 11/20/2024 for Resident 139. On this form was a section to indicate to whom the notice was provided and listed the resident or resident representative. Staff E documented in this section Resident 139 was sent to the emergency department and a copy of the form was, left at bedside. Resident 139 had no access to this form, which included their appeal rights, until after their return to the facility, seven days later. In an interview on 12/13/2024 at 9:48 AM, Staff E stated they were responsible for providing the written notice of transfer/discharge forms to the residents and stated they do not provide the form to a resident representative unless requested. Staff E stated they did not receive any requests to provide the form to a representative. Staff E stated Resident 65 and Resident 139, did not receive the notice of transfer/discharge until after they were readmitted to the facility and stated they did not provide the notices to their representatives.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident39> Review of Resident 39's 05/22/2024 Modified Discharge Return Anticipated MDS showed Resident 39 discharged to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident39> Review of Resident 39's 05/22/2024 Modified Discharge Return Anticipated MDS showed Resident 39 discharged to an acute care hospital on [DATE]. Review of Resident 39's census report showed they transferred out of facility on 05/22/2024, returned on 06/04/2024, and transferred out of facility again on 08/28/2024 and returned on 09/14/2024. Review of Resident 39's 08/28/2024 Discharge Return Anticipated MDS showed Resident 39 discharged to an acute care hospital on [DATE]. Record review of Resident 39's health records showed no documentation staff reviewed the facility bed hold policy with the resident or offered a bed hold for either of the transfers on 05/22/2024 or 08/28/2024 as required. In an interview on 12/13/2024 at 8:24 AM Staff E stated Resident 39 was not offered a bed hold for their transfers on 05/22/2024 or 08/28/2024 but should have been offered a bed hold. Staff E stated it was important to offer a bed hold for resident rights. In an interview on 12/13/2024 at 11:18 AM Staff M stated bed holds were not offered to Resident 39 for either transfers out of facility on 05/22/2024 and 08/28/2024. Staff M stated the bed hold policy should have been reviewed and offered to Resident 39 within 24 hours of both transfers out of facility on 05/22/2024 and 08/28/2024. REFERENCE: WAC 388-97-0120 (4). <Resident 18> Review of Resident 18's 12/04/2024 Discharge Return Anticipated MDS showed Resident 18 discharged to an acute care hospital on [DATE]. Review of Resident 18's record showed Resident 18 was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 18's record on 12/11/2024 showed no documentation indicating a bed hold notification was provided to Resident 18 when they discharged to the hospital on [DATE] as required. In an interview on 12/11/2024 at 10:22 AM, Staff B (Director of Nursing) stated the admission coordinator should have the bed hold notification record for residents discharged to the hospital. In an interview on 12/13/2024 at 11:18 AM, Staff M reviewed the records for Resident 18 and was not able to locate documentation they were offered and/or provided a bed hold as required.Based on interview and record review, the facility failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 of 4 sample residents (Resident 65, 18, & 39) reviewed for hospitalization and 1 supplemental resident (Resident 139) reviewed. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making. Findings included . <Facility Policy> Review of a 12/2022 revised facility, Bed Hold Notice Upon Transfer policy, showed at the time of transfer for hospitalization or therapeutic leave, the facility would provide to the resident and/or the resident representative written notice which specifies the duration of the bed hold policy and addresses information explaining the return of the resident to the next available bed. This policy showed in the event of an emergency transfer of a resident, the facility would provide, within 24 hours, written notice of the facility's bed hold policy. <Resident 65> According to a 10/19/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 65 was discharged emergently to an acute care hospital on [DATE] with return anticipated. Review of Resident 65's records did not show the facility discussed and/or offered the resident or their representative a bed hold for the discharge to the hospital on [DATE] as required. <Resident 139> According to a 11/20/2024 Discharge MDS, Resident 139 was discharged emergently to an acute care hospital on [DATE] with return anticipated. Review of Resident 139's records did not show the facility discussed and/or offered the resident or their representative a bed hold for the discharge to the hospital on [DATE] as required. In an interview on 12/13/2024 at 9:48 AM, Staff E (Director of Social Services) stated it was their expectation bed holds would be offered and would expect to see documentation of that in a resident's records. Staff E stated bed holds were the responsibility of the admissions department. In an interview on 12/13/2024 at 11:18 AM, Staff M (Admissions Director) stated it was their expectation the social services department and/or the nurses were responsible for obtaining bed holds. Staff M stated they would check with their supervisor to confirm this information. No further information was provided by Staff M. Staff M stated it was their expectation bed holds be completed within 24 hours of a resident's transfer to a hospital. Staff M reviewed the records for Resident 65 and Resident 139 and was not able to locate documentation they were offered and/or provided a bed hold as required.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

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 Care Plans (CP) were updated as needed to reflect changes in residents' care needs for 2 of 5 residents (Residents 3 & 39) reviewed for CP's. The facility failed to provide care conferences for 2 of 5 residents (Residents 39 & 49) reviewed. The failure to update CPs with changes in residents' health status and conduct care conferences placed residents at risk for unmet care needs, unnecessary care, and frustration. Findings included . <Facility Policy> Record review of the facility's 4/01/2021 policy titled Care Planning - Resident Participation showed the facility would support residents' right to be informed about and actively participate in their CP and treatment decisions. The CP process would include an assessment of the residents' strengths and needs and incorporate the residents' preferences. Record review of the facility's 3/17/2024 admission Agreement showed residents had the right to participate in developing and being informed of changes to their care and/or treatment. <CP Revision> <Resident 3> Record review of the 10/25/2024 admission Minimum Data Set (MDS - an assessment tool) showed Resident 3 was assessed with altered mental status, disordered communication, and limited range of motion which placed them at risk of injury. Record review of a revised 11/04/2024 CP showed Resident 3 was at risk for serious fall-related injuries due to incontinence, weakness, impaired cognition, limited communication and anticoagulant use. Staff were directed to place bilateral floor mats, when Resident 3 was unattended. Record record review of Resident 3's physician orders showed an 11/21/2024 order, changing the bilateral mats to left side only. During observations on 12/10/2024 at 1:20 PM and 12/11/2024 at 6:39 AM, Resident 3 was observed in bed and unattended with no floor mats placed on either side of bed. In an interview on 12/12/2024 at 2:07 PM Staff G (Registered Nurse Manager) stated the facility failed to update the CP to reflect the physician's newest order, which resulted in a risk of inconsistent and uncoordinated care.<Resident 39> Review of the 06/10/2024 admission MDS showed Resident 39 readmitted to facility on 06/04/2024. The MDS showed Resident 39 was able to make themselves understood and usually understood others. The MDS showed Resident 39 had moderately impaired vision without corrective lenses available. Review of a 06/15/2024 Impaired Visual Function CP Resident 39 preferred to not wear glasses. In an interview on 12/12/2024 at 7:11 PM Resident 39's Representative (RR) stated they requested social services schedule Resident 39 an eye exam to get glasses on several occasions over the past few months verbally and in text messages. Review of Resident 39's RR text message communications showed requests to schedule an eye exam with a 10/23/2024 at 3:05 PM response from the facility's social worker that stated they would include Resident 39 on the list to be seen by the eye doctor. In an interview on 12/13/2024 at 8:24 Staff E (Social Service Director) stated the social worker Resident 39's RR communicated with was no longer an employee at the facility and quit about one and a half weeks before the date of this interview. Staff E stated there was no documentation in Resident 39's records showing the communication with the RR, but the previous social worker should have update Resident 39's CP to reflect their wishes for vision services. <Care Conference> <Resident 39> According to the 10/30/2024 Quarterly MDS Resident 39 had moderate cognitive impairment and had their legally authorized representative participate in the assessment. The MDS showed Resident 39 was able to make themselves understood and understood others. Review of Resident 39's records showed they admitted to the facility on [DATE]. These records showed Resident 39 was offered and received one care conference on 06/07/2024 since admission to the facility. In an interview on 12/08/2024 at 9:35 AM Resident 39 stated they were not offered a care conference. Resident 39 stated staff did not discuss their care plan with them or provide them with a copy of their care plan. In an interview on 12/12/2024 at 7:11 PM Resident 39's RR stated the facility staff had not attempted to schedule a care conference with them since the one they had right after Resident 39 admitted in June 2024. In an interview on 12/13/2024 at 8:24 Staff E stated Resident 39 only had one care conference on 06/07/2024 without any others offered. Staff E stated Resident 39 should have been offered care conferences quarterly. <Resident 49> According to the 11/27/2024 Quarterly MDS Resident 49 had no cognitive impairment. The MDS showed Resident 49 was able to make themselves understood and understood others. Review of Resident 49's records showed they admitted to the facility on [DATE]. These records showed Resident 49 was offered and received care conferences on 06/17/2024 and 12/02/2024 with no other documentation of care conferences being offered. In an interview on 12/08/2024 at 10:12 AM Resident 49 stated they were offered and received only one care conference when they first admitted . Resident 49 stated they were not offered a copy of their plan of care. In an interview on 12/13/2024 at 8:24 AM Staff E stated Resident 49 was not offered care conferences per regulation. Staff E stated Resident 49 should have had a quarterly care conference offered in September of 2024 but was not. Staff E stated they expected care conferences to be offered upon admission, within 48-72, quarterly, and as needed. Staff E stated it was important to offer care conferences per regulation so residents could participate in their plan of care, express any concerns, and get questions they might have answered. Refer to F685 Vision Services Refer to F842 - Resident Records REFERENCE: WAC 388-97-1020(2)(c)(d)(e)(f),-(4)(b)(c)(i-ii)(f). .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Bathing> <Resident 3> Review of the 10/25/2024 Resident/Representative Preference Assessment showed that Resident 3...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Bathing> <Resident 3> Review of the 10/25/2024 Resident/Representative Preference Assessment showed that Resident 3's Health Care Power of Attorney (HCPOA) indicated the preference of bed baths twice per week. Review of the 10/25/2024 CP showed that the facility would monitor and document Resident 3's abilities for ADLs and assist as needed. Record review of the 10/25/2024 admission MDS showed Resident 3 was assessed with altered mental status, disordered communication, limited range of motion and assistance was required by staff to complete bathing. On 12/08/2024 at 8:30 AM, the HCPOA stated they were concerned that bathing assistance from staff was inadequate to meet Resident 3's hygiene needs. The HCPOA stated Resident 3 should receive two baths per week but was only receiving one per week. Review of the 12/08/2024 facility bath schedule showed Resident 3 was scheduled for two showers per week on Monday evening and Thursday morning. Review of Resident 3's 11/2024 and 12/2024 daily documentation of care provided by the CNA showed Resident 3 was scheduled for 10 showers between 11/11/2024 and 12/12/2024. The documentation showed Resident 3, refused one shower, and only received four showers in 32 days, one per week. In an interview on 12/12/2024 at 10:31 AM, Staff B stated they expected staff to check the resident's preferences related to bathing and follow the CP. If the resident refused, staff should document the refusals in the resident's record. In an interview on 12/12/24 2:10 PM, Staff G (Resident Care Manager) stated Resident 3's bathing preferences should be written on the CP. Staff G reviewed the bath schedule and stated Resident 3 was scheduled two showers per week. Staff G reviewed Resident 3's bathing documentation and stated only one shower was documented per week. REFERENCE: WAC 388-97-1060 (2)(c) <Resident 22> According to the 12/05/2024 Annual MDS, Resident 22 admitted to the facility on [DATE] due to a stroke with weakness on one side of the body and was dependent on staff for bathing, dressing and personal hygiene. According to the revised 10/12/2024 ADL self-care performance deficit CP, Resident 22 had deficits due to left side body weakness and delusional disorder. Resident 22 required one-person total assistance with bathing, dressing, locomotion and personal care. Resident 22 needed one person stand by assistance with personal hygiene. Review of Resident 22's care staff task list from 12/01/2024 through 12/13/2024 showed no documentation of refusals for showers, dressing, personal hygiene, or dressing services. In an interview and observation on 12/10/2024 at 8:37 AM, Resident 22 stated they could not find their shoes and had just bought new shoes. Resident 22's hair was long just above the ears and hair appeared greasy. The resident's room smelled of urine. Observation on 12/10/2024 at 12:23 PM showed Resident 22's eyebrows were long and the resident had a moustache and beard. Resident 22 stated they wanted a haircut and to be shaved. Resident 22 was wearing a hospital gown. Observation on 12/11/2024 at 10:38 AM Resident 22 smelled like urine and hair was long and greasy. In an interview on 12/11/2024 at 10:45 AM Staff U (Certified Nursing Assistant - CNA) stated Resident 22 did not have any shoes, they had never seen Resident 22 with any shoes. Staff U stated Resident 22 was on the shower schedule but refused showers. Staff U stated staff offered assistance to the resident with shaving and changing but Resident 22 refused. In an interview on 12/11/2024 at 11:07 AM Staff Y (Licensed Practical Nurse), stated Resident 22 should have shoes on and should be getting up. Staff Y stated if Resident 22 refused showers, staff should document the refusals and notify the supervisor. In an interview on 12/13/2024 at 9:58 AM Staff B stated they needed to check why Resident 22 did not have any shoes and was not aware of this issue. Staff B stated for Resident 22 refusals of care, the approach for staff would be not to agitate the resident. Staff B stated if Resident 22 allowed beard care, staff could do it for the resident. Staff B stated staff should document if Resident 22 refused the care and notify the supervisor. Staff B stated Staff should make Resident 22 feel comfortable and must try and offer the care service. Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 3 (Residents 18, 22, & 3) of 18 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 18), bathing (Residents 22 & 3), and nail care (Resident 18), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life. Findings included . <Facility Policy> According to the facility's revised 08/2024 ADL policy, a resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's 2/2021 policy titled, Dignity, showed that the requirement for facility staff was to honor resident preferences. The policy stated that the facility would ensure residents were groomed as they wished and encouraged to dress in clothing that they prefer. The policy showed the Care Plan (CP) should include the resident's preferences. <Shaving and nail care> <Resident 18> According to the 09/23/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 18 admitted to the facility on [DATE] with left leg amputation below the knee, was assessed as cognitively intact, and required one person assistance with personal hygiene. Observations on 12/09/2024 at 10:48 AM, on 12/11/2024 at 8:55 AM, and on 12/12/2024 at 12:14 PM showed Resident 18 was in bed, was not shaved, and had long fingernails. Observation and interview on 12/12/2024 at 1:09 PM showed Resident 18 was up in a wheelchair in the dining room for lunch. Resident 18 was not shaved and had long facial hair. Resident 18 stated they needed staff assistance with shaving and staff shaved residents only on shower days. Resident 18 stated, I look like a homeless guy with this beard. I would like to be shaved at least every other day but did not happen. According to the 09/30/2024 ADL self-care performance deficit CP, Resident 18 required one person extensive assistance with bathing and personal hygiene. In an interview on 12/12/2024 at 10:31 AM, Staff B (Director of Nursing) stated they expected staff to check the resident's preferences related to ADLs and provide assistance as needed. If the resident refused, staff should document the refusals. Staff B reviewed Resident 18's record and stated the facility should have documented Resident 18's preferences and provided assistance with shaving their facial hair and clip their fingernails, but they did not.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Oxygen Monitoring> <Facility Policy> According to the facility's undated, Medication Administration policy dated 01...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Oxygen Monitoring> <Facility Policy> According to the facility's undated, Medication Administration policy dated 01/23 showed medications were to be administered in accordance with written orders of the prescriber. If necessary, the nurse would contact the prescriber for clarification of orders. The interaction would be documented in the nursing notes and elsewhere in the medical record. <Resident 27 > According to an 11/15/2024 Quarterly MDS Resident 27 had a disability related to cardiorespiratory conditions, heart failure and chronic obstructive pulmonary disease. Resident 27 had chronic respiratory failure with low oxygen and was on oxygen therapy. Resident 27 required assistance with transferring, moving from a lying to sitting position, and was not able to walk. Review of Resident 27's revised 07/03/2024 altered respiratory CP showed Resident 27 had difficulty breathing. Interventions listed on CP showed that Resident 27 would have oxygen delivered through nasal canula per the PO. Review of the 12/2024 Medication Administration Record (MAR) showed an order dated 06/25/2024 for Resident 27 to have continuous supplemental oxygen at 2 liters per minute. Nurses were required to initial that the oxygen concentrator was set at 2 liters of oxygen per minute. On 12/08/2024, 12/09/2024 and 12/20/2024 nurses initialed that oxygen was set at 2 liters. Observations on 12/08/2024 at 12:11 PM, 12/09/2024 at 1:11 PM, 12/10/2024 at 12:51 PM and 12/11/2024 at 6:48 AM showed Resident 27's oxygen setting was set at 2.5 liters of oxygen per minute. In an interview on 12/11/2024 at 10:35 AM, Staff B stated staff were expected to check oxygen settings every shift according to the instructions provided on the MAR. Staff B stated staff should follow the PO, adjust the oxygen setting if incorrect, or follow up with physician if the order needed to be change from the original order of 2 liters of oxygen per minute. <Nutrition Refusals> <Resident 71> According to the 10/31/2024 Quarterly MDS, Resident 71 had dementia, diabetes, depression, a brain disorder, muscle weakness, and a cardiac pacemaker. Review of the antidepressant medication CP revised on 10/15/2024, showed that Resident 71's family stated that Resident 71 was sad or depressed when the resident refused to eat. Interventions listed on the CP showed staff were to provide monitoring of side effects and effectiveness of the antidepressant medications and provide calm reassurance. One of the side effects listed for antidepressant medications included monitoring for appetite loss and weight loss. No interventions were listed on the CP on what to do when Resident 71 refused to eat. Review of the ADL CP revised 10/15/2024 showed Resident 71 had deficits related to stroke-like symptoms. The CP showed Resident 71 had a brain disorder, dementia and behaviors due to refusals of care. Interventions for Resident 71 included one-person total assistance with ADL's, provide maximum assistance with eating, set up the food tray and provide encouragement to eat. The CP did not show interventions for what staff would do when Resident 71 refused care or refused to eat. The Nutrition CP revised on 10/15/2024, showed Resident 71 had a variable appetite, inadequate oral intake and frequent refusal of meals and medications. The goal listed on the CP was Resident 71 would maintain adequate nutritional status by maintaining their weight. Interventions listed on the CP showed staff were to monitor side effects and effectiveness of prescribed medications and to monitor for malnutrition. The CP did not provide instructions on what to do when Resident 71 refused to eat or be weighed. The Palliative Performance Score (PPS) score CP dated 11/07/2024, showed Resident 71 had a score of 40%. A score of 40% showed that Resident 71 was totally dependent on staff for ADLs, was bed bound and had poor appetite and dementia. The CP showed Resident 71 refused food and medication and did not want to be forced to eat or drink. The CP showed if Resident 71 was unable to be referred to hospice, then Resident 71 would be transitioned to palliative (comfort) care. An intervention listed on the CP showed staff were to assist with Resident 71's wishes and to adjust ADL's assistance due to resident's changing abilities. Staff were to work with nursing staff to provide maximum comfort. The CP did not describe what interventions provided comfort to Resident 71 and did not show interventions when Resident 71 refused to eat or drink. The CP was not revised to show Resident 71 had hospice or palliative care services in place. Review of the [NAME] (care staff information sheet about resident's care) on 12/12/2024 showed staff were to report sad statements. No instructions were provided on the [NAME] on what interventions were needed when Resident 71 refused care, refused medications, or refused to eat. Review of progress notes dated 12/03/2024 by the facility ARNP (Advanced Registered Nurse Practitioner), showed Resident 71 had intermittent refusals of care and medications but was usually redirectable. Review of the 10/07/2024 care conference notes showed Resident 71 had no advanced directives or living wills set up to provide instructions on residents' wishes for care. Resident 71 only had a Physician's Order for Life Sustaining Treatment (POLST) for resuscitation and not receiving medically assisted nutrition. Review of the 12/2024 MAR for the review period of December 1 to 12, showed Resident 71 refused aspirin, depression medication, bedtime snack, hypertension medication, appetite suppressant, weekly weights, vitamin D and juice based or nutritional supplemental drinks every day. No documentation was found in the December MAR on who was notified of refusals. No documentation was found in the MAR of interventions staff were to provide when Resident 71 refused their medications, snacks, or being weighed. Review of the Capacity for Medical Decision form dated 4/24/2024 and signed by facility ARNP showed Resident 71 was unable to comprehend the risks, benefits and alternatives to medical decision and was not capable of making medical decisions on their own behalf due to dementia. In an interview on 12/08/2024 at 12:30 PM, Staff T (Restorative Aide) stated Resident 71 was able to feed themselves, but refused to eat. Staff T stated Resident 71 needed to be fed. In an observation on 12/09/2024 at 8:38 AM, Resident 71 stated no to a question about if they ate breakfast, observed Resident 71 stated no to all questions asked. Observed breakfast tray was set up approximately 15 minutes ago in room but was taken away 15 minutes later. Observations on 12/11/2024 at 8:24 AM, showed Staff U (Dietician) asked Resident 71 if they wanted breakfast and offered orange juice. Resident 71 stated no and Staff U removed tray. In an observation and interview on 12/11/2024 at 11:08 AM, Staff Y (Licensed Practical Nurse) stated Resident 71 did not have a weight taken this week. Observed December MAR showed an order dated 10/03/2024 for weekly weight checks. Staff did not weigh Resident 71 until surveyor requested. In an interview on 12/11/2024 at 12:38 PM, Staff Y had staff take Resident 71's weight using a mechanical lift and Resident 71 now weighed 149 pounds Staff Y stated there was a significant weight loss from last weight taken on 12/01/2024 which was documented as 168 pounds for a 19 pound weight loss. In an interview on 12/12/2024 1:06 PM, Staff J (Regional Social Services Director) stated social services staff should be immediately involved in resident refusals of care and services. There should be interventions and discussions with all involved and interventions should be updated in the CP. Staff J stated it was their expectation that nursing staff would notify the social services team of refusals of care and the effectiveness of refusal interventions, but notification did not happen. In an interview on 12/13/2024 at 9:21 AM, Staff K (Dietary Manager) stated Resident 71 was very depressed. Staff K stated Resident 71 did not want to eat and just said no to questions. Staff K stated, when residents have dementia, we don't ask them if they want to eat, we just take the meal to the resident. In an interview on 12/13/2024 at 9:58 AM Staff B stated for residents with decline in health conditions due to refusals of care impacting their medical conditions, staff should notify the provider and family and make referrals to coordinate services. Staff should continue to re-approach the resident and try to manage the refusals. If the goal was to keep Resident 71 comfortable, staff should still try to offer care. Staff B stated, when care staff observed changes of condition for Resident 71, staff should have reported these changes to the nurse. Staff B stated the CP should address refusals and what to do when Resident 71 refused care. Staff B stated staff should have weighed Resident 71 however the goal was to keep Resident 71 comfortable by not weighing them. In an interview on 12/13/2024 at 1:23 PM Staff B stated we tried supplements but Resident 71 refused. Staff B stated if Resident 71 did not refuse hospice services, we could do more to help Resident 71 be more comfortable. Based on observation, record review, and interview the facility failed to follow provider orders for 1 of 2 residents (Resident 35) reviewed for bed rails, failed to provide oxygen monitoring for 1 of 1 residents (Resident 27), failed to follow treatment as ordered by the physician, monitor, and document bruises for 3 of 12 residents (Residents 139, 15, and 45) reviewed for skin issues, and failed to provide interventions for nutrition refusals for 1 of 7 residents (Resident 71) reviewed for nutrition. These failures placed the residents at risk for poor clinical outcome and a decreased quality of life. Findings included . <Policy> According to a facility policy titled, Proper Use of Bed Rails, revised 11/2024, the facility would ensure correct installation, use, and maintenance of the bed rails. <Following Provider Orders> <Resident 35> According to a 11/13/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 35 had no bed rails in use. The MDS showed Resident 35 was dependent on staff to roll side to side in bed. The MDS showed lying to sitting in bed was not attempted for Resident 35 during the assessment period. Review of 06/08/2023 Activities of Daily Living (ADL) self-care performance deficit Care Plan (CP) related to right hand contracture, Resident 35 would have bilateral bed rails on their bed to assist with increased self-mobility. Review of Resident 35's records showed a 06/09/2023 provider order for bilateral bed rails to enhance bed mobility and independence. Resident 35's records showed a 06/09/2023 Physician's Order (PO) to check skin every shift for injury related to bed rails. Review of a 08/16/2023 bed rail use assessment form showed Resident 35 was assessed to require bilateral bed rails for assessed medical need, safety, treatment of a medical symptom/condition, and for mobility/transferring assistance. The assessment showed the bed rails would benefit Resident 35 in movement up or down in bed, assist resident in easier access to bed control, assist the resident turning side to side in bed, assist with balance while attempting to stand, and would assist the resident getting in and out of bed. According to the bed rail assessment, Resident 35 was able to transfer between positions, turn independently side to side in bed, and was able to safely exit/enter the bed. The assessment showed bed rails were recommended to be always used while in bed for Resident 35. Review of Resident 35's records showed a revised 12/15/2023 provider order for bilateral bed rails to enhance bed mobility and independence. Resident 35's records also showed a revised 12/15/2023 provider order to check skin every shift for injury related to bed rails. Observations on 12/09/2024 at 9:29 AM, 12/10/2024 at 8:56 AM, and 12/11/2024 at 7:55 AM showed Resident 35 lying in bed with no bed rails installed to their bed. In an interview on 12/11/2024 at 9:15 AM, Staff F (Registered Nurse Manager) stated therapy would assess resident's needs for bed rails and provide recommendations. Staff F stated staff were expected to assess proper placement of bed rails and the resident's skin for any injuries every shift, and document in the TAR. Staff F stated Resident 35 was assessed to require bilateral bed rails to assist with bed mobility and for their safety. In an interview on 12/11/2024 at 1:10 PM Staff F stated Resident 35 did not have bed rails installed on their bed, but they should have as therapy assessed bilateral bed rails to be required. Staff F stated staff should not sign the TARs that the bed rails were in place when they were not. In an interview on 12/13/2024 at 9:12 AM Staff B (Director of Nursing) stated they expected staff to follow provider orders and recommendations. Staff B stated it was important to follow provider orders as part of the resident's CP. <Resident 15> According to the 10/14/2024 Quarterly MDS, Resident 15 was alert and usually understood others. Resident 15 required one person assistance with ADLs. Review of December 2024 POs showed an 11/14/2024 order directed staff to clean Resident 15's right shin, apply antibiotic ointment, and cover with border gauge every day. Review of Resident 15's December 2024 Treatment Administration Record (TAR) showed licensed nurses signed every day that they provided the treatment as ordered by physician. Observations on 12/08/2024 at 10:06 AM, on 12/09/2024 at 9:02 AM, on 12/10/2024 at 9:19 AM and at 12:41 PM, and on 12/11/2024 at 11:43 AM showed Resident 15 was up in their wheelchair, had dry scabs on their lower legs and no dressing observed on their legs. In an interview on 12/11/2024 at 12:25 PM, Staff B stated it was their expectations from the staff they follow the POs. Staff B went to Resident 15's room with the surveyor and observed no dressing was applied on Resident 15's leg as ordered. During observation, Staff B noticed Resident 15 had no open skin issues, had only dry scabs on lower legs. Staff B reviewed Resident 15's record and stated staff should assess Resident 15's skin and notify the physician to change the order, but they did not. Staff B stated staff should not sign the treatment they did not provide. <Resident 45> According to the 11/12/2024 Quarterly MDS, Resident 45 admitted to the facility on [DATE] with muscle weakness and seizure disorder and had no memory impairment. The MDS showed Resident 67 had more than two falls since their admission in the facility. Observation on 12/08/2024 at 11:58 AM showed Resident 45 was lying on the floor in their room, screaming, I fell again, help me. Observation on 12/09/2024 at 9:20 AM showed Resident 45 was lying in their bed in hospital gown and observed multiple faded small bruises on both arms and another big purple bruise on left upper arm. In an interview on 12/10/2024 at 11:37 AM, Resident 45 stated they keep falling all the time and getting those bruises on their arms. Review of Resident 45's record on 12/11/2024 showed no PO and no CP to direct staff to monitor the bruises on Resident 45's body for any changes and document. In an interview on 12/11/2024 at 12:13 PM, Staff B stated they expected the facility staff to perform skin check every week and after every fall and document in resident's record. Staff B reviewed Resident 45's record and stated staff should have assessed the resident's skin after the fall happened on 12/08/2024 and documented the bruises in Resident 45's record to monitor for any change, but they did not. REFERENCE: WAC 388-97-1060(1). <Resident 139> According to the 12/03/2024 admission MDS Resident 139 had multiple medically complex diagnoses including liver disease. This MDS showed Resident 139 had recent major surgery. Review of a revised 11/27/2024 skin impairment CP showed staff identified the goal for Resident 139 was to have no complications related the alteration of the skin integrity. The CP listed interventions for staff to follow facility protocols for treatment of the injury and to refer Resident 139 to a contracted wound team for evaluation and treatment. Review of Resident 139's POs showed a 12/04/2024 order for staff to adjust the settings of a wound Vacuum-Assisted Closure (VAC - a device that uses suction to help in wound healing), to negative 75 Millimeters of Mercury (mmHg) continuous suction for a surgical wound to Resident 139's abdominal area. Observations on 12/08/2024 at 9:52 AM showed a wound VAC machine sitting on Resident 139's bedside table. This container was positioned upside down on the table, with the liquid collection chamber on the bottom. Observations on 12/09/2024 at 2:53 PM showed the wound VAC machine on Resident 139's bedside table with the liquid collection chamber on its side. On 12/10/2024 at 1:03 PM, Resident 139's wound VAC machine was sitting upright, with a label showing, must remain upright. The wound VAC machine was set at 125 mmHg. Observations on 12/11/2024 at 6:32 AM showed Staff G (Resident Care Manager) providing surgical wound care to Resident 139. Once finished, Staff G checked the wound VAC settings, which showed the setting was at 125 mmHg. Staff G adjusted the wound VAC settings to negative 75 mmHg. In an interview on 12/13/2024 at 12:15 PM, Staff G stated the placement of a wound VAC machine should be checked every shift by nursing staff, with the proper function assessed, and to assure the physician ordered settings were followed. Staff G stated the wound VAC container should be positioned upright at all times for proper suction. Staff G stated Resident 139's wound VAC settings should have, but were not, set to negative 75 mmHg. Staff G stated incorrect settings could affect effective wound healing and it was their expectation nurse staff would follow the PO.

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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Based on observation, interview, and record review the facility failed to ensure residents with vision deficits were assessed and provided assistive devices to maintain vision abilities for 1 of 2 residents (Resident 39) reviewed for vision needs. These failures placed Resident 39 and other residents at risk for unmet care needs and a decreased quality of life. Findings included . <Policy> According to a facility policy titled, Hearing and Vision Services, revised 12/2022, the facility would identify and assess a resident's vision abilities through ongoing monitoring of sensory problems. The policy showed the social worker was responsible for assisting residents and their representatives in locating and utilizing any available resources for the provision of the vision services the resident needed. The policy showed the social worker would assist residents by making appointments and arranging transportation to and from vision provider services. The policy showed employees would assist the resident with the use of adaptive equipment needed to maintain vision such as talking books or magnifying lenses. <Resident 39> Review of the 06/10/2024 admission Minimum Data Set (MDS - an assessment tool) showed Resident 39 readmitted to facility on 06/04/2024. The MDS showed Resident 39 was able to make themselves understood and usually understood others. The MDS showed Resident 39 had moderately impaired vision without corrective lenses available. Review of a 06/15/2024 Impaired Visual Function Care Plan (CP) Resident 39 preferred to not wear glasses. The CP showed staff were to identify and record environmental factors affecting visual function. In an observation and interview on 12/08/2024 at 9:41 AM Resident 39 was unable to see their television and did not have glasses or any other visual assistive devices available for their use. Resident 39 stated their Resident Representative (RR) had talked with social services department and requested an eye exam because their eyesight was bad, and Resident 39 needed glasses. Resident 39 stated their RR told the social service department at the facility that they could not see their television and needed glasses. Resident 39 stated the facility kept putting the eye exam off and they were waiting for months. Resident 39 denied ever refusing eye exams and stated they were not offered an exam since being at the facility. In an interview on 12/12/2024 at 7:11 PM Resident 39's RR stated they requested social services schedule Resident 39 an eye exam to get glasses on several occasions over the past few months verbally and in text messages. Review of Resident 39's RR text message communications showed requests to schedule an eye exam with a 10/23/2024 at 3:05 PM response from the facility's social worker stating they would include Resident 39 on the list to be seen by the eye doctor. Resident 39's RR stated Resident 39 was not seen by the eye doctor and did not receive any explanation as to why the appointments did not occur. In an interview on 12/13/2024 at 8:24 Staff E (Social Service Director) stated the social worker Resident 39's RR communicated with was no longer an employee at the facility and quit about one and a half weeks before the date of this interview. Staff E stated the previous social worker cleared their data from their laptop prior to turning it into the facility. Staff E stated there was no documentation in Resident 39's records showing the communication with the RR, but the previous social worker should have saved this in Resident 39's records. Staff E stated the eye doctor came monthly but Resident 39 was never put on the list to be seen. Staff E stated Resident 39 should have been included on the list when the previous social worker replied they would add them and was not sure why this did not happen. Refer to F657 - Care Plan Timing and Revision Refer to F842 - Resident Records REFERENCE: WAC 388-97-1060(3)(a). .

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to ensure 2 of 5 residents (Resident 71 & 1) reviewed for Pressure Ulcers (PU- injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, report, and implement wound prevention recommendations and interventions placed residents at risk for deterioration in skin condition(s), pain, and diminished quality of life. <Facility Policy> Review of the revised 11/2024 Pressure Injury Prevention and Management policy, the facility was committed to the prevention of avoidable pressure injuries and to provide treatment and services to heal the injury, prevent infection and the development of additional pressure ulcers/injuries. The facility would establish and utilize a systematic approach for pressure injury prevention and management including prompt assessment and treatment. Nursing assistants would inspect the skin during baths and report any concerns to the resident's nurse immediately after the task. <Resident 71> According to the 10/31/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 71 had Non-Alzheimer's dementia, diabetes, depression, muscle weakness, and was at risk for pressure ulcer and injury. Review of the revised 02/04/2024 impairment to skin integrity Care Plan (CP) showed Resident 71 had potential for impairment to skin integrity due to incontinent of bowel and bladder and weakness. Interventions instructed staff to prevent skin injury, encourage good nutrition and hydration, monitor and report signs and symptoms of skin breakdown to the physician, complete weekly skin checks, and report abnormalities to the physician. Review of the 12/04/2024 weekly skin assessment showed Resident 71 had no new skin issues. Review of Resident 71's caregiver task sheet from 12/01/2024 thru 12/09/2024 showed staff documented no observation of skin issues. On 12/10/2024 staff documented a reddened area as a new issue. On 12/11/2024, 12/12/2024, and 12/13/2024 staff documented no observations of skin issues. Observation and interview on 12/09/2024 at 1:22 PM showed Staff W (Certified Nursing Assistant) was providing personal care to Resident 71. Observation of Resident 71 showed an open area on their coccyx area about 0.4 X 0.4 Centimeter (cm) with redness and had no dressing on it. Staff W stated they did not notice the open area before. In an interview on 12/10/2024 at 10:47 AM, Staff X (License Practical Nurse) observed Resident 71's skin and stated Resident 71 had recurring pressure areas on their back. Staff X stated the wound was open and they would notify their nursing director. Staff X measured the wound approximately 0.5 by 0.5 cm in size with small amount of bloody drainage. Staff X stated the CNAs were supposed to notify the nurse and document the skin conditions to trigger the nurse to look at the wound. Staff X stated they were not notified about Resident 71's new skin issue from 12/9/24. In an interview on 12/13/2024 at 1:23 PM, Staff B (Director of Nursing) stated care staff were expected to notify the nurse of any skin changes. The nurses would obtain and implement new interventions. Staff B stated the staff did not follow facility policy for Resident 71's open area to their coccyx, but should have. <Resident 1> According to the 09/23/2024 MDS, Resident 1 had morbid obesity, back pain, severe pain due to damaged nerves, and osteoporosis (weakened bones). The MDS showed Resident 1 was dependent on staff for toileting hygiene, bathing, upper and lower body dressing and personal hygiene. Review of the revised 10/08/2024 impairment to skin integrity CP, showed Resident 1 had recurring moisture associated skin damage to the buttock, coccyx, and bilateral thighs. Resident 1 had a chronic wound to the right lower leg. Interventions listed on the CP instructed staff to keep the skin clean and dry, follow up with wound care recommendations given by the wound care specialist and monitor the size, treatment to the skin injury, and to report abnormalities and signs and symptoms of infection to the provider. The interventions included instructions for the licensed nurses to complete the weekly skin assessments. Review of Resident 1's December 2024 Treatment Administration Record (TAR) showed weekly skin checks were completed on 12/02/2024, 12/09/2024 and no new skin issues were identified. Review of December 2024 TAR showed Resident 1 refused the compression wraps treatment order on 12/09/2024 and 12/10/204. Review of Resident 1's record showed no documentation staff notified the provider or social services about Resident 1's refusals of treatments of compression wraps on right lower leg wound. There was no documentation that showed staff discussed with the resident the reason for refusals or notified the physician to receive alternative orders. Interview on 12/10/2024 at 9:00 AM showed Resident 1 stated their wound on the right leg was supposed to be dressed with a special type of dressing but staff did not have that dressing available last week. Observation of the right lower leg dressing showed it was soiled with yellow/brown drainage, with a strong odor. Resident 1 stated Staff F (Resident Care Manager) came to their room last night and told the nurses to change the soiled dressing but no one changed the dressing. Observation and interview on 12/10/2024 at 12:13 PM showed Staff X (Licensed Practical Nurse) observe Resident 1's loose undated gauze dressing on the right leg wound, saturated with drainage. Staff X observed the wound was draining onto Resident 1's bed and exhibited a strong odor. Staff X stated they would change the dressing. Observation and interview with the wound team on 12/11/2024 at 7:02 AM showed the wound care consultant along with Staff B stated, Resident 1 did not receive the skin graft dressing on right leg wound because there was a delay in the skin graft dressing delivery because of the holiday. Wound consultant measured the right leg wound as 3.5 x 2 x 0.2 cm open with drainage with odor. The wound care consultant stated they received the skin graft dressing today and would apply the dressing on Resident 1's wound for 7 days. The wound care consultant told Staff B if Resident 1 did not want to use the compression wraps, another tubular shaped bandage could be used. In an interview on 12/12/2024 at 12:57 PM Staff F (Resident Care Manager) stated their expectations was the direct-care staff would report any skin issues to the nurses on duty immediately and nurses would notify the provider to get treatment orders. Staff B stated staff should follow the physician orders and notify the physician if the dressing was not available, but they did not. REFERENCE: WAC 388-97-1060(3)(b). .

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 the resident environment was free of accident hazards for 2 of 6 units (East Central 2 & [NAME] Central 2) sampled for accidents. This failure to store chemicals safely, placed residents at risk for exposure to unsafe chemicals. Findings included . <Facility Policy> Review of a facility policy titled, Environmental Services Safety Procedures, revised December 2024, showed the facility would validate general safety procedures were followed while performing housekeeping and/or laundry duties. Staff would validate the chemicals were properly stored and not left unattended in areas that were accessible to residents. When not in use, chemicals would be stored in a locking closet, cabinet or storage area for safety. Chemicals would be stored out of reach of residents and always locked up while in storage. Observation on 12/08/2024 at 8:30 AM, showed the second-floor central hall had a facility cabinet sink located by room [ROOM NUMBER]. One bottle of Insect killer ant, roach, and fly spray was found in an unsecured and unlocked drawer within the facility cabinet. The insect killer spray had a caution warning on the can. Observation on 12/08/2024 at 8:34 AM, the housekeeping supply closet on second floor central hall, did not have a lock on the door. Observed one bottle of enzymatic cleaner and one bottle of spray polish and cleanser on a shelf within the closet. Observation on 12/09/2024 at 9:31 AM showed the utility room located by the facility's stairwell was open. The door had a biohazard sticker on the door and a security number to access the room, but the door was ajar. Several bottles of no rinse foam cleanser conditioning for hair and skin, with a warning label that read for external use only were located in the utility room. There was a biohazard material only - no trash sign posted within the room. In an interview on 12/09/2024 at 9:28 AM Staff P (Housekeeping Aid), stated the chemicals should not be in the utility room/housekeeping closet. Staff P stated some staff may not be able to open the other locked housekeeping closets and may have put chemicals in the unlocked closet. Staff P stated the chemicals were not supposed to be there for resident's safety. Staff P then went to the facility sink cabinet on the second-floor unit and stated the insect killer bottle in the drawer should not have been there. In an interview on 12/10/2024 at 12:34 PM Staff C (Regional Administrator) stated chemicals should be locked up. Staff C stated per our policy, all chemicals should be locked up. This was important for safety as the facility does not want residents to eat or drink chemicals. Staff C stated some housekeeping closets had locks on them but not all of them. REFERENCE: WAC 388-97-1060(3)(g). .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview the facility failed to ensure Narcotic Ledgers were accurate for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to ensure accurate account of resident narcotic medications placed the residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances. Findings included . <Policy> Review of the facility policy titled, Controlled Medication Storage, dated 01/2024, controlled substances were subject to special record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. <East 2 Narcotic Ledger> Observation and record review on 12/09/2024 at 3:13 PM of the East 2 narcotic lock box and ledger showed page 83 with 30 tablets remaining transferred to page 101. Review of page 101 showed the starting count was 29 tablets, 1 tablet missing from the remaining balance from page 83. Page 96 showed 14 tablets remaining with the whole page crossed off and no card of medications in the lock box for page 96. Page 99 showed 20 tablets remaining with the page crossed off and transferred to page 99 written in, balanced transferred to unit box was left blank, and no card of medications was in the lock box. Page 103 showed 20 tablets remaining with the whole page crossed off and no card of medications in the lock box for page 103. Page 111 and 112 was missing from the East 2 narcotic ledger, the pages were ripped out. In an interview on 12/09/2024 at 3:13 PM Staff I (Licensed Practical Nurse) stated they reported the missing narcotics to Staff F (Resident Care Manager) and Staff B (Director of Nursing) when first observed counting off with the night nurse on 11/08/2024. In an interview on 12/09/2024 at 3:15 PM Staff B stated they were notified of the missing narcotics and the pages torn out, pages 111 and 112, in the East 2 narcotic ledger by Staff I on 11/11/2024. Staff B stated they instructed Staff F (Registered Nurse Manager) and staff H (Registered Nurse Manager) to make a notation on each page that was incorrect so that it was corrected in the narcotic ledger for future nurses accepting the keys to that medication cart, but they did not check to ensure Staff F and Staff H made the notations. Staff B stated they ordered a pharmacy narcotic audit which was completed on 12/05/2024 and 12/06/2024. Staff B stated the pharmacist did not report any other discrepancies at the time of the audit. Refer to F609 - Reporting of Alleged Violations Refer to F610 - Thorough Investigation REFERENCE: WAC 388-97-1300(1)(b)(i-ii). .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview the facility failed to ensure expired medications were removed timely from use in 2 of 2 medication carts (West 1 & East 2), 1 of 2 medication storage rooms (East 2 medication room), and cleanliness was maintained for 2 of 2 medications carts (West 1 & East 2 carts) reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective medications, potential infections, and a diminished quality of life. Findings included . <Policy> According to a facility policy titled, Medication Storage/Storage of Medications, dated 01/2023, showed expired, contaminated, discontinued, or deteriorated mediations and supplies would be immediately removed and disposed of. The policy showed staff would keep all medication storage areas clean. The policy showed medication storage conditions would be monitored and corrective action would be taken for problems identified. < [NAME] 1 Medication Cart> Observation, record review, and interview on 12/09/2024 at 1:22 PM showed a 09/30/2024 expired bottle of laboratory testing solution, a 12/2024 expired bottle of laxatives, and a bottle of pain medication with the expiration date worn off/illegible during the medication storage review of the [NAME] 1 medication cart. Review of the [NAME] 1 medication cart showed liquid medications spilled in bottom of the drawers with several medication bottles stuck to the drawers. In an interview at this time Staff BB (Licensed Practical Nurse-LPN/Supervisor) stated nurses were expected to ensure the carts were clean and expired medications were removed before handing off to next shift nurse. Staff BB stated the [NAME] 2 cart was not cleaned as expected and the expired medications should have been removed and disposed of. <East 2 Medication Cart> Observation, record review, and interview on 12/09/2024 at 2:32 PM showed a 11/3/2024 expired card of medications with four tablets remaining, and a 12/6/2024 expired card of medications with 30 tablets remaining. Review of the East 2 medication cart showed loose pills in the bottom of the drawers. In an interview at this time Staff I (LPN) stated they were expected to remove and dispose of the expired medications and clean the cart before handing off to the next shift nurse. Staff I stated the expired medications, and loose pills should have been removed and disposed of prior to accepting the cart from the night nurse but they were not. <West 2 Medication Room> Observation, record review, and interview on 12/10/2024 at 12:52 PM showed a 06/30/2024 expired Intravenous (IV) start kit, fourteen 10/09/2024 expired IV sets, twenty one 02/15/2024 expired IV lock caps, three 02/13/2024 expired IV lock caps, three 03/21/2024 expired IV lock caps, twelve 07/17/2024 expired IV lock caps, twelve 09/16/2024 expired IV lock caps, fourteen 09/06/2024 expired IV lock caps, six 08/31/2024 expired IV lock caps, ten 10/10/2024 expired IV lock caps, eight 10/04/2024 expired IV lock caps, three 10/02/2024 expired IV lock caps, one 09/14/2024 expired IV flush, and one 05/31/2024 expired syringe with a needle in the [NAME] 2 medication storage room. In an interview at this time Staff I stated they were expected to keep the medication storage room free of expired medications and supplies and dispose of them before or by the expiration dates. Staff I stated the expired medications and supplies observed in East 2 medication storage room should have been disposed of by the listed expiration dates. In an interview on 12/11/2024 at 9:53 AM Staff B (Director of Nursing) stated they expected the nursing staff to dispose of expired medications by the expiration dates and keep the medication carts and storage rooms clean at all times. REFERENCE: WAC 388-97-1300(2). .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 5 residents (Resident 39) reviewed for dental services. This failure placed residents at risk for oral discomfort and a diminished quality of life. Findings included . <Policy> Review of a facility policy titled, Dental Services, revised 12/2022, showed the facility would assist residents in obtaining routine and emergency dental care. The policy showed residents dental needs would be identified through a physical assessment and, oral and denture care would be provided in accordance with the resident's identified needs. The policy showed referrals to dental providers would be made by the facility for residents. The policy showed all actions and information regarding dental services, including any delays related to obtaining dental services, would be documented in the resident's medical records. <Resident 39> According to the 10/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 39 was able to make themselves understood and understood others. The MDS showed Resident 39 was dependent on staff for oral care. Review of a 06/23/2024 Alteration in Dentition and/or Oral Hygiene Care Plan (CP) showed staff would refer Resident 39 to the dentist/dental hygienist for evaluation and recommendations. The CP showed Resident 39 had no teeth or dentures available. In an observation and interview on 12/08/2024 at 9:41 AM Resident 39 had no teeth and no dentures available for their use. Resident 39 stated their Resident Representative (RR) talked with the social services department and requested a dental exam so Resident 39 could be fitted for dentures. Resident 39 stated the facility kept putting the dental exam off. Resident 39 stated they were waiting months for a dental appointment. Resident 39 denied ever refusing dental exams and stated they were not offered an exam since being at the facility. In an interview on 12/12/2024 at 7:11 PM Resident 39's RR stated they requested social services schedule Resident 39 a dental exam to get dentures on several occasions over the past few months. Resident 39's RR stated the facility social worker informed them they would put Resident 39 on the list to be seen by the dentist, but they were not. In an interview on 12/13/2024 at 8:24 Staff E (Social Service Director) stated the social worker with whom Resident 39's RR communicated, was no longer an employee at the facility and quit about one and a half weeks before the date of this interview. Staff E stated the previous social worker cleared their data from their laptop prior to turning it into the facility. Staff E stated there was no documentation in Resident 39's records showing the communication with the RR, but the previous social worker should have documented this in Resident 39's records. Staff E stated they were unable to recall the last time the dentist was in the facility because they canceled due to illness and then the facility canceled the dental visits due to an infectious outbreak in the facility. Staff E stated Resident 39 was never put on the dentist list to be seen. Staff E stated Resident 39 should have been included on the dentist list when the previous social worker informed the RR they would add them and was not sure why this did not happen. REFERENCE: WAC 388-97-1060(1)(3)(j)(vii). .

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to keep all Protected Health Information (PHI) in the residents' records confidential and out of view from unauthorized individuals for 4 of 84 residents (Resident 340, 80, 10, & 39). This failure placed all former and current residents at risk for a violation of their right to privacy. Findings included . <Facility Policy> Record review of the facility's 9/1/2021 policy titled Health Information Portability and Accountability Act-HIPAA Security Measures policy showed that the facility would implement appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that were in electronic format. Record review of the facility's 2/2021 policy titled Dignity policy showed that the staff would protect confidential clinical information. Record review of the facility's 3/17/2024 admission Agreement showed the resident has the right to personal privacy and confidentiality of their personal and clinical records. <Resident 340> An observation on 12/10/2024 at 1:14 PM, showed the electronic wall device on the first floor hallway displayed Resident 340's full name and care information. The device was unattended with no staff nearby. A visitor was observed passing by the visible PHI on two separate occasions. In an interview on 12/10/2024 at 1:50 PM, Staff Q, (Certified Nurse Assistant), stated they left the device open with PHI visible, because they were in a rush and forgot to log out. Staff Q stated PHI should not be left unattended or visible to unauthorized individuals. Staff Q stated Resident 340's right to privacy was violated. In an interview on 12/13/2024 at 11:26 AM, Staff R, (Medical Records Director), stated that no laptops or electronic screens used to display PHI should be left unattended nor visible to unauthorized individuals. Staff R stated the purpose is to protect residents' privacy. <Resident 80> Observation on 12/12/2024 at 8:09 AM Staff S (Registered Nurse) walked away from medication cart with computer open to Resident 80's medical records. In an interview on 12/12/2024 at 8:10 AM Staff I (Licensed Practical Nurse) stated all resident information must be kept confidential, and they should have locked their computer before they walked away from it. Staff I stated it was important to keep resident information confidential for resident's privacy. <Resident 10> Observation on 12/10/2024 at 8:45 AM Staff I walked away from cart with computer open to Resident 10's medical records. In an interview on 12/10/2024 at 8:48 AM Staff I stated they didn't normally leave resident records unsecured. Staff I stated confidentiality of resident records was important for resident rights and privacy. <Resident 39> Observation on 12/12/2024 at 7:11 PM Resident 39's representative showed text message communications regarding Resident 39's care with a facility social worker. Review of Resident 39's records did not show documentation of the communication with Resident 39's representative and the social worker. In an interview on 12/13/2024 at 8:24 Staff E (Social Service Director) stated the social worker Resident 39's RR communicated with was no longer an employee at the facility and quit about one and a half weeks before the date of this interview. Staff E stated the previous social worker cleared their data from their laptop prior to turning it into the facility. Staff E stated there was no documentation in Resident 39's records showing the communication with the RR, but the previous social worker should have saved this in Resident 39's records. In an interview on 12/13/2024 at 9:12 AM Staff B (Director of Nursing) stated they expected staff to keep resident records confidential. Staff B stated they expected staff to lock computers before they walked away from them for resident's rights to privacy. Staff B stated they expected resident records to be accurately documented and readily accessible as required. REFERENCE: WAC 388-97-1720(1)(c),-0360(1). .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Ice Machine> Observation on 12/11/2024 at 12:40 PM showed the first floor ice machine had a plastic cover over the ice in...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Ice Machine> Observation on 12/11/2024 at 12:40 PM showed the first floor ice machine had a plastic cover over the ice inside of the ice machine. The white plastic cover had brown debris and a slimy pink debris along the edges and the bottom of the plastic cover. Observation of the cleaning log posted on the outside of the ice machine showed the last cleaning was completed on 12/06/2024 and the prior cleaning was completed on 11/10/2024. In an observation and interview on 12/11/2024 at 12:47 PM, Staff D checked the ice machine and wiped off slimy pink film and brown from the plastic cover within the ice machine. Staff D stated the ice machine should be cleaned weekly if not more, but it did not look like this was done recently. Staff D stated this should be reported by staff frequently using the ice machine, but was not. Staff D stated they did not routinely check the inside of the ice machine. Staff D stated it was important for the ice machine to be cleaned regularly otherwise infections could occur. In an interview on 12/13/2024 at 8:52 AM Staff L (Maintenance Assistant) stated they cleaned the outside of the ice machine weekly and cleaned the inside of the ice machine monthly but did not keep a log of cleaning of the inside of the ice machine. <Enhanced Barrier Precautions> <Resident 71> According to a 10/31/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 71 was admitted to the facility on [DATE] with a gall bladder obstruction. Review of a 10/15/2024 revised EBP Care Plan (CP) showed, Resident 71 had an indwelling gall bladder tube (inserted through the body) that was attached to a drainage bag located on the outside of Resident 71's right abdominal area. The goal listed on Resident 71's CP showed EBP would reduce the risk of transmission of multidrug resistant organisms (MDRO). Interventions showed for EBP, staff would use gowns and gloves during high contact resident care. High contact care activities listed on CP showed when assisting Resident 71 with dressing, bathing, transfers, linen changes, incontinent care and wound and/or indwelling device care. Posting of EBP signage and a supply bin of PPE would be placed outside of the resident's room so staff had access to PPE supplies. Observation on 12/09/2024 at 1:22 PM, Staff W (Certified Nursing Assistant) was observed to change the incontinent pad of Resident 71. Staff W had on gloves and a mask but did not have on a protective gown. There was no signage on the door to indicate Resident 71 was on EBP. Observation on 12/10/2024 at 8:43 AM, Resident 71 had a gall bladder drainage bag on the right side of their body. The drainage bag was leaking brown and yellow drainage on Resident 71's bed sheets. An EBP sign was not posted in Resident 71's room or on/near the door and there were no PPE supplies available. Review of the facility's list of residents on EBP precautions was supplied by Staff D on 12/11/2024 at 12:47 PM. The list did not show Resident 71 was on the EBP list. <Resident 1> Observation on 12/09/2024 at 8:32 AM, Resident 1 had a dressing on their right lower leg related to chronic open wound with drainage. Resident 1's room was observed to have EBP signage on the room door as well as EBP PPE supplies in a cart within Resident 1's room. Observation on 12/10/2024 at 12:13 PM Staff X (Licensed Practical Nurse - LPN) went into Resident 1's room to observe the wound to right lower leg. Staff X lifted up the blanket covering Resident 1's leg and wound dressing on the right side of Resident 1's lower leg. Staff X observed Resident 1's wound was wet and fluid drained onto their bed sheets. Staff X stated they would come back to change the dressing on Resident 1. Staff X did not put on a PPE gown before assessing Resident 1's wound as noted for EBP protocols. <Resident 43> Observation on 12/09/2024 at 8:38 AM showed Resident 43 had EBP signage posted on the wall near the resident's room. Resident 43 had a indwelling urinary catheter. The signage posted for EBP within the room read staff must put on a gown and gloves before room entry and discard the PPEs before exiting the room. Staff Z (MDS LPN) was observed to come into Resident 43's room to respond to the call light. Staff Z assisted Resident 43 with fixing their hospital gown and helped to slide and reposition Resident 43 in bed. Staff Z did not put on a protective gown on when they entered Resident 43's room. In an interview on 12/11/2024 at 9:16 AM, Staff D stated for residents on EBP, there should be a sign on the door, so staff knew when to wear PPE. Staff D stated for any device that goes into the body and for any open skin treatment, EBP should be in place. Staff D stated all staff were trained on EBP precautions and how to use PPE supplies. Staff D stated they were not aware that Resident 71 had an indwelling device and needed to be on EBP precautions. In an interview on 12/11/2024 at 9:34 AM Staff B (Director of Nursing) stated EBP had to be in place whenever staff were in close contact with resident's who had high contact activities. Staff B stated all staff needed to follow instruction on the EBP signage. Staff B stated Resident 71 should have had EBP precautions due to the gall bladder indwelling device. REFERENCE: WAC 388-97-1320 (1)(a), -1320 (1)(c), -1320 (3). Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. The facility failed to implement and/or follow isolation precautions for 4 of 7 residents (Resident 18, 71, 1, and 43) reviewed for Enhanced Barrier Precautions (EBP) , failed to follow Transmission Based Precaution for 1 of 1 residents (Resident 339) reviewed for TBP, failed to consistently perform Hand Hygiene (HH) for 1 of 1 residents (Resident 80), failed to clean the shower room, and failed to sanitize the ice machine. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <Facility Policy> According to the facility's 03/2023 Infection Control Policies and practices policy, the facility would maintain a safe, sanitary, and comfortable environment to help prevent and manage the transmission of diseases and infections. The facility would establish guidelines for implementing isolation precautions, including Standard and Transmission based Precautions; and would provide guidelines for hand hygiene, safe cleaning and processing of reusable resident care equipment. <Enhanced Barrier Precautions> <Resident 18> Observations on 12/08/2024 at 8:52 AM and 10:09 AM showed Resident 18 was lying in bed. The resident had an indwelling catheter (a tube inserted in bladder to drain urine) hanging on the bed frame. Observations showed no isolation sign outside or inside Resident 18's room to demonstrate EBP were required. In an interview on 12/08/2024 at 10:42 AM, Resident 18 stated they came back from the hospital with a catheter in their bladder. Review of Resident 18's clinical record showed a 12/06/2024 physician order that instructed staff to implement EBP related to Resident 18's indwelling catheter placement. In an interview on 12/08/2024 at 1:18 PM, Staff D (Infection Control Preventionist) stated it was their expectation residents with an indwelling catheter were placed on EBP. Staff D stated Resident 18 came back from the hospital with an indwelling catheter on 12/06/2024. Staff D stated the facility should have placed Resident 18 on EBP, but they did not.<Shower Room> Observations on 12/08/2024 at 9:36 AM showed a shower room on West-1 unit with a shower drain cover full of debris and dried hair. The floor was dry. A log documenting shower room cleaning was found in the room. Staff documented in this log the last date of cleaning was listed as 08/28/2023. Observations on 12/10/2024 at 8:27 AM showed staff assisting a resident in the West-1 unit shower room. On 12/10/2024 at 8:48 AM, staff brought the resident out of the shower room, at which time observations showed the shower drain still contained the same debris and hair previously noted from 12/08/2024, two days earlier. Observations on 12/10/2024 at 8:55 AM showed Staff J (Registered Nurse Manager) enter the West-1 unit shower room and upon exit the drain was clean. In an interview on 12/10/2024 at 9:00 AM, Staff J stated it was their expectation staff sanitize the shower drain and surrounding area after each resident use. Staff J stated they cleaned out the shower and indicated it had a lot of build up from previous uses. Staff J stated they needed to do some training with staff and come up with a plan of who and when the shower would be cleaned. <Cross-Contamination> <Resident 80> Observations on 12/09/2024 at 10:30 AM showed Staff J wearing gloves and using a bottle of wound cleanser while performing wound care for Resident 80, Staff J put the bottle on the resident's bed, used it during resident care, and then placed it on the resident's overbed table. Staff J, while using the same soiled gloves, touched the resident's bed remote control to adjust the bed position. Staff J then removed their gloves, did not perform hand hygiene, and touched the call light to place it within Resident 80's reach. Staff J picked up the contaminated wound cleanser bottle, placed it on an isolation cart while they removed their gown, gloves, performed hand hygiene, picked up bottle again and placed the contaminated bottle inside the cart without sanitizing it. In an interview on 12/12/2024 at 2:58 PM, Staff D stated staff should utilize barriers to prevent supplies from having direct contact with a resident or their environment. Staff D stated if supplies were contaminated, staff should sanitize them before returning them to the treatment cart. Staff D stated it was important to sanitize contaminated items to break the chain of infection. <Transmission Based Precautions> <Resident 339> Observations on 12/09/2024 at 2:38 PM showed Resident 339 had a contact precautions sign posted on the wall near the resident's room. This sign stated providers and staff must: put on a gown and gloves before room entry and discard before room exit. This sign was located to the right of some Christmas decorations. Inside Resident 339's room was a provider without a gown or gloves and sitting in the resident's chair, next to the resident, who was in bed. In an interview on 12/09/2024 at 2:39 PM, Staff J stated the provider, forgot to gown up. Staff J stated they expected the provider to put on a gown and gloves prior to entering Resident 339's room. Staff J moved the posted sign closer to the entrance to the room to increase visibility. Observations on 12/09/2024 at 2:45 PM showed the provider exit Resident 339's room, perform hand hygiene, enter another resident's room and sit in a chair at that resident's bedside. On 12/09/2024 at 3:05 PM the provider continued to enter other resident rooms, after they had been in Resident 339's room without the required Personal Protective Equipment (PPE). In an interview on 12/12/2024 at 2:58 PM, Staff J stated for a resident on contact precautions, staff should put on a gown and gloves at the door, prior to entering the resident's room. Staff J stated it was their expectation if an isolation sign was posted at a resident's door, everyone should follow the required PPE identified in order to prevent the risk of spreading of infection.

CONCERN (D)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <West Central Hallway Sink> In an observation and interview on 12/09/2024 at 9:28 AM, Staff P (Housekeeping aide) stated t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <West Central Hallway Sink> In an observation and interview on 12/09/2024 at 9:28 AM, Staff P (Housekeeping aide) stated there used to be a lot of ants around the sink and Staff P had to use bleach because of the ants around the sink. Observation of a facility sign posted above the west central hallway sink, showed only pour water down the drain, fruit flies attracted by food. <Second Floor Hallway> Observation on 12/10/2024 at 12:42 PM showed fruit flies on the second floor in the hallways. <Resident 43> Observation on 12/10/2024 at 12:53 PM showed fruit flies in Resident 43's room. <Resident 22> Observation on 12/11/2024 at 10:38 AM showed fruit flies at the door of Resident 22's room. <West Central Office> Observation on 12/13/2024 at 9:54 AM showed fruit flies in Staff B's (Director of Nursing) office. Based on observation and interview, the facility failed to ensure an effective pest control program was in place to prevent insects from entering and or gathering in resident rooms for 3 (Resident 49, 43, & 22 rooms) of 18 sample resident rooms and common areas (West Central Sink, Second Floor Hallway, [NAME] Central Office, & Kitchen/Dining Room) of the facility. This failure placed residents at risk of infection and contributed to a less than homelike environment. Findings included . <Policy> According to a facility policy titled, Pest Control Program, revised 09/01/2022, the facility would maintain an effective pest control program that eradicated common household pests and rodents. The policy showed the facility would maintain a report system of issues that arise in between scheduled visits with the contracted pest service and would treat as indicated. <Resident 49> In an observation and interview on 12/11/2024 at 6:57 AM Resident 49 stated there's bugs all over in their room (room [ROOM NUMBER]), they did not know where they were coming from. Resident 49 stated they had a hard time sleeping at night because the bugs would fly in their face, waking them up. Resident 49 stated they had reported the bugs to the staff on multiple occasions, but they had not heard back from the staff on how they were going to get rid of them. In an interview on 12/13/2024 at 9:51 AM Staff N (Regional Plant Operation Manager) stated they were aware of the bugs in the halls and resident rooms. Staff N stated the monthly pest control services were not working in treatment of the bugs. Staff N stated the bugs could possibly be due to the open windows with missing screens in the resident's rooms. Staff N stated it was important the bugs be effectively treated for a homelike environment for the residents at the facility. <Kitchen/Dining Room> Observations of the kitchen dry food storage area on 12/08/2024 at 8:32 AM showed a fruit fly trap and a tray with clear liquid in a bowl sitting on one of the shelves. The bowl contained 10 fruit flies floating in the liquid and a few fruit flies flying near the trap. Observations on 12/11/2024 at 10:00 AM showed the door from the kitchen to the dining room was open, and flies were seen in the dining room. During food service observations on 12/11/2024 at 11:22 AM flies were noted in the air flying above the food in the tray line assembly area. There was food in pots of water on the stove and several flies flying over the pots. In an interview on 12/13/2024 at 8:46 AM, Staff K (Dietary Manager) stated the fruit flies were a problem for some time and they were seeking assistance from pest control. Refer to F584 - Safe/Clean/Comfortable/Homelike Environment. REFERENCE: WAC 388-97-3360(1)(2). .

CONCERN (E)

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

Deficiency F0572 (Tag F0572)

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 ensure newly admitted residents were informed in a timely manner (prior to or upon admission) of their rights and responsibilities and provided services as a resident in the facility for 3 (Resident 85, 139, & 339) of 5 residents reviewed. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life. Findings included . Review of the facility's 03/17/2022 admission Packet provided by staff, showed information and consent forms for the admission policies, resident rights, rules and operations of the nursing home, grievance process, right to choose their physician or contact information for the facility physician, charges for services, advanced directives and designation of a resident representative, privacy practices, healthcare privacy act, consent for release of medical information, bed hold policy, facility-initiated discharge policy, designation of funeral home, laundry services, policy on personal property, vaccination policies and consent, smoking policy, trust fund policy, arbitration agreement, information on state and local contacts for the State Hotline for abuse/neglect/complaints, contact for the State Ombudsman Program, Adult Protective Services, Medicaid Fraud Office, and information on the benefits/rights under Medicare. The admission packet contained multiple areas for the resident to sign acknowledgement to the facility policies, procedures and provide consent to the facility for specified care. <Resident 85> According to a 11/07/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 85 admitted to the facility on [DATE]. Review of Resident 85's records on 12/12/2024, over 30 days after the resident's admission, showed no admission packet was completed by staff upon admission. <Resident 139> According to a 12/03/2024 admission MDS, Resident 139 admitted to the facility on [DATE]. Review of Resident 139's records on 12/12/2024, over two weeks after the resident's admission, showed no admission packet was completed by staff upon admission. <Resident 339> According to a 12/11/2024 admission MDS, Resident 339 admitted to the facility on [DATE]. Review of Resident 339's records on 12/12/2024, two weeks after the resident's admission, showed no admission packet was completed by staff upon admission. In an interview on 12/12/2024 at 1:52 PM, Staff O (Vice President for Business office) stated having a resident and/or their representative review and sign an admission packet was important so residents would be informed of their rights and understand the services they would be offered or receive in the facility. Staff O stated they were behind in getting admission packets done timely due to staffing changes. Staff O stated it was their expectation an admission packet be reviewed and signed with a resident and/or their representative within 72 hours from the date of admission. REFERENCE: WAC 388-97-0300(1)(a), (7)(b). .

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <room [ROOM NUMBER]> Observation on 12/08/2024 at 9:00 AM showed room [ROOM NUMBER]'s window had missing blinds allowing s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <room [ROOM NUMBER]> Observation on 12/08/2024 at 9:00 AM showed room [ROOM NUMBER]'s window had missing blinds allowing sunlight to come through the window when the blinds were fully closed. The bathroom in room [ROOM NUMBER] showed the faucet was dripping, although it was shutoff, and brownish black dirt soiled the bathroom floor. Observations at this time showed boxes stacked on top of the closet with a mattress pad partially folded up on top of the closet, inches below the ceiling. <room [ROOM NUMBER]> Observation on 12/8/2024 at 10:18 AM, showed room [ROOM NUMBER] had several dirty, mismatched and chipped tiles on the floor. Observations of room [ROOM NUMBER] on 12/10/2024 at 1:25 PM showed a damaged hole-like area to the surface of the bathroom door. <room [ROOM NUMBER]> Observation on 12/10/2024 at 9:22 AM, showed room [ROOM NUMBER] had mismatched tiles, brown and black dirt was observed in the grout between the tiles. Broken tiles were chipped and some had chips in the corner of the tiles making the tiles uneven to walk on. In an interview on 12/13/2024 at 9:51 AM, Staff L stated they completed daily rounds of the facility and kept a list of repairs needed, however Staff L stated they did not have the authority to order supplies to make repairs to the facility. In an interview on 12/13/2024 at 9:51 AM Staff N stated repairs were important and were needed to keep the facility homelike for residents. Staff N stated the tiles should be fixed in rooms [ROOM NUMBERS]. Staff N stated, they were aware of missing blinds in room [ROOM NUMBER] and the facility was looking at different options for the vertical blinds as they were not good. Refer to F925 - Maintains Effective Pest Control Program REFERENCE: WAC 388-97-0880. Based on observation and interview, the facility failed to maintain a homelike environment for 17 of 67 resident rooms (Rooms 204, 215, 245, 100, 112, 101, 107, 242, 243, 246, 251, 253, 254, 256, 224, 240, & 241), 1 of 1 dining rooms (Main Dining Room), and 1 of 4 shower rooms (West 2 Shower Room) reviewed. These failures left residents at risk for a diminished quality of life and a less than homelike environment. Findings included . <room [ROOM NUMBER]> An observation on 12/08/2024 at 9:54 AM showed room [ROOM NUMBER]'s door did not latch and was unable to close completely. In an interview on 12/13/2024 at 9:51 AM Staff N (Regional Plant Operation Manager) stated it was important for the doors to latch and close completely for resident privacy and fire safety. <room [ROOM NUMBER]> An observation on 12/09/2024 at 9:28 AM showed a 3 inch diameter shallow hole in the floor tile between beds A and B. In an interview on 12/13/2024 at 9:51 AM Staff N stated it was important to make the repairs to the floors timely to maintain a homelike environment for the residents. <room [ROOM NUMBER]> An observation on 12/10/2024 at 12:00 PM showed room [ROOM NUMBER]'s window open without a screen. In an interview on 12/13/2024 at 9:51 AM Staff N stated they were aware of the missing screen. At this time Staff L (Maintenance Aide) stated they had measured for the screens and Staff N had ordered them a couple of months ago. Staff N stated they received the mesh screen material already but needed to purchase the frames. Staff N stated it was important to make repairs timely to maintain a homelike environment for the residents. Staff N stated the continued pest problems could be a result of the screens missing with the windows open.<room [ROOM NUMBER]> Observation on 12/08/2024 at 10:09 AM showed room [ROOM NUMBER] walls had scratches and different color patches on the walls. Resident stated staff removed the hand sanitizer from the wall and never painted the wall. <room [ROOM NUMBER]> Observation on 12/08/2024 at 10:16 AM showed room [ROOM NUMBER] walls had scratches behind the head of bed A and bed B. Observation showed the wall had a hole size of a door knob behind the entrance door inside the room. <room [ROOM NUMBER]> Observation on 12/08/2024 at 11:46 AM showed room [ROOM NUMBER] walls had scratches, tiles on the floor were chipped and had black stains on them. <room [ROOM NUMBER]> Observation on 12/08/2024 at 11:51 AM showed in room [ROOM NUMBER], resident's clothes, linens and other belongings were scattered on the floor. <room [ROOM NUMBER]> Observation on 12/08/2024 at 12:06 PM showed room [ROOM NUMBER], privacy curtain between bed A and B, was dirty, multiple stains of coffee or juice. <room [ROOM NUMBER]> Observation on 12/08/2024 at 12:45 PM showed room [ROOM NUMBER] was not clean and had strong urine odor. Resident stated they did not clean the room yet. <room [ROOM NUMBER]> Observation on 12/08/2024 at 8:55 AM and 12/09/2024 at 12:53 PM showed room [ROOM NUMBER] had no toilet in the bathroom and had a big hole in the bathroom wall. <West 2 Shower Room> Observation on 12/08/2024 at 12:50 PM showed [NAME] 2 shower room door was broken with multiple dents. Shower room had mold on the ceiling. In an interview on 12/13/2024 at 9:51 AM, Staff N stated they were aware of scratches on the walls, holes on the walls, chipped tiles in resident's rooms, missing toilet in resident's room, and broken shower door. Staff N stated it was important to make repairs timely to maintain a homelike environment for the residents. Staff N stated they needed to fix all these environmental issues.<room [ROOM NUMBER]- Bathroom> Observations on 12/08/2024 at 9:39 AM and 12/09/2024 at 2:12 PM showed a long screw with a pointed sharp tip sticking out of the wall between the toilet and the sink. In an interview on 12/13/2024 at 9:51 AM, Staff L stated there was a missing hook that should be covering the screw. <room [ROOM NUMBER]> Observations on 12/08/2024 at 10:04 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall under the resident's wall light. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <room [ROOM NUMBER]> Observations on 12/09/2024 at 8:48 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall on the wall at the head of resident's bed. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <room [ROOM NUMBER]> Observations on 12/09/2024 at 10:30 AM showed room [ROOM NUMBER] bed A with deep gouges and exposed drywall on the wall at the head of resident's bed. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <Dining Room> Observations on 12/08/2024 at 12:36 PM showed a long cabinet underneath a countertop in the dining room against the wall next to the kitchen. This cabinet had multiple drawers and doors with peeling and missing paint with warped and cracked wood surfaces. In an interview on 12/13/2024 at 10:47 AM, when asked if the dining room cabinet was in good repair, Staff C (Regional Director) stated the cabinet was not, cosmetically appealing. Staff C stated the cabinet would not be something they would want to look at every day. Staff C stated having an environment in good repair was important as the facility was the resident's home.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 3 of 6 residents (Residents 83, 3, & 16) whose meals were observed during tray line. Failure to follow the menu as directed, according to the dietician approved spreadsheet, and provide accurate portion sizes, placed residents at risk of unmet nutritional needs, and potential negative outcomes. Findings included . <Facility Menu> Review of the facility's menu showed for lunch on 12/11/2024 beef stroganoff over noodles, buttered brussel sprouts, peach cobbler made from fresh, peeled, pitted, and sliced thin peaches, and a dinner roll would be served. The 12/11/2024 lunch menu showed low concentrated sweet diets had a canned peach cobbler instead of the fresh peach cobbler. <Following Menu> According to the facility's diet spreadsheet form provided by staff on 12/08/2024, all residents, except those who were on the low concentrated sweets diet, should receive a full serving of the peach cobbler dessert, which was to be made with fresh, peeled, pitted, and sliced thin peaches, according to the recipe provided by staff on 12/11/2024. Observations on 12/11/2024 starting at 11:45 AM, during lunch service showed staff were serving a canned fruit version of peach cobbler to all residents. There was no dessert available to serve which was made from fresh, peeled, pitted, and sliced thin peaches as directed on the spreadsheet. All of the peach cobbler desserts available to serve, were the same size, none were prepared with half of the amount, as directed on the spreadsheet, for the residents on a low concentrated sweets diet. <Portion Sizes> <Resident 83> Observations of meal service on 12/11/2024 starting at 11:57 AM, showed Staff CC prepared Resident 83's lunch tray. Staff CC used a green scoop when dishing up the brussel sprouts. When asked, Staff K (Dietary Manager) stated the green scoop was a 3 ounce (oz) serving size. After Resident 83's tray was served, Staff K changed the scoop size for the brussel sprouts to a 4 oz serving. Review of the spreadsheet showed Resident 83 should have received a 4 oz serving, rather than the 3 ounce scoop which was used. <Resident 3> Observations of meal service on 12/11/2024 starting at 11:57 AM, showed Staff CC prepared Resident 3's lunch tray without providing large portions of all the food as directed on the tray ticket. <Resident 16> Observations of meal service on 12/11/2024 starting at 11:57 AM, showed Staff CC prepared Resident 16's lunch tray without providing large portions of all the food as directed on the tray ticket. During the meal service observations on 12/11/2024 starting at 11:57 AM, Staff K (Dietary Manager) stopped Staff CC (Dietary Cook) four times from serving trays without the large portions as directed. In an interview at this time, Staff K stated they were not usually standing at the tray line reading the resident meal tickets but indicated they were instructed to stay during meal service during survey observations. In an interview on 12/13/2024 at 8:46 AM, Staff C (Regional Administrator) stated it was their expectation staff follow the recipes and menus as directed by the dietician on the spreadsheet. Staff C stated the recipes were important to follow as they were designed for different diets and restrictions. Staff C stated they expected the cook to follow the diet orders and provide portion sizes as directed. Refer to 804- Nutritive Value/Appearance, Palatable/Preferred Temperature. Refer to 812- Food Procurement, Store/Prepare/Serve- Sanitary. REFERENCE: WAC 388-97-1180(1), -1200(1). .

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to prepare food in a manner that ensured meals were appetizing and palatable for 4 of 6 residents (Resident 43, 6, 74, 85) reviewed. This placed residents at risk for a decreased nutritional intake and dissatisfaction with meals. Findings included . Review of the facility's December 2024 food temperature log form showed directions to staff to place food on the tray line no more than 30 minutes prior to meal service. <Resident Interviews> <Resident 43> In an interview on 12/08/2024 at 10:18 AM, Resident 43 stated the quality of the food was not good at the facility. <Resident 6> In an interview on 12/08/2024 at 12:53 PM, Resident 6 stated they were unhappy with the food at the facility. <Resident 74> In an interview on 12/08/2024 at 1:30 PM, Resident 74 stated they were very unhappy with the food and stated it was too bland and often overcooked. <Resident 85> In an interview on 12/09/2024 at 9:15 AM, Resident 85 stated, this is the worst food, and stated they ordered food from outside the facility most of the time. Resident 85 stated the food was very bland, and the brussel sprouts were too plain and were served too often. <Meal Preparation> Review of the facility's menu showed for lunch on 12/11/2024 beef stroganoff over noodles, buttered brussel sprouts, peach cobbler, and a dinner roll would be served. Observations of meal preparations on 12/11/2024 starting at 9:01 AM showed staff putting a pot of water on the stove and began cooking brussel sprouts for the lunch service. Staff CC (Dietary Cook) finished cooking the noodles and put them on the steam table at 10:02 AM, an hour and a half prior to when the tray line service was scheduled to begin. <Meal Service> Observations on tray service started on 12/11/2024 at 11:45 AM, an hour and 45 minutes after the noodles were placed on the steam table. Observations on 12/11/2024 at 12:08 PM, two hours after the noodles were placed on the steam table, showed brown crusted noodles stuck to the bottom of the bin, Staff CC scraped the bottom of the bin, scooped the noodles onto a resident's plate, added the beef, and then served them. <Test Tray> Observations of the test tray received from lunch service on 12/11/2024 at 1:04 PM, two hours after tray line started, showed beef with noodles, pale colored brussel sprouts, and a dessert. The brussel sprouts were mushy with no taste and some of the noodles had hard, dry, brown areas. In an interview on 12/13/2024 at 8:46 AM, Staff K (Dietary Manager) stated it was their expectation food would be on the steam table no more than 30 minutes before service starts. Staff K stated having the food on the steam table longer could affect the food quality and the nutritional value of the food. In an interview on 12/13/2024 at 10:30 AM, Staff V (Dietician) stated 30 minutes prior to meal service was the goal for moving foods on to the steam table. Staff V stated the food was at risk for losing nutrient quality the longer the heat was on the food. Refer to 803- Menus Meet Resident Needs/Prepared in Advance/Followed. Refer to 812- Food Procurement, Store/Prepare/Serve- Sanitary. REFERENCE: WAC 388-97-1100(1), (2). .

CONCERN (E)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 3 of 3 residents (Resident 49, 23, and 43) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . <Facility Policy> The facility's 08/08/2022 Binding Arbitration Agreements policy showed the facility would explain to residents and their representatives the arbitration agreement upon admission to the facility in a form and manner that the resident understood, including in a language they understood. The policy showed the admissions coordinator was responsible for any questions the resident may have about the contract. <Resident 49> According to the 11/27/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 49 was alert and oriented, and their memory was intact. The assessment showed Resident 49 had adequate vision and hearing and had clear speech during communication. Review of a 06/05/2024 electronically signed arbitration agreement showed Resident 49's name was captured in the signature line and indicated the resident was bound by the terms and condition of the agreement. In an interview on 12/11/2024 at 6:40 AM, Resident 49 stated they did not know about the arbitration agreement, and no one explained to them about this agreement. Resident 49 stated they did not know about 30 days revoking period for the arbitration agreement because they did not know that they entered into one. <Resident 23> According to the 11/14/2024 Quarterly MDS, Resident 23 was alert and oriented, and their memory was intact. The assessment showed Resident 23 had adequate vision and hearing. Review of Resident 23's arbitration agreement showed the contract was electronically signed by the resident on 07/08/2023. In an interview on 12/12/2024 at 12:08 PM, Resident 23 stated they did not remember signing an arbitration agreement or know what an arbitration agreement was about. Resident 23 was presented with a copy of their signed arbitration agreement and Resident 23 stated they did not remember any staff talking to them about this agreement. <Resident 43> According to the 10/03/2024 Quarterly MDS, Resident 43 was alert and was able to make their own decisions. The assessment showed Resident 43 had adequate hearing, impaired vision, and had clear speech during communication. Review of a 08/27/2024 electronically signed arbitration agreement showed Resident 43's name was captured in the signature line and indicated the resident was bound by the terms and condition of the agreement. In an interview on 12/11/2024 at 10:24 AM, Resident 43 stated they signed a lot of papers during their readmission from the hospital. Resident 43 stated they did not know what the arbitration agreement was for. Resident 43 asked if any staff could explain what an arbitration agreement was. In an interview on 12/12/2024 at 11:22 AM, Staff B (Director of Nursing) stated admission coordinator was responsible for the facility's arbitration agreement process, and they assisted residents to sign the admission papers including the arbitration agreement upon admission. In an interview on 12/12/2024 at 2:22 PM, Staff O (Vice President for Business office) stated the admission coordinator who assisted residents to sign arbitration agreement was not an employee in the facility anymore. Staff O stated staff should have explained the details about an arbitration agreement to residents/their representatives before they signed an arbitration agreement. Staff O stated they were unsure where the disconnect was with the resident's arbitration agreement and they needed to do a better job explaining the contract in a form and manner that the resident's best understood. REFERENCE WAC: 388-97-1620(2)(a)(b)(i), -0180(1-4). .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review the facility failed to prepare and serve food under sanitary conditions in 1 of 1 kitchen. Failure to perform proper hand hygiene and glove use, properly clean kitchen equipment, adequately monitor food cooking temperatures, and ensure staff distributed and served food under sanitary conditions. These failures placed residents at risk of decreased nutritional intake, cross contamination leading to food-borne illness, and a diminished quality of life. Findings included . <Hand Hygiene> <Facility Policy> Record review of the facility's 5/21/2021 policy titled, Food Safety Requirements, showed staff would adhere to hygienic practices that prevent contamination of foods from hands or physical objects by proper hand washing and the appropriate use of gloves including changing them to reduce cross contamination. Observations on 12/11/2024 at 9:20 AM, showed Staff CC (Dietary Cook) preparing food. They removed their gloves, and, without performing hand hygiene, put on new gloves to continue preparing food. At 12/11/2024 at 9:26 AM, Staff CC was observed opening the garbage can with their gloved hand, picked up food that was dropped on the floor, removed gloves, put on new gloves without performing hand hygiene and resumed food preparation. Observations on 12/11/2024 at 10:03 AM, showed Staff CC went over to the sink to wash their hands. Staff CC turned on the water, rinsed their hands in the water, did not apply any soap, then got some paper towels to dry their hands. Staff CC then returned to the service area to continue preparing food. Observations on 12/11/2024 at 10:19 AM, showed Staff CC go over to the hand washing sink, turn the water on, touch the water with their hands, then immediately after, took some paper towels to dry their hands, and used the paper towels to turn off the water. Staff CC did not use soap when performing hand hygiene. Staff CC then returned to the service area to continue preparing food. Observations on 12/11/2024 at 11:44 AM, showed Staff CC preparing to start lunch meal service, Staff CC went to the sink to do hand hygiene, rinsed their hands in water, did not use soap, dried their hands with paper towels, and put on gloves. Staff CC began dishing up and serving meal trays. During meal service on 12/11/2024 at 12:02 PM, Staff CC removed their soiled gloves and put on a new set of gloves without performing hand hygiene. In an interview on 12/11/2024 at 1:09 PM, Staff K (Dietary Manager) stated it was their expectation staff perform hand hygiene when entering the kitchen, between tasks, if they touch any potentially contaminated surfaces, and between glove changes. Staff K stated staff should wash their hands for at least 20 seconds and to use soap and water. <Cross-contamination> <Facility Policy> Record review of the facility's 5/21/2021 policy titled, Food Safety Requirements, showed the facility would implement additional strategies to prevent cross-contamination of foods. Suggested strategies included washing hands before handling clean containers, touching only the outside surfaces and handles of tableware, and storing food items in a manner to prevent deterioration or contamination. Observations on 12/11/2024 at 9:01 AM showed a staff's personal phone placed inside a bin full of salt and pepper condiment packets in the area where food was cooked and prepared for tray line service. Observations on 12/11/2024 at 9:16 AM, Staff DD (Dietary Aide) filling cups with juice and putting on lids. During the process, Staff DD was placing their fingers inside the cup ledge when picking up the cups to carry to the juice machine. Observations on 12/11/2024 at 9:28 AM showed Staff CC putting raw chicken into a food bin with a gloved hand. Staff CC picked up a bottle of oil and drizzled it on the raw chicken while they used their gloved hands to spread the oil over the raw chicken. With the contaminated gloves, Staff CC picked up a bottle of seasoning and used on the chicken, mixed the chicken up with their gloved hands, and covered the container with tin foil. Staff CC opened the oven, using the same contaminated gloves, touched oven knobs, and put the chicken inside. Staff CC removed their gloves, washed hands less than 20 seconds and put on new gloves. On 12/11/2024 at 9:54 AM, Staff CC was observed to touch and move the contaminated bottle of seasoning, with their bare hands, so they could fill a pot of water from the sink. Staff CC then carried the pot of water to the stove using the handles with their contaminated hands. Staff CC removed their gloves, washed hands less than 20 seconds and put on new gloves. Observations on 12/11/2024 at 9:31 AM, showed Staff CC using gloved hands to place frozen hamburger patties on a tray. Staff CC wrapped the remaining hamburger up, touched the freezer door handle with their contaminated gloves, and placed the hamburger inside. Staff CC removed their gloves, and without performing hand hygiene, put on a new pair of gloves and began stirring some meat on the stove. Staff CC did not sanitize the freezer door handle after it was contaminated from touching the hamburger patties. Observations on 12/11/2024 at 12:14 PM, showed Staff CC touched the front of their face mask with their gloved hands, pick up a clean plate with their contaminated hand, and dish up food on the plate to serve. Staff CC continued to prepare plates of food for residents during meal service, while at times, touching the area of the plate where the food will be placed. On 12/11/2024 at 12:31 PM, Staff K gave directions to Staff CC to go wash their hands. Staff CC went to the sink to perform hand hygiene, rinsed hands in water without using soap, dried their hands, and returned to continue food preparation. Observations on 12/11/2024 at 12:36 PM, showed the resident meal tray tickets sitting on a dirty cart used for holding the clean plates. Staff K was touching the tickets with their bare hands and handing them to Staff CC to prepare the food. Once the plate was prepared, Staff CC would put the plate up on a counter with the ticket under the plate. Staff DD would take the plate, the ticket would fall into a bin of rolls, touching the food. Staff DD would pick up the ticket and place it on a tray. Staff DD would use tongs, without gloves, and pick up a roll to place on the resident's tray. The tongs kept falling into the bin with the handles coming in contact with the rolls. Staff K gave directions to Staff DD to be careful with the tongs and make sure they do not fall into the bin with the rolls. The tongs continued to fall into the bin. Observations on 12/11/2024 at 12:44 PM showed Staff EE (Dietary Aide) take a paper menu, which a resident had written their food choices on, and placed it on a bin of clean and partially peeled cucumbers in the food preparation area. The paper was touching the food. In an interview on 12/11/2024 at 1:09 PM, Staff K stated staff's personal items should not be in the food preparation or service area in order to reduce the risk of cross-contamination. Staff K stated staff should not touch the rim of cups or the food area of plates with their bare hands or soiled gloves because there would be a risk of cross-contamination. Staff K stated this was important as the resident drinks out of the cup and eats the food from the plate. Staff K stated it was their expectation staff do not touch surface areas after handling raw meat and without performing proper hand hygiene, routinely sanitizing equipment area, and not touching food-ready surfaces with bare hands. <Food Temperatures> <Facility Policy> According to a 05/21/2021 facility, Food Safety Requirements policy, when preparing food, staff should take precautions in the food preparation process to prevent, reduce, or eliminate potential hazards. This policy showed when cooking foods, the foods should be prepared as directed until the recommended temperatures for the specific foods were reached. Review of the facility's beef stroganoff over noodles recipe, provided by staff on 12/11/2024, showed directions the beef's final internal cooking temperature should be 165 degrees Fahrenheit prior to turning off the heat, adding the remainder of the ingredients, and holding until ready to serve. Observations on 12/11/2024 at 10:02 AM, showed Staff CC removing noodles, beef, and vegetables from the ovens, and placed them on the steam table. Staff CC did not check the final food temperatures when they finished cooking the food. In an interview on 12/11/2024 at 10:11 AM, Staff CC stated they only check the temperatures of food prior to tray line service. In an interview on 12/11/2024 at 10:11 AM, Staff K stated it was their expectation staff check the temperatures of meats when they are pulled out of the oven, to assure the food got to the appropriate temperatures. Staff K stated they expected staff to check the temperatures of all foods again, just prior to starting tray line service. Staff K stated Staff CC should have checked the temperature of the meats when they moved them from the oven to the steam table. Review of a December 2024 facility food temperature log on 12/11/2024 at 10:18 AM, showed no food temperatures were logged for the lunch food items once cooking was completed. During tray line service on 12/11/2024 at 11:17 AM, Staff CC and Staff K were checking food temperatures of all food prior to meal service. Staff K instructed Staff CC to put many of the food products, including some meats, back in the oven and/or on the stove to get the temperatures higher. <Soiled Surface Areas> <Facility Policy> Record review of the facility's 5/21/2021 policy titled, Food Safety Requirements, showed the facility would follow food service safety throughout the entire food handling process from procurement to service of food. All equipment would be cleaned and sanitized to prevent contamination. Observations on 12/11/2024 at 10:13 AM, showed the dish cart holding the clean plates for tray service had dried food and debris on the top next to the clean plates and many dried drips were going down the sides of the cart. In an interview on 12/11/2024 at 10:13 AM, Staff K observed the soiled dish cart and confirmed it needed to be cleaned and stated, I need to add that to the cleaning rotation. At 12:08 PM on 12/11/2024 staff were using clean plates from the soiled cart during the lunch meal service. In an interview on 12/11/2024 at 1:09 PM, Staff K stated sanitary conditions were important to prevent residents from getting sick and to decrease the risk for potential exposure to food-borne illnesses. Refer to 803- Menus Meet Resident Needs/Prepared in Advance/Followed. Refer to 804- Nutritive Value/Appearance, Palatable/Preferred Temperature. REFERENCE: WAC 97-388-1100(3), -2980. .

Nov 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Staffing Data (Tag F0851)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS - a federal agency managing health care programs and health insurance standards) for Quarter 1 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provision of resident care and services. Findings included . <CMS - PBJ Public Use Employee Detail File: Technical Specifications> According to the July 2023 PBJ guideline, Long-Term Care facilities must electronically submit to CMS through the PBJ system complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The guideline showed Employee Data File included the hours worked by all employees and contract workers in any of the job categories (nurse and non-nurse) for which PBJ data submission was mandatory. Review of the facility's 05/12/2024 CMS Submission Report - PBJ Submitter Final File Validation Report showed the direct care staffing report submitted by the facility was incomplete and the Total Employee Link Records were not submitted as required. In an interview on 11/01/2024 at 10:21 AM, Staff B (Director of Nursing) stated they were responsible for ensuring the facility met direct care staffing levels as required on a daily basis for safe resident care. Staff B stated PBJ data submission was done at their corporate level. In a phone interview with Staff C (Chief Executive Officer - owner) and Staff D (Regional Operations Manager) on 11/01/2024 at 11:56 AM, Staff D stated the facility's PBJ validation report showed incomplete employee data submission. Staff D stated they speculated a technical issue from payroll. At 12:01 PM, Staff D stated PBJ data submission needed more oversight to ensure compliance with the regulation. In an interview on 11/01/2024 at 1:56 PM, Staff A (Administrator) stated they follow the PBJ guideline for NH staffing level data submission. Staff A stated the facility should have submitted complete and accurate direct care staffing information as required, but did not. REFERENCE: WAC 388-97-1090 (1)(2)(3). .

Apr 2024 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

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 assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for 4 of 6 sampled residents (Resident # 1, 2, 3 & 4) reviewed for skin and non pressure wound management. This failure placed residents at risk for unidentified wounds, wound decline, infection, and diminished quality of life. Findings included . The facility's Skin Assessment policy revised 04/23/2024 stated a full body, or head to toe, skin assessment would be conducted by a Licensed Nurse (LN) or Registered Nurse (RN) upon admission/re-admission and weekly thereafter. The assessment might also be performed after a change of condition. For documentation of skin assessment and monitoring, nursing staff were directed to enter Y (Yes) for new skin issues and follow the protocol for notification and to initiate an incident report as indicated, and mark N (No) for no new skin issues. <Resident 1> Resident 1 admitted to the facility 12/03/2022. Review of the 04/12/2024 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 1 was dependent on staff for toileting hygiene, bathing, and bed mobility and was always incontinent of bowel and bladder. Resident 1 was assessed as at risk of developing pressure ulcers/injuries, and was assessed with no skin impairments, including Moisture Associated Skin Damage (MASD - incontinence associated dermatitis). Treatments listed included applications of ointments/medications. Review of the Incontinence Care Area Assessment (CAA) dated 04/17/2024 showed incontinence placed Resident 1 at greater risk for impaired skin integrity. The LN and Nursing Assistants (NA) were to assist with Activities of Daily Living (ADLs) as indicated and LNs were to to monitor and notify the Medical Doctor (MD) of any changes. Review of the 04/17/2024 CAA for skin showed Resident 1 was at risk but there were no new concerns at that time. Review of the at risk for unavoidable skin breakdown Care Plan (CP) dated 12/08/2023 showed a goal that Resident 1 would be free of skin breakdown. Interventions listed included, keep clean and dry, monitor for signs of skin breakdown, notify the MD of any new skin issues, and perform weekly skin checks by LNs. Review of the April 2024 Treatment Administration Record (TAR) showed Physician Orders (PO) that instructed staff to conduct a weekly skin check, if a new skin injury was noted, staff were to complete the Weekly skin observation, notify the MD and family, open a risk management, and place the resident on alert charting. No new skin impairments were noted on the weekly skin checks dated 04/03/2024, 04/10/2024 and 04/17/2024. Review of the last 30 days of NA skin observation documentation retrieved 04/23/2024 showed a new open area was identified on 04/19/2024. Review of April 2024 progress notes, assessments, and other documentation in Resident 1's electronic medical record showed no documented assessment by an LN. Review of the April 2024 TAR showed POs for a cream ordered 12/15/2023 to be applied to Resident 1's bilateral buttocks, bilateral thigh folds, and groin area every shift for skin protection. The treatments were documented as done by Staff D (Licensed Practical Nurse - LPN) on 14 distinct dates in April, including 04/21/2024 and 04/22/2024. Another PO dated 02/23/2024 for a skin protectant external paste to be applied to perineum (groin) and sacrum (buttocks) three times a day for skin protection after peri-care (personal care) was documented as done 25 times in April by Staff D, including twice on 04/21/2024 and twice on 04/22/2024. During an interview on 04/23/2024 at 11:09 AM, Staff D stated they were unaware Resident 1 had any skin problems, open areas or bleeding. Staff D stated if an NA observed any concerns they would notify the LN. Staff D stated the resident did have a cream to be applied to their bottom. During an interview on 04/23/2024 at 11:57 AM, when asked who applied the cream, Staff D stated the NAs. Staff D was unable to recall the last time they looked at Resident 1's bottom. Resident 1 was discharged from the facility on 04/22/2024 to an Adult Family Home (AFH). Review of the 04/22/2024 Discharge Summary showed Resident 1's skin condition was noted as normal, clear, and intact. During an interview on 04/23/2024 at 11:02 AM, Staff C (Registered Nurse - RN, Resident Care Manager - RCM) stated Resident 1 was dependant on staff for care, was incontinent, and had no skin impairments prior to discharge. Review of documents provided by the receiving facility showed on 04/22/2024 the Registered Nurse Delegator of the AFH conducted a skin assessment and identified Resident 1 had open areas on their coccyx (tailbone), back, under their breasts, abdominal fold, and redness/bleeding on their peri-area (groin) skin. Photographs reviewed showed extensive MASD. During an interview on 04/25/2024 at 10:17 AM, Resident 1's son stated that the facility staff previously mentioned Resident 1 had a wound, but I didn't realize it was that bad. Resident 1's son stated that at discharge they were told that the wound resolved and there were no current skin issues. During an interview on 04/23/2024 at 11:12 AM, Staff B (Director of Nursing), stated Resident 1 had fragile skin, was incontinent, and had a history of open areas which quickly healed. Staff B stated Resident 1 had a PO for an ointment to be applied to Resident 1's groin, buttocks, and peri-area (groin) for preventative measures. Staff B stated the expectation was that an LN would apply the PO ointment and assess the resident's skin at that time. If the skin improved or worsened they would document this in a treatment note. Staff B stated a skin assessment was not, but should have been conducted by the nurse at discharge. <Resident 2> Review of the 04/15/2024 Annual MDS showed Resident 2 was dependent on staff for toileting hygiene and bed mobility, was occasionally incontinent of urine, and frequently incontinent of bowels. Resident 2 was assessed as at risk of developing pressure ulcers/injuries, and was assessed with no skin impairments, including MASD. Treatments listed included applications of ointments/medications. Review of the 04/17/2024 Urinary CAAs showed incontinence placed Resident 2 at greater risk for impaired skin integrity. The LNs and NAs were to assist with Activities of Daily Living (ADLs) as indicated and LNs to monitor and notify the MD of any changes. Review of the 04/17/2024 CAA for skin showed Resident 2 was at risk, the LN would complete weekly skin checks, monitor, and notify the MD of changes. The at risk for unavoidable skin breakdown CP initiated on 05/22/2023 listed the goal that Resident 2 would be free of skin breakdown. Interventions listed included: Monitor for signs of skin breakdown, weekly skin checks by LNs and notify the MD for any new skin issues. Review of the April 2024 TAR showed POs to staff to conduct a weekly skin check, if new a skin injury was noted, to complete the Weekly skin observation, notify the MD and family, open a risk management, and place the resident on alert charting. No new skin skin impairments were noted on the weekly skin checks dated 04/05/2024, 04/12/2024, and 04/19/2024. Review of the prior 30 days of NA documented skin observations, retrieved on 04/25/2024 showed staff noted Resident 2 had red and open areas on 03/31/2024, 04/02/2024, 04/11/2024, and 04/19/2024. According to the NA documentation, none of the areas were new. Review of the April 2024 TAR showed a 02/09/2024 PO to apply cream to the coccyx area redness every shift and notify the MD for signs of worsening. Review of progress notes showed a 03/31/2024 progress note that staff provided total assistance with peri care and applying cream to the resident's buttock, on 04/20/2024 Resident 2 had no new rash or new skin conditions. During an interview on 04/23/2024 at 12:19 PM Staff E (RN, RCM), stated Resident 2 had ongoing MASD. When asked how staff documented monitoring of the MASD, Staff E stated they entered a PO. Staff E looked in Resident 2's electronic medical record and stated, I don't see it. Staff E stated when the nurse applied the treatment, the nurse assessed the area and if the area worsened, staff were to notify the physician and write a progress note. Staff E stated, Resident 2 was assessed every Wednesday during wound rounds. When asked for the documented assessment, Staff E stated the last Wound Healing visit Resident 2 received was in January 2024. Staff E then stated the nurses conducted weekly head to toe skin assessments and if new issues were noted then a skin assessment would be completed. Staff C stated the MASD was present on Resident 2 from the coccyx down to the buttock circle (anus). Observation with Staff E on 04/23/2024 at 1:16 PM showed Resident 2 had pink colored cream visible on the whole area of the resident's buttocks and down the resident's thighs. Multiple scattered open areas were noted. During an interview on 04/23/2024 at 1:21 PM, Staff E stated the affected area had gotten bigger with open areas and soreness. <Resident 3> Review of the 03/08/2024 Annual MDS showed Resident 3 was dependent on staff for all mobility and ADLs and was assessed with no skin impairments. Review of the risk for skin impairment CP initiated 04/17/2023 showed interventions to include weekly skin check by the LN. Review of the NA skin observations for the prior 30 days, retrieved on 04/25/2024 showed no skin impairment was documented as observed 03/27/2024 through 04/24/2024. Review of the 2024 TARs showed a 02/11/2024 PO to conduct a weekly skin check. No new skin skin impairments were noted on the weekly skin checks dated 03/03/2024, 03/10/2024, 03/17/2024, 03/24/2024, 04/07/2024, 04/14/2024, and 04/21/2024. Review of the April 2024 TAR showed a 03/17/2024 PO to cleanse the open area to the right great toe, apply ointment to wound bed, and cover the area with border gauze every shift until healed. Review of progress notes dated 03/16/2024, showed Resident 3 was noted to have an open area to the right great toe 1.5 centimeters long with pink perimeters. The MD was notified and an order received. On 03/17/2024 the dressing to the right great toe was intact without signs of infection. Staff documented On 03/18/2024 the right great toe had an open area with a dry dressing and that was intact, with no signs of infection noted. No further documentation, monitoring, or assessments of the wound were located in Resident 2's electronic medical record. During an interview on 04/23/2024 at 12:15 PM Staff G (LPN) stated Resident 3 had an open area to their toe, which became infected, but was now healing. When asked where the assessments and ongoing monitoring were documented, Staff G stated the wound team assessed the wound every Wednesday. On 04/23/2024 at 12:47 PM Resident 3 was observed up in a wheelchair in their room, with a bandage on their right toe. Resident 3 was observed with redness on both sides of their face and eyebrows. During an interview on 04/23/2024 at 1:00 PM Staff F (Certified NA) stated Resident 3's face was crusted, with peeling skin. Staff F stated Resident 3 also had crust to their scalp which they tried to scrub off, but it was still there. Staff F stated they applied A & D ointment to Resident 3's face. When asked if they reported it to the nurse, Staff F stated, Not yet, but they already know from before. Staff F stated they reported Resident 3's hair/head issue to Staff E two weeks prior. During an interview on 04/23/2024 at 12:54 PM, when asked what was wrong with Resident 3's face, Staff E stated they did not notice anything. On 04/23/2024 at 1:01 PM, Staff E denied having been told about Resident 3's skin issues of the hair/head concerns. During an interview on 04/23/2024 at 1:45 PM, Staff B denied receiving a skin incident report for Resident 3's toe and confirmed the resident was not followed by the wound care team. <Resident 4> Review of the 03/08/2024 significant change in status MDS showed Resident 4 was dependent on staff for all mobility and ADLs and was assessed with no skin impairments. Review of the potential for impairment to skin integrity CP showed a rash to Resident 4's left underbreast was added to the CP on 04/22/2024. Interventions included a treatment order in place for the rash. Review of the April 2024 TAR showed a PO to conduct a weekly skin check. No new skin skin impairments were noted on the weekly skin checks dated 04/02/2024, 04/03/2024, 04/09/2024, 04/10/2024, 04/16/2024, and 04/17/2024. Review of the April 2024 Medication Administration Record (MAR) showed a 04/17/2024 to apply medicated cream under left breast two times a day for 14 days for a rash. Review of progress notes showed the Resident was noted with redness under left breast on 04/16/2024. A 04/17/2024 note showed receipt of a PO to apply medicated cream under the left breast with a plan for documented monitoring for any worsening of the skin rash. A 04/19/2024 and 04/20/2024 note showed the nurses applied the cream under the breast and left underarm for a rash without documented MD notification that the rash spread. On 04/23/2024 at 12:03 PM, Staff H (LPN) was observed to apply the cream under Resident 4's left breast. No rash was observed to the resident's left underarm. During an interview at that time Staff H stated the left armpit rash resolved and the rash under the breast was improving. During an interview on 04/23/2024 at 2:18 PM, Staff B stated the facility recently identified concerns regarding skin care and were in the process of implementing changes in procedures and staff education. REFERENCE: WAC 388-97-1060(1). .

Aug 2023 20 deficiencies

CONCERN (D)

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

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure mail was being delivered timely and unopened to 1 (Resident 5) of 1 residents reviewed. By not ensuring mail was delivered, unopened, and in a timely manner placed residents at risk for lack of privacy and autonomy. Findings included . Review of the 06/2023 Mail Delivery facility policy showed residents had the right to privacy regarding written communications, and to promptly send and receive unopened mail. The policy showed the activity director or designee would coordinate resident mail delivery. Unopened mail would be delivered to the resident and/or outgoing mail would be postmarked within 24 hours on operational postal service days. Residents would be given the choice of reading their own mail or having a designated person read the mail to them. In an interview on 08/23/2023 at 2:00 PM, Resident 5 stated the facility was opening the resident's mail recently. Resident 5 stated the facility had an issue with the resident ordering over-the-counter vitamins and started opening their mail. Resident 5 stated Sometimes they [vitamins] come in boxes and just yesterday, my box was opened. I told the activity assistant to try to at least make sure [staff] don't open my boxes until I feel I can't open them myself, or at least in my presence. They could at least bring it to my room and open it in front of me, but lately, my boxes have been coming opened. Resident 5 stated staff opened the resident's packages at least once or twice per month. Resident 5 stated staff should not be opening the resident's mail and stated sometimes there was a delay in staff delivering the mail, especially if the designated staff person was off for the day. Resident 5 stated sometimes it took a day or more to receive mail. In an interview on 08/24/2023 at 7:40 AM, Staff H (Activity Director) stated it was the facility's process to open certain healthcare packages, but staff were to open those packages in front of Resident 5 with nursing staff present since most of the packages contained vitamins. Staff H stated they only opened packages in the presence of Resident 5. REFERENCE: WAC 388-97-0500(1). .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure residents were informed and provided with written information concerning the right to accept, refuse, or formulate an Advanced Directive (AD - legal documents reflecting a resident's wishes if they became incapacitated) for 2 (Residents 52 & 74) of 27 residents reviewed for ADs. The failure to offer assistance to formulate an AD placed residents at risk of not having a Power of Attorney (POA - surrogate decision maker) when unable to make their own healthcare or financial decisions. Findings included . <Resident 52> According to the 06/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 52 was assessed to make their own decisions, was understood, and able to understand conversations. Review of the 01/25/2023 AD Care Plan (CP) showed the interventions included the facility would place their AD in their medical record. Record review showed no ADs were available for Resident 52. In an interview on 08/21/2023 at 10:32 AM, Resident 52 stated no staff talked to them about ADs and they were not offered assistance with formulating an AD. In an interview on 08/24/2023 at 10:19 AM, Staff B (Director of Nursing - DNS) stated they offered AD assistance to residents upon admission and at quarterly care conferences. Staff B was unable to find AD documentation in Resident 52's record. In an interview on 08/24/2023 at 10:29 AM, Staff G (Social Services Director - SSD) stated they communicated with Resident 52 about ADs at admission and Resident 52 told them they had an AD. Staff G was unable to find documentation showing they followed up with Resident 52 to bring ADs documentation to the facility. Staff G stated they should have followed up with the resident and family to bring ADs to the facility and document the conversation but they did not. <Resident 74> According to the 08/14/2023 Quarterly MDS, Resident 74 was assessed to make their own decisions, was understood and able to understand conversation. The assessment showed Resident 74 needed an interpreter to communicate with health care staff and Resident 74's primary language was Amharic. In an interview on 08/22/2023 at 9:02 AM, Resident 74 stated they do not speak or understand English. In an interview on 08/22/2023 at 2:55 PM with an interpreter, Resident 74 stated they did not have AD and they did not remember any staff speaking with them about ADs. Review of the 11/11/2022 revised AD CP showed interventions directed staff to honor Resident 74's AD and wishes. Record review showed no ADs were available for Resident 74. In an interview on 08/24/2023 at 10:19 AM, Staff B stated they offered AD assistance to residents upon admission and at quarterly care conferences. Staff B was unable to find AD documentation in Resident 74's record. In an interview on 08/24/2023 at 10:29 AM, Staff G stated they communicated with Resident 74 and their spouse about ADs at admission. Staff G was unable to find documentation showing they followed up with Resident 74's spouse to bring AD documentation to the facility. Staff G stated they should have followed up with the resident and their spouse to bring a copy of their AD to the facility and document the conversation but they did not. REFERENCE: WAC 388-97-0280(3)(c)(i-ii). .

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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Based on interview and record review the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF-ABN) to 1 of 4 residents (Resident 65) reviewed for beneficiary notices. The failure to provide residents the information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program. Findings included . <Resident 65> The 08/02/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 65 was assessed as cognitively intact and able to make their own decisions. Review of a Notice of Medicare Non-Coverage (NOMNC) signed by Resident 65 and dated 08/07/2023 showed a last covered day for skilled services on 08/10/2023. There was no ABN document found in Resident 65's record to show a SNF-ABN was also provided on 08/07/2023. Review of another NOMNC signed by Resident 65 and dated 08/15/2023 showed a last covered day for skilled services on 08/17/2023. There was no ABN document found in Resident 65's record for 08/15/2023. In an interview on 08/25/2023 at 9:34 AM, Staff V (Social Services Assistant) stated the ABN was not provided to Resident 65 when the NOMNC was signed on 08/10/2023 and 08/15/2023. In an interview on 08/25/2023 at 12:00 PM, Staff A (Administrator) stated the ABN was expected to be provided to the resident every time a NOMNC was provided. Staff A stated the ABN informs residents of their appeal rights and the resident's cost of skilled care services if the appeal is not overturned. REFERENCE: WAC 388-97-0300(1)(e)(5)(6). .

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

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 the Preadmission Screening and Resident Review (PASRR - a screening process for residents who have indicators of intellectual disability, related disability, or serious mental illness) was followed for 1 (Resident 75) of 6 residents reviewed for PASRR. The facility failed to ensure a PASRR Level I was corrected upon admission to include serious mental illness which would have required a PASRR Level II (a more in-depth screening). This failure placed the resident at risk of not receiving the appropriate mental health services needed and placed them at risk for diminished quality of life. Findings included. Review of the 12/2022 facility policy Resident Assessment-Coordination with PASRR Program, showed This facility coordinates assessment with the preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. The Social Services Director shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. <Resident 75> Review of the admission Record showed Resident 75 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, and PTSD (Post Traumatic Stress Disorder). Review of the 07/21/2022 Level I PASRR completed by the hospital prior to admission to the facility showed, in Section I A. Serious Mental Illness (SMI)/Intellectual Disability (ID)/or Related Condition (RC) Determination was checked, No and instructed, no PASARR Level II would be required. Review of the 07/03/2023 Annual Minimum Data Set (MDS - an assessment tool)) showed Resident 75 was cognitively intact for daily decision-making and had rejected care from staff for one to three days during the seven-day observation period. During an interview on 08/22/2023 at 8:07 AM, Resident 75 was asked about her diagnosis of PTSD. Resident 75 stated they were abused during their childhood and married life. Resident 75 was asked if they received counseling or psychiatric services. Resident 75 stated they did not receive psychiatric services. During an interview on 08/24/2023 at 10:16 AM, Staff G (Social Services Director) was asked if there was a corrected PASRR Level I obtained upon admission, to include Resident 75's SMI. Staff G stated they must have missed it during quarterly audit. REFERENCE: WAC 388-97-1915(1)(2)(a-c). .

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 appropriate services to maintain and ensure that resident's ability to perform activities of daily living (ADLs) do not diminish, for two of three (Resident 17 & 74) residents reviewed as non English speaking residents. The facility failed to implement the use of alternative communication methods, such as a communication board in the language they understood to ensure their needs were met consistently. This failure placed the residents at risk of experiencing a decline in their physical well-being, psychosocial well-being, and their quality of life. Findings included . Review of the facility policy titled, Communicating with Persons with Limited English Proficiency. Dated 12/2022, showed, .It is the policy of this facility to take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits. The purpose of this policy is to ensure meaningful communication with LEP residents and their authorized representative involving their medical conditions and treatment . <Resident 17> Review of the admission Record showed Resident 17 was admitted to the facility on [DATE] with diagnoses of a stroke, aphasia (a language disorder that affects the way person speaks), and major depressive disorder. Review of the 08/08/2023 Annual Minimum Data Set (MDS - as assessment tool) showed Resident 17 was assessed to require extensive assistance from one staff for ADLs, and was always incontinent of bowel and bladder. The assessment showed Resident 17 had rejection of care for one to three days during the seven-day observation period. Review of the 08/28/2022 Communication Care Plan (CP) showed Resident 17 had a communication problem related to Aphasia. Resident 17 spoke Vietnamese and no English. CP interventions included to Provide communication board with English to Vietnamese translations for common/needs in resident's room. During an observation on 08/23/2023 at 10:57 AM, Resident 17 was in their wheelchair, self-propelling down the hallway using only their left hand. Resident 17 was dressed in a hospital gown. During an interview on 08/24/2023 at 12:03 PM, Staff M (Certified Nurse Assistant) was asked if Resident 17 had a communication board. Staff M stated there was no communication board for Resident 17. Staff M was asked how they communicate with Resident 17 to meet their daily needs. Staff M stated Resident 17 understood some lip reading and used gestures. During an interview on 08/24/2023 at 1:43 PM, Staff B (Director of Nursing) stated the facility had tried to use the language line and that did not go well. Resident 17 was pretty good at gesturing with their hands. Staff B was asked if there was a communication board for Resident 17 to use to communicate their needs with nursing staff. Staff B stated the facility did a full audit of residents in the building who were LEP and assigned a person to complete this task of developing the communication boards, but the assigned staff quit three weeks ago. The task has not been done yet. <Resident 74> According to the 08/14/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 74 was assessed to make their own decisions, was understood and able to understand conversation. The assessment showed Resident 74's primary language was Amharic and they needed an interpreter to communicate with their physician and health care staff. Observations on 08/21/2023 at 8:58 AM and 11:06 AM, and on 08/23/2023 at 2:03 PM showed Resident 74 in bed, their face was covered with a blanket. In an interview on 08/22/2023 at 11:06 AM, Resident 74 stated they did not speak or understand English, they spoke an Ethiopian language. In an interview on 08/22/2023 at 2:55 PM with an interpreter, Resident 74 stated they did not understand staff and could not explain their needs to the staff. Resident 74 stated they understood very little English and sometimes they had to wait for their friends or family to come and ask staff about Resident 74's needs. Resident 74 stated they did not have a communication board or book in their room for staff to use to communicate with Resident 74. Review of the revised 07/13/2023 Communication CP showed Resident 74 had a communication problem related to a language barrier. The interventions directed staff to anticipate and meet needs, and to speak clear, slower than normal, and on adult level. Review of a 08/08/2023 MDS nurse note showed Resident 74 was alert and oriented, non-English speaking, and unable to communicate. In an interview on 08/22/2023 at 10:09 AM, Staff Z (Certified Nursing Assistant - CNA) stated Resident 74 did not speak English and staff communicated with the resident by gestures or waited for any staff who spoke their language. In an interview on 08/24/2023 at 7:42 AM, Staff X (Resident Care Manager - RCM) stated staff were getting help from the staff, who spoke the same language as Resident 74. Staff X stated the language barrier affected Resident 74's care. They should have a communication book with pictures in Resident 74's room but they did not. In an interview on 08/24/2023 at 10:44 AM, Staff G (Social Services Director) stated the facility should have provided a communication board or book for Resident 74 in their room but they did not provide one. Refer to F 679 - Activities Meet Interests/Need of Each Resident REFERENCE: WAC 388-97-1060(2)(a)(v). .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 100> The 08/07/2023 admission MDS showed Resident 100 admitted to the facility on [DATE] with debility related t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 100> The 08/07/2023 admission MDS showed Resident 100 admitted to the facility on [DATE] with debility related to heart and lung conditions. Resident 100 was assessed to be totally dependent on two staff for bathing support. The 08/01/2023 nursing admission assessment showed Resident 100 was cognitively intact and made their own decisions. The assessment showed a resident interview was completed and Resident 100 preferred to receive a shower, not a bed bath. The 08/01/2023 CP for ADLs showed Resident 100 had a self-care performance deficit related to weakness, impaired mobility, and pain. The CP showed Resident 100 was incontinent of bladder and bowels, had risk of skin impairment and directed staff to provide bathing/showering assistance one to two times per week. In an interview and observation on 08/23/2023 at 7:45 AM, Resident 100 stated they were not getting help with trimming their moustache and were not having help with a shower twice a week. Resident 100 stated they wanted showers twice a week. Resident 100 stated they had medical appointments during the day and did not get back to the facility until 5:00 PM. In an interview and record review on 08/23/2023 at 11:08 AM, Staff W stated there was a shower schedule on the wall. The undated shower schedule showed Resident 100 was scheduled for Thursday and Sunday evening shift showers. Staff W stated if a resident did not get a shower according to the schedule, staff was supposed to notify the charge nurse so arrangements could be made for another shower time. Staff W stated when a resident refused a shower, it was offered multiple times and all showers and refusals are supposed to be documented. On 08/23/2023 a review of the August 2023 shower documentation for Resident 100 showed a bed bath was documented on 08/02/2023 and 08/13/2023. A refused shower was documented on 08/07/2023. There was no documentation a bath or shower was provided for the scheduled dates of 08/09/2023, 08/17/2023 or 08/21/2023. Resident 100 was not provided a shower since admission on [DATE] as they preferred. Resident 100 was bathed with a bed bath on 08/13/2023 and went 10 days without bathing or showering. In an interview on 08/25/2023 at 11:36 AM, Staff D stated Resident 100 should have been offered and provided a shower two times a week according to the CP and the shower schedule. Staff D did not know why there was no staff documentation for showering assistance for the last 10 days for Resident 100. Refer to F725 Sufficient Staffing. REFERENCE: WAC 388-97-1060(1)(2)(c). Based on observation, interview, and record review the facility failed to provide hygiene according to resident needs and preferences for 2 of 4 residents (Resident 65 & 100) reviewed for Activities of Daily Living (ADL) for dependent residents. The failure to provide oral care and supplies to Resident 65 or provide showers and facial hair trimming to Resident 100 placed both residents at risk for poor self-esteem, isolation from others, infection, and diminished quality of life. Findings included . <Resident 65> The 08/02/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 65 was admitted on [DATE]. The MDS showed Resident 65 was able to understand and make self-understood, had no cognitive impairment, and had cavities and broken teeth upon oral exam. The MDS showed Resident 65 required set up for oral hygiene prior to admission. Resident 65 was assessed to require limited assistance of one person for hygiene during the assessment period. The 07/26/2023 ADL Care Plan (CP) showed Resident 65 needed one-person limited assistance with oral hygiene. In an observation and interview on 08/22/2023 at 2:47 PM, Resident 65 stated they had broken and missing teeth on the top gums and only had seven teeth on the bottom. Resident 65 stated they used to brush their teeth at home but had not brushed their teeth since coming to the facility (4 weeks ago). Resident 65 stated they did not have a toothbrush or toothpaste. When looking in the bedside drawers, the overbed table and the bathroom, no toothbrush or toothpaste was found. In an interview on 08/24/2023 at 12:41 PM, Staff W (Certified Nursing Assistant) searched Resident 65's room and was not able to find a toothbrush or toothpaste. Resident 65 stated to Staff W, I have not had them since I got here. Outside the room, Staff W stated residents usually come to the facility with their own supplies but if they do not have them, the staff can provide a toothbrush and toothpaste. Staff W stated Resident 65 should have received supplies on admission. In an interview on 08/24/2023 at 12:50 PM, Staff D (Resident Care Manager) stated Resident 65's care plan showed they needed assistance with oral care. Staff D stated the caregivers were signing that oral care was being provided. Staff D stated if there were no supplies for oral care in Resident 65's room, they were not getting oral care. Staff D stated the staff should have provided the care if they signed the care was done.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on observations, interview, and record review the facility failed to communicate and implement individualized activity plans for 1 of 3 (Resident 74) residents reviewed for activities. Failure to consistently implement group or individual activity plans left the resident at risk for boredom, isolation, and a diminished quality of life. Findings included . <Resident 74> According to the 08/14/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 74 was cognitively intact. The MDS showed Resident 74's primary language was Amharic and they needed an interpreter to communicate with their physician and health care staff. The MDS showed participating in activities with a group of people, and listening to music was very important for Resident 74. Review of a 07/21/2023 Activities/Recreation Quarterly/Annual Review assessment showed Resident 74 liked to talk to others, listen to music in their language, and activity staff would provide one on one time with Resident 74 in their room. Staff would continue to encourage Resident 74 to participate in group activities including exercise and church services. Review of a 07/21/2023 Social Needs Care Plan (CP) showed Resident 74 liked to talk to others and listen to music in their language. The CP instructed activity staff to encourage Resident 74 to participate in group activities and provide an activity calendar to Resident 74. The interventions included Resident 74 needed assistance to get to activity functions. Review of the one on one activity record showed from 07/23/2023 to 08/23/2023 Resident 74 was offered one on one activities on two occasions: 08/11/2023 and 08/14/2023. On 08/04/2023 the documentation showed one on one activity as not applicable. In an interview on 08/22/2023 at 2:55 PM with an interpreter, Resident 74 stated they would like to go to activities and stated, but no one told me about the activities schedules and performed 1:1 activity with me. Resident 74 stated they could not read the activities calendar. In an interview on 08/24/2023 at 7:42 AM, Staff X (Resident Care Manager- RCM) stated activity staff gave the activity calendar to residents and nursing staff assisted residents to attend the activities. Staff X stated Resident 74 had a hard time understanding English and explaining their needs to staff. In an interview on 08/24/2023 at 11:55 AM, Staff H (Activity Director) stated Resident 74 did not speak much English and facility used the staff from Ethiopia as translators. Staff H stated it was very hard to explain activities to Resident 74. Staff H stated the facility should have offered activities in language that Resident 74 could understand and should have assisted them more but they did not. Refer to F 676 - Communication, Language. REFERENCE: WAC 388-97-0940(1). .

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

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 1 of 6 (Resident 52) residents reviewed for Restorative Nursing Programs (RNP) received the care and services they were assessed to require. These failures placed residents at risks for declines in Range of Motion (ROM) or functional status, and other negative health outcomes. Findings included . <Resident 52> According to the 06/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 52 admitted to the facility on [DATE] and had multiple medical diagnoses including quadriplegia (symptom of paralysis affecting person's all limbs), and Osteoarthritis (form of arthritis causing joint pain and stiffness). The MDS showed Resident 52 had intact memory and was able to communicate and understand effectively. This assessment showed Resident 52 participated in RNP, Passive ROM (PROM) five times and splinting four times during the seven-day assessment period. In an interview on 08/22/2023 at 10:45 AM, Resident 52 stated the restorative aides worked with them for ROM on their left hand and they were supposed to put a brace on their left hand but it did not happen every day. Resident 52 stated the restorative aide was not consistent with applying brace on their left hand. Resident 52 stated their left hand had a contracture and the facility should help them to put the palm guard on every day. Observations on 08/23/2023 at 8:23 AM, 12:02 PM, and 3:54 PM, on 08/24/2023 at 8:02 AM, 10:37 AM, and 4:02 PM, and on 08/25/2023 at 7:54 AM, and 11:26 AM showed Resident 52 had no brace or splint on. Review of a 05/30/2023 revised Restorative Care Plan (CP) showed Resident 52 had PROM to left upper extremity. The CP instructed restorative staff to apply a palm guard to the left hand for six to eight hours, seven days a week. Review of the RNP left hand palm guard program documentation from 07/25/2023 to 08/25/2023 showed Resident 52 received assistance to put palm guard on their left hand on 07/29/202, 08/03/2023, 08/05/2023, 08/07/2023, 08/8/2023, 08/10/2023, 08/12/2023, 08/13/2023, 08/14/2023, 08/19/2023, 08/20/2023, 08/22/2023 and was documented as not available on 08/15/2023. Staff documented Resident 52 refused RNP on 08/18/2023, and not applicable on 08/4/2023, and 08/11/2023. This documentation showed Resident 52 received assistance with their left hand palm guard 12 times in last 30 days. Record review showed an 08/24/2023 therapy note stating Resident 52 did not want to use the left arm resting splint because it was not comfortable and Resident 52 wanted to use left palm guard every day instead. In an interview on 08/24/2023 at 2:36 PM, Staff FF (Occupational Therapist Assistant) stated Resident 52 did not feel comfortable wearing the left arm resting splint. Staff FF stated they modified the splint, but the resident did not feel comfortable wearing the arm splint. Staff FF stated Resident 52 had a RNP for applying the left palm guard every day and Resident 52 was agreeable. In an interview on 08/25/2023 at 11:26 AM, Staff X (Resident Care Manager) stated restorative staff should have performed the left palm guard program every day as Resident 52 tolerated but they did not. Staff X spoke with Resident 52 about RNP and Resident 52 stated they did not get assistance to put the palm guard on for the last three days, the palm guard was observed sitting in their lap. Resident 52 stated they were looking for restorative aides to put the brace on their left hand but could not find the staff. In an interview on 08/25/2023 at 11:32 AM, Staff BB (Restorative aide) stated they knew Resident 52 should have a left palm guard on every day, but they did not have time to do those seven days a week. Staff BB stated sometimes they had to help wound nurse with treatments and sometimes, they got pulled to work on the floor. Staff BB stated they reported this issue to their supervisors, the Director of Nursing (DON) and MDS coordinator who oversaw the RNP. In an interview on 08/25/2023 at 11:38 AM, Staff J (MDS Coordinator) stated Resident 52 had an order to apply a left hand palm guard seven days a week and restorative staff should have done this program every day. Staff J stated no staff member reported to them about not being able to provide the program as required. In an interview on 08/25/2023 at 11:50 AM, Staff B (DON) stated restorative staff must assist the resident to apply the left hand palm guard seven days a week as required but they did not. REFERENCE: WAC 388-97-1060 (3)(d). .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure medications were secured for 3 of 25 (Resident 36, 74, & 89) residents observed with medications left in their rooms. This failure placed residents at risk for receiving wrong medications, and non-assessed, self-administration of medications by residents. Findings included . According to the revised 12/2022 Medication Storage facility policy, the facility was to ensure during medication pass, medications must be under the direct supervision of the person administering medications or locked in the medication cart. <Resident 36> On 08/22/2023 at 7:22 AM, two medicine cups containing pills and an inhaler were observed on the bedside table. Resident 36 was not in their room at that time. In an interview on 08/22/2023 at 7:36 AM, Staff GG (Licensed Practical Nurse - LPN) stated Resident 36 went to the dining room without taking their medications. Staff GG stated those were morning medications for Resident 36 and should not be left at the bedside. Staff GG took the medicine cups back to the medication cart. In an interview on 08/22/2023 at 8:45 AM, Resident 36 stated they went to the dining room for breakfast. When asked about what time they take their morning medications, Resident 36 stated some nurses gave their medications before breakfast and some nurses left their medications in their room to take after breakfast. <Resident 74> On 08/22/2023 at 7:32 AM, a medicine cup containing pills was observed on the bedside table in Resident 74's room. Resident 74 was sleeping in bed with their face covered with a blanket. In an interview on 08/22/2023 at 7:49 AM, Staff GG (Licensed Practical Nurse - LPN) stated Resident 74 usually take their medication. Staff GG stated it was their fault and should not leave the medications in Resident 74's room unattended. In an interview on 08/22/2023 at 7:52 AM, Resident 74 stated No English. In an interview on 08/22/2023 at 7:58 AM with an interpreter, Resident 74 stated they did not know about the nurse leaving their medications on the bedside table. <Resident 89> On 08//22/2023 at 7:40 AM, an inhaler was observed on the bedside table in front of Resident 89. In an interview on 08/22/2023 at 7:42 AM, Resident 89 stated the nurse left the inhaler in their room for them to use it. In an interview on 08/22/2023 at 7:46 AM, Staff GG stated they should not have left Resident 89's inhaler in their room. In an interview on 08/24/2023 at 10:36 AM, Staff B (Director of Nursing) stated if residents were assessed for self-medication administration program, then it was ok to leave the medications in their room with physician orders. Staff BB stated Resident 36, 74, and 89 were not assessed for the self-medication administration program. Staff B stated nurses were expected to watch and validate all medications were taken by the residents, and medications were not allowed to be left at the bedside. REFERENCE: WAC 388-97-1300 (2), -2340. .

CONCERN (D)

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to provide Specialized Rehabilitative (Rehab) Services according to Physician Orders (POs) for 1 of 3 residents (Resident 65) reviewed for therapy services. The failure to provide physical and occupational therapy to Resident 65 placed them at risk for decline in physical and functional mobility, deterioration of muscle strength and diminished quality of life. Findings included . The 08/02/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 65 required no physical assistance was needed with Activities of Daily Living (ADL - self care tasks such as mobility, dressing, and hygiene). The MDS showed Resident 65 required extensive assistance for all ADLs at the time of admission for skilled therapy services. The MDS showed direct care staff and Resident 65 both believed Resident 65 was capable of functional rehab to increased independence in ADL self-care. The MDS showed Resident 65 had a discharge plan to the community after completing rehab. The 07/27/2023 ADL Care Plan (CP) showed Resident 65 had a self-care deficit related to impaired mobility and other chronic conditions. The CP showed Resident 65's goal was to maintain or improve their level of functioning. The CP intervention directed staff to provide physical therapy and occupational therapy according to POs. The 07/27/2023 POs showed Physical Therapy (PT) was to be provided five times a week for 30 days and Occupational Therapy (OT) was to be provided five times a week for 30 days. In an interview on 08/22/2023 at 2:25 PM, Resident 65 stated I did not get PT or OT today. Resident 65 stated they used to get more therapy when they first came to the facility, three weeks ago, and was not getting out of bed. In an interview on 08/24/2023 at 12:36 PM, Resident 65 stated they did not have therapy for the last five days. Resident 65 stated they could just be at home on the couch if they were not going to be getting therapy anymore. In an interview on 08/24/2023 at 3:22 PM, Staff L (Rehab Director) stated Resident 65 had no PT since 08/19/2023 and no OT since 08/18/2023. Staff L stated there was confusion about insurance coverage which caused Resident 65 to not be scheduled for PT or OT for five days. Staff L stated Resident 65 should have, but did not, receive PT and OT five days a week. In an interview on 08/24/2023 at 3:33 PM, Staff V (Social Services Assistant) stated there was a last covered day notification provided to Resident 65 that skilled services would not be covered after 08/24/2023. Staff V stated Resident 65 completed an appeal to the notification and should have continued to receive PT and OT while the appeal was pending. In an interview on 08/25/2023 at 12:00 PM, Staff A (Administrator) stated Resident 65 should have continued receiving PT and OT while the insurance appeal was pending. REFERENCE: WAC 388-97-1280(1)(a). .

CONCERN (E)

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

Deficiency F0572 (Tag F0572)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to inform residents of their rights and responsibilities, services provided by the facility and facility rules and regulations both orally and in writing and receive receipt of the information acknowledged in writing for 3 of 3 residents (Residents 2, 96, & 23) reviewed for arbitration agreements and 8 of 8 residents (Residents 3, 5, 32, 34, 36, 45, 73, & 82) represented at the Resident Council meeting. The failure to inform residents of the admission policies, resident rights, facility rules, and operations of the nursing home and the failure to ensure resident rights were reviewed and discussed regularly after admission and posted in a location accessible by all residents, placed all residents at risk of poor understanding and inability to execute their rights, lack of access to information required to make decisions about care, and a diminished quality of life while living in the nursing home. Findings included . Review of the (undated) template of the facility admission Packet showed information and consent forms for the admission policies, resident rights, rules and operations of the nursing home, grievance process, right to choose their physician or contact information for the facility physician, charges for services, advanced directives and designation of a resident representative, privacy practices, healthcare privacy act, consent for release of medical information, bed hold policy, facility-initiated discharge policy, designation of funeral home, laundry services, policy on personal property, vaccination policies and consent, smoking policy, trust fund policy, arbitration agreement, information on state and local contacts for the State Hotline for abuse/neglect/complaints, contact for the State Ombudsman Program, Adult Protective Services, Medicaid Fraud Office, and information on the benefits/rights under Medicare. The admission packet contained multiple areas for the resident to sign acknowledgement to the facility policies, procedures and provide consent to the facility for specified care. <Resident 2> A 06/28/2023 physician signed Capacity for Medical Decisions form showed Resident 2 was the decision maker for medical decisions and had a Power of Attorney to make healthcare decisions. A 06/27/2023 Consent to admission and Treatment acknowledgement form showed a full signature in cursive of Resident 2's first and last name. The form was also signed by a facility representative without a printed name to identify the staff signature. Review of Resident 2's admission Agreement dated 06/27/2023 showed Staff JJ (Admissions Director 2) was the facility representative that reviewed the document with Resident 2 on 06/30/2023 and obtained signatures on the agreement. The signature of Resident 2 was written as two letter initials throughout the document on the various consent forms and acknowledgement of policies forms for a total of 24 signatures. The signature on the admission Agreement did not match Resident 2's signature on the Consent to admission and Treatment form signed on the same date. <Resident 96> A 07/24/2023 physician signed Capacity for Medical Decisions form showed Resident 96 was unable to comprehend the risks and benefits and alternatives to medical decisions and was not capable to make medical decision on their own behalf. A resident representative was indicated on the form for the hierarchy for medical decision makers. A 07/25/2023 Consent to admission and Treatment acknowledgement form showed a signature in cursive of Resident 96's first and last name. The signature was not on the signature line and was not legible. The form was also signed by a facility representative without a printed name to identify the staff signature. A 08/15/2023 Notice of Medicare Non-Coverage (NOMNC) form was signed by Resident 96. The signature was in cursive and legible to verify Resident 96's name. Review of Resident 96's admission Agreement dated 07/25/2023 showed Staff K (Admissions Director 1) was the facility representative that reviewed the document with Resident 96 on 07/27/2023 and obtained signatures on the agreement. The signature of Resident 96 was written as two letter initials throughout the document on the various consent forms and acknowledgement of policies forms for a total of 24 signatures. The signature on the admission Agreement did not match Resident 96's signature on the Consent to admission and Treatment form. In an interview on 08/25/2023 at 9:23 AM, Staff K stated they did not review the admission agreement with Resident 96, even though their name was on the document. Staff K stated a different Admissions Director reviewed the agreement with Resident 96 and signed Resident 96's initials on the document. Staff K stated there was no documentation from the other admissions director that the document was reviewed or that a copy was provided to Resident 96. <Resident 23> A 06/05/2023 physician signed Capacity for Medical Decisions form showed Resident 23 was the decision maker for medical decisions and had a Power of Attorney to make healthcare decisions. Review of two other documents signed by Resident 23, a Physician Order for Life Sustaining Treatment (POLST) form dated 08/02/2023 and a Notice of Medicare Non-Coverage (NOMNC) form dated on 05/04/2023. The documents showed a cursive signature of Resident 23. Review of Resident 23's admission Agreement dated 07/14/2021 showed Staff K (Admissions Director 1) was the facility representative that reviewed the document with Resident 23 on 07/28/2023 and obtained signatures on the agreement. The signature of Resident 23 was written as a printed last name throughout the document on the various consent forms and acknowledgement of policies forms for a total of 24 signatures. The signature on the admission Agreement did not match Resident 236's signature on the POLST or NOMNC. In an interview on 08/25/2023 at 9:17 AM, Staff K stated the admissions staff must review the admission agreement with the resident if they were cognitively intact and able to understand the conversation. The admissions staff used an iPad to review the agreement and had the resident sign the agreement on the iPad one time. When the resident signs one time, the electronic document transferred the signature to all 24 areas on the admission agreement. Staff K clarified, the resident does not sign each consent form separately, the one signature was copied to all consents on the electronic admission agreement. In an interview on 08/25/2023 at 9:23 AM, Staff K stated they did not review the admission agreement with Resident 23, even though their name was on the document. Staff K stated a different Admissions Director reviewed the agreement with Resident 23 and signed Resident 23's initials on the document. Staff K stated there was no documentation from the other admissions director that the document was reviewed or that a copy was provided to Resident 23. In an interview on 08/25/2023 at 9:23 AM, Staff K stated an admissions director was not allowed to assess a resident's cognition or ability to understand the agreement. The admissions director must review the physician or the nurse assessment to determine if the resident could sign documents. Staff K explained that if a resident was not able to physically sign, then staff would sign the resident's initials on the electronic document with the resident's permission. In an interview on 08/25/2023 at 9:23 AM, Staff A (Administrator) stated the facility completed an audit of residents that did not sign admission agreements. Staff A explained another admissions director was assisting the facility to review the agreements with residents and had residents sign the admission agreements. Staff A acknowledged Resident 2, 96 and 23's admission agreements were not signed by the resident. Staff A acknowledged if the resident did not sign the documents, then consent was not obtained. Staff A stated facility staff was not authorized to sign the resident's name or initials on any documents. <Resident Council> Review of the facility's 05/2023 policy Resident Rights showed the facility will inform residents of their resident rights, resident responsibilities, and all rules and regulations during the stay in the facility. Review of the past four months of the Resident Council Meeting Minutes dated 05/17/2023, 06/21/2023, 07/19/2023, and 08/16/2023 showed no documentation that any resident rights were discussed with the residents during the council meetings. During a Resident Council Meeting held on 08/23/2023 at 2:00 PM, when residents were asked if resident rights were reviewed and discussed during the monthly council meetings, Resident 82 stated, No. Resident 34 stated, I've asked about my rights, and I never got any information. Resident 3 stated, They never reviewed or go over our rights with us at our council meetings. Resident 82 stated, It's a communication problem, isn't it? They just don't cover those. When Resident 5 was asked if resident rights were reviewed at each council meeting, they stated, No, they were not. They don't do that. Resident 45 and Resident 73 were observed shaking their heads, no. Resident 32 stated, No. They don't. On 08/23/2023 at 2:00 PM, Staff H (Activity Director) confirmed the activity department staff was responsible for coordinating and communicating all information to residents. Staff H stated, I've been doing council meetings for years now, and I never covered [resident rights]. Observation and interview on 08/24/23 at 7:55 AM showed no posted information regarding resident rights on the second floor in the dining room, corridors, hallways, or by the nurse's station. At this time, a small 8 x 11 picture frame was observed hanging on a wall located by the Director of Nursing Services (DNS) office with resident rights listed. It was in very small print, hard to read, and not accessible to the height of any residents in a wheelchair. In an interview on 08/24/2023 at 8:00 AM, Staff A stated the admission agreement was provided at the time of admission and a copy of the resident rights was given to the resident at that time. Staff A stated resident rights should also be reviewed at the resident council meetings. REFERENCE: WAC 388-97-0300(1)(4)(6)(7)(8)(9)(10).

CONCERN (E)

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

Deficiency F0574 (Tag F0574)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure the ombudsman information was reviewed with residents and information was discussed on how to file a complaint with the state agency for 8 (Resident 3, 5, 32, 34, 36, 45, 73, & 82) of 8 residents who regularly attended monthly Resident Council Meetings (RCMs). The failure to not provide accessible ombudsman information and not provide residents with information on how to file a complaint with the state agency, left residents at risk for not having rightful resources available to them. Findings included . <Facility Policies> Review of the 03/14/2023 Resident and Family Grievances facility policy showed the facility would support each resident's right to voice grievances. The policy showed resident rights regarding grievances would be posted in prominent locations throughout the facility. Information on how to file a grievance or complaint would be available to the resident. Information would include contact information of independent entities with whom grievances could be filed such as the pertinent state agency, State Survey Agency, and State Long Term Care Ombudsman (LTCO) program. Review of the 05/2023 Resident Rights facility policy indicated a posting of names, addresses and phone numbers of all pertinent state client advocacy groups would be available in the facility. This policy showed a list of names and contact information of all pertinent state regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State LTCO program, the protection, and advocacy agency would be available to the residents. Review of the 05/2023 Facility Required Postings facility policy showed the facility would post required information in an area that was accessible to all staff and residents. Facility postings would include a list of names and contact information of all pertinent state agencies and advocacy groups to include the State Survey Agency, State Licensure Office, and Office of the LTCO. Review of the 05/17/2023, 06/21/2023, 07/19/2023, and 08/16/2023 RCM minutes showed no documentation the ombudsman contact information was discussed and no documentation of how to file a complaint with the state agency if needed was reviewed. During a RCM held on 08/23/2023 at 2:00 PM with the surveyor and residents, residents stated they were unaware of where the LTCO information was posted, who the ombudsman was, or how to contact them. Resident 5 (Resident Council President) stated they did not know how to contact the ombudsman or state agency and thought it should be posted. Resident 82 and Resident 34 both stated, they had never heard of an ombudsman and did not know what the ombudsman was for. Resident 45 was observed shaking their head no when asked about the ombudsman. Resident 3 stated ombudsman information was not reviewed with them. Resident 32 confirmed they did not know anything about ombudsman. Resident 82 stated they were unaware on how to file a complaint and information was not discussed related to that process. Resident 34 and Resident 3 confirmed they did not know how to file a complaint with the state agency. During the RCM on 08/23/2023 at 2:00 PM, Staff H (Activity Director) confirmed the ombudsman information was not covered during RCMs. Staff H confirmed they did not discuss how to file a complaint with the state agency during RCMs. In an interview on 08/24/2023 at 7:40 AM, Staff H stated they thought ombudsman information was posted downstairs. Staff H stated they thought the information regarding how to file a complaint with the state agency was and should be posted. Staff H confirmed they did not provide this information to residents during the RCMs. Observation and interview on 08/24/2023 at 7:55 AM with Staff H, showed no postings of the ombudsman contact information or information on how to file a complaint with the state agency on the second-floor hallways, corridors, or dining room. At that time, Staff H stated they expected the ombudsman and complaint information would be posted for the residents. An observation at that time showed an 8-inch by11-inch picture frame with small font lettering located on the second floor by the Director of Nursing's office with the ombudsman's phone number on it. The picture frame was posted high up on the wall and was not accessible to any residents in a wheelchair. The lettering was difficult to read when up close to it. In an interview on 08/24/2023 at 8:00 AM, Staff A (Administrator) stated it was their expectation ombudsman contact information and information on how to file a complaint with the state agency was reviewed during RCM meetings. Staff A confirmed ombudsman and state agency information was posted on the first floor but not the second floor. Staff A stated it was their expectations the residents were informed of where this information could be located. REFERENCE: WAC 388-97-0300(7)(a-d). .

CONCERN (E)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure the state survey inspection results were made available for 8 (Residents 3, 5, 32, 34, 36, 45, 73, and 82) of 8 residents who regularly attended monthly resident council meetings. Findings included . Review of the 05/2023 Resident Rights facility policy showed residents had a right to view the most recent survey results and any plan of correction in effect. Review of the 05/17/2023, 06/21/2023, 07/19/2023, and 08/16/2023 Resident Council Meeting minutes showed no documentation the state survey inspection results were discussed with residents or where the information was available for residents to review. During a Resident Council Meeting on 08/23/2023 at 2:00 PM, Resident 3, Resident 5, Resident 32, Resident 34, Resident 36, Resident 73, and Resident 82 stated they were unaware of where the state survey results were located. Resident 45 shook their head, no regarding knowledge of the survey results. Staff H (Activity Director) (who was present during the Resident Council Meeting) stated they did not review the information during resident council meetings because they were unaware they needed to provide information about the state survey results to the residents. Resident 34 stated the state survey information should be covered with all residents and available for them to read. In an interview on 08/24/2023 at 7:40 AM, Staff H stated they thought the state survey results were posted near the front desk but were unsure. During an observation and interview on 08/24/2023 at 7:55 AM, survey results were not observed to be located on the second floor in the dining room, hallways, corridors, elevators, or by nurses' station. At that time, Staff H stated inspection results should be posted but they were not. An observation of the first floor, showed a binder mounted on the wall by the nurse's station and contained the state inspection results. The survey results were on the wall and not easily accessible to residents. In an interview on 08/24/2023 at 8:00 AM, Staff A (Administrator) stated there was a binder posted by the nurse's station on the first floor but not on the second where it would be accessible to most residents. Staff A stated it was their expectation residents were aware of where the state inspection information was located. Staff A stated they expected the information to be reviewed with the residents. REFERENCE: WAC 388-97-0480(1)(a-c). .

CONCERN (E)

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

Safe Environment (Tag F0584)

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 maintain a safe, clean, comfortable, and homelike environment without safety risks for 20 of 107 residents (Resident 65, 23, 53, 84, 3, 45, 74, 36, 37, 47, 91, 21, 6, 14, 41, 59, 46, 2, 92, & 16) reviewed for facility environment. The failure to maintain adequate lighting, clean carpets, absence of odors, working window blinds, and operational hand sanitizer dispensers placed residents at risk for unsatisfactory living conditions and diminished quality of life. Findings included . <Odor> Multiple observations on 08/22/2023 from 7:00 AM to 4:00 PM, on 08/23/2023 from 7:00 AM to 4:00 PM, on 08/24/2023 from 7:00 AM to 4:00 PM and 08/25/2023 from 8:00 AM to 1:00 PM showed an overwhelming odor of urine and feces smell on the second floor west, east, and central hallways. <Blinds> Observation and interview on 08/22/2023 at 2:36 PM showed Resident 65 stated there is nowhere to plug in the fan. The blinds do not open anymore- I have been here a couple weeks, the blinds never worked. Observation of the blinds showed missing slats and the inability to twist to darken or lighten the room light. Observations on 08/22/2023 at 10:00 AM and 08/23/2023 at 7:45 AM showed Resident 23 had several slats in their window blinds missing on the left, right, and middle of the window. Observation on 08/22/2023 at 9:10 AM showed Resident 53's window blinds were broken and the window screen was hanging off the window unsecured. Observation on 08/23/2023 at 7:30 AM showed Resident 84's window blinds were broken. Several pieces of long blinds were missing. The wand to open/close blinds it was broken and blinds were not able to be open or closed. Observation and interview on 08/24/2023 at 8:50 AM showed room [ROOM NUMBER] blinds were missing slats. Resident 3 stated I mentioned it to maintenance, they agreed it needed to be replaced but I don't think there are any slats available, I think they are all used up. The window doesn't have a screen on it, the birds could come in and bugs come in too. I just leave it as it is, when I mentioned it to maintenance, they said they would get my blinds replaced about 6 months ago. It has not been done yet. Observation and interview on 08/24/2023 at 9:22 AM showed room [ROOM NUMBER] had slats missing in the blinds on the left side of the window. Resident 45 stated I only open the blinds so far because some of them are missing. <Walls> Observation on 08/22/2023 at 1:35 PM showed (Residents 74 &36) room [ROOM NUMBER]'s bathroom door had holes filled with patches of a white substance and the walls in the bathroom had many scratches in the paint. Observation on 08/22/2023 at 9:00 AM showed (Resident 37) room [ROOM NUMBER]-B with tape on the baseboard to affix it to the wall and wall paint coming off in the bathroom. Observation on 08/22/2023 at 9:06 AM showed (Resident 47) room [ROOM NUMBER]-B with paint falling off, scratched paint on the walls and doors with unpainted white patches. Observation on 08/22/2023 at 9:15 AM showed (Resident 91) room [ROOM NUMBER]-B with paint scratched off the wall by the headboard of the bed. Observations on 08/22/2023 at 8:20 AM showed (Resident 21) room [ROOM NUMBER]-A with paint missing from the walls and white patches. Observation on 08/23/2023 at 8:37 AM showed (Resident 6) room [ROOM NUMBER] walls with multiple scratches in the paint. Observation on 08/22/2023 12:55 PM showed a patch of paint missing from wall between the oxygen room and emergency water supply room on the east hall of second floor. 28 residents resided on the 2 east hall. <Lighting> Observation and interview on 08/22/2023 at 8:45 AM showed the bathroom in room [ROOM NUMBER] was dark, and the light bulbs were burnt out. Resident 14 stated their roommate and the other residents next door used the bathroom. Observation on 08/22/2023 at 9:55 AM showed room [ROOM NUMBER]'s bathroom lighting was observed to be dim, with only two of the three light bulbs working. In an interview on 08/24/2023 at 9:15 AM Resident 41 stated, I noticed there was a bulb burnt out. It can be difficult sometimes to see things when its dim in there. Observation on 08/22/2023 at 9:10 AM showed room [ROOM NUMBER]'s bathroom lighting was dim. On 08/24/2023 at 9:07 Resident 53 stated, The light was dim in the bathroom. I wish it could be brighter. I have a bit of a hard time seeing in there. Observation on 08/22/2023 at 12:45 PM showed room [ROOM NUMBER] had a plastic garbage bag tied to the light cord and draped to the bed where Resident 59 could reach the cord. Observation on 08/22/20233 at 8:32 AM showed room [ROOM NUMBER] with a light cord that was too short for Resident 46 to reach to turn the over-bed light on or off. Observation and interview on 08/24/2023 at 9:22 AM showed room [ROOM NUMBER] had dim lighting in the bathroom. Resident 45 stated it was hard to see in the bathroom sometimes. Observation on 08/24/2023 at 9:45 AM showed room [ROOM NUMBER] with two light bulbs burned out in the bathroom. Resident 34 stated, It's hard for me to see in the bathroom, it's quite dark in there. <Floors> Observations on 08/22/2023 at 8:20 AM showed (Resident 21) room [ROOM NUMBER]-A had a sticky floor to which shoes stuck to the surface when walking to the resident's bed. Observation on 08/22/2023 at 9:09 AM showed (Resident 40) room [ROOM NUMBER] with broken floor tiles. Observation on 08/22/2023 at 1:03 PM showed (Resident 9) room [ROOM NUMBER]-B had a dirty and broken base board. Observations on 08/22/2023 at 2:15 PM showed the first floor hallway carpet with multiple large, dark spots outside Rooms 100, 101, 102, 117, 116, 104, 115, 105, 14, 113, 106, 107, and 112. 29 residents resided on the first floor. Observation on 08/22/2023 at 7:22 AM showed the elevator laminate flooring was cracked with pieces of the floor missing. There was a black sticky substance on the floor and in the cracks of the laminate. Observation on 08/23/2023 at 7:42 AM showed (Resident 100) room [ROOM NUMBER] had a dirty film on the baseboard heater, the floor was unclean and shoes stuck to the floor when walking in the room to see the resident. Observation on 08/23/2023 at 7:25 AM showed (Resident 2) room [ROOM NUMBER] had a sticky floor when walking in to see the resident. There was clutter on top of the counters. Observation on 08/23/2023 at 8:37 AM showed (Resident 6) room [ROOM NUMBER] with dirt and a sticky substance on the floor. Observation on 08/22/2023 at 12:55 PM showed multiple stains on the carpet on the east second floor hallway. The hallways had a strong smell of urine. 28 residents resided on the east 2 hall. Observation on 08/22/2023 at 1:03 PM showed (Residents 13 & 51) room [ROOM NUMBER]'s bathroom floor was wet and dirty. There was no soap in bathroom soap dispenser. <Clutter> Observation on 08/22/2023 at 7:44 AM showed (Resident 74) room [ROOM NUMBER] with dirty gloves on the floor and the footboard of the bed broken. Observation on 08/22/2023 at 12:35 PM showed (Resident 46) room [ROOM NUMBER] had two wheelchairs a large round blue exercise ball and a walker stacked along the wall. The resident stated it was a storage area. Observation on 08/23/2023 at 7:25 AM showed (Resident 2) room [ROOM NUMBER] had clutter on top of the counter surfaces. Observation on 08/22/2023 at 8:21 AM showed (Resident 92) room [ROOM NUMBER] had a wheelchair stacked with personal belongings including clothes, incontinent products, and papers in the corner of the room. The bedside table and the chair next to the bed was piled with books, papers, tissues, and clothes. The resident stated they needed to find their notepad. Observation on 08/22/2023 at 1:30 PM showed (Resident 16) room [ROOM NUMBER] with multiple personal items seen on surfaces in room, appeared cluttered with personal belongings. <Hand Dispensers> 08/22/2023 at 8:45 AM there was no hand sanitizer in the dispenser on wall between rooms 247-248. A second observation on 08/22/2023 at 1:10 PM there was still no hand sanitizer available in hallway in between rooms [ROOM NUMBERS]. On 08/24/2023 at 9:17 AM, there was still no hand sanitizer in the dispenser. Hand sanitizer container checks: 08/23/23 07:30 AM showed empty/non-working dispensers between rooms 247-248, between the clean linen closet and west shower room, between room [ROOM NUMBER] and 246, between room [ROOM NUMBER] and staff office, between 227 and 226, between 225 and storage, between 224 and 225, between restroom and clean linen closet, and between coordinator office and 216. In an interview on 08/24/2023 at 1:10 PM, Staff A (Administrator) acknowledged the strong odor of urine in the second floor hallway and provided mitigation steps taken so far. Staff A stated there was improvement and the odor came in waves. Staff A was aware of the many window blinds in the resident rooms and stated there was a plan for replacement. Staff A stated the carpet was cleaned weekly and there were no plans at this time to do more than cleaning. Staff A acknowledged the missing paint and patched walls. Staff A acknowledged the hand dispensers that were not dispensing sanitizer and stated they sometimes got clogged and housekeeping was expected to keep them supplied. REFERENCE: WAC 388-97-0880.

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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Based on interview and record review, the facility failed to provide written notification to residents or their Resident Representative (RR) of the reason for transfer/discharge and/or to properly notify the Office of State Long-Term Care Ombudsmen (SLTCO - an advocacy group for residents in a nursing home) of discharges to the hospital for 3 of 3 residents (Residents 6, 18, & 96) reviewed for hospitalization. These failures denied the resident and/or their RR information of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , prevented access to an advocate who could inform residents of their options and rights, and failed to ensure the SLTCO was aware of facility practices and activities related to transfers and discharges. Findings included . The 12/2022 facility policy Transfer and Discharge, showed the facility transfer/discharge notice was provided to the resident and the resident's representative in a language and manner they could understand. The notice would include the specific reason and basis for transfer or discharge, the effective date, the specific location, the contact information to the SLTCO. The policy stated the facility would maintain evidence the transfer/discharge notice was sent to the SLTCO. <Resident 6> A 01/15/2023 nurse progress note showed Resident 6 was transferred to the hospital. Review of Resident 6's medical record found no documentation of a transfer/discharge notice provided to Resident 6. <Resident 18> A 01/24/2023 nurse progress note showed Resident 18 was transferred to the hospital. Review of Resident 18's medical record found no documentation of a transfer/discharge notice provided to Resident 18. <Resident 96> Review of Resident 96's medical record showed a progress note dated 08/18/2023. The note showed Resident 96 was transferred to the hospital for a change in condition. There were no documents found in the medical record that Resident 96 or a RR was provided written notification of transfer to the hospital. In an interview on 08/24/2023 at 10:16 AM, Staff G (Social Services Director) was not able to provide documentation the transfer/discharge notice was given to Resident 6, 18 or 96. Staff G was not able to provide documentation that the SLTCO was notified of the transfer/discharge of Resident 6 or Resident 18. REFERENCE: WAC 388-97- 0120(2)(a-d), -0140(1)(a)(b)(c)(i-iii). .

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** Based on observation, interview, and record review, the facility failed to reassess 1 (Resident 48) of 5 residents reviewed for weight (wt) loss, identify interventions to prevent wt loss for two (Resident 17 & 48) of 5 residents reviewed for wt loss, and offer 2 (Resident 17 & 74) of 2 residents reviewed for food preferences, culturally appropriate foods, resulting in wt loss. Failure to identify wt loss interventions and offer culturally appropriate foods resulting in wt loss placed resident at risk for continued wt loss. Findings included . <Resident 17> Review of the admission Record showed Resident 17 was admitted to the facility on [DATE] with diagnoses including stroke, aphasia (a language disorder that affects a person's ability to communicate), and severe protein malnutrition. The 05/08/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 17 was assessed to require extensive assistance of one staff for eating, had greater than 51% of their intake through Tube Feeding (TF -a tube into the stomach into which liquid nutrition was instilled), weighed 119 pounds (lbs), and experienced no wt loss. The 08/09/2022 Physician Orders (PO) instructed staff to provide 360 ml (milliliters) of liquid nutrition at 400 ml/hour via pump three times daily. The 10/28/2022 diet order showed Resident 17 was on a regular diet that was mechanically altered to improve the resident's ability to swallow the food, thin liquids, vegetarian options, and fortified (high calorie) foods for nutrition. The revised 06/09/2023 TF Care Plan (CP) showed Resident 17 required the TF, was at high risk for choking on food, and refused the TF by gesturing. The 08/07/2023 Nutritional Evaluation showed Resident 17's wt was 110 lbs. Staff E (Registered Dietitian) documented in the last three months Resident 17's wt was down 9 lbs or 7.5% and their intake for meals and TF averaged 34%. Review of the 08/08/2023 Annual MDS showed Resident 17 refused care and services on 1 to 3 days, required extensive assistance of one staff for eating, received greater than 51% of their intake from the TF, weighed 110 pounds, and did not lose wt. An observation on 08/22/2023 at 12:49 PM showed Resident 17's noon meal tray was uneaten. The meal contained a grilled cheese sandwich, cooked carrots, dessert, and a glass of milk. In an interview on 08/22/2023 at 12:59 PM, Staff P (Licensed Practical Nurse) stated Resident 17 often refused meals because they did not like the facility food and their family brought them Vietnamese food. In an interview on 08/23/2023 at 12:30 PM, Staff E stated they changed Resident 17's continuous TF to a one time instillation of liquid nutrition feeding to see if it would increase Resident 17's appetite. Staff E stated it was not effective. Staff E stated Resident 17 preferred Vietnamese food. Staff E stated the facility tried rice with various sauces and fish. Staff E stated they did not meet with Resident 17 or their family recently to determine Resident 17's preferences. In an interview on 08/23/2023 at 12:45 PM, Staff E stated Staff F (Dietary Manager) tried to use Google translate and the language line to communicate with Resident 17 about food preferences but was not successful. Staff E stated the last time Resident 17's food preferences were attempted to be updated was a year ago. In an interview on 08/24/2023 at 11:30 AM, Resident 17 stated (with Staff D (Resident Care Manager) translating) they liked rice and vegetables but no meat or sauces. Resident 17 stated they did not want the TF. Staff D stated the facility asked Staff D to initiate a communication board for non-English speaking residents upon the resident's admission. Staff D did not know why Resident 17 did not have a communication board to facilitate discussions about food and food preferences. In an interview on 08/24/2023 at 1:43 PM, Staff B (Director of Nursing) stated Resident 17's family brought in some Vietnamese food. Resident 17 would eat the food sometimes, and other times they would push the food away. The facility had concerns about Resident 17's cognition which was why staff needed to talk to the family about food preferences. Staff B stated they were aware Staff E had tried a few things to help the resident, but Staff B thought they could reapproach Resident 17 to see what they prefer to discourage further weight loss.<Resident 48> According to a 06/19/2023 Quarterly MDS, Resident 48 had a severe mental illness that caused them to have disorganized behavior and speech. Resident 48 had a diagnosis of repetitive, involuntary movements related to side effects from the treatment of their metal illness. Observation on 08/23/2023 at 10:57 AM showed Resident 48 was walking down the hallway with a shuffled gate. Resident 48's left arm was swinging uncontrollably as they walked. At 1:10 PM, Resident 48 was sitting on their bed, eating their lunch. The resident was vigorously rocking back and forth as they ate. Review of Resident 48's wt records showed they had an 11 lb or 6.29% wt loss between 07/02/2023 and 08/02/2023. Resident 48's active 09/13/2019 diet order showed they were on a regular diet with large portions. Review of the 08/09/2023 Nutrition Meeting notes showed Resident 48 was identified for their 11 lb/6.23% wt loss. Staff E documented Resident 48 consumed 75-100% of their meals and requested a re-wt of the resident to ensure the wt loss was accurate. Review of Resident 48's wt records and Nursing Progress Notes (NPNs) from 08/11/2023 to 08/23/2023 showed no re-wt was obtained. There were no NPNs showing a re-wt was attempted or the resident refused. Review of the 08/16/2023 and 08/23/2023 NPNs showed Resident 48 was not reviewed. In an interview on 08/23/2023 at 1:24 PM, Staff E confirmed Resident 48 burned excessive calories due to their involuntary movements. Staff E confirmed they should have followed up on the recommendation to obtain a re-wt, but they did not. In an interview on 08/23/2023 at 1:38 PM, Staff B stated if a resident refused to be weighed, then Staff B expected the refusal to be documented in the resident's record. <Resident 74> According to the 08/14/2023 Quarterly MDS, Resident 74 was cognitively intact, their primary language was Amharic/Ethiopian, and they needed an interpreter to communicate with their physician and health care staff. The MDS showed Resident 74 required extensive assistance with all activities of daily living including transferring and meal set up. Observations on 08/22/2023 at 8:47 AM, 08/23/2023 at 8:07 AM, and on 08/25/2023 at 8:11 AM showed Resident 74 was lying in bed, they did not eat their breakfast. Resident 74 was observed in the dining room on 08/22/2023 at 1:37 PM, 08/23/2023 at 1:37 PM, and 08/24/2023 at 2:29 PM for lunch but did not eat the facility food. Resident 74's friend/family were observed to provide Ethiopian food from home, which the resident ate. Review of the revised 05/12/2023 Nutritional CP instructed staff to encourage the family to bring Ethiopian food to help Resident 74 maintain adequate meal intake and provide assistance with eating. Review of the 07/27/2023 dietary manager note showed the facility discussed food preferences with Resident 74 but Resident 74 was unable to provide specifics about food preferences. Review of Resident 74's wt records showed they experienced a 10 lb wt loss in 14 days, between 08/08/2023 and 08/21/2023. In an interview on 08/22/2023 at 3:19 PM with an interpreter, Resident 74 stated they liked their Ethiopian food. Resident 74 stated the facility did not offer them Ethiopian food and were required to ask their family to bring Ethiopian food from home. Resident 74 stated their friends and family brought their Ethiopian food from home every day. In an interview of 08/24/2023 at 7:53 AM, Staff X (Resident Care Manager) stated they knew Resident 74 liked their Ethiopian food and did not eat facility food. Staff X stated Resident 74 liked the food their family brought from home. Staff X did not know about Resident 74's wt loss and stated staff did not report to them about the wt loss. In an interview on 08/24/2023 at 2:34 PM, Staff E confirmed Resident 74 liked their Ethiopian food that their family brought food from home every day. Staff E stated they met with Resident 74 about their preferences but the problem was language, Resident 74 could not explain their preferences. Staff E stated they offered Resident 74 what the facility provided but Resident 74 did not like their food. Staff E stated Resident 74 had 10 lb wt loss in two weeks and they asked staff to reweigh the resident to ensure this was accurate. In an interview on 08/24/2023 at 3:08 PM, Staff B stated they knew Resident 74 liked their Ethiopian food and did not like facility food. Staff B stated the facility should have offered food to Resident 74 preferred but they did not. 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 observation, interview, and record review, the facility failed to schedule sufficient staff to provide care and services for 7 (Resident 3, 32, 36, 34, 82, 5, & 45) of 7 residents reviewed. This failure prevented residents from receiving; assistance with Activities of Daily Living (ADLs) for Resident 65, 100, 3, & 82; and restorative nursing services (a program that helped residents maintain or improve independence with ADLs) for Resident 52. This failure prevented the facility from maintaining an odor free environment on 1 of 2 floors in the building. These failures placed residents at risk for unmet care needs, diminished quality of life, and other negative outcomes. Findings included . <Facility Assessment (FA)> According to the updated 02/23/2023 FA, the facility would provide enough staff for a census of 75 residents. The FA showed the facility would gather input from residents, family members, and/or resident representatives, Certified Nurse's Assistants (CNAs), licensed nurses providing direct care, and the local long-term care ombudsman about how the current staffing plan was working, and any concerns obtained. The FA showed a range of two to seven residents were independent with ADLs. The FA showed one to two staff were required to provide ADL assistance for 50 to 67 residents, and 4 to 15 residents were totally dependent on staff for ADL assistance. Review of the census upon entrance to the facility on [DATE] showed the census was 107 total residents. The FA did not address the services and care needed for the additional residents who admitted to the facility. <Resident Interviews> <Resident 3> In an interview on 08/22/2023 at 2:30 PM, Resident 3 stated at times, it took staff an hour to respond to the call light. Resident 3 stated this occurred on any given day but more often in the evening shift. In an interview on 08/23/2023 at 2:00 PM, Resident 3 stated the staff did not provide care and services for each other's residents when staff took breaks. <Resident 32> In an interview on 08/23/2023 at 2:00 PM, Resident 32 stated their roommate needed help to receive personal care, there were no staff to help them. Resident 32 stated residents needed help to get out of bed but there are no staff available. Resident 32 stated they waited at least 45 minutes for someone to come help them. <Resident 36> In an interview on 08/23/2023 at 2:00 PM, Resident 36 stated sometimes staff would enter their room and shut their call light off. Resident 36 stated they waited at least 45 to 60 minutes for staff to answer their call light. Resident 36 stated Saturday and Sundays were especially bad. Resident 36 stated they had to wait a long time during the day and evening shift to get help with toileting. <Resident 34> In an interview on 08/23/2023 at 2:00 PM, Resident 34 stated there were not enough staff to help on the weekends. Resident 34 stated some weekend staff would relax for the first part of their shift. <Resident 82> In an interview on 08/23/2023 at 2:00 PM, Resident 82 stated there was no organization related to the order in which call lights were answered. Resident 82 stated If there are five call lights going off, they will not be answered timely. Resident 82 stated they noticed staff would go into rooms and turn call lights off without helping the residents. Resident 82 stated they were able to help themselves but would go to the nurse's station on the weekends for other residents and find two to three nurses chatting away behind the desk with several call lights going on and [no staff] taking any notice . <Resident 5> In an interview on 08/23/2023 at 2:00 PM, Resident 5 stated at night, it was sometimes difficult to find a nurse. Resident 5 stated sometimes they had to wait two to three hours before a nurse would come. The resident stated when a staff member went on break, the residents did not get any help because there were no staff to cover for the staff on break. <Resident 45> In an interview on 08/23/2023 at 2:00 PM, Resident 45 who was unable to speak, nodded their head yes when asked if they had to wait a long time for help. <Resident Showers and ADLs> <Resident 65> The 08/02/2023 admission Minimum Data Set (MDS - an assessment tool) showed Resident 65 admitted to the facility on [DATE] and had no memory impairment. This assessment showed Resident 65 required assistance from staff with personal hygiene. In an observation and interview on 08/22/2023 at 2:47 PM, Resident 65 stated they were not assisted with brushing their teeth since admitting to the facility. Observation showed no toothbrush or toothpaste was present in Resident 65's room or bathroom. In an interview on 08/24/2023 at 12:50 PM, Staff D (Resident Care Manager) confirmed Resident 65 needed staff assistance with oral care. Staff D stated Resident 65's record showed staff were signing oral care was completed for Resident 65 and confirmed if no supplies were available in the room, then oral care was not provided as documented. <Resident 100> Review of the 08/07/2023 admission MDS showed Resident 100 admitted to the facility on [DATE]. Resident 100 had no memory impairment and was dependent on staff for assistance with bathing. The 08/01/2023 ADL care plan directed staff to provide bathing assistance to Resident 100 one to two times per week. In an interview on 08/23/2023 at 7:45 AM, Resident 100 stated they were not getting bathing assistance twice weekly as they preferred. Review of the August 2023 bathing records on 08/23/2023 showed staff only provided bathing assistance to Resident 100 twice in the month of August. In an interview on 08/25/2023 at 11:36 AM, Staff D stated staff should have provided bathing to Resident 100 twice weekly per Resident 100's preferences. <Resident 3> In an interview on 08/23/2023 at 2:00 PM, Resident 3 stated they were supposed to have two showers per week, but they were lucky if they got one shower. Resident 3 stated they would be on the shower schedule on a given day and the showers would be canceled. Resident 3 stated when they would ask staff why they could not have a shower, staff told Resident 3 they were pulled from showers to provide care for a set of residents instead. <Resident 82> In an interview on 08/23/2023 at 2:00 PM, Resident 82 stated they would agree to a shower and the staff would not follow through and give them a shower. Resident 82 stated the staff were way late on getting [them bathed]. <Restorative Nursing Program> <Resident 52> Review of a 05/30/2023 revised restorative care plan showed restorative CNAs were to apply a palm protector (device used to prevent fingers from digging into the skin) to Resident 52's left hand seven days per week. Review of Resident 52's restorative documentation from 07/25/2023 to 08/25/2023 showed staff only applied Resident 52's palm protector on 12 of the 32 opportunities. In an interview on 08/25/2023 at 11:32 AM, Staff BB (Restorative Aide) stated they were aware Resident 52 required the palm protector seven days per week. Staff BB stated they did not have the required time to complete the program as ordered because they were often assigned other tasks including helping nurses with wound rounds. Staff BB stated they were often pulled from their restorative duties to work the floor as a CNA. <Odor Free Environment> Observation on 08/22/2023 at 7:22 AM, the East Two wing had an overwhelming urine odor near rooms [ROOM NUMBERS]. The carpet in the hallway was stained with various dark stains the entire length of the hall. Observation on 08/24/2023 at 9:08 AM, upon stepping off the elevator onto the [NAME] Central wing, an overwhelming urine odor was present near room [ROOM NUMBER]. In an interview on 08/23/2023 at 2:00 PM, Resident 5 stated the carpet throughout the building made the hallway stink. Resident 5 stated the hallways sometimes smelled like feces and felt the facility needed to focus on improving the odors for the residents, families, and visitors. <Staff Interviews> Observation on 08/25/2023 showed a sign posted outside the first-floor nurse's station. The sign showed open positions for evening shift CNA's and open positions for licensed nurses and therapy staff. In an interview on 08/25/2023 at 9:02 AM, Staff Z (CNA) stated management often asked them to work double shifts, especially on the weekends. Staff Z stated the facility was often short staffed. Staff Z stated an eight-hour shift was not always enough time to complete their work because some residents required more care than others. In an interview on 08/25/2023 at 9:10 AM, Staff BB stated they were pulled from doing their restorative work at least once per week. Staff BB stated there were staffing challenges on the weekends due to staff calling off work. Staff BB stated they were assigned to help CNAs with transferring some residents who required more care. Staff BB stated when they were allowed to strictly focus on their duties, they had enough time to complete their work, but they often felt their time was stretched thin because of the other tasks they were assigned during their shift. In an interview on 08/25/2023 at 10:30 AM, Staff Q (Licensed Practical Nurse) stated shower aides and restorative aides were pulled from their duties at least once per week. Staff Q stated staff called off work on the weekends and Staff Q was required to come in and work if they were on call. In an interview on 08/25/2023 at 10:35 AM, Staff HH (Restorative Aide) stated they got removed from providing restorative care to provide routine care often. Staff HH stated they were supposed to be doing restorative at the time of interview but were removed from restorative care duties to provide routine care that day. Staff HH stated that was their third day in a row being pulled from restorative to provide routine care. In an interview on 08/25/2023 at 10:42 AM, Staff DD (Restorative Aide) stated they were often pulled to work the floor and were unable to perform their restorative programs. In an interview on 08/25/2023 at 11:14 AM, Staff B (Director of Nursing) stated their process for determining staffing levels was based on how many residents were admitted and discharged for the day. Staff B stated the facility was assessing those needs five days per week. Staff B stated there were no issues with weekend staffing. Staff B stated they had shower aides and restorative aides on the weekend, if CNAs called out and other staff members were unable to come in, management pulled the shower and restorative aides to work the floor. Staff B stated they thought they were okay with nursing staff and did not believe they had open positions despite the signs observed posted on the first floor. Refer to F584 Safe/Clean/Comfortable/Homelike Environment Refer to F677 ADL Care Provided for Dependent Residents Refer to F688 Increase/Prevent Decrease in Range of Motion/Mobility Refer to F838 Facility Assessment REFERENCE: WAC 388-97-1080(1). .

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to maintain a system of records for accurate reconciliation of narcotic drugs for 3 of 4 medication carts. The failure to count and acknowledge the count was accurate - narcotic drugs through reconciliation at shift change, placed residents at risk for potential financial loss, not receiving narcotic pain medication, and possible drug diversion. Findings included . In an observation and interview on 08/23/2023 at 8:52 AM, Staff AA (Licensed Practical Nurse - LPN) was at the Middle medication cart when a random narcotic reconciliation was completed. The narcotic ledger book showed nurses did not sign the narcotic count and acknowledge the count was accurate for narcotic medications at the beginning of the shift and end of the shift 5 times out of 19 days for July 2023. In August 2023 staff did not sign nine times out of 22 days. Staff AA stated two nurses were supposed to count all the narcotic medications in the medication cart in the beginning of the shift and at the end of the shift and sign the narcotic book to acknowledge the count was accurate but they did not. Observation on 08/23/2023 at 10:41 AM showed Staff II (LPN) was at [NAME] One medication cart when a random reconciliation was completed. The narcotic ledger book showed nurses did not count and sign the narcotic book four times in July 2023, and eight times out of 23 days in August 2023. In observation on 08/23/2023 at 2:52 PM, Staff P (LPN) was at the [NAME] Two medication cart when a random reconciliation was completed. The narcotic ledger book showed nurses did not count and sign the narcotic book to acknowledge the count was accurate, on five occasions in July 2023 and sixteen times out of 24 days in August 2023. In an interview on 08/24/2023 at 10:16 AM, Staff B (Director of Nursing) stated the facility protocol was to count all the narcotic medications in the medication cart by both nurses (oncoming and leaving for the shift) in the beginning of the shift and end of the shift, sign both times in the narcotic book to acknowledge the narcotic count was accurate. Staff B stated there was no option for staff not to count and sign the narcotic book. Staff B stated both nurses at shift change should have reconciled the medication count and sign as required but they did not. REFERENCE: WAC 388-97-1300(1)(c)(ii), (3)(a). .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to maintain clean, sanitary surfaces and equipment in the kitchen in accordance with standards for food service safety. The failure to maintain a clean/sanitized kitchen placed residents at risk for cross-contamination (a physical spread of germs), food-borne illnesses. Findings included . <Dry Storage> Observation on 08/22/2023 at 7:22 AM showed the floor inside the dry storage area contained an unidentifiable residue on the floor. Four bulk bins were empty in the storage room and contained an unidentifiable substance in the bottom of the bins. <Housekeeping Closet> Observation on 08/22/2023 at 7:28 AM showed a small room with a sign on the door stating the door must remain shut. Inside the room were materials intended for cleaning the kitchen. The entire room was covered in a dark grime. A clear plastic bag, contained rags, was on the floor inside the closet. The floor was covered in a black unidentifiable grime. <North Wall> Observation on 08/22/2023 at 7:40 AM showed brown unidentifiable material spattered across the ceiling and on a support beam in the same area. <East wall> Observation on 08/22/2023 at 7:25 AM showed the door to the walk-in refrigerator had a dark brown grime, covering the front of the door. The door handle to the walk-in refrigerator had a sticky residue and required the knob to the door to be pulled out to ensure the door would close shut. The walk-in refrigerator showed insect-like sticky material attached to the light covering. The floor of the walk-in refrigerator was covered with an unidentifiable brown sticky material. Observation on 08/22/2023 at 7:28 AM showed the wall adjacent to the walk-in refrigerator had a brown sticky material that dripped down to the floor. The wall was observed to have a soft-ball sized hole and the tile around the hole was broken with sharp edges. Observation on 08/22/2023 at 7:30 AM showed a wall with three doors that opened to the walk-in refrigerator and one door that opened to the walk-in freezer. The wall around the area showed visible streaks of an unidentified brown substance. A red speckled rust-like substance was present around the freezer door and showed signs of breakdown. Observation on 08/22/2023 at 7:35 AM showed a machine intended to dispense concentrated beverages contained an unidentifiable orange sticky material in the bottom of a stainless-steel box that held the dispensing aspect of the machine. Several tubes extended from the machine and connected to bags of juice concentrate. One of the tubes was observed on the floor. The connecter that plugged into a concentrated juice bag was touching the floor. Observation on 08/22/2023 at 7:37 AM showed a cobweb above the beverage machine that contained numerous remnants of insect-like debris. <Test Tray> Observation on 08/24/2023 at 8:35 AM showed a test tray was received once the room trays were delivered. The meal consisted of a glass of juice, a bowl of oatmeal, a round sausage patty, scrambled eggs, and a brown and yellow cake-like cinnamon flavored pastry. The eggs tasted like the pastry on the plate and the oatmeal had wing-like debris on top. <South wall> Observation on 08/24/2023 at 9:29 AM showed a thick layer of dust on the duct work above the facility oven. Sweet potatoes were being placed inside the oven for the current lunch meal. Observation on 08/24/2023 at 9:32 AM showed a thick layer of unidentified grime on the back wall of the range. Observation on 08/24/2023 at 9:35 AM showed a mixing machine covered in an unidentifiable multicolored sticky substance on all surfaces of the machine. Observation on 08/24/2023 at 9:37 AM showed a cobweb containing remnants of insect-like debris on the ductwork, above the area where food was prepped. <West wall> Observation on 08/24/2023 at 10:10 AM showed a microwave in the corner. The outside was spattered in sticky unidentifiable material. The wall behind the machine was covered in spattered sticky unidentifiable material. A knife rack was attached to the wall behind the microwave and was covered with a spattered unidentified sticky substance. Review of the 08/13-19/2023 facility document Daily Cleaning Schedule showed kitchen staff had a daily cleaning schedule. The mixer and microwave were on the schedule for daily cleaning and signed off by staff that they were cleaned daily. In an interview on 08/24/2023 at 11:00 AM Staff F (Dietary manager) confirmed the contents inside the test tray oatmeal was a fly and stated they expected the food to be free from unintended debris. Staff F stated it was their expectation the kitchen was in a clean and sanitary condition. REFERENCE: WAC 388-97-1100(3). .

CONCERN (F)

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to update the Facility Assessment (FA - a required document that comprehensively assesses the level and type of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff) to accurately reflect the resources the facility determined were necessary for day-to-day resident care and emergency operations. The failure to assess staffing needs according to the facility census placed the residents as risk for not receiving needed care, services, and resources. Findings included . Review of the updated 02/23/2023 FA showed the facility would provide enough qualified staff to care for the 75 residents residing in the facility. The FA showed the facility utilized agency staff to supplement the staffing needs of the facility. The FA showed the management team would gather input from residents, resident representatives or family members, certified nurse assistants, licensed nurses, and the local Long-Term Care Ombudsman regarding how the current staffing plan was working and address any concerns. Observation and record review on 08/22/2023 at 8:39 AM during the facility's entrance conference and resident screening process showed the current resident census was 107 residents. Record review of the facility census for 08/05/2023, 08/07/2023, 08/09/2023, 08/14/2023, 08/17/2023, 08/18/2023, 08/20/2023, and 08/21/2023 showed the number of residents in the facility was over 100. In an interview on 08/23/2023 at 1:34 PM, Staff KK (Staffing Coordinator) stated the facility did not currently use any staffing agency. In an interview on 08/25/2023 at 11:32 AM, Staff A (Administrator) stated the facility census had increased significantly. Staff A confirmed the FA did not accurately reflect the staffing needs. Refer to F725 Sufficient Nursing Staff REFERENCE: WAC 388-97-1620(2)(b)(i)(ii). .

May 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide vision treatment and services for one of three residents (Resident 1) reviewed for vision. This failure had the potential to compromise Resident 1's ability to reach the highest practical well-being, meet their vision needs, and diminish their quality of life. Findings included . Review of the 01/17/2023 Quarterly Minimum Data Set (MDS - an assessment tool), showed Resident 1's vision was impaired and they wore corrective lenses. Diagnoses included cataracts, glaucoma (condition where the eye's optic nerve is damaged, which if untreated causes gradual vision loss), or Macular Degeneration (eye disease that affects central vision). Review of the 04/02/2021 Impaired Visual Function Care Plan showed a goal that the resident would maintain optimal quality of life within limitation imposed by visual function. A listed intervention included, Arrange consultation with eye care practitioner as required. On 05/03/2023 at 1:40 PM Resident 1's Representative stated that Resident 1 was referred to an eye appointment regarding eye surgery but the facility did not follow through. Review of the Eye Surgery Clinic visit notes dated 06/10/2021, showed a recommendation for a follow up consultation for evaluation and management of a large neurovascular glaucoma (an aggressive form of secondary glaucoma, caused by abnormal blood vessel growth between the iris - colored part of the eye-, and the cornea (transparent front layer of the eye). During an interview on 05/17/2023 at 12:30 PM Staff D, (Referral Coordinator) stated they were aware the eye doctor saw Resident 1 and they received new glasses. The resident was also sent out for new eye drops. Staff D stated they were not aware of an appointment for eye surgery. Review of a 05/10/2022 Optometry Consultation showed that Resident 1 was assessed with an early cataract to the right eye and was blind in the left eye due to glaucoma. The Optometrist ordered eye drops four times a day to treat the glaucoma. Review of a Social Services Note dated 02/01/2023 at 3:43 PM showed Staff E (Social Services Director) followed up with the Resident about a surgery that may have been recommended by the eye doctor. Staff E could not determine from the eye doctor's notes if that was the case and was waiting for optometrist to follow up with more information. During an interview on 05/17/2023 at 1:01 PM, Staff E stated Resident 1 got new glasses from optometry. Staff E stated they recalled a conversation with nursing regarding eye surgery, but they were unable to find any record of that conversation. Staff E stated they did not follow up with the optometrist to get more details. Review of a 03/23/2023 1:06 PM email to facility administrative staff (including Staff A) showed they were notified that Resident 1 was to be evaluated at an eye clinic for potential eye surgery as they were losing their eyesight. A request was made for the facility to look into any appointments Resident 1 was supposed to have and/or make a new appointment for a surgical consult. On 03/23/2023 at 1:17 PM, the Director of Nursing at the time responded that they would look into the matter. Review of the resident's record showed no documentation to support the facility made the appointment the resident was assessed to require. During an interview on 05/25/2023 at 1:06 PM Staff A (Administrator) stated they did not follow up as the Director of Nursing at the time replied they would, and there was a different Administrator at the time. REFERENCE: WAC 388-97-1060(3)(a) .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide dietary services to meet the individual needs/preferences for two (Residents 1 & 2) of three sampled residents who went out of the facility for dialysis. Failure to provide a hot meal upon their return to the facility, placed residents at risk for decreased dietary intake and decreased quality of life. Findings included . Review of the Facility Assessment revised April 2023 showed on average the facility had three residents who required Dialysis, and the dietary department sought to fulfill the preferences of each resident. Under resource needs, the facility identified Kitchen access was available to residents during working hours; and they provided breakfast, lunch and dinner. Review of the facility Hemodialysis (HD) Policy and Procedure revised 12/2022 showed the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving Hemodialysis. <Resident 1> According to the 01/17/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 had renal disease, required dialysis and was able to feed themselves with set up and supervision. A preference form dated 04/07/2023 showed that Resident 1 indicated they would like to have a dinner meal when they returned to the facility from dialysis. Review of the Nutritional Problem Care Plan revised 04/14/2023 showed Resident 1 did not want an early meal prior to HD. Resident 1 wanted dinner when they returned from HD and a sack meal with HD. On 05/04/2023 Resident 1's representative stated in the late summer or early fall (2022), an unnamed staff member refused to provide Resident 1 with food and medication after the resident returned from dialysis. Resident 1's representative stated they filed a grievance. Review of the Grievances showed a grievance dated 08/26/2022 that Resident 1 did not received medications the night of 08/25/2022. Review of a 12/12/2022 5:27 PM Nutrition/Dietary Note showed due to Resident 1's HD schedule they returned after the kitchen was closed, so they did not have a hot meal available to them. The dinner meal was not ready before they left for HD. Staff offered alternatives that Resident 1 could get before they went to HD, however they would have to ask for what they wanted. Review of a 01/18/2023 4:55 PM Nutrition/Dietary Note showed the facility dietitian discussed options for a late meal for Resident 1 related to comments given to the dietitian at the kidney center; will discuss options as a team to develop a plan that team could manage in order to meet resident's needs. Unable to serve hot meal when they return from HD at this time due to resident's late time return from dialysis (after 9 PM). Review of a 01/20/2023 11:49 AM Nutrition/Dietary Notes showed Resident 1 was provided a sack lunch on HD days and would have a second sack meal available when they returned from HD. Snack cart items were also available for the resident to choose from when they returned at night after the kitchen was closed. During an interview on 05/04/2023 at 11:37 AM, Staff B (Director of Nursing) stated that Resident 1 was scheduled to return from dialysis at 8:45 PM. During an interview on 04/26/2023 at 2:14 PM Staff F (Dietary Manager) stated all dialysis residents were asked their preferences. Resident 1 declined an early (dinner) meal and wanted a sack lunch. Staff F stated Resident 1 wanted hot food after dialysis, but they came back late and there was no safe way to heat it up. <Resident 2> According to the 05/10/2023 Quarterly MDS, Resident 2 had renal disease, required dialysis and was able to eat with one person physical assist. During an interview on 05/04/2023 at 1:03 PM, Resident 2 stated that they usually returned from dialysis at 4:15-4:45 PM and they ate dinner when they returned to the facility. Resident 2 stated the night prior they did not return until 8:30 PM. I wanted something hot and staff offered snacks, I had to door dash [a food delivery service]. When asked why they were not offered dinner, Resident 2 stated the kitchen closed and when they got back the staff were all gone. Review of the Meal Monitor showed on 05/03/2023 the Resident was not available for dinner. During an interview on 05/25/2023 at 1:06 PM Staff A (Administrator) stated their expectation was the staff would hold the meal tray until the resident returned and reheat the meal tray, or provide an alternate meal tray. During an interview on 05/25/2023 at 1:55 PM Staff B stated for residents with late dialysis appointments they would send the resident with a sack lunch and warm up and serve dinner to them upon their return. REFERENCE: WAC 388-97-1100 (1) .

Dec 2022 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0678 (Tag F0678)

Someone could have died · 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 have systems in place that ensured basic life support was initiated, including Cardio-Pulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air) when one of one residents reviewed for emergency situations (Resident 1) was found unresponsive and required immediate staff action. The failure of facility staff to initiate basic life support, including CPR potentially contributed to the residents unsuccessful response to CPR when initiated by 911 emergency responders and increased the likelihood/risk of serious imminent harm for all residents who choose to have CPR initiated in an emergency. On [DATE] at 5:13 PM, the facility was notified of an immediate jeopardy in F678. The facility removed the immediacy on [DATE] by re-educating the facility staff on policies and procedures for CPR, which included mock code drills, and an audit of staff CPR cards, an audit of deaths in the past 30 days, and an audit of all resident Portable Orders for Life-Sustaining Treatment (POLST- a form that directed medical staff what to do if the resident had a medical emergency) forms and identified CPR certified staff on the daily schedule which ensured an effective system was in place to provide needed services when residents require life-saving measures. Findings included . Review of a [DATE] facility Cardiopulmonary Resuscitation (CPR) policy showed if a resident experienced cardiac arrest (a medical emergency when the heart stops beating) the staff would provide basic life support, including CPR, prior to the arrival of emergency medics. CPR certified staff would be available at all times and staff would maintain current CPR certification. Resident 1 According to the [DATE] Quarterly Minimum Data Set (an assessment tool) Resident 1 admitted to the facility on [DATE] and had medically complex conditions including; diabetes, dementia, and chronic kidney disease. Resident 1 had a life expectancy of six months or more. Review of Resident 1's medical record showed a [DATE] POLST form signed by Resident 1 and the Physician. The POLST form showed Resident 1 chose CPR and full treatment if they were found without a pulse or breathing. Review of Resident 1's physician's orders (PO) showed a [DATE] PO for Full Code (if a person's heart stopped beating or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of a [DATE] Advanced Directive (a legal document that specifies what actions should be taken for their health when a resident was not able to make that decision) care plan (CP) showed Resident 1 had a POLST completed and was a full code. The CP showed staff would understand and follow the healthcare directive. Review of Nursing Progress Notes (NPN) showed on [DATE] at 11:30 PM Staff C (Licensed Practical Nurse-LPN) documented that Staff E (Hospitality Aide) and Staff F (Certified Nursing Assistant - CNA) went to Resident 1's room at 9:23 PM and found the resident non-responsive. The NPN showed Staff C checked Resident 1, confirmed they were non-responsive and called 911 for emergency assistance. A supplemental note on [DATE] at 11:40 PM showed that paramedics arrived, and Resident 1 passed away at 10:00 PM. In an interview on [DATE] at 10:58 AM Police Officer 1 stated they (Police Officer 1 and 2) received a call at 9:30 PM for an unresponsive individual and arrived at the facility at 9:33 PM. Upon their arrival to the building they were delayed entering the building, due to the front door being locked and no staff available in the facility lobby to let them in the building. Once Officers arrived to Resident 1's room they observed 5 staff members (Staff C, Staff D, Staff G, Staff F, and Staff J (CNA) , Resident 1 on the floor, and no staff performing any CPR or life-saving measures. Police Officer 2, a certified Emergency Medical Technician (EMT specially trained and certified to administer basic emergency services), asked the facility staff about a DNR (Do Not Resuscitate) order for Resident 1 and was told the Resident did not have one. Police Officer 2 questioned why CPR was not started if Resident 1 was a full code and proceeded to check Resident 1 who was still warm to the touch, and began chest compressions at 9:36 PM. Police Officer 1 stated all but 1 staff member left the room and when they asked for help by staff, a staff member directed another staff member to help with compressions and that staff member left the room. Police Officer 2 requested an oxygen mask. The facility staff attempted to give it to Police Officer 2 who was performing chest compressions instead of putting the oxygen mask on the Resident themselves. When EMT's arrived they took over resuscitation efforts that were unsuccessful and Resident 1 passed away at 9:57 PM. In an interview on [DATE] at 4:27 PM Staff C stated they asked Staff E and Staff F to check on Resident 1 and obtain vital signs. On [DATE] at 9:23 PM Staff E and Staff F found Resident 1 to be unresponsive and notified Staff C. Staff C stated they went to Resident 1's room and checked for a pulse, no pulse was detected and they directed Staff E and Staff F to get the crash cart and inform the other nurses on the floor that help was needed with Resident 1. Staff C stated they called 911 from the nurses station and Staff D (Registered Nurse-RN) and Staff G (LPN) went to Resident 1's room with the crash cart. Staff C stated they did not initiate CPR for Resident 1 because they were on the phone with 911. Staff C stated they were preparing the transfer paperwork (pertinent resident medical information that it sent to the hospital with the resident) and did not see if Staff D or Staff G initiated CPR. Review of a [DATE] facility provided Detailed History for fire incident from the local police and fire dispatch department showed at 9:28 PM police and fire were dispatched to the facility for an unresponsive resident. Police arrived on scene first at 9:33 PM. This revealed that facility staff called 911 at 9:28 PM, five minutes after Resident 1 was found not breathing or with a heart rate. Police arrived on scene at 9:33 PM and per Officer 1's statement, Officer 2 initiated CPR at 9:36 PM, leaving an additional 8 minutes the staff failed to render emergency care to Resident 1, for a total of 13 minutes. In an interview on [DATE] at 9:37 AM Staff D stated at approximately 9:40 PM on [DATE] Staff F informed them that Staff C needed urgent help with Resident 1 because the resident was not breathing. Staff D stated they locked their medication cart and went to Resident 1's room where they met Staff C in the hallway pushing the crash cart. Staff D told Staff C finish the transfer paperwork and they [Staff D, Staff G, and Staff F) would initiate CPR. Staff D had staff clear the room of equipment and placed Resident 1 on the floor. Staff D stated they were about to kneel down and start compressions when officers arrived on scene. Staff D stated they did not start compressions on Resident 1. Attempts were made to contact other staff, present at the time police arrived and that were not involved in CPR. None of these staff responded to these attempts to obtain first hand information about what transpired the care of Resident 1. In an interview on [DATE] at 2:00 PM Staff B (Director of Nursing) stated there was a miscommunication between the aides (Staff F and Staff E) and Staff C. The aides informed Staff C that Resident 1 was unresponsive, not that they were not breathing or had no heart rate. When asked why Staff F and Staff E who found Resident 1 unresponsive didn't start CPR, Staff B was not sure. When asked which staff member initiated CPR, Staff B stated Staff C and Staff D did initiate CPR. Staff B was asked why Staff C & Staff D's statements and interviews showed they did not initiate CPR, Staff B replied that Staff C called 911 first to get Resident 1 help faster. Staff B acknowledged there was a delay in initiating CPR for Resident 1 and the staff who found the Resident unresponsive should have initiated CPR immediately and had another staff member call 911. REFERENCE: WAC 388-97-1060(1) .

Apr 2022 34 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected multiple residents

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Heating Pad Resident 81 According to the 03/20/2022 Medicare 5 Day MDS, Resident 81 had diagnoses including Acute Respiratory Failure. The resident was assesed as cognitively impaired and able to make their decisions, and required extensive assistance from staff with bed mobility, dressing, toileting, personal hygiene, and bathing. A review of the 03/14/2022 CP showed Resident 81 required extensive assistance from staff for bed mobility, dressing, toileting, and bathing. Observation and interview on 04/24/2022 at 11:02 AM, showed Resident 81 lying on their bed on their back with an electric heating pad under their neck and upper back area. Resident 81 stated their family brought the heating pad from home to relieve their back pain. In an interview on 04/24/2022 at 11:50 AM, Resident 81 stated they were independently putting the heating pad under their back. A review of the visitor sign in log on 04/24/2022 at 12:23 PM, showed Resident 81's family visited Resident 81 on 04/22/2022 at 2:57 PM. Observations on 04/24/2022 at 12:57 PM showed no skin issue on Resident 81's back. Resident 81 stated the heating pad shuts off automatically after 2 hours. The temperature of the heating pad was noted at 93 degrees Fahrenheit by thermometer. During an interview with Staff B and Staff C on 04/24/2022 at 1:23 PM, Staff C stated Resident 81 could reposition themselves in bed and the CP was inaccurate. Staff B stated they were not aware Resident 81 used a heating pad and stated the facility policy prohibited the use of heating pads by residents because they could cause burns. Based on observation, interview, and record review the facility failed to ensure the residents' environment was free from accident hazards, including securing portable oxygen tanks (contains compressed oxygen). The failure to secure portable oxygen tanks in 3 (Resident 90, 84 & 66) resident rooms and in an oxygen storage room placed the residents at risk for serious adverse outcomes if oxygen tanks fell or tipped over, with the potential for an explosion and/or serious bodily injury, and constituted an immediate jeopardy (IJ). On 04/22/2022 at 10:57 AM an IJ was identified and the Provider was informed. On 04/25/2022 at 12:00 PM, the facility removed the immediacy by ensuring all portable oxygen tanks were secured, all resident rooms, offices, therapy gyms, and closets were audited to ensure oxygen tanks were properly stored and secured, and staff were trained on oxygen storage and handling. Additionally, the facility failed to identify potential accident hazards, assess potential hazards, and provide interventions for 2 (Resident 84 & 81) residents, one of whom smoked a cigarette while the portable oxygen tank flow was on, and one resident who used a heating pad. Additional accident hazards were identified in common resident areas, to include sharp metal filings in the resident activity room, unsecured stairwell door, unattended cookies and a cookie baking oven easily accessible to residents, and one (Resident 67) resident room with multiple stacked boxes, all of which had the potential to result in avoidable accidents and/or injury to the residents. Findings included . Review of the 04/22/2022 facility Oxygen Safety policy showed oxygen cylinders (tanks) would be properly chained or supported in racks or carts to prevent tanks from falling. The policy directed staff to protect tanks from damage by not storing portable oxygen tanks in locations where they could tip over. The policy showed No Smoking rules will be strictly enforced while oxygen was in use, including removal of smoking materials from residents receiving oxygen. Compressed Oxygen Tanks Unsecured Resident 90 Review of the 03/23/2022 admission Minimum Data Set (MDS an assessment tool) showed Resident 90 had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), required oxygen, and was not a smoker. Resident 90 was assessed with moderately impaired cognition, was capable of making their own decisions, and required limited assistance from staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Physicians Orders (PO) showed a 03/18/2022 PO that directed staff to titrate (continuously measure and adjust) oxygen (O2) 1-5 L (liters) to keep O2 saturations (indicates the amount of oxygen in blood) between 88-92%. An observation on 04/21/2022 at 8:38 AM showed Resident 90 sitting in a wheelchair at their bedside table trying to rearrange a very long oxygen tube. There was a portable oxygen tank standing on the floor near the resident's feet. The tank was not in a cart, rack or secured in any way. In an interview on 04/21/2022 at 8:44 AM, Staff Q (Licensed Practical Nurse) stated Resident 90's oxygen tank was not secured and it should be in a cart. On 04/21/2022 at 8:45 AM Staff T verified Resident 84's oxygen tank should not be on the floor or on the seat of the walker and placed the oxygen tank in the bag under the seat to secure it from falling. Staff Q removed the immediacy of potential harm. Resident 84 Review of the 03/18/2022 Quarterly MDS showed Resident 84 had diagnoses including COPD, required oxygen, and was not a smoker. The resident was assessed with mildly impaired cognition, was capable of making their own decisions, and required staff supervision for bed mobility, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Review of PO's showed a 01/31/2021 PO that directed staff to administer O2 at 2 L per minute via a nasal cannula (tubing used to deliver oxygen) and remind the resident to keep it on. An observation and interview on 04/21/2022 at 8:46 AM showed Resident 84 was sitting on their bed with their four-wheeled walker observed at the foot of the bed, a portable oxygen tank was observed standing on the floor next to the wheel of the walker. Resident 84 stated they did not have an oxygen holder to secure the tank and usually laid the tank on the seat of the walker when ambulating. In an interview and observation on 04/21/2022 at 8:53 AM, Staff T (Certified Nursing Assistant) stated the oxygen tank was usually on the seat of Resident 84's walker and not on the floor. Staff T placed the tank on the seat of the walker. Resident 66 Review of the 03/17/2022 Medicare 5 Day MDS showed Resident 66 had diagnoses including Congestive Heart Failure, and did not use oxygen. The resident was assessed as cognitively intact, was able to make their own decisions, and required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. Review of PO's showed a 03/21/2022 PO that directed staff to titrate O2 1-2 L to keep O2 saturations greater than 93%. Observation on 04/22/2022 at 8:42 AM and 9:22 AM showed an oxygen tank standing upright on the floor of Resident 66's room, unsecured and next to the oxygen concentrator. 200 East Hall Oxygen Storage Room Observation on 04/22/2022 at 8:52 AM showed an unsecured oxygen tank sitting on the cement floor inside the door of the oxygen storage room on the 200 East Hall. Unlabeled Oxygen In Use Signs In an interview on 04/22/2022 at 11:25 AM, Staff CC (Chief Nursing Officer) verified Resident 6, Resident 90, and Resident 84 used oxygen in their rooms. Staff CC acknowledged there was no sign at the resident's door instructing staff that oxygen was in use In an interview on 04/21/2022 at 8:50 AM, Staff BB (Certified Nursing Assistant) stated it was their second day at the facility and to ask someone else how to secure portable oxygen tanks. On 04/22/2022 at 10:57 AM Staff EE (Chief Executive Officer- CEO), Staff A (Administrator), Staff B (Director of Nursing), and Staff C were informed of the unsecured portable oxygen tanks and took immediate action to remove the immediacy and acknowledged portable oxygen tanks must be secured in a rack, cart, or holder to prevent tipping or falling over. On 04/22/2022 at 11:25 AM the Fire Marshall identified nine unsecured oxygen tanks in a crate in the back of the 200 East Hall oxygen room. At 11:45 AM on 04/22/2022 the Fire Marshall identified 12 portable oxygen tanks and an oxygen re-filling tank located in the physical therapy gym that were unsecured. On 04/22/2022 at 11:46 AM Staff DD (Administrator in Training) and Staff EE were made aware of the unsecured oxygen tanks in the physical therapy gym and started relocating the oxygen tanks to the 100 hall oxygen room. Smoking and Oxygen Use Resident 84 Observations on 04/28/2022 at 10:23 AM showed Resident 84 walked down the driveway, through parked cars to a small stairwell. At 10:30 AM, Resident 84 sat on the concrete parking curb with the oxygen tank secured to the walker and the oxygen tubing in their lap. The oxygen regulator was open, and oxygen was flowing from the tank. Resident 84 had a burning cigarette in their hand and a package of cigarettes sitting on the ground next to them. Resident 84 confirmed the oxygen was flowing and they usually turned it off, but not this time. In an interview on 04/28/2022 at 12:55 PM Staff V (Receptionist) identified Resident 84 as a smoker who went outside to smoke. Staff V could not recall if Resident 84 used oxygen or carried an oxygen tank. In an interview on 04/28/2022 at 1:01 PM Staff C and Staff B stated they were not aware that Resident 84 was a smoker or went off the facilities property to smoke. On 04/28/2022 at 1:22 PM Resident 84 stated they knew smoking while using oxygen was not allowed, knew the facility was non-smoking, and confirmed they were smoking the same pack of cigarettes since February 2022. Activity Room Sliding Door On 04/24/2022 at 10:08 AM, the sliding door from the Activities room was noted to be bolted shut. A screw hole in the handle was noted with sharp metal filings extending from the drill hole. During environmental rounds and interview conducted on 04/29/2022 at 7:34 AM, Staff D (Maintenance Director) stated the metal filings represented a potential accident hazard to a resident trying to open the door and needed to be removed so a resident doesn't cut themselves on the sharp metal pieces. Staircase Magnetic Lock Mechanism On 04/25/2022 at 10:38 AM, the magnetic door fastener at the top of the stairway located next to the Activities Room was observed to be fastened with duct tape and was not secured. During environmental rounds and interview conducted on 04/29/2022 at 7:34 AM, Staff D stated the mechanism was not but should be secured to remove a potential accident hazard if a resident was able to go through the door into an unsupervised stairwell. Room Storage Resident 67 On 4/28/2022 at 12:07 PM, residents' personal items were noted on top of the closet. A sign was observed on the side of the closet that stated DO NOT PLACE ANYTHING ABOVE THIS LINE PER FIRE REGULATION. During environmental rounds conducted on 04/29/2022 at 7:34 AM, Staff D stated that the items should not be there. Cookie Baking Oven On 04/22/2022 at 12:13 PM a cookie baking oven was observed in the second floor activity room, unplugged and not in use. A sticker on the front door stated, Caution Hot. Next to the oven was an unlocked clear box that contained 4 cream colored cookies, easily accessible to any resident. During an interview on 04/22/2022 at 12:34 PM, when asked about the cookie oven, Staff X (Activities Assistant) stated they never used it and When I came in the morning, I was surprised to see that, We don't usually leave food sitting out. On 04/22/2022 at 12:35 PM an empty cardboard box the size of the oven, with the name of the cookie company was observed in the Activity office. The box had a shipping label dated 04/04/2022, and was addressed to Staff FF (Food Service Manager from a sister facility). During an interview at that time, Staff X stated, It showed up in our office the other day. On 04/22/2022 at 12:39 PM Staff FF confirmed they brought the cookie oven to the facility in the box. When asked if staff training was provided, Staff FF stated that the user only needed to engage the on/off switch. Staff FF stated that the activity staff were given a diet roster two days prior to verify the residents who could eat the freshly baked cookies. Staff FF stated that they expected the cookies to be given out under staff supervision. On 04/22/2022 at 1:01 PM Staff Y (Activities Director) stated they used the oven the day before and when it was plugged in the fan broke so the cookies were baked in the kitchen oven. Staff Y stated that they passed out the cookies and did not have any cookies leftover. On 04/22/2022 the kitchen staff baked cookies again. According to Staff Y who stated, The ones I had left over, I left there in the activity room. Staff Y acknowledged that food should not be left unattended. On 04/22/2022 at 1:14 PM Staff FF plugged in and turned on the cookie oven. The oven was observed heating up, and the front door warm to touch. At 1:17 PM the oven started making loud noises and sounded like the fan was malfunctioning. REFERENCE: WAC 388-97-1060(3)(g). .

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · 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 3 (Residents 36, 251 & 153) of 17 residents reviewed, received the necessary care and services in accordance with professional standards of practice and their comprehensive person-centered care plan. The failure to implement monitoring and interventions for skin care (Resident 251),and air mattress settings (Resident 153) resulted in the potential for unmet care needs and diminished quality of life. The failure to provide physician ordered treatments for 1 (Resident 36) of 3 residents reviewed for non-pressure skin issues resulted in worsening of the skin condition, discomfort, and psychological distress to the resident. Findings included . Non-Pressure Skin Resident 36 The 04/27/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 36 was cognitively intact, able to make themselves understood and understand others. Resident 36 was identified as high risk for skin injuries and had moisture associated skin damage with applications of ointments and medications to the skin. A review of the Physician Orders (PO) showed: 1. 01/17/2022 an antifungal powder that directed staff to apply to skin folds topically two times a day for itching 2. 01/17/2022 a barrier paste that directed staff to apply to skin folds topically two times a day for itching 3. 01/17/2022 an anti-inflammatory ointment that directed staff to apply topically to affected area every 12 hours as needed for itching. 4. 01/17/2022 a lotion that directed staff to apply to affected area topically every eight hours as needed for itching three times a day 5. 01/19/2022 a topical solution that directed staff to apply to skin folds topically as needed for excess moisture two times a day as needed. 6. 02/23/2022 treatment for multiple areas of dermatitis (rash) in folds of skin bilateral flanks (underarm), pannus (abdomen) area, and behind knees, recommended by wound specialist: Cleans folds gently with warm water, pat dry, apply a anti-inflammatory ointment and anti-fungal powder and moisturizing cream, place sheets when available in folds (washable and reusable product) Provide treatment three times a week until resolved or new treatment needed, one time a day every Monday, Wednesday, and Friday, wound nurse provide treatment when available. Review of the 04/2022 Medication Administration Record (MAR) showed: 1. Anti-fungal Powder ordered for twice daily was not administered seven times on day shift and 12 times on evening shift between 04/01/2022 and 04/21/2022. 2. Barrier paste ordered for twice daily was not administered nine times on day shift and 17 times on evening shift. 3. Anti-inflammatory ointment, lotion and topical solution was not administered at all in the month of April 2022. 4. The anti-inflammatory and anti-fungal powder and moisturizing cream with bed sheets in skin fold daily on Monday, Wednesday and Friday was not administered on Friday, 04/22/2022 as scheduled. A review of the 03/02/2022 wound specialist note showed the left flank with a rash and maceration (broken skin from moisture) noted to skin fold with a treatment prescribed- anti-inflammatory ointment and anti-fungal powder followed by a moisturizer daily, place pillowcase between folds. These recommendations were not found on the physician orders to replace the 01/17/2022 and 02/23/2022 treatment orders. Review of the 04/2022 [NAME] (care instructions) showed no instructions to staff to clean Resident 36's skin daily or place the pillowcases between the skin folds. A review of the weekly wound evaluation assessments for Resident 36 showed the last assessment for the left flank wound was completed on 03/10/2022 at 8:44 AM. There were no assessments of the left flank wound after 03/10/2022 to indicate the facility was managing the wound care with updated orders or ensuring daily skin hygiene. The 04/01/2022 Care Plan (CP) directed staff to administer treatments as ordered and monitor for effectiveness, if the resident refuses treatment, confer with the resident to determine why and try alternative methods to gain compliance, document alternative methods. There was no CP for the left flank skin care or hygiene. In an interview on 04/22/2022 at 2:25 PM, Resident 36 stated they had redness under the arms in the skin folds that was itchy, painful, and not being taken care of by the staff. Resident 36 stated the doctor ordered daily cleaning and an ointment and a powder. Resident 36 raised their left arm and moved the fold of skin which showed bright red, moist, bumpy skin that had patches of white. The rash spanned from the chest to the back and covered the entire inner skin fold. Resident 36 stated the area was not cleaned or a treatment applied since Monday, 3 days earlier. Resident 36 stated the nurse often came between 11:00 PM and 1:00 AM to do the treatment while they were already asleep, and they would refuse and send the nurse away. Resident 36 stated, the nurse should come when I am awake, I am tired of them waking me in the middle of the night. Resident 36 stated , with tears in their eyes, no one should have to live like this. In an interview on 04/25/2022 at 12:22 PM, Resident 36 stated the facility got rid of the shower aide and made the caregivers do the showers. Resident 36 stated they had not had a shower since the beginning of March and only had bed baths. Resident 36 showed under their arm and the skin was redder and flakier and had drips of moisture than what was observed on 04/22/2022 at 2:55 PM. Resident 36 stated their sheets were all wet and it was that way all night. Resident 36 said they told the staff that morning about the sheets, but the staff did not change the sheets yet. Observation showed the sheets were wet, spanning the entire width of the resident from mid back down to where the resident was sitting in the bed. Resident 36 stated, I want to have a shower, I need them to take care of my skin, I am on the low priority for wound care. When they don't do the wound treatments the rash gets worse, and it hurts, In an interview on 04/27/2022 at 12:38 PM, Staff F (RCM & MDS Nurse) stated physician orders for wound care was not obtained or administered as prescribed. Staff F stated the facility wound care nurse resigned three or four weeks ago and the position was not filled. In an interview on 04/28/2022 at 2:13 PM, Staff C (Chief Nursing Officer) confirmed the orders written by the wound specialist on 03/02/2022 was not updated in the resident's record and the prior orders were not discontinued. Staff C acknowledged the treatments were not administered when Resident 36 was awake to avoid refusal of treatments. Air Mattress Settings Resident 153 According to the 04/07/2022 Quarterly MDS, the resident had diagnoses including Schizophrenia, Diabetes, Dementia, and Parkinson's Disease. Resident 153 was assessed at risk for pressure ulcers and required a pressure reducing device for the bed. Review of PO's showed a 10/04/2021 PO for a specialty mattress, and directed staff to check function every shift. Green light equals proper functioning. LN (Licensed Nurse) initials indicates functioning as per order. Review of a 12/31/2020 Potential for skin breakdown/pressure injury CP showed an intervention that resident requires a pressure relieving device on the bed. On 04/24/2022 at 9:08 AM the resident was observed lying on an air mattress. The air mattress settings were observed on alternating and the weight setting was at 450 lbs (pounds). Similar observations were made on 04/25/2022 at 9:13 AM and 12:26 PM, 04/26/2022 at 9:36 AM, and 04/27/2022 at 10:08 AM. Review of the resident's weight record showed on 04/25/2022 the resident weighed 107.5 Lbs. In an interview on 04/28/2022 at 9:53 AM Staff C stated they expected the air mattress to be set at the appropriate weight, and acknowledged Resident 153 did not weigh 450 lbs. REFERENCE: WAC 388-97-1060(1). Resident 251 Resident 251 was admitted to the facility on [DATE]. According to a 04/15/2022 admission MDS, Resident 251 had multiple medically complex diagnoses including Peripheral Vascular Disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). This MDS assessed Resident 251 to be at risk of Pressure Ulcers/Injuries and had two venous ulcers (wounds on the leg or ankle caused by abnormal or damaged veins). According to the 04/21/2022 Pressure Ulcer/Injury Care Area Assessment, Resident 251 was identified on admission with two small open skin areas on the left lower leg and was receiving treatment per the April 2022 TAR. Review of the April 2022 TARs showed an order that directed staff to apply compression bandages used for the management of venous ulcers to both lower legs in the morning and to remove at night. Observations on 04/23/2022 at 9:53 AM showed Resident 251's legs partially wrapped with loose sagging woven gauze and no compression bandage. Similar findings of Resident 251 without compression bandages was observed on 04/25/2022 at 8:05 AM and 04/27/2022 at 10:05 AM. In an interview on 04/29/2022 at 7:33 AM, Staff C stated it was their expectation that staff complete Resident 251's treatments as ordered.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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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 care is provided consistent with professional standards of practice to prevent and/or provide treatment and services for pressure ulcers for 3 of 8 (Resident 3, 97, & 76) residents reviewed for Pressure Ulcers (PU). Failure to identify and assess changes in skin condition, notify the practitioner to obtain orders for treatment, and complete weekly documentation of PU progress caused harm to Resident 3 who obtained two stage four PUs on the right hip, one stage 4 PU on the right outer ankle and one stage 4 PU on the right outer foot. Failure to implement preventative measures (Residents 97 &76) such as positioning, placed residents at risk for deterioration in skin condition. Findings included . According to the 05/17/2021 facility policy titled, Pressure Injury Risk Assessment, residents determined as at risk for developing pressure injuries would have interventions documented in the Care Plan (CP) based on specific factors identified in the risk assessment. According to the National Pressure Injury Advisory Panel (NPIAP) PU stages are defined as; Stage 1 PI: intact skin with a localized area of non-blanchable (discoloration of the skin that does not turn white when pressed), Stage 2 PI: partial thickness loss of skin with exposed dermis (second layer of skin), may present as an intact or ruptured serum-filled blister, granulation tissue (indicates healing), slough (yellow/white material in wound bed) and eschar (dead tissue) are not present. Stage 3 PI: full thickness loss of skin, in which adipose (fat) is visible, slough and/or eschar may be visible. Stage 4 PI: full thickness skin and tissue loss with exposed or directly fascia (connective tissue), muscle, tendon, ligaments, cartilage, or bone in the ulcer. Resident 3 The 02/10/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 3 was admitted to the facility on [DATE] and was on hospice care. Resident 3 had diagnoses of malnutrition, dehydration, and one stage 4 PU on the low back and one stage 4 PU on the right hip. Resident 3 was assessed as high risk for PU development and the assessment only identified one PU on the MDS. Resident 3 was assessed to require extensive assistance with bed mobility and total dependence with transfers using a mechanical lift. A review of the 03/16/2022 wound specialist notes showed Resident 3 only had one PU on the low back that was a stage 4 with increased breakdown to the ulcer edges with more dead skin cells in the wound. The recommended treatment was to be completed daily. A 03/17/2022 Physician Order (PO) showed treatment orders for a Pressure ulcer (on low back) stage 4: Cleanse, pack wound and cover with foam dressing daily. Change daily by floor nurse except Wednesday when wound specialist sees the resident. The treatment was scheduled to be performed every night shift. A review of the 03/23/2022 nurse progress note showed Resident 3 refused wound care by the wound specialist on the 03/23/2022 weekly rounds. There is no documentation of nursing staff assessment or care provided to the PU's on 03/23/2022. The 03/23/2022 CP showed Resident 3 had a stage 4 pressure ulcer on the low back. The interventions directed staff to assess, record, and monitor wound healing weekly including measurements, status of the wound, and healing progress. The CP specified use of foam boots on both feet and an air mattress with settings to be checked every shift. The CP directed staff to refer assessments and treatment recommendations to the wound specialist. The CP directed staff to inform the resident, family, and caregivers of any new area of skin breakdown. A review of the 03/25/2022 nurse progress note showed the Resident Care Manager (RCM) called the hospice nurse to come and see Resident 3 for a new red area on the right hip. The RCM wanted the hospice nurse to help with a plan to prevent PUs. The 03/29/2022 weekly skin observation assessment identified the ankle and right outer foot pressure ulcers. The assessment showed these PU were not new and further assessment was not required. There was no documentation to show the nurse staff notified the physician on this assessment information. There was no documentation or PO for treatment for the two new PUs. A review of the 03/30/2022 nurse progress note showed Resident 3 refused wound care, a second time, by the wound specialist on the weekly rounds and the Director of Nursing and Hospice was notified. There is no documentation that the facility nursing staff provided assessment or PU care to the current five (1-low back, 2-right hip, 3-right hip, 4-right ankle, 5-right foot) PUs on 03/30/2022. A review of the 04/01/2022 nurse progress note showed the RCM called hospice to inform them the wound specialist would no longer be visiting Resident 3 because of hospice services. The RCM asked the hospice nurse to manage wounds and was waiting for a call back. A review of the 04/01/2022 hospice nurse visit notes showed the facility did not report any concerns at this visit. The hospice nurse validated and verified that the caregiver demonstrates and verbalizes understanding of the plan of care and will notify hospice with falls, uncontrolled symptoms, changes in condition, questions, concerns. The hospice nurse was still uninformed about the status of the right hip, new right ankle, and new right foot PUs. A 04/06/2022 nurse progress note showed the hospice nurse visited Resident 3 but Resident 3 did not allow the hospice nurse to assess the right hip area. The nurse note showed the plan was to continue current treatments to the low back only and reposition resident as they allow. A review of the 04/06/2022 hospice nurse visit notes showed the RCM called and requested the hospice nurse visit because a new open area on the right hip was identified. The 04/06/2022 hospice note showed Resident 3 refused to let the nurse assess the right hip PU, so the hospice nurse did not give treatment recommendations to the facility for care of the PU. Resident 3 also did not allow the hospice nurse to complete a full skin check, thus the hospice nurse did not identify the additional PUs on the right ankle or right foot. There were no recommendations for treatment of the right hip, right ankle or right foot PU provided by the hospice provider or forwarded to the facility practitioner for nursing staff to implement. An observation on 04/21/22 at 11:18 AM showed Resident 3 was lying on their right side on the air mattress that was set to 400 pounds, and not wearing foam boots. Resident 3 did not appear to be 400 pounds. The last weight recorded on 01/24/2022 was 107 pounds. The 04/22/2022 hospice nurse visit notes showed no concerns or issues reported by the floor staff at this visit. The hospice nurse validated and verified that the caregiver demonstrates and verbalizes understanding of the plan of care and will notify hospice with falls, uncontrolled symptoms, changes in condition, questions, concerns. The hospice nurse was still uninformed about the right ankle and right foot PUs. An observation on 04/23/22 at 10:56 AM showed Resident 3 was lying on their back, no foam boots and air mattress setting at 400 pounds. An observation on 04/25/2022 at 8:59 AM showed Staff S (Registered Nurse) in the middle of providing wound care to Resident 3. Resident 3's right ankle and right foot were covered with a clean foam dressing. There was a PU at the base of the back and two PU on the right hip that had a paste surrounding the wound on the intact skin. Staff S placed the packing material in the low back wound and covered with a foam dressing. Staff S placed an ointment in both hip wounds and covered with a foam dressing. When asked, Staff S stated the right foot, right ankle, low back, and two right hips PU were all stage 4 PU. Staff S stated the wound specialist comes on Wednesdays and that is when the wounds are measured and evaluated for a change in treatment. Staff S was not aware the wound specialist was no longer directing wound care for Resident 3. Staff S confirmed there were no PO for treatments for the right hip, right ankle and right foot and there should be PO obtained. A 04/25/2022 nurse progress note identified the PU on the low back, right hip, right outer ankle, and right outer foot. The note showed staff would report the new PU to the care team, hospice nurse, and the physician. A 04/27/2022 in person physician visit note showed provision of wound care changed from the wound specialist to hospice services. The physician documented Resident 3 had a long history of a low back PU and referenced the 04/25/2022 nurse progress note. The physician did not mention changes in PU assessment or treatment plan for the hip, ankle, or foot pressure ulcers. A review of the nursing progress notes from 03/29/2022 to 04/27/2022 showed no documentation the physician was notified of the two hip, one ankle and one foot ulcers. There was no documentation the hospice nurse was notified of the ankle or foot ulcers. In an interview on 04/27/2022 at 12:38 PM, Staff F (RCM & MDS nurse) stated when the new PU was identified the physician and the hospice nurse were expected to be notified. Staff F stated a treatment order was expected to be obtained and must be in place before the nurse could provide the treatment. Staff F reviewed Resident 3's record and was not able to find any documentation that the physician or hospice nurse were notified. Staff F reviewed the POs and stated there were no treatment orders for the hip, ankle, or foot. Staff F observed Resident 3's hip, ankle, and foot and confirmed the placement of a dressing on all three areas. In an interview on 04/27/2022 at 12:36 PM Staff E (Staff Development Coordinator) stated the facility performed competency checks for all nurses who provided wound care. Staff E was unable to provide a competency evaluation for Staff S who was observed providing wound care without orders on 04/25/2022. Staff E was not able to provide a competency evaluation for wound care for Staff U (RCM) responsible for coordinating care and treatment with the wound specialist, hospice nurse, and the physician. In an interview on 04/27/2022 at 3:21 PM Staff B (Director of Nursing) stated the nurses are expected to identify and assess changes in skin condition, notify the practitioner to obtain orders for treatment, and complete weekly documentation of wound progress. Staff B acknowledged the nurses did not follow the expectation and resulted in Resident 3's PUs not being treated. Resident 97 Resident 97 was admitted to the facility on [DATE]. According to the 03/25/2022 Quarterly MDS Resident 97 had multiple medically complex diagnoses and was assessed to be at risk for developing PU. This MDS assessed Resident 97 to require extensive physical assistance from staff for bed mobility, transfers, and dressing. Observations on 04/21/2022 at 10:38 AM showed Resident 97 asleep sitting in wheelchair (w/c) next to their bed. On 04/21/2021 at 12:41 PM and 1:50 PM showed Resident 97 remained sitting up in w/c at side of bed. According to a 12/19/2021 PU Care Area Assessment (CAA) associated with Resident 97's 12/14/2021 admission MDS, showed staff documented Resident 97 had preventative measures in place, which included repositioning and stated, .will proceed to plan of care. Review of Resident 97's CP on 04/22/2022 revealed no identified concerns or interventions related to the resident being at risk for developing PUs. In an interview on 04/23/2022 at 8:47 AM, Staff Z (Certified Nursing Assistant- CNA), indicated Resident 97 had no skin risks or concerns. Observations on 04/25/2022 at 10:41 AM with Staff AA (Registered Nurse - RN) showed Resident 97 had redness noted to bilateral buttocks. In an interview at this time, Staff AA indicated Resident 97 was at risk for developing PUs and should be repositioned frequently. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated staff should have but did not update and revise Resident 97's CP to include interventions to prevent the development of PU. Resident 76 According to the 03/15/2022 Quarterly MDS Resident 76 had diagnoses including dementia with behavioral disturbances, diabetes, and depression. The resident was assessed to be at to be at risk for developing PUs and currently had no PUs. A 03/21/2022 nursing progress note showed staff identified an open and unopened blister to the right lateral thigh during the weekly skin assessment that caused Resident 76 mild pain to the area. Staff documented they were unsure how the blister developed. Review of a 03/21/2022 Weekly skin observation assessment showed no new skin issues. Additional notes showed Resident 76 had a right lateral upper thigh open skin area that measured 8 x 4.5 cm (centimeters) and a fluid filled blister on the right upper lateral thigh that measured 3.5 cm x 2.5 cm. Review of a 03/21/2022 Incident report showed, the root cause analysis presents that the resident has large friction rub and provider agreed. The investigation did not determine what caused the large friction rub. A 03/22/2022 Physician note showed the resident presented with an apparent large friction blister to the right lateral thigh. The resident informed the physician they did not experience acute trauma to the area. Review of a 03/22/2022 Potential for impairment to skin integrity related to edema, fragile skin, redness to the bi-lateral lower extremities, and an actual skin impairment of a open blister to the lateral right thigh. The CP interventions included educate resident and caregivers of causative factors and measures to prevent skin injury, and to monitor the open and unopened blister to the right lateral thigh. There were no identified interventions on the CP to prevent the wound from worsening or reoccurring. A 03/30/2022 nursing progress note showed the resident missed the wound provider visit and the PU was assessed by facility staff. Staff documented the PU measured 4.5 cm x 9 cm x 0.1 cm, had no odor but did have yellowish colored slough. A 03/31/2022 wound provider assessment showed the cause of the resident's right lateral thigh PU was an abrasion with partial thickness injury of the skin. On 04/27/2022 at 10:04 AM Resident 76 was observed in their power wheelchair, the wheelchair controls were observed on the right side of the chair, making contact with the residents right lateral thigh, where the PU was located. In an interview on 04/27/2022 at 11:12 AM the contracted wound provider stated the CAUSE may be from pressure caused by the resident's wheelchair. Refer to F849 Hospice Services. Refer to F726 Competent Nursing Staff. REFERENCE: WAC 388-97-1060(3)(b). .

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Incontinence Care (Tag F0690)

A resident was harmed · 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 bowel and bladder care and catheter care was provided according to professional nursing standards for 3 (Residents 65, 13 & 67) of 7 residents reviewed. Failure to identify and provide care for diarrhea (Resident 13) and failure to provide appropriate catheter care (Resident 67) left residents at risk for dehydration, urinary tract infection, skin breakdown, and negative health outcomes. Additionally, the failure to implement catheter care and monitoring to Resident 65 according to professional nursing standards resulted in hospitalization for a blood infection, bladder and kidney infection. The harm caused to Resident 65 caused a decline in condition which may have contributed to the death of Resident 65. Findings included . Resident 65 The closed record review for Resident 65 showed they admitted to the facility on [DATE] for rehabilitation for a left lower leg fracture and a bowel infection. Other diagnosis included quadriplegia (paralysis) and use of a urinary catheter (for urination related to paralysis). The 02/24/2022 admission practitioner note showed Resident 65 had a (urinary) catheter and directed staff to change catheter and drainage bag together using aseptic technique as needed for disconnection, leakage, obstruction, bleeding, or infection. The practitioner also directed staff to continue skilled nursing care and maintenance of the catheter. The 02/24/2022 admission Physician Orders (POs) showed no orders for Resident 65 to have an indwelling urinary catheter or instructions to monitor, change catheter tubing or nursing care for catheter maintenance. The 02/26/2022 nursing baseline Care Plan (CP), completed two days after admission showed Resident 65 had a catheter for urination. No instructions for care or monitoring were shown on the care plan. Resident 65's 02/2022 and 03/2022 Medication Administration Record (MAR), and the Treatment Administration Record (TAR) showed no directions for care and maintenance for the catheter and no documentation of nursing care and monitoring of urination or the catheter. The 02/2022 and 03/2022 [NAME] (caregiver directions) and flowsheets showed no documentation of hygiene care was provided to the catheter for Resident 65. The 03/03/2022 Minimum Data Set (MDS- an assessment tool) showed Resident 65 required a urinary catheter. The 03/03/2022 Care Area Assessment (CAA) showed the facility triggered further care planning for the catheter. The CAA provided direction to the licensed nurses to plan interventions for the care of the urinary catheter, including following physician orders and to create a catheter focused care plan. The 03/02/2022 CP for bladder dysfunction and use of a catheter was initiated 26 days after admission. The CP goal showed Resident 65 would be free of infection related to the urinary catheter. There were no interventions initiated to meet the defined goal. There were no interventions for care and monitoring of the catheter or urinary function. The daily nursing skilled progress notes on 03/13/2022, 03/14/2022, 03/15/2022, and 03/16/2022 described Resident 65's urine in the catheter bag as amber and cloudy. There was no documentation in the progress notes of notification of the provider about the assessment of abnormal urine color and clarity to identify a possible urinary tract infection. The 03/17/2022 provider note showed the nursing staff emergently contacted the provider about the resident's change in condition, including unresponsiveness, an elevated blood sugar of 400, high blood pressure 180/117 (a hypertensive crisis is greater than 180/120), and pulse was 148 (normal pulse is 60-90). There was no report to the provider of the change in urine color and clarity in the catheter bag. The provider directed staff to transfer Resident 65 to the emergency room. The 03/17/2022 hospital records showed Resident 65 presented to the emergency room with altered mental status, elevated blood sugar, abnormal heart rate and an abnormal heart rhythm. The hospital physician documented the urinary catheter contents were red, abnormal, and positive for infection. The urine lab results showed a urinary infection. The blood lab results showed a serious infection. The resident was placed on intravenous fluids and antibiotics for a diagnosis of catheter related urinary tract infection and sepsis (systemic infection). In an interview on 04/27/2022 at 12:14 PM, Staff F (RCM & MDS Nurse) stated POs for catheter care, maintenance, monitoring and care directions to staff are required for residents with a catheter. In an interview on 04/27/2022 at 3:21 PM with Staff B (Director of Nursing) and Staff C (Chief Nursing Officer), Staff B acknowledged Resident 65 did not have an order from the physician for use of a catheter, there were no interventions in place to care for and monitor the catheter which resulted in hospitalization for a blood, bladder and kidney infection. Staff B and Staff C agreed the care and monitoring interventions should have been in place to prevent infection, timely identify an infection, and prevent hospitalization and declined condition. Resident 67 According to the 03/07/2022 Quarterly MDS, Resident 67 was cognitively intact, had diagnoses including a neurogenic bladder (a condition where a person lacks bladder control due to a nerve condition) and used an indwelling urinary catheter (a device to drain urine from the bladder). According to the 10/13/2019 Suprapubic Catheter CP, nurses should monitor and document Resident 67's fluid intake and output (I&O) and should flush Resident 67's catheter with 30 cc (cubic centimeters) of normal saline each shift. Review of the April 2022 MAR revealed no monitoring and documentation of Resident 67's I&O. The MAR showed 3 occasions where the nurses failed to document that Resident 67's catheter was flushed. Review of the March 2022 MAR showed nurses failed to document a catheter flush on four occasions, and review of the February 2022 MAR showed nurses failed to document a catheter flush on three occasions. In an interview on 04/28/2022 at 9:36 AM, Staff C stated they expected the catheter to be flushed every shift as ordered. In an interview on 04/28/2022 at 4:02 PM, Staff C stated the facility was not but should be monitoring Resident 67's I & O. Resident 13 According to the 04/06/2022 Quarterly MDS, Resident 13 was cognitively intact. The MDS showed Resident 61 was always incontinent of bowel and bladder. In an interview on 04/22/2022 at 12:11 PM, Resident 13 stated that they sometimes experienced diarrhea and stated they believed it might be a side effect of their medications. According to the resident's records, between 03/28/2022 and 04/25/2022, Certified Nursing Assistants (CNAs) documented Resident 13 had loose stools (diarrhea) on 04/01/2022, 04/07/2022, 04/09/2022, 04/11/2022, 04/16/2022, 04/17/2022, 04/18/2022, 04/19/2022 and twice on 04/21/2022. Review of Resident 13's progress notes from 03/28/2022 to 04/25/2022 revealed no evidence CNAs reported the loose stools to the nurse. Review of Resident 13's POs showed no orders for an antidiarrheal medication or any other orders to treat Resident 13's loose stools. In an interview on 04/28/2022 at 3:59 PM, Staff C stated that CNAs should have, and did not, report the loose stools to the nurse, that this omission prevented the nurse from notifying the physician, and prevented Resident 13 from receiving the treatment they required. REFERENCE: WAC 388-97-1060 (3)(c). .

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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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 abuse and neglect policies and procedures for 1 (Resident 65) of 2 residents reviewed for hospitalization. The failure to identify a fracture of unknown origin, investigate to rule out abuse and report to the state agency placed Resident 65 at risk for further unidentified injury and all residents at risk for unidentified abuse and injury. Findings included . The 09/2020 facility policy titled Abuse, Neglect, Exploitation, Misappropriation Resident Property Policy showed the facility policy was to investigate all injuries of unknown source. The policy showed facility staff should immediately report all such allegations to the Administrator and the (Department). The facility procedure described identification of events such as suspicious bruising that may constitute abuse and determined the direction of the investigation. Upon completion of an investigation, the facility would determine modifications to a resident's care plan to prevent similar incidents or injuries from occurring in the future. The administrator or designee would report injuries of unknown source as soon as possible but no later than 24 hours from the time the incident was made known to the staff member. Resident 65 The 03/03/2022 admission Minimum Data Set (MDS, an assessment tool) showed Resident 65 was admitted [DATE] with no diagnosis of a left arm fracture. A 03/16/2022 skilled nursing assessment showed Resident 65 was alert, responsive, and usually understood others, with no pain and no skin bruising on upper left arm. A 03/17/2022 nurse discharge note showed Resident 65 was sent to the hospital for unresponsiveness at 8:00 AM. The 03/23/2022 hospital discharge summary showed Resident 65 was admitted to the hospital on [DATE] with the diagnosis of urosepsis (a blood infection from a bladder infection) and pyelonephritis (a kidney infection). The summary showed an x-ray was completed on 03/21/2022 for pain, bruising, and swelling on the left upper arm. The x-ray showed an upper arm fracture. A 03/22/2022 orthopedic (bone specialist) consult note showed the upper arm fracture was of indeterminate age. The color of bruising determined an injury of 6-10 days prior to 03/22/2022. Resident 65 was admitted to the facility during this timeframe of 03/12/2022 up to the hospital transfer on 03/17/2022. A 03/23/2022 7:10 PM nurse progress note showed staff re-admitted Resident 65 to the facility. Resident 65 presented with left upper arm swelling, bruising, and pain associated with the fracture. Resident 65 had an arm sling in place for support. In an interview on 04/27/2022 at 2:47 PM Staff DD (Administrator in Training) stated there was no investigation report, to rule out abuse/neglect, for Resident 65's left upper arm fracture. A review of the March 2022 incident log showed no entry, and no report to the state agency as required. In an interview on 04/27/2022 at 3:21 PM Staff B (Director of Nursing) stated the facility assumed the left arm fracture was from the fall prior to admission on [DATE]. Staff B stated the admitting nurse did not identify the fracture as possible abuse/neglect or notify the DNS. Staff B stated there was no investigation upon learning of the fracture on 03/23/2022 to determine the cause or rule out abuse/neglect. Staff B confirmed the incident was not reported to the state agency as required. Staff B stated the facility should have, and did not, follow their abuse policy. Refer to F684 Quality of Care. Refer to F726 Competent Nursing Staff. REFERENCE: WAC 388-97-0640(2). .

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a system by which the office of the State Long-Term Care Ombudsman (LTCO) received required resident transfer information for 1 (Resident 61) of 2 residents reviewed for discharges to the hospital, and failed to ensure to offer bed holds for 1 (Resident 61) of 2 residents reviewed for discharges to the hospital. Failure to ensure required notification was completed, prevented the LTCO from educating and advocating for residents regarding their rights. Failure to provide bed hold information left residents at risk for unwanted room changes upon readmission. Findings included . Facility Policy According to the facility's 05/02/2022 Transfer and Discharge Policy, in the event of an emergency transfer, the Social Services Director or their designee will notify the LTCO via a monthly list. The policy directed staff to provide the transferring resident with a bed hold notification no later than 24 hours after transfer. Resident 61 According to a 01/18/2022 progress note, Resident 61 was observed to be confused and drowsy and was sent emergently to the hospital where they were diagnosed with a respiratory infection. Review of the resident's record revealed no evidence the LTCO was notified within 30 days of Resident 61's emergent transfer to the hospital, as required. The resident record did not include any evidence Resident 61 was offered a bed hold as required, either at the time of transfer or after. In an interview on 04/28/2022 at 01:03 PM, Staff G, (Social Services Director) stated that notifying the LTCO of emergent transfers was the responsibility of another department. In an interview on 04/28/2022 at 3:15 PM, Staff W (Admissions Coordinator) was asked to provide evidence the facility provided Resident 61 a bed hold, and notified the LTCO of Resident 61's emergent transfer to hospital. After briefly reviewing Resident 61's records, Staff W stated they would look into it and provide further information. In an interview on 04/28/2022 at 3:43 PM, Staff W stated there was no record showing the facility provided a bed hold. No further information regarding LTCO notification was provided. REFERENCE: WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii). .

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

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 identify a significant change and complete a timely Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for 1 (Residents 3) of 22 sampled residents reviewed. Failure to complete the SCSA timely placed the residents at risk for unmet care needs, decreased quality of care and diminished quality of life. Findings included . According to the Resident Assessment Instrument Manual (RAI- a document directing staff on how to accurately assess the status of residents), the SCSA must be completed when the Interdisciplinary Team has determined that a resident meets the significant change guidelines for either major improvement or decline in status or when a terminally ill resident enrolls in a hospice program and remains at the nursing home. Resident 3 The 07/30/2021 admission Minimum Data Set (MDS, an assessment tool) showed Resident 3 was admitted to the facility on [DATE] with a diagnosis of a non-curable progressive neurological condition and was not enrolled in a hospice program. The 08/13/2021 Hospice Notice of Election of Benefit/Consent Form showed Resident 3 started hospice services on 08/13/2021. 08/13/2021 was the date that started the assessment period for a significant change according to the RAI manual. The 11/18/2021 SCSA MDS was completed and signed on 12/01/2021, 105 days late. In an interview on 04/26/2022 at 12:55 PM, Staff J (MDS Nurse) stated the SCSA was due 14 days after hospice started on 08/27/2021 and was completed late. REFERENCE: WAC 388-97-1000(3)(b). .

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 36 A 10/19/2021 Level 1 PASRR completed by hospital staff upon discharge showed Resident 36 had Bipolar 1 (a mood disorder) without serious functional limitations or any need for mental health in the past six months. Anxiety Disorder and Psychotic Disorder were not identified on the PASRR. No Level II evaluation was checked on the form. The 10/28/2021 admission MDS showed Resident 36 was admitted to the facility on [DATE]. Resident 36 was assessed to require antipsychotic, antianxiety, and antidepressant medications. Resident 36 was assessed to be cognitively intact, with clear speech, the ability to make self understood and understood others. The 11/02/2021 Care Area Assessment (CAA, a tool to create a care plan) showed Resident 36 required a care plan for an altered mood state. The CAA showed Resident 36 was interviewed and reported little interest or pleasure in doing things, had impaired functional mobility, and diagnoses including Bipolar Disorder with Depression, Post-Traumatic Stress Disorder (PTSD), and Anxiety. The 11/02/2021 CAA showed Resident 36 required a CP for psychotropic medication use. The CAA showed Social Services was developing a CP for the specific diagnoses. A 12/29/2021 Level I PASRR for a re-admission after hospitalization was completed by hospital staff. The PASRR showed Resident 36 had diagnoses including Bipolar 1 Disorder, PTSD, Anxiety and Attention-Deficit-Hyperactivity Disorder (ADHD) without serious functional limitations or the need for mental health services in the past six months. In an interview on 04/26/2022 at 3:30 PM, Staff G confirmed the 10/19/2021 and the 12/29/2021 PASRR forms were incorrect and should have been corrected by the facility staff at admission. Staff G stated Resident 26 needed a PASRR Level II referral and evaluation which was not completed as required. REFERENCE: WAC 388-97-1915(4). Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II evaluation recommendations were implemented and incorporated into the Care Plan (CP) for 3 (Resident 21, 30, 36) of 7 residents reviewed for Level II PASRRs. Failure to incorporate and implement treatment plans into the comprehensive CP placed residents at risk for not receiving necessary mental health and counseling services and unmet psychosocial needs. Findings included . Resident 21 According to the 01/17/2022 Quarterly Minimum Data Set (MDS an assessment tool) the resident admitted to the facility on [DATE] and had diagnoses including Schizophrenia, Anxiety disorder, and drug-induced Tardive Dyskinesia (TD- abnormal, involuntary movements of the face, neck, limbs and body). Review of 02/25/2020 Level II PASRR showed Resident 21 was referred for behaviors of being resistive to care (including showers) and showing little interaction with people at the facility. The Level II PASRR instructed the facility to complete an AIMS (Abnormal Involuntary Movement Scale) assessment, repeat the AIMS every 90 days and document the progression, due to Resident 21's long term antipsychotic use and TD diagnosis. Recommendations included: establishing a lowest effective dose for the antipsychotic medication; consideration of a trial of a medication used to treat TD, and a referral for a psychiatric consult to further assess. Review of the resident's CP showed a 02/25/2020 PASRR I reviewed and sent for review due to SMI (Serious Mental Illness), PASRR II completed. The CP did not include the most current recommendations made by the PASRR II evaluator. Review of the resident's record showed AIMS assessments were completed every six months and not every 90 days or three months as recommended. Review of Physician's Orders (PO) showed no indication a trial of the medication to treat TD was initiated, and no indication a lowest effective dose for the resident's antipsychotic was determined, as the resident continued on the same dose of the antipsychotic used to treat Schizophrenia since 10/01/2019. In an interview on 04/28/2022 at 3:34 PM Staff G (Social Services Director) stated the recommendations from the Level II PASRR evaluator should be implemented and the recommendations added to the CP. Staff G acknowledged the recommendations were not implemented and the CP did not reflect the recommendations, as they would expect. Resident 30 According to the 04/13/2022 Quarterly MDS the resident admitted to the facility on [DATE] and had medically complex conditions including Schizophrenia, Neurocognitive disorder, Traumatic Brain Injury, and Seizure Disorder. Review of the PO's showed a 04/18/2020 PO for 1.5 mg daily for an antipsychotic medication to treat Schizophrenia. Review of the 06/17/2020 Level II PASRR showed the the referral was completed because the resident experienced auditory hallucinations and delusions to which the resident responded. The Level II PASRR evaluator recommended completing an AIMS and repeating the AIMS every 3 months due to some mouth movements. The Level II PASRR evaluator recommended a referral for a psychiatric consult and assessment of the resident after antipsychotic medication was restarted. Review of the resident's CP showed no indication the facility incorporated the recommendations. No Level II PASRR CP was located in the resident's record. Review of Resident 30's record showed AIMS assessments were completed every six months and not every three months as recommended. On 04/21/2022 at 1:52 PM Resident 30 was observed smacking their lips and rolling their tongue around their mouth. Similar observations were made on 04/25/2022 at 9:03 AM, and 04/26/2022 at 2:45 PM. In an interview on 04/28/2022 at 3:43 PM Staff G stated the recommendations from the Level II PASRR evaluator should be carried out and added to the CP. Staff G acknowledged the recommendations were not carried out and the CP did not reflect the recommendations, as they would expect.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

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 and implement individualized activity plans for 4 of 5 residents (Residents 61, 251, 59 and 23) reviewed for activities, and one supplemental resident (Resident 69). Failure to consistently implement group or individual activity plans left residents at risk for boredom, isolation, and a diminished quality of life. Findings included . Resident 61 According to the 11/01/2022 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 61 was cognitively intact. This MDS showed, Resident 61 stated having books, magazines, and newspapers available was very important to them. This MDS showed participating in activities with groups of people was not very important for Resident 61. According to the 01/21/2021 activities Care Plan (CP), Resident 61's goal was to actively participate in independent leisure activities of choice daily in his room. The CP stated Resident 61's activity preferences were reading [the] daily newspaper, listening to music, animals, keeping up with the news, [sic] doing his favorite activity is very important. The CP directed staff to provide 1:1 [one-to-one] bedside/in-room visits 2-3 times per week or as resident allows, target: Reminisce, Current News, Hobbies, Games. The CP stated Resident 61 prefers independent activities at this time [ .] Declines most offers for supplies, does enjoys a daily newspaper when available. Review of the resident's record showed activities staff charted both Group Activities and 1:1 Activities for Resident 61. The Group Activities charting showed that from 3/27/2022 to 4/24/2022 Resident 61 was invited to participate on 19 occasions. Resident 61 was noted to refuse the activity on 16 occasions and was charted as not applicable on three occasions. Review of the the 1:1 Activities charting showed that from 3/27/2022 to 4/24/2022 Resident 61 was offered 1:1 Activities on only five occasions, three of which were recorded as not applicable and two as resident refused. In an interview on 04/23/2022 at 8:41 AM, Resident 61 stated they would like to participate more in activities. In an interview on 04/25/2022 at 10:55 AM, Resident 61 stated that currently they did not have access to a newspaper and that they used to enjoy the newspaper daily when the facility formerly provided a free copy. Resident 61 stated they inquired last week with the activities department if it would be possible for Resident 61 to buy their own newspaper, and was told activities would get back to them but did not provide a newspaper or information on how to obtain a newspaper. In an interview on 04/26/2022 at 10:53 AM, Staff X (Activities Assistant) stated they were familiar with Resident 61. Staff X stated they knew Resident 61 preferred individual rather than group activities and that Resident 61 enjoyed the newspaper, reading, and listening to music. Staff X stated the facility no longer had newspapers delivered which prevented Resident 61 from reading it. In an interview on 04/27/2022 at 10:55 AM, Staff X and Staff Y (Activities Director) stated they did not recall that Resident 61 asked if they could purchase a newspaper subscription. Resident 251 Resident 251 admitted to the facility on [DATE]. According to the 04/15/2022 admission MDS Resident 251 was assessed as cognitively intact, with clear speech, understood and was able to understand others. This MDS identified that it was very important to Resident 251 to participate in their favorite activities, listen to music, and it was somewhat important to have books, newspapers, and magazines to read, and do things with groups of people. Review of a 04/15/2022 Activities/Recreation Initial Review assessment showed Resident 251 liked to read, listen to music and attended some groups including the exercise group. According to a 04/20/2022 social needs CP, it was identified that staff would need to remind the resident of different programs that were available during the day and help to escort them to the activities of interest. This CP did not have any goals established for Resident 251. In an interview on 04/23/2022 at 9:09 AM, Resident 251 indicated they would like to go to activities and stated, but they don't do anything here. Observations of Resident 251's room on 04/21/2022 at 10:20 AM, 04/22/2022 at 12:46 PM, 1:57 PM, & 2:34 PM, 04/25/2022 at 8:05 AM, 12:01 PM & 12:31 PM, and 04/27/2022 at 10:05 AM showed Resident 215 lying in bed with no radio or mechanism to play music or personalized activities at the bedside. Review of the April 2022 1:1 Activities charting revealed, Resident 215 had only one documented activity participation on 04/19/2022, four occasions were documented as refused, and six occasions documented as not applicable. According to the April 2022 Group Activities charting, Resident 215 was invited to participate in activities on nine occasions but staff documented the resident refused, and had six occasions that were coded as not applicable In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated it was their expectation that staff offer, encourage, and assist residents to participate in activities and be provided with individual activities per preference. Resident 59 Resident 59 was admitted to the facility on [DATE]. According to the 02/24/2022 admission /Medicare - 5 Day MDS, had multiple medically complex diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). This MDS indicated it was very important for Resident 59 to listen to music and it was somewhat important: to do things with groups of people; to do their favorite activities; to get fresh air when the weather was good; and to participate in religious services. Review of a 03/01/2022 Activities/Recreation Initial Review assessment showed Resident 59 required assistance to get to activities and indicated staff would find appropriate activities for the resident to attend due to the resident's dementia. This assessment indicated the resident required 1:1 assistance for Activities, preferred to exercise when able, and staff would try to encourage them to do other activities. The other activities were not identified on this assessment. According to 03/01/2022 activity CP, Resident 59 had little, or no activity involvement and staff were to focus on things the resident liked to do and focus on bringing those activities to the resident. Interventions included Resident 59 needed a variety of activity types and locations to maintain interest. Resident 59's record review showed the 03/01/2022 Social Needs CP included interventions that indicated Resident 59 needed assistance with arranging community activities. This CP gave directions that Resident 59 needed 1:1 bedside/in-room visits and activities if the resident was unable to attend out of the room events. Observations on 04/21/2022 at 1:43 PM, 04/23/2022 at 8:33 AM, 04/24/2022 at 8:48 AM & 9:18 AM, 04/25/2022 at 8:11 AM, 8:54 AM & 12:03 PM showed Resident 59 either lying or sitting on bed without TV on, music, or personalized activities at bedside. In an interview on 04/25/2022 at 12:33 PM, Resident 59 asked what they should be doing during the day and expressed they were hoping to get up and do something. Observations on 04/25/2022 at 12:51 PM showed Resident 59 remained in bed without offer to attend a music activity that was scheduled to start at 1:00 PM. Similar observations of Resident 59 lying in bed were noted on 04/26/2022 at 9:52 AM, 1:19 PM, 2:19 PM, & 7:42 PM, and 04/27/2022 at 10:11 AM. Review of the April 2022 1:1 activities charting showed, Resident 59 did not have any documented participation in this activity but was coded as not applicable on 04/03/2022, 04/05/2022, 04/10/2022, 04/24/2022, and 04/28/2022. According to the April 2022 Group Activities charting, Resident 59 was invited to participate on 12 occasions but staff documented the resident refused, and on five occasions were coded as not applicable In an interview on 04/29/2022 at 7:33 AM, Staff C stated it was their expectation that Activities would be offered and encouraged for residents and that Activities programs were individualized as needed for resident's that are not able to remain in group activities settings. Resident 23 According to the 01/15/2022 Quarterly MDS Resident 23 had severe cognitive impairment, demonstrated no behaviors or rejection of care, and required extensive assistance from staff for bed mobility, transfers, dressing, toileting, eating, personal hygiene, and bathing. This MDS showed the resident was not assessed for activities this quarter. Resident 23's primary language was [NAME] but the resident was able to understand and converse with limited English. In an interview on 04/25/2021 at 11:22 AM, Resident's 23's family stated the resident enjoyed religious prayers, [NAME] music, and getting up in the chair during daytime. A review of the 11/26/2021 activity assessment indicated the resident liked to listen to their religious prayers on a portable player in their room. A review of the 08/25/2020 CP showed Resident 23 enjoyed activities such as watching TV, listening to [NAME] music, and religious prayers. The CP instructed staff to encourage the resident's involvement in activities of interest: Music, movies, religious prayers, [NAME] music, offer [NAME] speaking talking books, and provide individual in room activities. Observations on 04/23/2022 at 9:07 AM and 12:32 PM ; 04/24/2022 at 8:50 AM, 9:47 AM, 11:38 AM and 3:38 PM ; 04/25/2022 at 9:42 AM, 11:20 AM, and 12:05 PM, and on 04/26/2022 at 9:19 AM, 10:30 AM, 12:24 PM, and 02:01 PM, showed no TV on, no radio or mechanism to play music, and no readily available individual activities in room. Resident 23 was lying in bed in a night gown all the times. In an interview on 04/27/2022 at 11:07 AM, Staff B (Director of Nursing) stated their expectations were the resident should be dressed, up in their wheel chair and attend activities or their music/TV should be on but acknowledged it was not. Resident 69 According to the 03/08/2022 Significant Change MDS, Resident 69 had severely impaired cognition and diagnoses including Alzheimer's Disease and non-Alzheimer's dementia. The MDS showed while they were in the facility it was very important to Resident 69 to listen to music they liked, somewhat important to do their favorite activities, and not at all important to do things with groups of people. According to the 01/13/2021 Activities CP, Resident 69 had Activities Goals to participate in independent activities of choice and 1-2 special events per week as [resident] will allow and to participate in independent activities of choice and in-room activities every other day. The CP included an intervention for staff to Provide 1:1 visits 2-3 times per week as [resident] will allow, target: Reminisce, Current News, Hobbies, Travel, Games . Review of the 1:1 Activities charting revealed in March 2022, Resident 69 was offered 1:1 activities on three occasions, participated actively once, refused once and was charted as not applicable once at 5:53 AM on 03/19/2022. The April 2022 charting from 04/01/2022 to 04/24/2022, included no record of any attempt by staff to provide 1:1 activities. Review of the Group Activities charting revealed in March 2022, Resident 69 was invited to participate on 11 occasions, refused on 7 occasions and was charted as not applicable once at 5:53 AM on 03/19/2022. The April 2022 Group Activity charting from 04/01/2022 to 04/24/2022 included 13 refusals, one occasion where Resident 69 actively participated and one occasion where they observed. In an interview on 04/27/2022 at 10:55 AM, Staff Y stated that activities play an important function for residents with dementia, that 1:1 activities were appropriate and could assist with the maintenance of cognitive function and that 1:1 activities were preferred by Resident 69. REFERENCE: WAC 388-97-0940(1). .

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 vision services according to professional standards of nursing for 1 (Resident 67) of 3 reviewed for vision and hearing services. Failure to arrange vision services left residents at risk for impaired vision and diminished quality of life. Findings included . According to the 03/07/2022 Quarterly MDS (Minimum Data Set - an assessment tool) Resident 67 was cognitively intact, had impaired vision that required corrective lenses, and diagnoses including Myasthenia Gravis (MG - a disease affecting the immune system that can cause visual symptoms including drooping eyelids and double vision). According to the 10/13/2019 Resident Has Impaired Visual Function Care Plan (CP), Resident 67 required glasses. The CP directed staff to monitor for worsening vision/double vision (related to MG diagnosis) and to remind resident to wear glasses when up. Ensure resident is wearing glasses which are clean free from scratches and in good repair. Report any damage to nurse/family. During an interview on 04/22/2022 at 9:04 AM Resident 67 was observed not wearing glasses. Resident 67 stated that their glasses did not fit and were the wrong prescription. Resident 67 stated the facility optometrist was not professional and they wanted to see an outside optometrist. Resident 67 stated they had informed the facility they needed better glasses but felt staff were indifferent. I have to use a magnifying glass to read. Review of Resident 67's record showed they last saw the optometrist on 02/06/2020. According to a 03/06/2020 Social Services (SS) progress note Resident 67 received [their] new eyeglasses yesterday. A 04/05/2021 SS progress note showed Resident 67 received new glasses in February 2020 and should have a glasses appointment in a year or as necessary. A 03/30/2020 Activities progress note stated Resident 67 wears glasses for reading. From 03/30/2020 to 04/29/2022, there were no other progress notes that addressed Resident 67's vision or the resident's dissatisfaction with their glasses or their desire to see a different optometrist. In an interview on 04/27/2022 at 11:53 AM with Staff G (Social Services Director) and Staff H (Social Services Assistant), Staff H stated Resident 67 refused to see the optometrist on the 12th and said Resident 67 said the optometrist was no good. Staff G stated we should arrange some follow up with an outside provider. Staff H stated that a collateral contact of Resident 67 offered to assist with the arrangement of an appointment but they did not document the conversation. REFERENCE: WAC [PHONE NUMBER](3)(a). .

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** Fluid Restriction Resident 6 According to a 04/01/2022 Quarterly MDS, Resident 6 admitted to the facility on [DATE] with a diagnoses including end-stage kidney disease and received dialysis treatments three times a week. A 03/23/2022 PO showed Resident 6 was restricted to 1000 milliliters (ml) of fluid intake in a 24 hour period. The division of fluids showed each meal served 240 ml of fluid for a dietary total of 720 ml in 24 hours. Nursing staff were to give 180 ml on day shift and 100 ml on night shift for medications with a total of 280 ml in 24 hours. The order showed no water pitcher should be left at Resident 6's bedside. A review of the 04/01/2022 to 04/20/2022 MAR showed on 18 of 20 days nurses provided more than the 280 ml per day allotted to nursing. The MAR did not show a daily summary of fluid intake to monitor the 1000 ml per day restriction. A review of the 04/01/2022 to 04/20/2022 meal intake record showed on 20 of 20 days Resident 6's fluid intake exceeded the allotted 720 ml per day. In an observation and interview on 04/21/22 at 11:54 AM Resident 6 stated the staff just took their water pitcher and the resident did not know why, and they wanted it back. Resident 6 pointed to three cases of bottled water stacked near the wall and stated, they better not take that, it is mine. Observation of Resident 6's lunch tray showed 120 ml of red juice, 120 ml of milk and 180 ml of a hot drink. Resident 6 also had two opened bottles of water on the bedside table next to the lunch tray. The tray ticket showed dietary was to provide 720 ml of fluids per day. The ticket did not breakdown the volume per meal. In an interview on 04/26/2022 at 2:22 PM, Staff T (Certified Nursing Assistant) stated Resident 6 was on a fluid restriction but always asked for water. Staff T stated staff gave the resident water from the supply of cases on the floor when the resident requested or when the resident got mad. Staff T stated the staff were not able to keep track of the fluid intake for Resident 6. In an interview on 04/28/2022 at 2:25 PM, Staff B (Director of Nursing) stated a fluid restriction must have a 24-hour summary and the physician must be notified if restrictions were not followed. Staff B stated the process for maintaining fluid restrictions was not intact. REFERENCE: WAC 388-97-1060 (3)(h)(i). Based on interview and record review the facility failed to ensure 5 (Residents 153, 59, 97, 251 & 6) of 9 sampled residents reviewed for nutrition and/or hydration, maintained acceptable parameters of nutritional status or were adequately monitored for hydration status. Failure to ensure accurate intakes were documented, identified or acted on significant weight changes, and notified physicians of changes, placed residents at risk for delayed identification of interventions for continued weight loss. Findings included . According to a 05/14/2021 facility Weight Monitoring policy, a weight monitoring schedule would be developed upon admission for all residents. The policy stated weights would be monitored: weekly for four weeks for newly admitted residents; weekly for residents with weight loss; daily if clinically indicated; and monthly for all other residents. This policy directed staff to compare the resident's newly recorded weight to the previous recorded weights and identified a significant change in weight as: 5% change in 30 days; 7.5% change in 90 days; and 10% change in 180 days. This policy stated the physician should be informed of a significant weight change, meal consumption should be recorded, the registered dietician should be consulted, and observations pertinent to the resident's weight status should be recorded in the resident's records. Resident 153 According to the 04/07/2022 Quarterly MDS Resident 153 admitted to the facility on [DATE], had severe cognitive impairment, and sometimes was able to make themselves understood and sometimes able to understand others. The MDS showed the resident had Medically Complex Conditions, including Schizophrenia, Diabetes, Dysphagia (difficulty swallowing), and Anxiety. The MDS showed the resident had no or unknown weight loss in the last 6 months, had no swallowing disorder, and was on a therapeutic diet. Review of a 04/08/2022 Nutrition Care Plan (CP) showed a goal for no significant weight loss of 5% in 30 days or 10% in 180 days. The CP directed staff for RD (Registered Dietician) to evaluate and diet changes recommendations as needed. Review of Physician Orders (POs) showed a 12/09/2021 PO to weigh the resident every week. Review of the Resident 153's record showed on 06/28/2021 the resident weighed 123 lbs. (pounds) and the next weight documented on 07/27/2021 was 105 lbs. A total of 18 lb. weight loss or loss of 14.6 % of the residents body weight. Review of progress notes showed no indication the Physician or RD were notified about the weight loss. Review of the resident's record showed the resident's weight on 01/03/2022 was 106.5 lbs, on 01/17/2022 was 106.3 lbs., and on 01/31/2022 was 106.4 lbs. The resident was not weighed weekly on 01/10/22 and 01/24/2022, as the PO directed. Review of the resident's record showed in February 2022 the resident weighed 105.8 lbs on 02/21/2022. No other weights for the month of February were recorded in the weight record and the resident missed their weekly weights on 02/07/2022, 02/14/2022, and 02/28/2022. Review of the resident's record showed in March 2022 the resident weighed 105.5 lbs. on 03/21/2022 and 105.1 lbs. on 3/28/2022. The resident was not weighed weekly on 03/07/2022 or 03/14/2022. In an interview on 04/28/2022 at 9:53 AM Staff C stated they expect the staff to inform the Physician and RD about the weight loss, the Physician to document, and the PO's to be carried out as written. Staff C acknowledged the resident's weights were not being done weekly and stated they expected residents to be weighed as ordered. Resident 59 Resident 59 admitted to the facility on [DATE]. According to 02/24/2022 admission /Medicare -5 Day MDS, Resident 59 had multiple medically complex diagnoses including malnutrition. This MDS assessed Resident 59 to weigh 67 lbs and required supervision with eating. According to a 03/03/2022 Nutritional Status Care Area Assessment (CAA) staff indicated Resident 59 had severe malnutrition with inadequate oral intake related to decreased appetite. Review of a 02/21/2022 nutritional CP, directed staff to monitor Resident 59's meal intake and record every meal. Review of Resident 59's February 2022 nutritional intake documentation showed staff failed to document the resident's meal intake for 7 of the 30 meals provided. March 2022 records showed staff failed to document the resident's intake for 35 of the 93 meals provided. April 2022 records showed staff failed to document the resident's intake for 33 of the 78 meals provided. Review of February and March 2022 weight records showed staff failed to obtain weekly weights on 02/26/2022, 03/12/2022, and 03/19/2022 as required by facility policy. Resident 97 According to the 03/25/2022 Quarterly MDS Resident 97 was assessed to weigh 115 lbs and required supervision for eating. Record review revealed a 01/17/2022 PO directing staff to obtain weekly weights for Resident 97. Review of weight records showed staff failed to obtain weights weekly for Resident 97 from 02/23/2022 until 04/04/2022, missing five consecutive weeks of weights. The 04/06/2022 nutritional CP directed staff to monitor and record Resident 97's meal intake every meal. Review of Resident 97's March 2022 nutritional intake documentation showed staff failed to document the resident's meal intake for 34 of the 93 meals provided. April 2022 records showed staff failed to document the resident's intake for 31 of the 73 meals provided. Resident 251 Resident 251 admitted to the facility on [DATE]. According to a 04/15/2022 admission MDS, Resident 251 was assessed to weigh 220 lbs and required limited assistance from staff for eating. Record review revealed a 04/20/2022 PO directing staff to obtain Resident 251's weight weekly. According to Resident 251's weight records staff failed to obtain a weekly weight on 04/15/2022. According to a revised 04/20/2022 nutritional CP, staff were directed to monitor Resident 251's meal intake and record every meal. Review of Resident 251's April 2022 nutritional intake documentation showed, the staff failed to document the resident's meal intake for 30 of the 55 meals provided. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated it was their expectation that staff document meal intake with each meal, obtain weights according to physician orders, and facility policy and follow up as required with weight changes. Staff C stated having complete and accurate information allows staff to assess the resident's complete nutritional status.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

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 intravenous (IV- in a vein) fluids were administered according to professional nursing standards for 1 (Resident 23) of 1 resident reviewed for IV services. The failure to provide IV treatments by qualified and competent trained nurses, prevented nurse staff from obtaining and/or clarifying complete orders for maintaining and monitoring IV treatments which placed Resident 23 at risk for infection and other adverse outcomes. Findings included . The 08/2021 policy for Maintaining Patency of Peripheral Vascular Devices (maintenance of IV treatments) showed directions to the nurse to obtain a Physician Order (PO) for appropriate flush solutions, refer to the flush chart, the flush orders must be written as a complete medication order. The policy showed IV's were required to be flushed routinely when not in use to maintain unobstructed access. Flushes were documented in the resident's record. The policy flush chart showed directions for the nurse to flush the IV every eight hours and as needed to keep open. The 08/2021 policy for Infusion Therapy Procedures Summary showed directions to the nurse to inspect the bag of solution, verify the label and expiration date prior to hanging and infusion. The 08/2021 policy for Administration Set Change showed directions to the nurse to label the administration set with the date and time of starting the infusion. Resident 23 The [DATE] Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 23 had diagnoses of diabetes and Parkinson's Disease. The MDS section for cognition and mood was blank, which showed no assessment was completed for these areas. Resident 23 was assessed with clear speech in a language that was not English but was not assessed for cognition or mood. Observation on [DATE] at 8:56 AM showed Resident 23 with an IV site on the back of their right hand. An IV pole with an empty bag and tubing was next to the bed. The IV bag was labeled 5% dextrose and 0.9% NaCl (sodium chloride) and had a manufacture expiration date of [DATE]. There was not a label of the date and time the bag was hung, according to the facility policy. An observation on [DATE] at 11:27 AM showed Resident 23 with the IV site in the back of the right hand, the IV pole was removed from the room and the IV bag and tubing was in the trash can. In an interview on [DATE] at 11:31 AM, Staff N (Licensed Practical Nurse) viewed the IV bag and confirmed the label showed 5% dextrose and 0.9% NaCl, had an expiration date of [DATE], and did not have a date and time of administration on the bag. Staff N stated the IV solution was expired and there should be a label on the bag with the date and time it started infusing. Staff N looked the order up in the computer and stated the order was for 5% dextrose and 45% NaCl starting on [DATE] and ending on [DATE] for dehydration. Staff N stated the solution bag did not match the order. Staff N verified there were no physician orders for flushing the IV site, no order for removal and no directions for monitoring the IV site for adverse effects. Staff N stated they did not flush the IV on their shifts. A review of the 04/2022 Medication Administration Record (MAR) showed no administration of IV flushes and no monitoring the IV site for adverse effects. A review of the [DATE] through [DATE] nurse progress notes showed no documentation of monitoring, or assessment of the IV treatment, IV site or Resident 23's tolerance to the IV treatment, indicating an alert was not triggered for every shift documentation. There was no follow up documentation from the practitioner for evaluation of the IV treatment. In an interview on [DATE] at 1:26 PM, Staff B (Director of Nursing) stated standard nursing practice was to place a resident on alert charting for IV monitoring every shift for complications and the IV was expected to be flushed every shift to keep the line open. In an interview on [DATE] at 11:33 AM, Staff B stated the standard of care was in the policy and nurses were expected to follow the policy. Staff B stated the current pharmacy IV policy book was located on the first floor. Staff B acknowledged Resident 23 lived on the second floor and there was no pharmacy IV reference manual on the second floor. In an interview on [DATE] at 11:54 AM, Staff B reviewed the contents of the emergency pharmacy storage room and electronic storage device. The storage room contained an empty box of Dextrose 5% and 0.9% NaCl with a manufacturer expiration date of [DATE]. The electronic pharmacy storage contained one available bag of Dextrose 5% with 0.45% NaCl with the expiration date of [DATE]. Staff B obtained a list of items checked out form the electronic pharmacy storage device and no items were removed for Resident 23 during the IV administration timeline. Staff B acknowledged the incorrect solution was administered to Resident 23 and the solution was expired. Staff B stated a medication error investigation would be initiated. In an interview on [DATE] at 12:36 PM, Staff E (Staff Development Coordinator) was asked to provide competency documentation related to IV administration for five selected nurses, including Staff N, Q, S, and U. Staff E only provided two of the five competencies requested, three nurses did not have IV competencies on file. Refer to F726 Competent Nursing Staff. REFERENCE: WAC 388-97-1060(3)(j)(ii). .

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (Resident 451) of 1 resident reviewed for oxygen use. The failure to provide Resident 451 with portable oxygen to use outside of their room, placed resident at risk for decline in condition and decreased quality of life. Findings included . Resident 451 The 04/20/2022 admission Minimum Data Set (MDS, an assessment tool) showed Resident 451 was assessed as cognitively intact, able to make self understood, and understood others. Resident 451 was admitted for the diagnoses of lung disease, pneumonia (lung infection), and recovering from COVID-19 (Coronavirus disease 2019, a respiratory disease). According to the MDS Resident 451 was assessed to require continuous supplemental oxygen. Observations of Resident 451 not wearing portable oxygen included; 04/21/2022 at 1:01 PM at the nurse's station asking to use the phone, and no portable oxygen observed in room; 04/21/2022 at 2:14 PM at the nurse's station on the phone; 04/22/2022 at 9:06 AM at the nurse medication cart, and no portable oxygen observed in resident's room; 04/22/2022 at 11:30 AM at the doorway of room and hallway; 04/23/2022 at 9:03 AM in the elevator headed to the entrance door; 04/23/2022 at 9:10 AM back to room from lobby with staff, and no portable oxygen observed in room; 04/23/2022 at 11:45 AM in the hallway, and no portable oxygen observed in room; 04/23/2022 at 11:50 AM at the nurse's station, and no portable oxygen observed in room; 04/24/2022 at 10:01 AM at the elevator asking for the nurse to be told they were going to therapy; 04/24/2022 at 10:50 AM in the hallway, and no portable oxygen observed in room; 04/24/2022 at 10:26 AM in the hallway; 04/25/2022 at 12:04 PM sitting on bed, not wearing oxygen, concentrator running, and no portable oxygen in the room. A 04/13/2022 Physician Order (PO) showed Resident 451 was to wear continuous oxygen by nasal cannula (tubing) running at three to five liters per minute for the diagnosis of lung disease and respiratory (breathing) failure. An observation on 04/24/2022 at 10:01 AM showed Resident 451 in the hallway walking out of the activity room not wearing portable oxygen. Staff LL (Physical Therapist Assistant) greeted Resident 451 and asked them to come to the therapy gym. Resident 451 agreed and told another staff person in the hallway to tell the nurse they were going to therapy. An observation (five minutes later) on 04/24/2022 at 10:06 AM, Resident 451 was using the stairs in the therapy gym and complained of being dizzy. Staff LL had the resident sit down and tried to take their oxygen level. The device did not read an oxygen level. Staff LL tried again at 10:12 AM and could not obtain a reading on the left or the right hands. Staff LL escorted Resident 451 back to their room when an oxygen level of 77% was obtained. (A normal oxygen level is 92-100%) Resident 451 was placed back on the oxygen concentrator by nasal cannula and their oxygen level went up to 85%. When the oxygen level was checked again at 10:22 AM, it was 92%. In an interview on 04/24/2022 at 10:20 AM, Resident 451 stated they only wore the oxygen while in bed because the tubing was not long enough to stretch any farther. Resident 451 stated they knew they were supposed to wear the oxygen all the time they were not able to walk around with the short tubing. Resident 451 stated they wore oxygen at home before admission and had a portable tank to take with them. In an interview on 04/24/2022 at 10:22 AM, Staff Q (Licensed Practical Nurse) stated they were not told that the resident went to therapy. Staff Q stated Resident 451 refused oxygen before when going to therapy, but that anyone can put oxygen on the resident including the therapist and the nursing assistant. Staff Q stated most residents are on two liters of oxygen and any staff can set it to two liters. When asked if nurses should check the order and be setting the oxygen flow rate, Staff Q stated, if they needed help from the nurse, I would help them. In an interview on 04/25/2022 at 8:47 AM, Staff U (Resident Care Manager) stated the therapists should know which residents wear oxygen and should make sure they take portable oxygen when the resident goes to the therapy gym. Staff U stated only nurses should be setting the oxygen flow rate, but anyone can help the resident put on the nasal cannula. In an interview 04/26/2022 Staff MM (Therapy Director) stated all therapists are expected to know which residents on therapy also use oxygen. Staff MM stated the therapists are expected to ensure the resident has oxygen when coming to therapy. Staff MM looked at the therapy notes for Resident 451 from 04/24/2022 and stated a 77% oxygen reading was recorded on room air and the resident was placed back on oxygen by nasal cannula in their room. Staff MM was informed the notes as written were not what was observed by the surveyor present. Refer to F726 Competent Nursing Staff. REFERENCE: WAC 388-97-1060(3)(j)(ix). .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured, labeled with required resident identifying information, dated when opened, and expired medications and biologicals were disposed of timely in accordance with professional standards in 1 of 4 medication carts, and 2 of 22 resident rooms reviewed. This failure placed residents at risk for not receiving medication, receiving expired medications and at risk for medication errors. Findings included . According to the 05/25/2021 facility Medication Storage policy is to ensure all medications housed at the facility will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient enough to ensure proper security and all drugs and biologicals will be stored in locked compartments. 100 [NAME] Medication Cart Observations on the 100 [NAME] Medication Cart on 04/26/2022 at 11:00 AM, with Staff F (RCM- Resident Care Manager), showed a bottle of supplement tabs that expired on 02/23/2021, a bottle of artificial tears was opened but had no open date and was unlabeled with no resident name. During an interview on 04/26/2022 at 11:34 AM, Staff F confirmed the presence of above mentioned expired, undated, and unlabeled medications. Medication at the Bedside Resident 84 Observations on 04/26/2022 at 08:00 AM and 10:00 AM, showed Resident 84 had a bottle of nasal spray sitting on their bedside table. There was an open date 11/13/2021 on the bottle and expired date was 03/2022. In an interview on 04/26/2022 at 10:00 AM, Resident 84 stated they had the bottle of nasal spray for a long time and they used it independently. In an interview on 04/26/2022 at 10:07 AM, Staff Q (LPN- Licensed Practical Nurse), confirmed the bottle of Saline nasal spray on Resident 84's nightstand and stated medications should not be left unsecured at the bedside. Resident 8 On 04/24/2022 at 9:21 AM 3 pills were observed in Resident 8's top drawer in their bedside table. Similar observations were made on 04/26/2022 at 9:41 AM. In an interview on 04/26/2022 at 3:34 PM Staff SS (LPN) stated someone left the pills unsupervised with the resident and they [Resident 8] would take their pills one at a time and I stay with them to ensure they swallow all the medication. Staff SS confirmed the 3 pills by comparing the pills to the resident's medication in the medication cart, and stated they were the resident's evening medication consisting of a small oval pink pill that was confirmed a medication that treats high cholesterol, a large oval white pill that was confirmed as a supplement, and a large oval pink pill that was confirmed as medication that treats bipolar disorder. Staff SS stated they would not expect nurses to leave pills at the resident's bedside, especially with Resident 8, they will put their pills in their pockets, drawers, or stash them unsecured. REFERENCE: WAC 388-97-1300(2),-2340 .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide prompt dental services for 2 (Resident 82 & 251 ) of 4 residents reviewed for dental services. This failure placed the resident at risk for unmet dental needs, weight loss and a diminished quality of life. Findings included . Review of a 05/20/2021 facility Dental Services policy showed the facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. This policy indicates that in the case of an acute dental condition or loss/damage of dentures, the facility will take measures to ensure residents are still able to eat and drink while awaiting dental services. Interventions included in this policy were, but were not limited to: Notifying the Physician of pain medications or other needs; Modifying diet consistency; Providing room temperature liquids for heat/cold sensitivity; Referral to a dietician for food preferences during the interim; and Referral to a speech therapist for chewing or swallowing problems. This policy stated all actions and information regarding dental services will be documented in the resident's record. Resident 82 According to 03/17/2022 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 82 was assessed with impaired cognition, able to make their decisions, required extensive assistance with oral care, and had obvious or likely cavities or broken natural teeth. In an interview on 04/23/2022 at 08:44 AM, Resident 82 stated they had broken teeth, that were painful, and a dentist saw them few months back but nothing happened after that visit. Resident 82's record review showed Resident 82 was seen by the dentist on 02/11/2022 at the facility. Review of the 02/11/2022 dental consult showed the resident was assessed with red irritated gums, medium plaque and calculus, broken tooth number 12, loose teeth number 11 and 13, missing upper teeth number 1, 5, 15, 16 and missing lower teeth number 17 and 32. The form was marked for referral for X-rays, evaluation and extraction of teeth # 12,13/9-11 and had a hand written note on the form stating [Resident 82] would like ext. [extractions]/rest. [restoration]. A review of Resident 82's 11/25/2020 Care Plan (CP) showed Resident had oral/dental health problems, Recommendations for Hygiene cleaning local dental company to provide outside referral. The CP revised on 03/08/2021 directed staff to Coordinate arrangements for dental care, transportation as needed/as ordered. In an interview on 04/26/2022 at 02:10 PM, Staff F (RCM) acknowledged there was no documentation that facility staff followed up with the dentist recommendations to schedule appointment. In an interview on 04/27/2022 at 10:23 AM, Staff H (Social services Assistant) stated Resident 82 was seen by the dentist on 02/11/2022 and indicated staff should have followed up on the recommendations to schedule appointments for X-rays and teeth extractions after the appointment. Resident 251 According to a 04/15/2022 admission MDS, Resident 251 was assessed as cognitively intact, with clear speech, and able to understand and be understood in conversation. In an interview on 04/23/2022 at 9:38 AM, Resident 251 reported they did not have their upper dentures with them and stated, that's why I eat so slow. Resident 251 indicated they forgot the dentures at home when they went to the hospitalized and were unsure how to obtain them. Observations at this time showed Resident 251 had no upper teeth and had several missing lower teeth. Review of a 04/15/2022 progress note showed staff documented Resident 251, is edentulous [without teeth] upper with few natural teeth bottom. According to a 04/18/2022 Nutrition Evaluation staff identified Resident 251 had upper dentures. Review of a dental CP initiated on 04/15/2022 showed staff identified Resident 251 was edentulous to upper and had few lower teeth. Resident 251's record review showed no indication that facility staff attempted to assist Resident 251 with contacting family and obtaining their upper dentures. In an interview on 04/29/2022 at 8:13 AM, Staff DD (Administrator in Training) asked Resident 251 about their dentures and verified the resident would like assistance to obtain them. REFERENCE: WAC 388-97-1060(1),(3)(j)(vii) .

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 have a system to ensure consistent communication and collaboration of care occurred between the facility and hospice staff for 1 (Resident 3) of 1 resident reviewed for hospice services. The failure to develop and maintain a comprehensive hospice care plan (CP), collaborate with hospice for the needs and changes of the resident, and obtain hospice nurse visit notes and recommendations to implement into resident care, placed Resident 3 at risk for not receiving necessary comfort care, services, and a diminished quality of life. Findings included . The 05/12/2021 policy Hospice Services Facility Agreement showed the facility would designate a clinician responsible for collaborating with hospice staff for services provided. This designee would maintain communication to coordinate the hospice CP, obtain hospice physician orders, and visit notes to incorporate into a collaborative hospice CP. Resident 3 The 02/10/2022 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 3 admitted to the facility on [DATE] on palliative (comfort-focused) care with a diagnosis of a non-curable progressive neurological disease. The 03/23/2022 CP showed Resident 3 chose hospice services to provide support for coping with grief/loss and maintaining the resident's comfort. The CP showed an intervention to establish a facility and hospice collaborative CP. This CP had no resident specific interventions designating hospice's role in Resident 3's care. On 04/25/2022 a copy of the hospice care plan for Resident 3 was requested from the facility. No document was readily available in the resident record, and no document was provided. A 03/29/2022 weekly skin observation assessment showed Resident 3 developed a new pressure ulcers (PUs) on the left outer ankle and the right outer foot. Review of the 04/01/2022, 04/06/2022, and 04/23/2022 hospice nurse notes showed no mention of the two new PUs. The progress notes did not demonstrate facility staff reported any concerns during the corresponding hospice visits. In an interview on 04/27/2022 at 12:38 PM, Staff F (Resident Care Manager & Minimum Data Set Nurse) stated when new PUs were identified on Resident 3, the physician and the hospice nurse were expected to be notified and a treatment order obtained prior to placing a treatment on the resident. Staff F reviewed the resident record, and did not find documentation of the physician or hospice notification of the PUs or treatment orders for the new PU. REFERENCE: WAC 388-97-1020(5)(a). .

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Assistance with Eating Resident 49 According to a 03/30/2022 Quarterly MDS Resident 49 was assessed to require physical assistance for eating from staff. Observations on 04/22/2022 at 12:49 PM showed facility staff holding a cell phone to their ear while standing in front of Resident 49 assisting them with eating. Similar observations were made of staff standing in front of Resident 49 and providing feeding assistance on 04/23/2033 at 8:48 AM. Resident 97 According to a 03/25/2022 Quarterly MDS Resident 97 was assessed to require physical assistance and supervision with eating. Observations on 04/22/2022 at 8:49 AM showed facility staff standing at bedside assisting Resident 97 with feeding. Similar findings were observed on 04/25/2022 at 8:38 AM of staff standing while providing feeding assistance. Resident 54 According to a 02/17/2022 admission MDS, Resident 54 was assessed to require extensive physical assistance from staff for eating. Observations on 04/22/2022 at 12:56 PM showed facility staff standing at Resident 54's bedside while assisting the resident with eating. Similar findings were also noted on 04/24/2022 at 8:46 AM when facility staff was observed standing at Resident 54's bedside while providing feeding assistance. In an interview on 04/29/2022 at 7:33 AM, Staff C stated staff should not be providing residents assistance with feeding while standing and indicated their expectation is for staff to sit and provide eating assistance as needed. Labels on Clothing Resident 49 Resident 49 was admitted to the facility on [DATE]. According to the 03/30/2022 Quarterly MDS, Resident 49 was assessed with severe cognitive impairment and required physical assistance from staff for bed mobility, transfers, dressing, eating, and personal hygiene. Observations on 04/21/2022 at 11:01 AM showed Resident 49 sitting in wheelchair (w/c) and wearing light colored shoes. Resident 49's last name was written in large black writing on the outside of shoe straps and was visible to others. In an interview on 04/29/2022 at 7:33 AM, Staff C stated Resident's clothing should not be labeled on the outside and visible to others. Resident 69 Similar findings for Resident 69. According to the 03/08/2022 Significant Change MDS, Resident 69 was severely cognitively impaired, and had diagnoses including Alzheimer's Disease and non-Alzheimer's Dementia. Observations on 04/21/2022 at 10:19 AM, and on 04/27/2022 at 09:43 AM showed Resident 69 wearing pants marked with sharpie to indicate whom they belonged to. Informed of Resident Rights In an interview on 04/27/2022 at 2:47 PM, Staff DD (Administrator in Training) confirmed that the admissions agreement contains information including but not limited to resident rights in a nursing home. Staff DD stated Residents 36, 13, 81, 451, 97, 58, & 86 did not have a signed admission agreement and were not informed of their resident rights while residing in a nursing home as required. Staff DD confined the process for providing admission agreements and informing residents of their rights was not intact. REFERENCE: WAC 388-97-0860(1)(a-b)(2), -0900(1)(3). Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individual needs and preferences for 5 (Residents 77, 153, 49, 97, & 54) of 22 residents reviewed for resident rights. The failure to accommodate residents choices in their frequency and schedule of bathing, failure to provide opportunities to make health care decisions, failure to provide dignity during assistance with eating, and in labeling of clothing placed residents at risk for feelings of embarrassment, helplessness, diminished self-worth, and quality of life. Additionally, the facility failed to inform residents of their rights upon admission. The failure to follow the facility identified admission agreement process prohibited 5 (Residents 36, 13, 81, 451, & 86) of 5 residents reviewed for Advanced Directives and 2 supplemental residents (Residents 97 & 58) from receiving a copy of their rights and detracted from the residents' ability to act upon their rights. Findings included . Choices Resident 77 Review of the 03/15/2022 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 77 was a long-term care resident, alert and oriented, The resident felt it was very important to choose between a tub bath, shower, bed bath or sponge bath. Review of the 04/08/2022 Bathing/Showering Care Plan (CP) noted the resident preference for showers during day but did not indicate which days. Review of the [NAME] on 04/26/2022 showed that the resident's bathing preferences were Monday and Friday Days. Review of the Shower Schedule on 04/22/2022 showed that Resident 77 was scheduled to be showered on Thursday and Sunday Mornings. Review of the Resident's record showed the resident was offered and refused a shower on Sunday 04/24/2022. During an interview on 04/22/2022 at 12:23 PM, Resident 77 stated that Staff B (Director of Nursing) made a shower schedule, but it was incorrect, My showers have been Wednesday and Friday for five years. Resident 77 stated that when they asked for a shower, the nursing assistant stated that it was not on the schedule, so the resident stated that they went around Staff B and told Staff Y (Activities Director) that they needed a shower Friday. Resident 77 stated, I don't know what their schedule is, but mine is Wednesday and Friday and I'm keeping it!. Health Care Decisions Resident 153 According to the 04/07/2022 Quarterly MDS, the resident had Medically complex conditions, including Schizophrenia, and had severe cognitive impairment, and was able to make their own decisions. The MDS showed the resident received antidepressants during the assessment period. Review of Physicians Orders (PO) showed a 08/25/2021 PO for an anti-depressant daily for an appetite stimulant. Review of the resident's record showed no consent was obtained for the use of the anti-depressant and the resident was not given the opportunity to make an informed decision about using an anti-depressant for an off label use or educated on the risks and benefits. In an interview on 04/28/2022 at 9:53 AM Staff C (Chief Nursing Officer) stated they expected a consent to be obtained and risk and benefits explained before administering an anti-depressant, even if it is being used for an off-label use, it is still classified as an antidepressant.

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** Based on interview and record review, the facility failed to ensure residents were informed and provided written information concerning the right to accept, refuse, formulate an advance directive for 5 (Residents 36, 13, 81, 451, & 86) of 5 residents reviewed for Advanced Directives and 2 supplemental residents (Residents 97 & 58). The failure to review, provide, and have the resident sign the facility admission agreement prevented residents from being able to choose or refuse to formulate an advanced directive or to provide their previously formulated advanced directive documents. This placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare/financial decisions. Findings included . Resident 36 The 01/25/2022 5-day Medicare Minimum Data Set (MDS, an assessment tool) showed Resident 36 admitted to the facility on [DATE], was cognitively intact, had clear speech, was able to make themselves understood and understood others. The assessment showed Resident 36 was able to participate by answering questions and making decisions about their care. In an interview on 04/26/2022 at 7:58 PM, Resident 36 stated no one from the facility spoke with them about an advanced directive. Resident 36 stated they did not have an advanced directive and needed assistance to complete this task. Resident 36 stated they never received an admission agreement and asked what it was and if they could have a copy. In an interview on 04/27/2022 at 1:56 PM, Staff R (Business Office Manager) stated there was not an admissions agreement in the resident's record for Resident 36. Staff R confirmed that the document was not completed for Resident 36. In an interview on 04/27/2022 at 2:47 PM, Staff DD (Administrator in Training) confirmed that the admissions agreement contained information including but not limited to resident rights in a nursing home, charges for services, privacy practices, consent for release of information, authorization for immunizations, smoking policy, bed hold policy, trust fund policy, grievances policy, information about resident council, care plan conferences, personal property, advanced directives, and appointing a health care surrogate decision maker. Staff DD stated residents that do not have an admission agreement did not receive this required information upon admission. Staff DD stated the admissions agreement is expected to be reviewed with and signed by the resident or resident representative, and a copy provided to the resident, within 72 hours of admission. Residents 13, 81, 451, 86, 97, and 58 had similar findings when Staff R was unable to locate an admission agreement for each resident in their records. Staff R stated there was not an admission agreement or an advanced directive completed for these residents. Refer to F550 Resident Rights Refer to F585 Grievances REFERENCE: WAC 388-97-0180(1-4). .

CONCERN (E)

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

Safe Environment (Tag F0584)

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 and interview, the facility failed to ensure resident rooms were free of clutter and with adequate window covering, paper towel dispensers were functioning, and walls were free of gouges and burn marks. These failures left residents at risk for a decreased quality of life and a less than homelike environment. Findings included . Blinds In Resident Rooms On 04/22/2022 at 11:25 AM, observation in room [ROOM NUMBER] revealed many missing vertical slats for the window blinds. Resident 78 stated you can see my window isn't covered. The missing slats prevented Resident 78 from closing the blind for privacy and comfort if they wished. room [ROOM NUMBER] was also noted to be missing blind slats on 04/23/2022 at 9:51 AM; on 4/28/2022 at 12:07 PM, room [ROOM NUMBER] was observed to be missing a blind slat and the mechanism to adjust the slats was not working; on 4/28/2022 at 10:08 AM the blinds in room [ROOM NUMBER] were observed to be missing a slat. Missing blind slats were observed to be missing in rooms [ROOM NUMBERS] during environmental rounds conducted with Staff D (Maintenance Director), on 04/29/2022 at 7:34 AM. During these rounds Staff D acknowledged the missing slats and stated they would be replaced. Beds In room [ROOM NUMBER] on 04/26/2022 at 11:03 AM, the foot board of Resident 69's bed was noted to be broken. The entire right third of the board was missing, and particle board was exposed along the length of the split where the missing piece was once attached. The edging laminate along the entire perimeter of the footboard was also missing, exposing more particle board which could no longer be reliably cleaned. Similar findings were noted in room [ROOM NUMBER] where the head of the bed was missing laminate trim that exposed uncleanable particle board. These findings were noted during rounds with Staff D on 04/29/2022 at 7:34 AM who stated they would be fixed. Peeling laminate on footboards were also observed in room [ROOM NUMBER] and 109. Paper Towel Dispensers On 04/21/2022 at 8:17 AM, the paper towel dispenser in the bathroom of room [ROOM NUMBER] bathroom was noted to not be in proper working order; a paper towel roll was noted to be placed on top of the toilet tank rather than in the paper towel dispenser, preventing residents and staff from washing and drying their hands in a sanitary fashion and creating an un-homelike environment. During a meeting of the facility's Resident Council on 04/28/2022 at 1:48 PM, Resident 33 stated that the paper towel dispenser in their room, room [ROOM NUMBER], was not functioning and that a roll of paper towels was left on the tank of their toilet, rather than in the paper towel dispenser. During environmental rounds on 04/29/2022 at 7:34 AM, Staff D acknowledged there were paper towel dispensers in need of repair and demonstrated they repaired the dispenser for room [ROOM NUMBER] since the observation on 04/21/2022. Cluttered Resident Rooms On 04/21/2022 at 11:21 AM, room [ROOM NUMBER] was observed to be cluttered. The floor had an area surrounding the room heater marked with a perimeter of red tape where no items where to be placed. Resident items were noted to extend into the area. During environmental rounds on 04/29/2022 at 7:34 AM, Staff D stated that the room was cluttered, and that resident property was in the taped off area, and that the resident often placed their items where they should not. Walls On 04/21/2022 at 8:06 AM, the 100 Floor Dining room was noted with heat damage on wall; streaks of darkened panels ascended on the paneling directly above a baseboard heater. A plastic panel 1 foot by 4 feet was attached to the wall, preventing observation of part of the main panel. During environmental rounds on 4/29/2022 at 7:34 AM, Staff D stated they were unaware of the damaged paneling, and that the heater and the paneling required replacement. Wall gouges were noted on 04/21/2022 at 10:31 AM in room [ROOM NUMBER]. Gouges in resident rooms were also observed in room [ROOM NUMBER] where the head of the bed (HOB) rubbed against the wall, in room [ROOM NUMBER] on the wall by the HOB, and in room [ROOM NUMBER]. On 04/29/2022 at 7:34 AM, Staff D stated the walls needed to be repaired, we're painting all the time. REFERENCE: WAC 388-97-0880 .

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** Based on observation, interview, and record review the facility failed to ensure a system was in place to resolve resident grievances timely. Failure to timely resolve a grievance for 1 (Resident 60) of 7 Resident Council attendees, and failure to effectively educate residents on their right to file a grievance for 3 (Resident 81, 91 & 90) of 7 Resident Council attendees left residents at risk for unresolved grievances, missing property and frustration. Findings included . Facility Policy According to the facility's 05/13/2021 Resident and Family Grievances policy: the Grievance Official is responsible for overseeing the grievance process, grievances may be reported in various ways including verbally, in writing or during resident council. The policy stated notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. The policy did not describe how residents limited to their rooms, or with poor or no reading comprehension or who admitted during an outbreak (when residents are restricted to their rooms) would be educated on their right to file a grievance. Admissions Packet The facility's undated Admissions Packet (a collection of documents reviewed with residents upon admission) included a section titled Attachment E: Statement of Resident Rights. The Statement of Resident Rights did not include language explaining how residents could file a grievance with the facility. Resident Council During a meeting of the facility's Resident council on 04/28/2022 at 1:30 PM, residents expressed concerns about the facility's grievance process. Resident 67 (Council President) stated there were repeated concerns with missing property. Residents 67 and 33 stated they would like the Grievance Officials (Staff G, Social Services Director and Staff H, Social Services Assistant) to attend Resident Council but they had not lately. During the Resident Council meeting, of the seven resident attendees, four stated they knew how to file a grievance. Residents 81, 91, and 90 stated they did not know how to file a grievance. Resident 90, who admitted to the facility on [DATE] stated they had personal property missing the second day I was here. At 2:08 PM, Resident 60 stated they had a couple of boxes of a sports drinks delivered which were left with the receptionist. Resident 60 stated Staff G told the resident they were working on it in February, took a picture of the resident's phone screen with a delivery confirmation message, but did not resolve the resident's concern. In an interview on 04/28/2022 04:24 PM, Staff G stated they remembered Resident 60's missing sports drinks. Staff G was unable to provide any record the grievance was logged, investigated, or concluded. REFERENCE: WAC 388-97-0460 .

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 21 According to the 01/17/2022 Quarterly MDS, Resident 21 had diagnoses including Schizophrenia, anxiety, and drug induced Tardive Dyskinesia (abnormal and involuntary movements of the face, limbs, and trunk). The resident was assessed as rarely or never makes self understood, rarely or never understanding others, and had severely impaired cognition. This MDS showed the resident had no rejection of care, no wandering behaviors, and did not use a wander or elopement alarm. Review of the CP showed a 03/08/2021 the resident is an elopement risk/wanderer, with history of attempts to leave the facility unattended due to poor safety awareness and judgement. The CP interventions directed staff to check the expiration date and functioning of an elopement prevention device (Wanderguard- a device that alarms when going out a door) every week and to verify the placement of the device to the resident's right ankle every shift. Review of a 04/02/2020 CP showed the resident is resistive to care, showers, hygiene, changing clothes, MDS interviews and mental health visits. The CP directed staff to inform the LN (licensed nurse) of all continued refusals of care. Review of April 2022 Certified Nursing Assistant (CNA) documentation showed Resident 21 refused to take a shower and refused to have their vital signs taken on multiple occasions. A 09/18/2020 Physicians Order (PO) showed 1) check to ensure wanderguard device is on, not loose, or frayed, or missing, 2) Check to ensure the skin is intact beneath the wanderguard device, 3) Check wanderguard signal and expiration date, replace as needed. On 04/24/2022 at 9:01 AM a wanderguard device was observed on the resident's right ankle. On 04/26/2022 at 7:28 PM Resident 21 was observed walking out of their room, down the hall into the activity room where they sat for 10 minutes and returned to the hall, and started walking towards their room. The resident was later seen at 8:08 PM walking the hallway towards the activity room. In an interview on 04/26/2022 at 8:13 PM Staff DD (Administer in Training) stated the resident usually sticks to the same path when wandering the halls. They normally sit in the activity or dining room for a short period of time, head back to their room and repeat the path multiple times daily. In an interview on 04/28/2022 at 2:30 PM Staff F and Staff J stated Resident 21 wanders around the facility and has a wanderguard because they had a history of elopement. Staff J stated if the resident refused care, staff would re-approach the resident after some time and explain what type of care staff were trying to provide. Both Staff F and Staff J agreed the MDS was not accurate. REFERENCE: WAC 388-97-1000 (1)(b). Resident 58 Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's 02/23/2022 admission /Medicare - 5 Day MDS revealed the interviews assessing the resident's Cognitive Patterns, Mood, Behavior, Preferences, and Participation in Assessment were not completed by staff. This MDS showed it was not completed during the required 14 calendar days after admission to the facility. Resident 59 Resident 59 was admitted to the facility on [DATE]. Review of Resident 59's 02/24/2022 admission /Medicare - 5 Day MDS revealed the interviews assessing the resident's Cognitive Patterns, Mood, and Behaviors were not completed by staff. Additionally, this MDS showed it was not completed during the required 14 calendar days after admission to the facility Resident 97 Resident 97 was admitted to the facility on [DATE]. Review of the 12/14/2021 admission /Medicare - 5 Day MDS showed that it was not completed until 12/23/2021, two days after the required completion date. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated resident MDS's should be complete, accurate and completed within the required completion dates. Based on interview and record review the facility failed to accurately and completely assess 5 (Residents 61, 58, 59, 97, & 21 ) of 22 residents reviewed for assessments and failed to ensure comprehensive admission assessments were completed within the required time frames for 3 (Residents 58, 59, & 97 ) of 22 sample residents reviewed. These failures to ensure assessments were complete, accurate and timely placed residents at risk for unidentified care needs, delayed services, and decreased quality of life. Findings included . According to the Resident Assessment Instrument (RAI - a manual that instructs staff on timing requirements for assessments), admission assessments are required to be completed by the 14th calendar day of the resident's admission, and annual assessments are required to be completed within 14 days of the Assessment Reference Date (ARD, +14 days). Resident 61 Review of the 02/27/2022 Admissions Minimum Data Set (MDS - an assessment tool), showed the facility failed to assess Resident 61's cognition and preferences for activities and daily routine (Daily Preferences) either by resident interview or staff assessment. In an interview on 04/28/2022 at 2:57 PM, Staff J (MDS Nurse) and Staff F (MDS Nurse) confirmed the cognitive assessment and Activities and Daily Preferences were not completed either by resident interview or staff assessment. Staff F stated the assessments for cognition and preferences were important in order to ensure a resident's needs are identified and added to their Care Plan (CP) and in order to measure changes over time.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

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 services provided met professional standards of practice for 5 (Residents 251, 30, 95 21 & 58) of 25 sample residents reviewed. Facility nurses' failure to obtain, accurately transcribe, follow, and clarify Physician's Orders (POs) when indicated, and to sign only for tasks completed, placed residents at risk for medication errors, delays in treatment, unmet care needs, and potential negative outcomes. Findings included . Resident 251 Resident 251 was admitted to the facility on [DATE]. According to a 04/15/2022 admission Minimum Data Set (MDS - an assessment tool) Resident 251 had multiple medically complex diagnoses including Peripheral Vascular Disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.) The MDS assessed Resident 251 with two venous ulcers (wounds on the leg or ankle caused by abnormal or damaged veins). According to the April 2022 Treatment Administration Record (TAR) staff were directed to apply compression bandages (used for the management of venous ulcers) to both lower legs in the morning and to remove at night. Observations on 04/23/2022 at 9:53 AM showed Resident 251's legs partially wrapped with loose sagging woven gauze and no compression bandage. Similar observations of Resident 251 without compression bandages were made on 04/25/2022 at 8:05 AM and 04/27/2022 at 10:05 AM. Review of Resident 251's April 2022 TAR showed staff documented the compression bandages were applied in the morning on 04/23/2022, 04/25/2022, and 04/27/2022. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated it was their expectation that staff complete Resident 251's treatments as ordered and confirmed staff should not sign for tasks that were not performed. Resident 30 According to the 04/13/2022 Quarterly MDS Resident 30 admitted to the facility on [DATE] and had medically complex conditions, including Schizophrenia and a Seizure Disorder. Review of Resident 30's POs showed a 04/12/2020 PO for an anticonvulsant medication used to treat seizure disorder and a 02/18/2021 PO to obtain a laboratory test (lab) to assess the anticonvulsant medication's blood level every two months. Review of the resident's record showed a lab for the anticonvulsant drawn on 08/19/2021, six months after the PO, and a second lab drawn on 10/20/2021, and a third lad drawn on 04/19/2022, six months later. In an interview on 04/28/2022 at 9:53 AM, Staff C stated the anticonvulsant blood level should be checked every two months as ordered. Resident 95 According to the 03/25/2022 Quarterly MDS Resident 95 admitted to the facility on [DATE] and had diagnoses including Stroke (brain bleed) and Dysphagia (difficulty swallowing). Review of the resident's record showed Resident 95 admitted with a Gastrostomy tube (G-tube - a surgically placed device used to give direct access to the stomach). According to a progress note, Resident 95 pulled the G-Tube out of their stomach on 10/23/2021 and it was not replaced. Review of the PO's showed on 04/21/2022, six months after the G-tube was pulled out, the PO's changed from giving medications through the G-tube to giving medications orally. In an interview on 04/28/2022 at 9:53 AM Staff C stated they would expect staff to inform the Physician and obtain an order to give medications orally when the G-tube was pulled out. Staff C acknowledged that did not occur until 04/21/2022. Resident 21 According to the 01/17/2022 Quarterly MDS the resident admitted to the facility on [DATE] and had diagnoses including Schizophrenia, Anxiety, and drug-induced Tardive Dyskinesia (abnormal and involuntary movements of the face, limbs, and trunk). Review of the resident's record showed Certified Nursing Assistant (CNA) documentation on 01/25/2022 included a skin observation that documented a red area that was not previously observed. Review of the resident's record showed no indication the facility followed up with the newly identified red area. In an interview on 04/28/2022 At 9:53 AM Staff C stated the new red area should have been reported to the nurse, assessed by the nurse, and documented. Staff C acknowledged that did not occur. Resident 58 Resident 58 admitted to the facility on [DATE]. According to the 02/23/2022 admission /Medicare - 5 Day MDS, Resident 58 was assessed with clear speech, able to understand, and be understood by others. In an interview on 04/22/2022 at 2:10 PM, Resident 58 indicated they were having trouble with constipation and reported they spoke with their provider requesting treatment. Review of the 04/26/2022 progress note showed the Nurse Practitioner ordered a laxative daily for seven days. Review of April 2022 Medication Administration Records (MARs) showed Resident 58 did not receive the 04/26/2022 ordered laxative. No documentation was found in the resident's records explaining why it was not started. In an interview on 04/29/2022 at 7:33 AM, Staff C stated it was their expectation that staff review provider progress notes and follow up with orders as indicated. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). .

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** Resident 23 According to the 01/15/2022 Quarterly Minimum Data Set (MDS, an assessment tool), Resident 23 was cognitively severely impaired, demonstrated no behaviors or rejection of care, and required extensive assistance from staff for bed mobility, transfers, dressing, toileting, eating, personal hygiene, and bathing. A review of the 03/16/2018 care plan showed Resident 23 required 1-person extensive assistance for personal hygiene and oral care. Observations on 04/25/2022 at 12:05 PM, 04/26/2022 at 08:20 AM and 12:32 PM, 04/27/2022 at 12:25 PM, and on 04/28/2022 at 08:33 AM, showed Resident 23 with no dentures in their mouth and. Resident 23 was observed with dry food on their mouth and on beard. Resident 23's hearing aid was observed on top of their nightstand on each observation. In an interview on 04/26/2022 at 12:32 PM, Staff JJ (Nursing Assistant) stated they never saw the resident wearing dentures. Staff JJ stated they would expect the resident to receive oral care every day. Staff JJ stated Resident 23 should be assisted to use their hearing aids. According to 12/07/2021 dental consultation note, Resident 23 was not in their room during the dentist's visit. In an interview on 04/27/2022 at 10:23 AM, Staff H (Social Services) stated the resident did not have dentures and were on the list to see the dentist on 05/09/2022 in the facility. In an interview on 04/27/2022 at 11:37 AM Staff B stated the resident should have received oral care every morning and after meals and that Resident 23 should be assisted to use their hearing aids during the day. Resident 81 According to 03/20/2022 Medicare 5 Day MDS Resident 81 was assessed with impaired cognition, able to make their decisions and required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing. Observations on 04/23/2022 at 10:00 AM, on 04/25/2022 at 03:15 PM, and on 04/26/2022 at 10:00 AM, showed Resident 81 had long and dirty fingernails. A review of the 03/14/2022 CP showed Resident 81 required total assistance from staff for personal hygiene. In an interview on 04/25/2022 at 11:23 AM Resident 81 stated that they could not clip their own fingernails and staff had no time to clip their fingernails. In an interview on 4/26/2022 at 10:30 AM Staff Q (Licensed Practical Nurse) stated staff should be providing nail care weekly for the resident and confirmed Resident 81's fingernails were long and were not clipped weekly. Resident 82 According to 03/17/2022 Quarterly MDS, Resident 82 was assessed with impaired cognition, and able to make their decisions. Resident 82 admitted with diagnoses including Stroke, Hemiplegia (Left side weakness), Arthritis and Anxiety Disorder, and required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing. Observations on 4/23/2022 at 10:22 AM, 04/24/2022 at 9:13 AM, 04/26/2022 at 7:30 PM, and 4/28/2022 at 8:45 AM showed Resident 82 with toenails that were very long, both feet with very dry skin, and dry skin was all over on their bed sheet. A review of the CP initiated on 05/07/2018 and revised on 2/17/2022 showed Resident 82 required extensive assistance from staff for personal hygiene. In an interview on 04/26/2022 at 11:37 AM, Staff F RCM (Resident Care Manager), confirmed that Resident 82 had long toenails and dry skin. Staff F stated the staff should be applying lotion to the resident's feet and their toenails should have been clipped or referred to the podiatrist but were not. REFERENCE: WAC 388-97-1060(2)(c) Resident 153 According to the 04/07/2022 Quarterly MDS the resident admitted to the facility on [DATE], had severe cognitive impairment, was rarely understood and rarely able to understand conversation. The MDS showed the resident had Medically Complex Conditions, including Schizophrenia, Diabetes, Dementia, and Parkinson's Disease. The MDS showed the resident was assessed to require extensive assistance from staff for bed mobility, transfers, dressing, eating, and personal hygiene. On 04/21/2022 at 1:28 PM Resident 153 was observed in a hospital gown lying in bed with long beard hairs and dark debris under the resident's fingernails. On 04/24/2022 at 9:08 AM Resident 153 was observed in a hospital gown lying in bed, the resident's hair was observed as oily and greasy, the resident's teeth were coated with a whitish debris in between and coating their teeth, and their face had long beard hairs. Similar observations were made on 04/25/2022 at 9:13 AM and 12:26 PM, and 04/26/2022 at 9:36 AM. In an interview and observation on 04/26/2022 at 2:37 PM Staff SS (LPN Licensed Practical Nurse) observed Resident 153 and stated the resident's nails are long and dirty, they need to be cut and cleaned. Staff SS stated the resident had a bed bath today and they should have been shaved and their hair washed. Staff SS offered to cut the resident's nails and Resident 153 stated yes. Resident 30 According to the 04/13/2022 Quarterly MDS the resident admitted to the facility on [DATE], had severe cognitive impairment, was usually understood and able to understand conversation. The MDS showed the resident had Medically Complex Conditions, including Schizophrenia, Diabetes, and Seizure Disorder. The MDS showed the resident was assessed to require extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. During an observation and interview on 04/21/2022 at 9:01 AM Resident 30 was observed lying in bed in a hospital gown, their face had very dry skin . When asked what happened, Resident 30 stated, they probably haven't washed it. The resident had long facial hairs and fingernails were observed long in length. On 04/24/2022 at 9:17 AM Resident 30 was observed lying in bed in a hospital gown, with long facial hairs and dry skin on face. The resident's nails remained long and dark debris was observed under the finger nails. Similar observations were made on 04/25/2022 at 9:03 AM and 12:08 PM, and 04/26/2022 at 9:39 AM. In an interview on 04/26/2022 at 2:45 PM Staff SS stated Resident 30 normally does not have a beard and they should be shaved. Staff SS agreed the resident's nails were long with dark debris underneath and offered to cut the resident's nails. Resident 20 According to the 01/15/2022 Quarterly MDS the resident admitted to the facility on [DATE], had mildly impaired cognition, and was able to understand and be understood in conversation. The MDS showed the resident had diagnoses including Stroke (brain bleed), Non-Alzheimer's Dementia, and Depression. The MDS showed the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. During an interview and observation on 04/25/2022 at 12:13 PM Resident 20 was observed lying in bed, a hand splint was observed on their left hand. Resident 20 pointed to their left thumb and stated, this is terrible, look at this thumb nail! Resident 20's fingernails were observed to long, especially the thumb nail on the resident's left hand. In an interview and observation on 04/26/2022 at 2:48 PM Resident 20 stated as they pointed with their finger nails, they are too long, they are like razor blades. At this time Staff SS observed the resident's nails and stated they need to be cleaned and cut. Resident 95 According to the 03/25/2022 Quarterly MDS the resident admitted to the facility on [DATE], had severely impaired cognition, was sometimes able to understand and be understood in conversation. The MDS showed the resident had diagnoses including Stroke, Dysphagia (difficulty swallowing), and Dysarthria (weakness in muscles used for speech). The MDS showed the resident was assessed to require extensive assistance with bed mobility and toilet use, required limited assistance with transfers and dressing, and required supervision assistance with eating and personal hygiene. Review of the MDS showed bathing did not occur during the assessment period. On 04/22/2022 at 1:50 PM Resident 95 was observed sitting on the edge of their bed and a contracture (a permanent tightening of the muscles, tendons, skin that causes the joints to shorten and become stiff) was observed to their right hand and wrist. Similar observations were made on 04/25/2022 at 9:00 AM, and 04/27/2022 at 11:57 PM. On 04/25/2022 at 12:18 PM Resident 95 was observed with their lunch meal tray, which consisted of beef pot roast, roasted carrots, potatoes and onions, a side salad with dressing in a small cup with a lid, frosted gelatin poke cake, and a dinner roll. The resident's meat was not cut up, or the lids taken off the salad dressing cup. The resident was observed attempting to cut the meat using a fork in their left hand without success. In an interview on 04/28/2022 at 9:53 AM Staff C (Chief Nursing Officer) stated they would expect staff to assist a resident with one sided weakness and set up their meal tray by removing lids and assisting with cutting up foods a resident would not be able to do with the use of one arm. Resident 21 According to the 01/17/2022 Quarterly MDS the resident admitted to the facility on [DATE], had severe cognitive impairment, was rarely understood and rarely able to understand conversation. The MDS showed the resident had diagnoses including Schizophrenia, Anxiety Disorder, and Drug Induced Tardive Dyskinesia (abnormal and involuntary movements of the face, hands, limbs, and trunk). The MDS showed the resident was assessed to require supervision with bed mobility, transfers, walking, eating, bathing, and toilet use. The resident required limited assistance from staff for dressing. Review of a 04/08/2021 revised CP showed Resident 21 was resistive to changing their clothes and directed staff to inform them it is time to change their clothes and lay clothing out for the resident. On 04/24/2022 at 9:01 AM Resident 21 was observed wearing a yellow, blue, and white striped shirt, and grey sweatpants. Similar observations of the resident wearing the same outfit were made on 04/25/2022 at 8:40 AM, 04/26/2022 at 9:32 AM, and 04/27/2022 at 10:07 AM. In an interview on 04/28/2022 at 9:53 AM Staff C stated they expect the resident's clothes to be changed daily and as needed. Staff C stated staff should follow the CP and assist Resident 21 by laying clothes out for the resident daily. Resident 8 According to the 04/05/2022 Quarterly MDS the resident admitted to the facility on [DATE], had severe cognitive impairment, was usually understood and able to understand conversation. The MDS showed the resident had diagnoses including Dementia, Schizophrenia, and Bipolar Disorder. The MDS showed the resident was assessed to require staff supervision for bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene. Review of a 12/26/2020 CP showed the resident had an ADL self-care deficit and was independent with dressing. On 04/21/2022 at 1:48 PM Resident 8 was observed lying in bed wearing a pair of plaid lounge pants and a plaid button-down shirt. The residents face had long beard hair and their nails were observed long with dark debris under the nails. Similar observations were made on 04/24/2022 at 9:21 AM (when Resident 8's closet and drawers were observed with no clothing), 04/25/2022 at 8:59 AM, and on 04/26/2022 at 9:41 AM. In an interview on 04/26/2022 at 2:51 PM Staff SS stated it is hard to cut Resident 8's nails sometimes, but agrees they need to be cut and cleaned. Staff SS was not aware resident did not have any clothes available and stated they thought Resident 8 may have one more outfit. Based on observation, interview, and record review the facility failed to ensure residents who were dependent on staff to meet their Activities of Daily Living (ADLs) needs, were consistently provided such assistance for 11 (Residents 58, 97, 251, 59, 153, 30, 95, 21, 23, 81 & 82) of 14 sample residents reviewed for ADLs, and 3 supplemental residents (Residents 57, 20 & 8). Failure to provide assistance to residents who were dependent on staff for bathing (Residents 57, 58, 97, 251 & 59), nail care (Resident 57, 58, 97, 251, 59, 153, 30, 20, 30, 8, 81 & 82), eating (Resident 95), and personal hygiene (Residents 57, 251, 153, 30 & 21) placed residents at risk for unmet needs, poor hygiene, embarrassment and diminished quality of life. Findings included . According to the facility's 05/13/2021 ADLs policy, a resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident 57 According to the 02/20/2022 admission Minimum Data Set (MDS an assessment tool) Resident 57 admitted to the facility on [DATE], was assessed to have clear speech, to be understood by and understand others. The MDS assessed Resident 57 to require extensive physical assistance with bed mobility, transfers, dressing and personal hygiene, and indicated bathing did not occur during the look back period. According to a revised 04/09/2022 ADL Care Plan (CP) Resident 57 had interventions that directed staff to provide bathing twice weekly on Saturday and Tuesday. Review of Resident 57's bathing documentation for April 2022 showed no bathing was provided after 04/16/2022 until 04/26/2022, a wait of 10 days. Observations on 04/21/2022 at 11:48 AM showed Resident 57 with long, jagged fingernails on both hands, and was unshaven with greasy, uncombed hair. In an interview at this time Resident 57 indicated they asked staff for a shave and stated, they can't do it. Resident 57 reported it was about two weeks ago when they had their last shower. Observations on 04/21/2022 at 12:22 PM showed Resident 57 was upset and asked staff about getting a shower. Similar observations of Resident 57 being unshaven with greasy hair and long fingernails were noted on 04/23/2022 at 11:29 AM and 04/24/2022 at 8:46 AM. In an interview on 04/26/2022 at 2:19 PM, Staff AA (Registered Nurse), confirmed Resident 57 was unshaven with long, jagged fingernails and stated their expectation was that staff provide shaving daily as needed and for nail care to be provided with bathing. Resident 58 Resident 58 was admitted to facility on 02/17/2022. According to the 02/23/2022 admission MDS Resident 58 was assessed to have clear speech, to be understood by and understand others. The MDS assessed Resident 58 to require extensive physical assistance with bed mobility, transfers, dressing and personal hygiene, and indicated bathing did not occur during the look back period. In an interview on 04/22/2022 at 2:10 PM, Resident 58 stated, showers have been a bit of a disappointment. Resident 58 stated their nails, need to be trimmed and reported staff did not trim their fingernails since admission. Observations at this time showed Resident 58 was unshaven with long fingernails to the left hand and long, thick fingernails to the right hand. According to a revised 03/22/2022 ADL CP, Resident 58 had interventions that directed staff to provide bathing twice weekly on Saturday and Wednesday with extensive assistance. Review of Resident 58's bathing documentation for April 2022 showed Resident 58 went 27 days without a shower. In an interview on 04/26/2022 at 2:19 PM, Staff AA verified Resident 58 was not shaved and their fingernails were long. Staff AA stated staff should have, but did not provide ADL's as expected. Resident 97 Resident 97 was admitted to the facility on [DATE]. According to a 03/25/2022 Quarterly MDS, Resident 97 had moderate cognitive impairment and was not able to make decisions for themselves, but was able to be understood and understand others. The MDS assessed Resident 97 to require extensive physical assistance from staff for bed mobility, transfers, personal hygiene, and to require total assistance with bathing. Observations on 04/23/2022 at 9:59 AM, showed Resident 97 with dark debris under their long, untrimmed fingernails. Similar observations were noted on 04/25/2022 at 8:53 AM. According to a revised 01/25/2022 ADL CP, Resident 97 had interventions that indicated the resident required extensive assistance with personal hygiene and directed staff to provide bathing twice weekly on Monday and Friday. Review of the ADL documentation for April 2022 showed Resident 97 only had one documented occurrence of bathing on 04/14/2022, and no documented occurrences when nail care was provided. The resident went 24 days without a shower. In an interview on 04/25/2022 at 10:41 AM, Staff AA confirmed Resident 97 had untrimmed fingernails with dark debris under the nails on both hands and stated staff should have provided nail care and bathing as directed on the CP. Resident 251 Resident 251 was admitted to the facility on [DATE]. According to the 04/15/2022 admission MDS Resident 251 was cognitively intact, with clear speech, able to be understood and understand others. This MDS assessed Resident 251 to require extensive physical assistance from staff for bed mobility, transfers, dressing, personally hygiene and indicated bathing did not occur during the look back period. Observations on 04/23/2022 at 9:47 AM showed Resident 251 had long and jagged fingernails to both hands, white debris to lower teeth. In an interview at this time, Resident 251 stated they have only had two showers since admission. According to a 04/08/2022 ADL CP, Resident 251 had interventions that directed staff to provide bathing three times per week and to provide assistance with care. Review of Resident 251's bathing documentation for April 2022 showed the resident was only provided bathing twice since admission on [DATE] and 04/26/2022. In an interview on 04/29/2022 at 8:13 AM, Staff DD (Administer in Training) confirmed Resident 251 was not provided oral care as directed in the CP and verified Resident 251's fingernails were been trimmed. Resident 59 Similar findings were noted for Resident 59 who was assessed to require assistance from staff and was observed with untrimmed fingernails and was not provided bathing on three out of five scheduled opportunities in April 2022. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated it was their expectation staff provide assistance with bathing, shaving and nail care as directed by the residents CP.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

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 a system was in place to verify nursing staff had appropriate competencies, skill sets, and proficiencies to provide nursing and related services to residents with acute medical conditions. This failure placed all nursing staff at risk of providing unsafe, substandard quality care, and put all residents at risk for harm. The lack of a systematic approach to ensure competent nursing staff created a situation of harm for 2 (Resident 65 & 3) of 22 residents reviewed, and one (Resident 23) supplemental resident. According to the [DATE] [NAME] Administrative Code (WAC) 246-840-200 Continuing Competency, the Registered Nurse (RN) and Licensed Practical Nurse (LPN) shall be responsible and accountable for their practice based upon and limited to the scope of their education, demonstrated competence, and nursing experience consistent with their scope and the RN and LPN shall obtain instruction, supervision, and consultation as necessary before implementing new or unfamiliar techniques or procedures which are within their scope of practice. Findings included . Resident 65 Resident 65 was sent to the hospital on [DATE], and was diagnosed with a catheter related urinary tract infection and sepsis (systemic infection). Resident 65 died at the hospital on [DATE]. Review of the resident's record showed nursing staff failed to obtain Physician Orders (POs) to monitor, change catheter tubing, or provide nursing care for catheter maintenance, and failed to document any provision of catheter care. Review of the daily nursing skilled progress notes dated [DATE], [DATE], [DATE], and [DATE] showed Resident 65's urine in the catheter bag was described as amber and cloudy. The nursing staff failed to identify the abnormal urine quality as a possible urinary tract infection and failed to notify the provider of the change in condition. In an interview on [DATE] at 12:36 PM Staff E (Staff Development Coordinator) stated they did annual competencies (the knowledge, skills, and abilities that contribute to individual and organizational performance) on indwelling catheter management but have not been doing competencies lately. Staff E was asked to provide 5 Licensed Nurse (LN) competencies, and was able to provide 2 of the 5 that were requested. Of the 2 competencies provided; Staff Q (Licensed Practical Nurse LPN) had indwelling catheter management training on [DATE] and Staff L (LPN) had indwelling catheter management training on [DATE], over two years ago. Refer to F-684 (Quality of Care) for details related to Resident 65's hospitalization and death following signs and symptoms of a potential infection. Resident 3 An observation on [DATE] at 8:59 AM showed Staff S (Registered Nurse) was in the middle of providing wound care to Resident 3. Resident 3's right ankle and right foot were covered with a foam dressing. There were two Pressure Ulcers (PUs) on the right hip that had a paste surrounding the wound on the intact skin. Staff S placed an ointment in both hip wounds and covered them with a foam dressing. When asked, Staff S stated the right foot, right ankle, and two right hips PU were all stage 4 PU. Review of the resident's record showed the resident had a total of 5 PUs, the facility identified the Stage 4 PU to the sacrum and the lack of assessments but failed to identify 4 other PUs that were acquired at the facility. In an interview on [DATE] at 12:38 PM, Staff F (Resident Care Manager (RCM) & Minimum Data Set (MDS) Nurse) reviewed the Physicians Orders (POs) and stated there were no treatment orders for the right hip, right ankle, or right foot. Staff F stated a treatment order was expected to be obtained and must be in place before the nurse could provide the treatment. In an interview on [DATE] at 12:36 PM Staff E stated the facility performed competency checks for all nurses who provided wound care. Staff E was unable to provide a competency evaluation for Staff S who was observed providing wound care without orders on [DATE]. Staff E was not able to provide a competency evaluation for wound care for Staff U (RCM) who was responsible for coordinating residents' care and treatment with the wound specialist, hospice nurse, and the physician. Refer to F- 686 (Treatment and Services to Prevent/Heal Pressure Ulcers) for details related to Resident 3's lack of PU management and care. Resident 23 Observation on [DATE] at 8:56 AM showed Resident 23 with an intravenous (IV-existing within or administered into a vein) site on the back of their right hand. An IV pole with an empty bag and tubing was next to the bed. The IV bag had a manufacture's expiration date of [DATE]. There was no label that showed the date and time the bag was hung and fluids administered, according to the facility policy. In an interview on [DATE] at 11:31 AM, Staff N (Licensed Practical Nurse) viewed the IV bag and stated the IV solution was expired and there should be a label on the bag with the date and time it started infusing. Staff N reviewed the order and stated the order for the IV solution, was due to the residents dehydration, started on [DATE] and ended on [DATE]. Staff N stated the solution bag did not match the order. Staff N verified there were no POs for flushing the IV site, no directions for monitoring the IV site for adverse effects, and no order for removal of the IV catheter. Staff N stated they did not flush the IV on their shifts. In an interview on [DATE] at 1:26 PM, Staff B (Director of Nursing-DNS) stated standard nursing practice was to place a resident on alert charting for IV monitoring every shift for complications and the IV was expected to be flushed every shift to keep the line open. In an interview on [DATE] at 12:36 PM, Staff E was asked to provide competency documentation related to IV administration for five selected nurses, including Staff N, Q, S, L, and U. Staff E only provided two of the five competencies requested, three nurses did not have IV competencies on file. Review of the 2 competencies provided, showed Staff Q received IV therapy training on [DATE], and Staff L received IV therapy training [DATE], over two years ago. Refer to F-694 (Parenteral/IV Fluids) for details related to Resident 23's lack of IV management and care. REFERENCE: WAC 388-97-1080(1), 1090(1). .

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

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 ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) recommendations were reviewed and implemented timely for 6 (Residents 21, 30, 76, 153, 82 & 67 ) of 7 sample residents whose medication regimens were reviewed. This failure placed residents at risk for delays in necessary medication changes, adverse side effects and of receiving medications without required pharmacist oversight. According to the 2022 facility Addressing Medication Regimen Review Irregularities policy the facility would utilize a systemic approach for reviewing each resident's medication regimen which included preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities. The pharmacist must report any regularities to the attending physician, the facility's medical director, and director of nursing, and the reports must be acted upon. The attending physician must document in each resident's record that the identified irregularity was reviewed, and what, if any action was taken to address it. If there was no change in the medications, the physician should document the rationale in the resident's record. Findings included . Resident 21 According to the 01/17/2022 Quarterly Minimum Data Set (MDS an assessment tool) Resident 21 admitted to the facility on [DATE], and had diagnoses including Schizophrenia, Anxiety Disorder, and drug induced Tardive Dyskinesia (caused by long term use of psychiatric medications causing repetitive, and involuntary muscle movements ion the face, neck, arms, and legs). The MDS showed the resident received antipsychotic medications each day of the assessment period Review of Physician's orders (PO) showed a 10/01/2019 PO medication nightly for Schizophrenia and a 10/19/2021 PO for an NSAID (Non-Steroidal Anti-inflammatory Drug) three times daily for pain. Review of a 11/30/2021 MRR showed Staff HH (Consultant Pharmacist) recommenced a psychotropic gradual dose reduction (GDR) for the mental health medication and recommended the physician reevaluate the use of pain medications for Resident 21. A 12/30/2021 MRR showed a bolded and underlined sentence Pending a Final Response. The MRR again recommended a GDR for the mental health medication and evaluation of the chronic NSAID use in the elderly. The MRR was signed and dated on 01/28/2022, almost 2 months after the first recommendations were made. The mental health medication was marked as dose reduction clinically contraindicated at this time but did not indicate the clinical rationale for why a GDR was contraindicated. The NSAID medication was discontinued on 01/28/2022, almost 2 months after the first recommendations were made. Review of the resident's record and PO's showed no indication the facility reviewed or implemented the recommendations until 01/28/2022, almost 2 months later. Resident 30 According to the 01/17/2022 Annual MDS Resident 30 admitted to the facility on [DATE], and had diagnoses including Schizophrenia, Diabetes, and Seizure Disorder. The MDS showed the resident received antipsychotic medications each day of the assessment period. Review of PO's showed a 04/22/2021 PO for an antipsychotic medication nightly for Schizophrenia. Review of a 03/24/2022 MRR showed Staff HH recommended a GDR for the antipsychotic and the last GDR attempt was over a year ago in 04/2021. Review of the resident's record and PO's showed no indication the facility reviewed or implemented recommendations. Resident 76 According to the 03/15/2022 Quarterly MDS Resident 76 admitted to the facility on [DATE], and had diagnoses including Dementia with behavioral disturbances, Depression, and Adjustment disorder with mixed anxiety. The MDS showed the resident received antidepressant medications each day of the assessment period. Review of PO's showed a 03/30/2022 PO for an antidepressant daily for depression. Review of a 02/27/2022 and 03/24/2022 MRR showed Staff HH recommend a GDR attempt for the antidepressant and the last GDR attempt was 9 months ago in 07/2021. Review of the resident's record showed the Physician responded to the pharmacy recommendations on 03/14/2022 and agreed to decrease the antidepressant from 25 mg to 12.5 mg daily. The order to decrease the antidepressant was not carried out until 03/30/2022, 16 days after the physician had agreed to the GDR attempt. Resident 153 According to the 04/07/2022 Quarterly MDS Resident 153 admitted to the facility on [DATE], and had Medically Complex Conditions, including Schizophrenia and Anxiety. The MDS showed the resident received antidepressant medication each day of the assessment period. Review of PO's showed a 08/25/2021 PO for an antidepressant daily for appetite stimulant and an anti-convulsant for bipolar disorder. Review of a 02/27/2022 MRR showed Staff HH recommend a GDR attempt for antidepressant as there was no GDR attempts since the PO started on 08/25/2021. Review of the resident's record showed on 03/08/2022 the physician responded to the MRR and documented continue the antidepressant for appetite, there was no clinical rationale why a GDR attempt would be contraindicated. Resident 82 According to 03/17/2022 Quarterly MDS, Resident 82 was cognitively impaired, had diagnosis of anxiety disorder and Depression, demonstrated no behaviors and received antipsychotic and antidepressant medications during the assessment period. Review of the resident's record and PO's showed a 07/14/2021 order for an antidepressant daily for Depression and a 12/01/2021 order for an antipsychotic twice daily for Vascular dementia with behavioral Disturbance. Review of a 03/24/2022 MRR showed Staff HH recommended a GDR for the antidepressant and antipsychotic. Review of the resident's record showed no indication the facility followed up on this recommendation. Resident 67 Similar findings for Resident 67. According to the 03/07/2022 Quarterly MDS, Resident 67 received scheduled pain medication. Resident 67's POs at that time included a 12/10/2021 order for a narcotic medication containing an NSAID for a total of 3250 mg (milligrams) daily that was routinely administered, an 11/20/2021 order for a narcotic medication containing a NSAID every 6 hours for a total up to 1300 mg PRN (as needed), and a 06/12/2020 order for an NSAID 650 mg PRN every four hours for a total up to 3900 mg PRN. The 3 medication orders totaled 8450 mg of an NSAID, that is twice the recommended dose. Review of a 12/30/2021 MRR showed Staff HH recommended evaluating Resident 67's pain medication regimen due to a potentially toxic NSAID dose. The MRR showed that a daily maximum dose for an NSAID is 4000 MG. These recommendations were not carried out. A MMR on 02/27/2022 showed Staff HH recommended evaluating Resident 67's pain medication regimen due to a potentially toxic NSAID dose and identified the same three orders to be reviewed. On 03/01/2022, the 12/10/2021 the narcotic order was discontinued 3 months after the recommendation was made. In an interview on 04/28/2022 at 9:53 AM Staff C (Chief Nursing Officer) stated GDR's should be done on a quarterly basis, and the pharmacy recommendations should be reviewed with the physician, documented, and orders completed. Staff C acknowledged the pharmacy recommendations were not completed timely or at all, and Physicians are not documenting clinical rationales if GDR's are contraindicated, as they would expect. REFERENCE: WAC 388-97-1300 (1)(c)(iii) .

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 82 According to 03/17/2022 Quarterly MDS, Resident 82 was cognitively impaired, had diagnosis of anxiety disorder and Depression, demonstrated no behaviors and received antipsychotic and antidepressant medications during the assessment period. Record review showed Resident 82 had a 07/14/2021 order for an antidepressant (AD medication) daily for Depression and a 12/01/2021 order for an AP medication twice daily for Vascular dementia with behavioral Disturbance. A The resident uses antidepressant medication r/t (related to) depression CP, revised 06/21/2021, directed staff to review psychotropic medications every quarter at psychotropic management meeting to evaluate the effectiveness and continued need. A 07/19/2021 order directed staff to document each shift the number of episodes for excessive worry, negative statements related to AD medication use. A 07/19/2021 order directed staff to document the number of episodes of hallucinations and suicidal ideation related to Diagnosis of dementia for the AP medication. A review of Resident 82s February 2022, March 2022 and April 2022 TB's monitoring indicated no behaviors were noted. Record review showed Resident 82's 03/24/2022 monthly pharmacy review recommended a GDR for psychotropic medications. No evidence was found in Resident 82's record to indicate the facility followed up on this recommendation. Resident 82's record review showed Resident 82 received the AP medication 25 mg once daily from 06/04/2021 and on 12/02/2021 the dose was increased, and that the most recent AIMS assessment was completed on 06/29/2021. In an interview on 04/27/2022 at 10:09 AM, Staff F (Resident Care Manager) stated the facility should complete AIMS assessments every 6 months and that an AIMS should have been but was not completed in December 2021. Staff F stated the facility should have followed up on pharmacy recommendations but did not. In an interview on 04/28/2022 at 11:00 AM, Staff B (Director of Nursing) stated the facility was not consistently following the pharmacy recommendations and missed a couple of months of reviews. In an interview on 04/29/2022 at 08:02 AM, Staff G (Social Services Director) stated the facility did not have consistent meetings to discuss psychotropic medication review for GDRs. Staff G stated the facility should have reviewed Resident 82's medication for GDR but did not.Residents 36 and 451 Similar findings for Resident 36 and 451. Review of the residents' records showed the facilty did not identify individualized TB's for psychotropic medications, monitor TB's, or attempt GDRs or implement non-pharmaceutical interventions prior to administration of a PRN (as needed) medication. REFERENCE: WAC 388-97-1060(3)(k)(i). Resident 21 According to the 01/17/2022 Quarterly MDS the resident admitted to the facility on [DATE], had severe cognitive impairment, was rarely understood or able to understand, and had diagnoses including Schizophrenia, Anxiety Disorder, and Drug induced Tardive Dyskinesia (TD) (abnormal and involuntary movements of the face, limbs, and trunk). The MDS showed the resident received antipsychotic medication all 7 days of the assessment period. Review of the resident's record showed a 10/01/2019 PO for an antipsychotic used to treat Schizophrenia 20 mg (milligrams) nightly and a 09/13/2019 PO that directed staff to monitor the resident for any adverse side effects (ASE) related to the antipsychotic use, such as TD. On 04/21/2022 at 8:19 AM Resident 21 was observed on their bed rocking back and forth. Similar observations were made on 04/24/2022 at 11:36 AM, 04/25/2022 at 8:40 AM, and 04/26/2022 at 7:47 PM. Review of the resident's record showed a 11/30/2021 and a 12/30/21 Pharmacist recommendation for a GDR (Gradual dose reduction) for the AP medication. The form showed the last GDR attempt was in 11/2020 and was contraindicated due to history of failed GDR attempts. On 01/28/2022 the Physician signed the 12/30/2021 GDR recommendation and marked dose reduction clinically contraindicated at this time. Review of the form showed no clinical rationale for why any attempt would be likely to impair the resident's function. The resident went 17 months without any GDR attempts. Review of the February 2022, March 2022, and April 2022 MAR (Medication Administration Record) showed no ASE's documented by nursing staff. In an interview on 04/28/2022 at 9:53 AM Staff C (Chief Nursing Officer) stated GDR's should be done on a quarterly basis, and acknowledged the Physicians are not documenting clinical rationales if GDR's are contraindicated, as they would expect. Staff C stated Resident 21 had a diagnoses of TD and expect the nurses to document any ASE's they observe on the ASE monitoring. Resident 30 According to the 04/13/2022 Quarterly MDS the resident admitted to the facility on [DATE], had severe cognitive impairment, usually was understood and able to understand, and had medically complex conditions including Schizophrenia, Diabetes, and Seizure Disorder. The MDS showed the resident received an AP medication all 7 days of the assessment period. Review of the resident's record showed a 04/22/2021 PO for an AP medication 1 mg nightly and a 02/13/2020 PO to monitor the resident for ASE's related to the AP medication use. On 04/21/2022 at 1:52 PM Resident 30 was observed lying in bed, their lips and tongue were observed with movements of lip smacking and thrusting their tongue. Similar observation were made on 04/25/2022 at 9:03 AM and 12:08 PM, and 04/26/2022 at 9:39 AM and 2:45 PM. In an interview on 04/26/2022 at 2:45 PM Staff SS (LPN) confirmed that Resident 30 had mouth movements of lip smacking and tongue thrusting. Review of the April 2022 MAR showed no ASE's documented by nursing staff. Review of the resident's record showed a 03/24/2022 Pharmacist recommendation for the AP medication. The form showed the last attempted GDR was in April 2021, and the AP medication dose was decreased from 1.25 mg to the current dose of 1 mg. The form was not signed by the Physician and there was no indication the facility carried out the recommendations. The resident went 1 year without a GDR attempt. In an interview on 04/28/2022 at 9:53 AM Staff C stated GDR's should be done on a quarterly basis and acknowledged Resident 30 has not had a GDR attempt in the past year. Based on observation, interview, and record review the facilty failed to ensure residents' remained free of unneccesary psychotropic medications for 3 of 5 residents (Residents 69, 82 & 36) sample residents whose medications were reviewed for unnecessary psychotropic medications and 3 supplemental residents (Residents 21, 30 & 451). Failure to identify the adequate indications for use, identify triggers or specific behaviors, document behaviors, attempt GDR (gradual dose reductions) or implement non-pharmaceutical interventions before administering medication and failed to obtain informed consent prior to administration of anti-psychotic medications placed residents at risk of receiving unnecessary psychotropic medications, experiencing medication-related adverse side effects (ASE), and diminished quality of life. Findings included . Resident 69 According to the 03/08/2022 Significant Change Minimum Data Set (MDS, an assessment tool) Resident 69 originally admitted to the facility on [DATE] and had diagnoses including Alzheimer's Diesease, Non-Alzheimer's Dementia and Psychotic Disorder. The Assessment showed Resident 61 experienced delusions and halucinations, and received an Antipsychotic (AP) medication regularly. Review of Resident 69's record showed an 02/23/2022 order for an AP medication 75 mg, 2x daily for hallucinations. Review of a 12/24/2020 pharmacy consult, revealed a recommendation to discontinue Resident 69's AP medication 12.5 mg at bedtime. The recomendation was not followed by the facility; the declination completed by the physician on 01/21/2020 [sic] stated will discuss at next weekly psychiatry meeting. Review of the Physician's Orders (POs) from 12/2020 to present showed: Resident 61's AP medication was increased to 25 mg at bedtime on 02/10/2021 and to 50 mg at bedtime on 02/24/2021; a second PO for the AP medication 25 mg each morning was added on 11/16/2021 and increased to 50 mg each morning for a daily total of 100 mg on 12/06/2021; on 02/24/2022, Resident 61 was prescribed the AP medication 75 mg twice daily for hallucinations for a daily total of 150 mg. This represented a 12 times dose increase from 12.5 mg in 12/24/2020 to 75 mg in 02/24/2022. Review of the resident's record revealed an 04/05/2022 AIMS (Abnormal Involuntary Movement Scale) assessment with a score of 1. The assessment indicated Resident 69 demonstrated minimal abnormal facial expressions. Prior AIMS dated 04/18/2018, 10/02/2018, 01/15/2019, 07/15/2019, 07/16/2020, 10/01/2020 and 04/01/2021 all assessed Resident 69 with a score of 0. According a 02/18/2022 progress note, Resident 69 had hallucinations at 2:00 AM that morning. According to a 02/23/2022 progress note, Resident 69 had hallucinations on the night of 02/22/2022 at 10:30 PM. Review of Resident 69's Target Behavior (TB) monitoring showed no other epsiodes of halluinations in January and February 2022. In an interview on 04/26/2022 at 11:13 AM, Staff HH (Consultant pharmacist) stated that the recent AP medication dose increase was in response to the epsiodes of hallucinations. Staff HH stated given the series of dose increases that another AP medication might be considered to treat the resident. On 04/26/2022 at 01:12 PM, Staff HH provided a copy of a 03/24/2022 pharmacist recommendation that recommended evaluating the risks and benefits of Resident 69's AP medication use. The note showed Resident 69 has been on this medication for some time with escalating doses. Is it helping the hallucinations? Staff HH stated they had concerns with increased AP medication use for an [AGE] year old resident and questioned whether it was effective. In an interview on 04/28/2022 at 9:22 AM, Staff II (Nurse Practitioner) stated it would be appropriate to reevaluate Resident 69's AP medication use at that time.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to store and prepare food under sanitary conditions. Failure to ensure food items in the dietary department were properly stored, labeled, and out-of-date foods were identified and discarded, and staff used appropriate hand washing placed residents at risk for consuming expired/spoiled foods and potential exposure to food-borne illness. Findings included . According to a 04/21/2021 facility Food Safety Requirements policy, food would be stored, prepared and served in accordance with professional standards for food service safety. This policy defined food service safety as the handling, preparing, and storing food in ways that prevent foodborne illness. This policy indicated food safety practices should be followed throughout the facility's entire food handling process and included storage of food and employee hygienic practices. Initial Kitchen Rounds During initial observations of the dietary department on 04/21/2022 at 8:00 AM showed the following out-of-date: a bin of fruit loops cereal that was labeled with use by date of 06/30/2021; a bin of white sugar labeled with a use by date of 03/30/2022; a bin of brown sugar labeled with a use by date of 03/30/2022; a bin of dry milk with a use by date that was illegible. Observations on 04/21/2022 at 8:06 AM showed two unlabeled, undated bins, one that contained a breadcrumb like product and the other with a flour like product. Neither bin identified what the product was or was affixed with a use by date. In an interview on 04/21/2022 at 8:10 AM, Staff UU (Dietary Supervisor) confirmed the above observations of unlabeled, illegible, undated, and/or out of date products. Staff UU stated food items should be used before the use-by date and indicated staff should place a new label on a container when/if the food product is refilled into bins. In an interview on 04/21/2022 at 8:12 AM, Staff UU stated their process for canned food items was to label each can with an orange sticker with the date of when the product arrived. Staff UU indicated this was so staff could identify when to pull the product off the shelves. Observations at this time showed the following cans without an orange sticker: one can of budin de vanilla and three cans of pineapple. In an interview on 04/21/2022 at 8:15 AM, Staff UU stated the canned food items should have been, but were not labeled with the orange stickers. Observations on 04/21/2022 at 8:35 AM showed a bucket of fluids on a shelf that staff identified as a sanitizing solution. During an interview at this time with Staff VV (Dietary Cook) and Staff UU, Staff VV stated, the solution was used to sanitize surfaces and is changed every two hours. Staff VV stated the bucket was last changed at 5:30 AM, over two hours ago. Staff VV was asked to test the sanitizing solution. Staff VV was unable to locate the test strips. Staff UU tested the solution and stated the solution needed to be changed. Observations of Tray Line Observations on 04/27/2022 at 10:45 AM, showed kitchen staff washed their hands at the sink and was unable to obtain paper towels out of the dispenser. There was a paper towel roll sitting on the eye wash station nearby, staff reached over to grab the roll, and contaminated their hands during the process. At 10:50 AM on 04/27/2022 Staff XX (Dietary Aide) was rinsing off dirty dishes with debris using gloves. Staff XX then rinsed the gloves off with water nozzle, loaded a tray of dirty dishes and slid the tray into the dishwasher. Staff XX went back to rinsing dirty cups until the dishwasher cycle completed. At that time Staff XX opened the dishwasher and while using the same soiled gloves, touched the clean dish tray rack and dishes while sliding them down the tray line. Observations on 04/27/2022 at 11:00 AM, showed staff YY (Dietary Aide) wearing gloves, pulling clean dishes from the dishwasher tray line, and putting away the dishes in racks. Staff YY while still wearing the gloves, reached up and touched the front of their face mask twice. Staff YY, without changing gloves or performing hand hygiene, used the soiled gloves and grabbed another stack of clean plates to put away. On 04/27/2022 at 11:41 AM, during tray line preparation, Staff WW (Dietary Cook) was observed wearing gloves and touched the front of their face mask several times. With the same soiled gloves Staff WW continued to prepare the next plate, scooped the food, and touched the food with the contaminated gloves as it came onto the plate. Similar findings were observed of Staff WW, during tray line preparations, wearing the same soiled gloves, touching their mask, and touching the plated food. At 12:02 PM Staff WW changed their gloves, did not perform hand hygiene, and continued to touch prepared food with contaminated gloves throughout the remainder of the meal tray service. Observations on 04/28/2022 at 10:14 AM revealed the paper towel dispenser was still not functioning and no paper towels were available within reach after hand washing. In an interview at this time Staff UU confirmed the hand washing sink should have a functioning paper towel dispenser and paper towels should be available to staff for hand hygiene purposes. In an interview on 04/28/2022 at 10:30 AM, Staff UU stated it was their expectation that staff changed gloves and performed hand hygiene when going from dirty to the clean side of the dishwasher. Staff UU stated staff should not use contaminated gloves and touch food during food preparations and indicated their expectation was that staff perform hand hygiene between glove changes and when hands become contaminated. REFERENCE: WAC 388-97-1100(3), -2980. .

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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REFERENCE: WAC 388-97-1720(1)(a)(-iv)(b). Resident 86 Review of Resident 86's April 2022 nurse monitoring of the left arm fistula (dialysis administration site) showed staff failed to document monitoring for 9 of 44 shifts. Resident 6 Review of Resident 6's April 2022 nurse monitoring of oxygen saturation showed staff failed to document monitoring for 9 of 40 shifts. The monitoring record also showed staff failed to monitor the settings and function of the specialty air mattress for 9 of 40 shifts Resident 36 Review of Resident 36's April 2022 nurse monitoring for pain showed staff failed to document a pain assessment for 9 of 40 shifts. The monitoring record also showed staff failed to monitor for signs of over sedation for 9 of 40 shifts. Resident 451 Review of Resident 451's April 2022 nurse monitoring of oxygen saturation showed staff failed to document monitoring for 4 of 22 shifts. Resident 23 Review of Resident 23's April 2022 nurse monitoring of hours of sleep showed staff failed to document for 9 of 42 shifts. A review of bowel monitoring (BM) records for Resident 36, 86, 6, 451 and 23 showed multiple shifts missing documentation for each resident. In an interview on 04/28/2022 at 2:13 PM with Staff B (Director of Nursing) and Staff C (Chief Nursing Officer), Staff C stated all medications, treatments and nurse monitor records are expected to be documented by staff as scheduled each shift. Staff B and Staff C acknowledged the system for staff documentation on the medication, treatment, nurse monitor and caregiver records was not intact. Based on interview and record review the facility failed to ensure resident's records were complete, accurate, and readily accessible for 10 (Residents 86, 6, 36, 451 & 23) of 22 residents whose records were reviewed. The facility failed to ensure Nurse Monitoring Records (Residents 86, 6, 36, 451 & 23), Activities of Daily Living (ADL) records (Residents 59, 58, 97, 251 & 82), and nutritional intake (Residents 59, 58, 97 & 251) documentation was complete and accurate. Failure to ensure resident's records were complete and accurate placed residents at risk of for unmet care needs and inaccurate assessments. Findings included . Resident 59 Review of Resident 59's March 2022 nutritional intake documentation showed staff failed to document the resident's intake for 35 of the 93 meals provided. April 2022 records showed staff failed to document the resident's intake for 33 of the 78 meals provided. Similar findings were noted on March 2022 and April 2022 ADL documentation for bed mobility, dressing, personal hygiene, toileting, and oral care. Resident 58 Review of Resident 58's March 2022 nutritional intake documentation showed staff failed to document the resident's intake for 16 of the 93 meals provided. April 2022 records showed staff failed to document the resident's intake for 39 of the 78 meals. Similar findings were noted on March 2022 and April 2022 ADL documentation for bed mobility, dressing, personal hygiene, toileting, and oral care. Resident 97 Review of Resident 97's March 2022 nutritional intake documentation showed staff failed to document the resident's intake for 34 of the 93 meals provided. April 2022 records showed staff failed to document the resident's intake for 31 of the 73 meals provided. Similar findings were noted on March and April 2022 ADL documentation for bathing, bed mobility, dressing, personal hygiene, toilet use, bowels, and oral care. Resident 251 Review of Resident 251's April 2022 nutritional intake documentation showed, the staff failed to document the resident's meal intake for 30 of the 55 meals provided. Similar findings were noted on April 2022 ADL documentation for bathing, bed mobility, dressing, personal hygiene, toileting, and oral care. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated their expectation was that staff document completely and accurately in the resident's records. Staff C stated accurate documentation was important to help staff assess the overall health and nutritional status of a resident. Resident 82 According to 03/17/2022 Quarterly MDS (Minimum Data Set - an assessment tool) Resident 82 was assessed with impaired cognition, able to make their own decisions. Resident 82 was admitted with diagnosis of Stroke, Hemiplegia (Left side weakness), Arthritis and required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing. A review of April 2022's ADL documentation from 04/01/2022 to 04/28/2022 showed the following: Resident 82 was documented as receiving assistance with personal hygiene on 32 times out of 56 shifts, on 40 out of 84 shifts for toilet use, on 39 of 84 shifts for bowel and bladder elimination, on 39 of 84 shifts for pain monitoring and 39 of 84 shifts for oral care. In an interview on 04/28/2022 at 11:00 AM, Staff B stated they would expect the ADL Tasks documentation to be part of the resident's record and acknowledged it was not documented for Resident 82 on multiple occasions.

CONCERN (E)

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

Antibiotic Stewardship (Tag F0881)

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 establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of antibiotics, and reduce the risk of unnecessary antibiotic use for 2 (Residents 36 & 81) of 6 residents reviewed for unnecessary antibiotics and 6 (October 2021, November 2021, December 2021, January 2022, February 2022, and March 2022 ) of 6 months of Infection Control (IC) documents reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics and an increased risk for multidrug-resistant organisms (MDRO: microscopic organisms that are resistant to many antibiotics). Findings included . According to the 09/09/2021 facility Antibiotic Stewardship Program policy the Infection Preventionist (IP), with oversight for the Director of Nursing (DON), served as the leader of the Antibiotic Stewardship Program and received support from the Administrator and other governing officials of the facility. The Medical Director, Consultant Pharmacist, and Attending Physician support the program via active participation in developing, promoting, and implementing a facility-wide system for monitoring the use of antibiotics. The Consultant Pharmacist reviewed antibiotics prescribed to residents during their medication regimen review and served as a resource for questions related to antibiotics. All prescriptions for antibiotics should specify the dose, duration, and indication for use. Reassessment of empiric antibiotics (given before the specific organism is unknown) was conducted after 2-3 days for appropriateness and necessity, factoring in the results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. Documentation related to the IC Program was maintained by the IP, including Antibiotic Stewardship meeting minutes. Resident 36 Review of the resident's record showed the resident admitted to the facility on [DATE] and was prescribed an antibiotic twice daily for a diagnosis documented as antibiotic with no stop date. Review of the Care Plan (CP) 10/22/2021 showed no indication the resident was taking an antibiotic or the diagnosis for the antibiotic. A 11/15/2021 Physician note showed the resident had a history of rapidly progressing cellulitis in the past and was currently on an antibiotic twice a day for suppression. In an interview on 04/26/2022 at 10:26 AM Staff E (Infection Preventionist/Staff Development) stated the antibiotic was for wound infection prevention and confirmed there should be a diagnosis and stop date for the antibiotic. Staff E stated they did not have justification or documentation to continue the antibiotic without a stop date, and acknowledged the Physician should have clarified the diagnosis for the antibiotic. January 2022 Review of the January 2022 line list showed Resident 36 re-admitted to the facility on [DATE] from a local hospital with a skin infection. The line list showed under the symptoms box the IP documented admitted with UTI and cellulitis (skin infection), no cultures were obtained, and the infections were marked as CAI's (Community Acquired Infection). Review of progress notes showed on 12/17/2021 the Physician was notified of Resident 36's complaint of increased pain and swelling to the right lower leg and recommended the Resident 36 be seen in the emergency room to rule out a possible DVT (Deep Vein Thrombosis- blood clot). A 12/17/2021 Physician encounter note showed the resident was seen on 12/19/2021 for increased right foot swelling, fungal rash to skin folds, orange urine and URI (Upper Respiratory Infection). The note showed the resident had a history of recurrent abdominal cellulitis and right foot/shin abscess that improved after 10 days on antibiotics. The Physician noted some swelling to the right foot, but denied observing any warmth or redness. The note showed the resident had a UA (Urinalysis) done that came back negative for an infection and the orange urine could be from dehydration. The resident was sent to the emergency room on [DATE]. Review of Physicians Orders (POs) showed a 01/17/2022 PO for an antibiotic for 1 day to treat a UTI, a 01/25/2022 PO for a second antibiotic for 7 days to treat a skin infection and a 01/25/2022 PO for a third antibiotic for 10 days to treat a skin infection, the antibiotic was extended on 02/12/2022 for 7 more days. Review of the January 2022 IC documents showed no Resident Infection Report Form (used to determine if the infection met criteria) for Resident 36. Review of the resident's record showed no indication the facility attempted to obtain the urine culture results to determine if the current antibiotic being used was appropriate for the specific organism. No documentation to support the symptoms of a skin infection or alert charting to monitor the effectiveness of the antibiotic was present. Review of the January 2022 IC Summary Report showed no antibiotic stewardship reviewed. In an interview on 04/26/2022 at 10:26 AM Staff E stated the facility used McGeer's criteria (surveillance definitions of infections in long term care facilities) to determine if an infection met the criteria for treatment. Staff E stated the facility did not create a resident infection report form for CAI's, but do for Healthcare Acquired Infections (HAI). February 2022 Review of the February 2022 line list showed Resident 36 had two infections, consisting of a CAI skin infection from the previous month, and a HAI (healthcare acquired infection) urinary tract infection (UTI), and was prescribed antibiotics to treat the infections. A 02/12/2022 Nursing progress note showed the resident returned to the facility with a prescription for an antibiotic for 5 days to treat a UTI. Review of PO showed a 02/12/2022 PO for an antibiotic for 5 days to treat a UTI, and a 02/18/2022 PO for a second antibiotic for 7 days to treat a skin infection. A late entry 02/13/2022 Nursing progress note written on 02/17/2022 by Staff E showed the resident was noted with dysuria, suprapubic pain, an increase in urgency, and a UA was completed at the local hospital. A 02/14/2022 Resident Infection Report Form showed Resident 36 met criteria for a UTI, and the following symptoms were marked; acute dysuria (pain with urination) , suprapubic (region of the abdomen below the belly button) pain, new or marked increase in frequency, and a urine culture (lab test to check for bacteria) containing no more than 2 species of microorganisms (bacteria, virus, or fungus). Review of the 02/12/2022 hospital After Visit Summary showed Resident 36 was found to likely have a UTI . No UA or documented symptoms were found within the hospital paperwork. Resident 81 Review of the resident's record showed Resident 81 re-admitted to the facility on [DATE], and was being treated with an antibiotic upon admission for SBP (Spontaneous Bacterial Peritonitis- an infection of abdominal fluid) prophylaxis . Review of PO's showed a 03/16/2022 PO for an additional antibiotic for SBP prophylaxis. Review of a 03/14/2022 Hospital discharge orders showed two antibiotics, one to be continued and one that was discontinued. Review of a 03/14/2022 Hospital after visit summary directed Resident 81 to continue taking both antibiotic medications. Review of the resident's record should no indication facility staff clarified the discrepancy between the hospital discharge order and the hospital after visit summary orders. Review of the resident's CP showed no indication the resident was received a prophylactic antibiotics, goals of antibiotic therapy, or interventions including monitoring the resident for adverse side effects. In an interview on 04/26/2022 at 10:26 AM Staff E stated they were not aware Resident 81 was taking antibiotics and they were not included on the March 2022 line list. Monthly Summaries & IC Meetings Review of October 2021, November 2021, December 2021, January 2022, February 2022, and March 2022 IC summaries showed Staff E identified specific organisms related to infections on the line list but did not include the organisms in the analyzing of the monthly IC data summary. There was no indication the facility received monthly data from the lab about organisms identified or prevalent in the facility. Failure to identify the specific organisms or obtain lab reports deterred Staff E from analyzing the potential spread of specific organisms, trends of specific organism, and determining prevalent organisms in the facility. Review of the October 2021-March 2022 IC Summary Reports showed no indication the facility thoroughly analyzed the data from each floor/wing and compiled it together to determine the prevalent types of infections (i.e. skin infection, UTI) to identify specific trends on floors/wings and the building as a total. Review of the October 2021-March 2022 IC Summary Reports showed no CAI's had a Resident Infection Report Form showing if the infection met McGeer's criteria. On 04/26/2022 at 10:26 AM Staff E stated they did not check if antibiotics meet McGeer's criteria for residents who admitted to the facility with CAI's, they just go with them and only check McGeer's criteria for HAI. The failure to identify, monitor, assess for appropriate diagnosis, and justification placed residents who admitted with antibiotics at risk for unnecessary antibiotics, and potentially adverse side effects. Review of October 2021-March 2022 Pharmacist Medication Regimen Review Reports showed under Antibiotic Stewardship, a) infection control meeting: no invitation was received, please let me know if you would like me to attend, b) antibiotic stewardship: I [the pharmacist] review antibiotic usage regarding appropriate infection criteria, proper indication, dosing, and duration with each visit. In an interview on 04/26/2022 at 10:26 AM Staff E stated they do not conduct a monthly infection control meeting with the interdisciplinary team, Staff E does it on their own. In an interview on 04/28/2022 at 2:13 PM Staff C (Chief Operating Nurse) stated the Antibiotic Stewardship Program system was not intact, as required. REFERENCE: WAC 388-97-1060(3)(k)(i). .

CONCERN (E)

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

Deficiency F0886 (Tag F0886)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to have a system to ensure staff were accurately tested during an infectious disease, COVID-19 outbreak (Coronavirus, a highly transmissible infectious respiratory disease). The failure to identify the testing frequency criteria based on positivity rate (number of positive results in all tests completed in a designated region), document completed test results for each staff, and complete additional testing for exempted staff placed all residents at risk of infection from COVID-19 during a nationwide pandemic. Findings included . Review of the daily testing logs for April 2022 provided by Staff E (Infection Control Nurse) showed a staff list with highlighted names and a date at the top of the page. The log was unnamed and was not identifiable as a tracking log for COVID-19 testing. In an interview on 04/26/2022 at 10:26 AM, Staff E (Infection Control Nurse) stated the staff testing should be done twice a week for all staff and three times a week for the staff with exemptions. Staff E stated the testing was completed at the reception desk and a paper is completed and filed. Staff E stated there was not a system of tracking to ensure all staff were tested twice a week or that the exempt staff has tested three times a week. Staff E stated they do not have a system to track or document the community transmission rates. Staff E stated the LHJ (Local Health Jurisdiction) office was called or emailed to find out if the county is high or medium. When asked if there was a tracking log for transmission rates, Staff E said they would have to go thru their email to create a log. In an interview on 04/26/2022 at 2:25 PM, Staff V (Receptionist) stated staff will take a test kit and do their test, fill out a form and return to the reception desk indicating the testing was completed. Staff V stated there was a box under the desk to place all the completed test forms and when the stack was big enough, they were taken to the Infection Control Nurse office. The box under the desk was observed with a large stack (over 1000 pages equivalent to two packages) of testing pages. Staff V stated there was multiple days of testing in the box. Staff V stated the receptionists do not audit to ensure all staff was tested two or three times per week. On 04/26/2022 at 2:12 PM, Staff E was asked to provide the documentation for the exempt, unvaccinated staff. Staff E stated the test results were not filed and tracked and the facility would need time to sort thru the piles of testing pages to find the documentation of testing. In an interview on 04/28/2022 at 2:13 PM, Staff C (Chief Nurse Officer) acknowledged the lack of systems in infection control for ensuring testing, tracking, and documenting of COVID-19 tests. Staff C stated the system was not intact. REFERENCE: WAC 388-97-1320 (i)(a). .

CONCERN (E)

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

Deficiency F0888 (Tag F0888)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to ensure a system was implemented to ensure accurate tracking and reporting of COVID-19 vaccination status of residents, facility and contracted staff (provide care, treatment, or other services to the residents under contract with the facility). The failure to accurately track vaccination status, provide timely vaccination opportunities, implement vaccination exemption mitigation, and complete accurate identification for reporting to the MSN (National Healthcare Safety Network) placed residents at potential risk of an outbreak of COVID-19 in the facility. Findings included . Vaccination Tracking Review of the facility staff list provided at the entrance conference showed 157 staff worked for the facility. The facility provided the staff vaccination matrix with 133 staff. On 04/26/2022 Staff DD (Administrator in Training) was requested to reconcile the staff list with the matrix and provide documentation of vaccination for facility staff. The findings showed one staff partially vaccinated without exemption and five staff exempt for religious accommodation. The staff vaccination list and the matrix did not include contracted staff with direct contact with residents. In an interview on 04/28/2022 at 2:10 PM, Staff E, (Infection Control Nurse (IC)) stated they did not monitor the vaccination status of facility staff or contracted staff with direct contact with residents. Staff E stated they were not aware of the requirement to verify contracted staff vaccination status. Staff C (Chief Nurse Officer) present in the interview, stated Staff E was expected to track and report the accurate data for facility staff and contracted staff. Staff C confirmed the system for tracking and reporting was not intact. Vaccinations Offered A review of the 04/25/2022 resident vaccination tracking log showed five residents signed a consent form to receive the COVID-19 booster but did not receive the booster. The tracking log showed eight residents were not offered the vaccine. Review of the MSN facility reported data (week ending 04/03/2022) prior to entering the facility on 04/21/2022 showed the facility reported only 12% staff received a COVID-19 booster. In an interview on 04/29/2022 at 2:13 PM, Staff E was asked about good faith efforts to attempt vaccinations for residents and staff. Staff E stated there was no issue obtaining vaccine from the pharmacy, staff was able to sign up for boosters, residents signed consents to receive boosters and only a date to administer the vaccines needed to be set. Staff E stated the last offering of vaccination was in February 2022. There was no future date scheduled for staff and residents at this time to receive vaccines. Exempt Staff Precautions Review of the 04/26/2022 amended vaccination matrix showed there were five unvaccinated facility staff with an approved exemption and one staff who did not complete the two step vaccination series. In an interview on 04/26/2022 at 10:26 AM, Staff E stated the facility chose additional precautions for unvaccinated/exempt staff. The staff was required to test three times per week and use an N95 respirator when in the facility, to prevent the risk of COVID-19 transmission. Staff E was not aware of the partially unvaccinated Staff OO (Certified Nursing Assistant). Staff OO (Certified Nursing Assistant) was identified on the matrix as receiving the vaccination with only one of the two steps completed. Staff OO was observed on 04/21/2022, 04/22/2022, 04/23/2022 and 04/26/2022 working in the facility providing direct resident care and was not wearing an N95 respirator. Review of the limited testing records for April 2022 showed Staff OO was not tested for COVID-19 three times a week. Staff T (Certified Nursing Assistant) was identified on the matrix as unvaccinated and exempt. Observations on 04/21/2022, 04/23/2022, 04/24/2022, 04/25/2022 and 04/26/2022 showed Staff T working in the facility providing direct care to residents and did not wear an N95 respirator. Review of the testing records for April 2022 showed Staff T was not tested for COVID-19 three times a week. Staff R (Business Office Manager) was identified on the matrix as unvaccinated and exempt. Observations on 04/21/2022, 04/22/2022, 04/25/2022 and 04/26/2022 showed Staff R working in the facility less than 6 feet from residents and was not wearing an N95 respirator. Review of the limited testing records for April 2022 showed Staff R was not tested for COVID-19 three times a week. Staff AAA (Receptionist) was identified on the matrix as unvaccinated and exempt. Observations on 04/25/2022 and 04/26/2022 showed Staff AAA working at the reception desk in proximity of less than 6 feed from residents, staff and visitors and was not wearing an N95 respirator. Review of the April 2022 testing records showed Staff AAA was not tested for COVID-19 on the week of 04/24/2022. In an interview on 04/28/2022 at 2:13 PM, Staff C stated the IC was expected to ensure unvaccinated staff were compliant with COVID testing and used N95 respirators. Staff C confirmed the system for tracking and reporting was not intact. Staff Vaccination Reporting Review of the MSN facility reported data (week ending 04/03/2022) prior to entering the facility on 04/21/2022 showed the facility reported 92.6% staff fully vaccinated, 12% staff with booster. Review of the amended matrix provided by the facility on 04/26/2022 showed a total of 153 staff. The data showed one staff (Staff OO) completed one of two steps of the vaccination without a documented reason for being partially vaccinated. The contracted staff were not identified or included on the matrix and could not be counted in the facility vaccination rate. In an interview on 04/29/2022 at 2:13 PM, Staff E stated they did not know contacted staff with direct contact for resident care was to be included into the MSN report. In an interview on 04/29/2022 at 2:13 PM, Staff C (Chief Nursing Officer) confirmed the facility inaccurately reported the staff vaccination status to the MSN because they did not identify all facility staff vaccination status and had omitted the contracted staff that provided direct care and services to residents. REFERENCE: WAC 388-97-1320(1)(a) .

CONCERN (F)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 21 According to the 01/17/2022 Quarterly MDS, Resident 21 admitted on [DATE], had severe cognitive impairment, and diagnoses including Schizophrenia, Anxiety, and drug-induced Tardive Dyskinesia. The MDS showed the resident was assessed to require one-person physical assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Review of the resident's 09/16/2019 ADL (Activities of Daily Living) self-care performance deficit CP showed the resident was independent with bed mobility and transfers, required set up assistance with dressing, and supervision from staff with personal hygiene. Review of a 04/05/2022 revised CP showed the resident is at risk for pain related to immobility. Review of the resident's record indicated the resident was mobile and ambulated independently without staff assistance. Review of a 04/02/2020 CP showed the resident was resistive to changing their clothes and included an intervention that directed staff to inform the resident it was time to change their clothes, and to lay out new clothing for the day. On 04/24/2022 at 9:01 AM Resident 21 was observed wearing a yellow, blue, and white striped long sleeve shirt and grey sweat pants. Similar observations of the resident wearing the same outfit on 04/25/2022 at 8:40 AM, 04/26/2022 at 9:32 AM, 04/27/2022 at 10:07 AM. On 04/26/2022 at 7:28 PM Resident 21 was observed ambulating independently from their room into the hall and was observed siting in the activity room at 7:47 PM. On 04/28/2022 at 8:55 AM Resident 21 was observed wearing a t-shirt and plaid pants. In an interview on 4/28/2022 at 8:56 AM Staff NN (Certified Nursing Assistant) stated I put new clothes out for [the resident] on the bed. If you instruct them it is time to change their clothes, they will change their clothes. When asked why their clothes were not changed for the past four days, Staff NN stated they did not know because they were working on another hall. In an interview on 04/28/2022 at 9:53 AM Staff C stated the CP was not correct and needed to be updated. Resident 30 According to the 01/17/2022 Annual MDS, Resident 30 admitted to the facility on [DATE], had severe cognitive impairment, and diagnoses including Schizophrenia, Diabetes, and Seizure Disorder. The MDS showed the resident was assessed to require two-person extensive assistance with bed mobility, transfers, dressing, and personal hygiene. Review of a 02/12/2020 the resident has an ADL self-care deficit CP showed the CP included an intervention that indicated the resident was totally dependent on staff for dressing, and needed to be out of bed every shift. The CP indicated the resident preferred to be up around 8 AM and to return to bed at 12 AM. Resident 30's record review showed a 11/18/2020 resident had an actual fall without injury CP included an intervention directing staff to keep the bed in the lowest position while Resident 30 was in bed. Review of a revised 01/13/2022 Nutrition CP showed the resident was on a Carbohydrate-Controlled diet with mechanical soft textured food, with thin liquids and no straws. On 04/21/2022 at 1:52 PM Resident 30 was observed lying in a bed that was raised to hip level, wearing a hospital gown. On 04/24/2022 at 9:17 AM Resident 30 stated, I want to get up, while they were observed lying in their bed that was raised to hip level, wearing a hospital gown. A water pitcher with a straw was observed on the bedside table. On 04/25/2022 at 9:03 AM Resident 30 stated, It's been a while since I got out of bed. The resident was observed lying in bed that was raised to hip level, wearing a hospital gown. Similar observations were made on 04/26/2022 at 9:39 AM and 2:45 PM, and 04/27/2022 at 10:12 AM. During an observation and interview on 04/28/2022 at 8:58 AM Staff OO (Certified Nursing Assistant - CNA) stated Resident 30 never refused and preferred to stay in bed. When asked why the resident wore hospital gowns, Staff OO stated they had never tried to get the resident dressed. Observations on 04/28/2022 at 9:03 AM Staff OO asked Resident 30 if they would like to get dressed and the resident replied, yeah I want to. Staff OO proceeded to get resident dressed. In an interview on 04/28/2022 At 9:53 AM Staff C stated if a resident preferred to only wear a hospital gown or not get out of bed, it should be care planned. Staff C stated they were not aware Resident 30 could not have straws and would have to look into it. Staff C stated they expected the staff to keep the resident's bed in the lowest position, as directed by the CP. Resident 76 According to the 03/15/2022 Quarterly MDS Resident 76 admitted to the facility on [DATE], was cognitively intact, and had diagnoses including Dementia with behavioral disturbances, Diabetes, and Depression. The MDS showed the resident did not use bed rails. Review of a 08/27/2020 revised CP showed the resident had limited physical mobility and an intervention of a mobility bar to the right side of the bed to assist the resident to move themselves in bed. On 04/24/2022 at 9:04 AM Resident 76's bed was observed with mobility bars to both sides of the resident's bed. In an interview on 04/28/2022 at 9:53 AM Staff C stated they expect the mobility bars to both be care planned. Resident 95 According to the 03/25/2022 Quarterly MDS, Resident 95 admitted to the facility on [DATE], was assessed with severely impaired cognition, and had diagnoses including Stroke (brain bleed), Dysphagia (difficulty swallowing), and Dysarthria (slow or slurred speech). The MDS showed the resident required extensive assistance with bed mobility, transfers, and toileting, and limited assistance with dressing. On 04/21/2022 at 1:49 PM Resident 95 was observed sitting on the edge of the bed wearing only a brief. Similar observations were made on 04/22/2022 at 1:50 PM, 04/25/2022 at 9:00 AM and 12:18 PM, and 04/26/2022 at 9:42 AM. In an interview and observation on 04/27/2022 at 11:57 AM, a communication board was used to ask the resident who was observed wearing only a brief, if it bothered them that they had no clothes to wear. Resident 95 pointed to NO with their finger. During an interview on 04/28/2022 at 8:58 AM Staff OO stated the resident preferred not to wear clothes and that they take their clothes off. In an interview on 04/28/2022 At 9:53 AM Staff C stated they would expect the CP to be updated with the resident's preference of not wearing clothes. Resident 153 According to the 04/07/2022 Quarterly MDS, Resident 153 admitted to the facility on [DATE], was assessed with severely impaired cognition, and had Medically complex conditions, including Schizophrenia, Diabetes, and Parkinson's Disease. The MDS showed the resident required extensive assistance with bed mobility, transfers, toilet use, eating, and personal hygiene. Review of a 12/14/2021 revised CP showed the resident had an ADL self-care deficit and was independent for bed mobility, personal hygiene, transfers and toilet use. Review of a 12/06/2021 revised CP showed the resident was at risk for falls, and directed staff to ensure the resident was wearing appropriate footwear when ambulating. Review of a 01/14/2019 revised CP showed the resident had a communication problem related to speaking a foreign language. The CP indicated English was not the resident's primary language. The CP directed staff to utilize a communication board in the resident's room. On 04/21/2022 at 1:28 PM Resident 153 was observed lying in bed wearing a hospital gown. During an observation and interview on 04/24/2022 at 9:08 AM Resident 153 was observed lying in bed wearing a hospital gown and stated they did not like to get out of bed. Similar observations of Resident 153 in bed, wearing a hospital gown were made on 04/25/2022 at 9:13 AM and 12:26 PM, on 04/26/2022 at 9:36 AM, 1:54 PM, 2:37 PM, and 7:42 PM, and on 04/27/2022 at 10:48 AM. Observations on 04/26/2022 at 1:54 PM showed no communication board located in the resident's room. In an interview on 04/28/2022 at 8:55 AM Staff NN stated the resident used to be independent with mobility and ADL's but required more care after an acute illness. During an interview on 04/28/2022 at 9:53 AM Staff C stated they expected the CP to reflect the resident's current status, and acknowledged the CP needed to be updated. Staff C stated if the resident's CP included a communication board, it should be available in the room for staff to use. Resident 81 According to the 03/20/2022 Medicare 5 Day MDS, Resident 81 readmitted to the facility on [DATE], was cognitively impaired, able to make their own decisions and required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing. Resident 81's 03/14/2022 ADLs CP included a bed mobility intervention stating the resident was totally dependent on staff for repositioning, eating, transferring and toileting. Review of the 04/18/2022 Pressure Ulcer (PU) CP showed the resident had a Stage four PU to their sacrum (bony end of the tail bone). The CP did not include instructions for the staff regarding repositioning the resident or directions on the use of an air mattress, including functions and settings. Observations on 04/23/2022, and 04/24/2022, showed Resident 81 was able to reposition themselves in bed, able to sit on the edge of the bed during mealtimes, and was able to walk using a walker in their room and in the hallways. In an interview on 04/24/2022 at 10:08 AM, Staff B stated the CP was inaccurate, and needed to be updated. REFERENCE: WAC 388-97-1020(1), (2)(a)(b). Resident 58 Resident 58 was admitted to the facility on [DATE]. According to the 02/23/2022 admission /Medicare - 5 Day MDS, Resident 58 was assessed to have clear speech and to be able to understand and be understood by others. According to Resident 58's 02/22/2022 AC CP staff were directed to administer AC medications as ordered and to monitor for side effects and effectiveness every shift. Review of the March 2022 Medication Administration Records (MAR) showed the AC was discontinued on 03/09/2022. According to a 03/10/2022 social needs CP, The resident is independent for meeting emotional, intellectual, physical, and social needs r/t [related to] with a listed intervention that included, .The resident likes the following independent activities: (SPECIFY). The CP did not indicate what independent activities the resident likes. Review of CP on 04/25/2022 revealed no CP related to discharge planning for Resident 58. In an interview on 04/29/2022 at 7:33 AM, Staff C stated care plans should be individualized, updated, and revised to reflect the resident's current condition. Resident 59 Resident 59 was admitted to the facility on [DATE]. According to the 02/24/2022 admission /Medicare - 5 Day MDS, Resident 59 had multiple medically complex diagnoses and was assessed to require extensive physical assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. According to Resident 59's 03/01/2022 social needs CP, The resident is dependent on staff and family for meeting emotional, physical, and social needs r/t with a listed intervention that included to Ensure that adaptive equipment that the resident needs is provided and is present and functional. (SPECIFY). Staff did not indicate what the CP related to, or specify what adaptive equipment Resident 59 was assessed to require. Review of the 02/18/2022 constipation CP showed showed the CP included a goal for Resident 59 to have a normal bowel movement at least every (SPECIFY) day. Staff did not specify a frequency for how often the resident should have a bowel movement. According to Resident 59's 02/21/2022 nutritional CP, the resident had interventions that directed staff to provide and serve Resident 59's diet as ordered, and listed the diet as vegetarian. Review of Physician Orders (POs) on 04/22/2022 revealed no orders that reflected Resident 59 was on a vegetarian diet. In an interview on 04/29/2022 at 7:33 AM, Staff C stated Resident 59's CPs should have been individualized, updated, and revised to reflect the resident's current condition. Resident 97 Resident 97 was admitted to the facility on [DATE]. According to a 03/25/2022 Quarterly MDS Resident 97 had multiple medically complex diagnoses including Alzheimer's disease (A progressive disease that destroys memory and other important mental functions). According to a 01/03/2022 CP, staff indicated Resident 97 uses psychotropic medications. Staff identified a goal that the resident will be free of psychotropic drug related complications. Interventions indicated staff were directed to administer psychotropic medications as ordered and to monitor for side effects and effectiveness every shift. Review of Resident 97's PO's showed the psychotropic medication for the resident was discontinued on 12/21/2021. Review of CP on 04/22/2022 revealed no CP related to discharge planning for Resident 97. In an interview on 04/29/2022 at 7:33 AM, Staff C stated it was their expectation that CPs be updated and accurate to reflect the resident's current condition. Staff C indicated the CP should have been, but was not revised to reflect Resident 97 was no longer receiving psychotropic medications. Resident 251 Similar findings were noted for Resident 251 who according to a 04/15/2022 admission MDS had multiple medically complex diagnoses and was assessed as cognitively intact with clear speech. According to the 04/20/2022 social needs CP, no goals were established for Resident 251. Review of a 04/11/2022 chronic pain CP indicated no goals were established for Resident 251. Review of a revised 04/11/2022 impaired visual function CP, showed staff identified Resident 251 wore glasses and directed staff to ensure appropriate visual aids were clean and available to support resident's participation in activities. Review of a 04/15/2022 progress note by staff indicated Resident 251 was without glasses and stated the resident indicated they forgot their glasses at home. Review of CP on 04/25/2022 revealed no CP related to discharge planning for Resident 251. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Operating Nurse) stated Resident 251's CPs should have been individualized, updated, and revised to reflect the resident's current condition.Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were developed, revised, and implemented to include individualized resident-specific interventions that accurately reflected care needs, and gave adequate directions to care staff for 14 (Residents 13, 61, 67, 69, 58, 59, 97, 251, 21, 30, 76, 95, 153, & 81) of 22 reviewed for comprehensive CPs. This failure placed residents at risk for unmet care needs, adverse events and diminished quality of care/quality of life. Findings included . Resident 13 According to the 04/06/2022 Quarterly MDS (Minimum Data Set - an assessment tool), Resident 13 received anticoagulant (AC) medication daily and required extensive assistance from two or more persons for most care. Review of Resident 13's Comprehensive CP showed it did not include a CP to address AC medication, including how to manage adverse side effects associated with AC medications, such as bleeding and bruising. Resident 13's CP included an intervention dated 03/15/2022 that indicated The resident is (SPECIFY: independent/dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t (if dependent). The CP did not specify if the resident was dependent or independent. Resident 13's record Review showed the [NAME] (a care directive for Nursing Aides) did not include any instructions to Aides regarding AC precautions to prevent, or actions to take in the event of potential adverse effects. In an interview on 04/28/2022 at 04:02 PM, Staff C (Chief Nursing Officer) stated Resident 13's CP should have, but did not include an AC CP, and the absence of an AC CP and [NAME] instructions to the Aides put the resident at risk of AC adverse side effects/events. Staff C stated that the facility's CPs were not up to date. Resident 61 Resident 61's admission MDS dated [DATE] showed diagnoses including depression, a gait abnormality, and a lower back pressure ulcer. Review of progress notes dated 03/01/2022, 03/10/2022, 03/11/2022, 03/16/2022, 03/19/2022, 03/25/2022, 03/26/2022, 03/28/2022, 03/29/2022 and 04/17/2022 showed that Resident 61 refused to be weighed. A progress note on 3/16/2022 indicated wound care was also refused. In an interview on 04/27/2022 at 10:07 AM, Staff KK (outside wound care provider) stated Resident 61 was very noncompliant with care and had refused treatment the last two weeks. Review of the comprehensive CP indicated there was no CP problem to address the resident's depression diagnosis, or rejection of care. In an interview on 04/28/2022 at 09:30 AM, Staff C stated the Comprehensive CP should include interventions to address the resident's known pattern of refusals but did not. In an interview on 04/28/2022 at 01:00 PM, Staff G (Social Services Director) stated Resident 61 had a pattern of rejection of care and the CP should include a problem with interventions to address the behavior but did not. Resident 67 According to the 03/07/2022 Quarterly MDS, Resident 67 had diagnoses including Heart Failure and depression, for which they took Antidepressant (AD) medication. The MDS indicated Resident 67 was enrolled in Hospice services. Resident 67's record review showed Resident 67's Comprehensive CP did not include a CP addressing Hospice Services. Resident 67's record Review showed the Comprehensive CP included a Resident will remain here for long term care CP with a 10/14/2019 intervention to make arrangements with required community resources to support independence post-discharge (specify: homes care, PT, OT, MD, Wound Nurse). The intervention did not specify what type of post-discharge care Resident 67 required. The AD medication CP included a 05/01/2021 goal stating the resident will show decreased episodes (SPECIFY) of s/sx of depression (SPECIFY) through the review date. The CP did not specify a number of episodes or which signs and symptoms to monitor, and was not individualized or person-centered. In an interview on 04/28/2022 at 09:36 AM, Staff C stated the CP should have, but did not, include a Hospice CP. Resident 69 According to the 03/08/2022 Significant Change MDS, Resident 69 was severely cognitively impaired with diagnoses including Alzheimer's Disease and non-Alzheimer's Dementia. Resident 69's record review showed Resident 69's Dementia CP did not include quarterly cognitive and mood assessments. In an interview on 04/28/2022 at 09:16 AM, Staff C did not identify any measurable goals on Resident 69's Dementia CP. Staff C stated the facility assessed Resident 69 for mood and cognitive function quarterly, and that all residents received the same assessments on the same schedule.

CONCERN (F)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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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 employ sufficient staff to provide and supervise care as evidenced by information provided by 10 (Resident 15, 28, 7, 20, 61, 67, 58, 54, 77, 33) resident interviews, and Resident Council (Residents). The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADL) including showers and Restorative services, accurate and timely Minimum Data Set (MDS - an assessment tool) Assessments, and call light response in accordance with established clinical standards, care plans, and preferences. These failures placed residents at risk for unmet care needs and negative outcomes. Findings included . Resident Interviews During initial screening, residents raised the following concerns with facility nurse staffing: Resident 15 & Resident 28 In an interview with residents in room [ROOM NUMBER] on [DATE] at 12:37 PM, Resident 15 and Resident 28 stated staff entered their room, turned off the call light without providing assistance, promised to return and did not. The residents identified evenings after 2 PM as the worst time. In an interview on [DATE] 9:36 AM Resident 15 and Resident 28 stated the facility is understaffed. Resident 7 In an interview on [DATE] at 1:40 PM Resident 7 stated when you need help, sometimes have to wait 2 1/2 hours, and night time is the worst. In an interview on [DATE] at 9:15 AM Resident 7 stated they wanted to get out of bed and staff never came back to get me up, if my wheelchair was closer I would try to get up myself. At 9:31 AM Staff RR (Restorative Aide- RA) was told about Resident's 7's request to get out of bed. At 11:05 AM Resident 7 was still observed in bed. Resident 20 In an interview on [DATE] at 1:57 PM Resident 20 stated sometimes it seemed like there was only 1 person in the building, usually after dinner and on night shift. Resident 61 In an interview on [DATE] at 8:54 AM Resident 61 stated they were upset because they had to wait 45 minutes for their call light to be answered. Resident 67 In an interview on [DATE] at 8:59 AM Resident 67 stated there was not enough staff., that residents needed to wait half an hour for assistance after using their the call light, and identified shift change as a time of particular concern. Resident 58 In an interview on [DATE] at 2:10 PM Resident 58 stated when they used their call light, no one came to assist. Resident 54 In an interview on [DATE] at 12:00 PM Resident 54 stated there is not enough staff at certain times of the day, that sometimes no one came to help when they used their call light, and that at other times it took an hour for help to come. Resident 54 stated they were concerned with CNA (Certified Nursing Assistant) turnover. Resident 77 In an interview on [DATE] at 12:26 PM Resident 77 stated there was not enough and staff and that there were delays in responding to call lights. Resident 33 On [DATE] at 9:15 AM Resident 33 stated that the week prior they were told there were only two nurses upstairs for the evening/night shift, no nurse on one of the 3 medication carts and it would take longer for people to get their medications, That happens quite a bit. Resident Council Review of minutes from the [DATE] Resident Council included the following agenda items: the wait time for CNA's [sic] is too long. Resident's [sic] state that it takes almost two hours for care; Residents would also like snacks available during the day. During a meeting of the facility's Resident Council on [DATE] at 1:30 PM, residents expressed the following concerns regarding staffing. Resident 33 stated residents were unable to get snacks and was told they don't have enough people to provide them. Resident 67 (Council President) stated there was no improvement in the 2 hour waits mentioned in the [DATE] meeting. Resident Resident 33 stated if your Aide is available it's okay, but it can take forever. Resident 81 stated I've been here for two weeks and it's worse than when I first got here [ .] I am unsure what the deal is. I noticed that the CNAs are less and less. At the end of the meeting Resident 67 revisited the topic of snacks we still don't get them. There is nobody to ask. I feel that the snack issue should be addressed. Resident 91 nodded enthusiastically in agreement. Showers Unqualified Staff providing care Resident 33 During an interview on [DATE] at 9:15 AM Resident 33 stated, The Activity Director gave me a shower yesterday. Review of Point of Care documentation showed on [DATE] at 1:31 PM Staff Y (Activity Director) documented a shower given to Resident 33. Resident 77 On [DATE] at 11:57 AM Staff Y was observed exiting the [NAME] II Shower room with Resident 77 in a shower chair, with wet hair. During an interview on [DATE] at 12:23 PM, Resident 77 stated that the facility was still understaffed. Resident 77 stated, It wasn't a CNA who gave me a shower today. It was the Activity Director. During an interview on [DATE] at 1:01 PM, when asked why they were giving showers, Staff Y stated that they were trying to help the nursing assistants. On [DATE] at 2:06 PM, Staff PP (Human Resources) stated Staff Y was the Activity Director and was not a Nursing Assistant. Staff PP stated that Staff Y did not have a License, Certification or a Registration. Review of the Department of Health Credential Verification website on [DATE] showed that Staff Y's Nursing Assistant Registration expired in 2002. Resident 36 In an interview on [DATE] at 12:22 PM, Resident 36 stated the facility got rid of shower aides and currently CNAs did showers. Resident 36 stated I have not had a shower since beginning of March, only a bed bath and not very often. I want to have shower, I need them to take care of my skin. Restorative Program Resident 33 On [DATE] at 9:15 AM Resident 33 stated that the RA continued to be pulled to the floor. Signage In Facility On [DATE] at 8:55 AM, a sign titled Posted Mealtimes was observed to read Due to census and labor, times are estimated and may be served up to 15 minutes prior to or after posted times. Wound Care In an interview on [DATE] at 12:24 PM Staff F (Resident Care Manager/MDS Nurse) stated wound care including dressing changes was now managed by nurses. Staff F stated until three to four weeks prior, the facility employed a wound nurse who managed wound care including wound evaluation, treatment, and coordination with the outside wound provider. Staff F stated the wound nurse left their position unexpectedly and was not replaced at the time of the interview. Resident 36 In an interview on [DATE] at 12:22 PM, Resident 36 stated I need them to take care of my skin and added they felt they were on a low priority list for wound care. Staff Interviews During an interview on [DATE] at 11:28 AM Staff SS (Licensed Practical Nurse-LPN) stated the CNA's sometimes had up to 18 residents and they do their best to provide good care but it can be hard with that many residents. In an interview on [DATE] 02:22 PM, Staff T (CNA) stated there was not enough staff to complete resident showers because the facility took the shower aide away. Staff T stated aides were scheduled to do showers on the daily schedule, but on days when there insufficient Aides available, showers were not completed. Staff T stated the facility typically did not have as many staff on the floor as were present during survey. In an interview on [DATE] at 8:31 AM Staff ZZ (RA) stated they usually have two RA's but that didn't happen everyday. Staff ZZ states the RA's are pulled to work the floor as a CNA and do not have time to complete all the restorative programs. Refer to F684 Quality of Care Refer to F686 Treatment/Services to Prevent/Heal Pressure Ulcers Refer to F677 ADL Care Provided to Dependent Residents REFERENCE: WAC 388-97-1080(1), 1090(1). .

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The failure to implement and correctly identify 2 (Resident 451 & 6) of 5 residents on transmission based precautions (TBP) for COVID-19 (Coronavirus- a contagious respiratory illness) placed residents and staff at risk for contracting and spreading COVID-19. In addition, the facility failed to ensure staff practiced standard hand hygiene, wore required personal protective equipment (PPE), established a process to conduct COVID-19 risk assessments and failed to implement the facility policy for fit-testing N95 respirators (a mask that filters 95% of airborne particles) for 104 of 157 staff placing residents at risk for acquiring and spreading COVID-19 and/or other contagious infections. Findings included . TBP The 03/11/2022 facility policy WA State Policy for Suspected or Confirmed COVID-19 showed residents with suspected COVID-19 would be placed on contact/droplet precautions, hand hygiene would be used before and after all patient contact, staff would use PPE including gloves, gown, mask, and eye protection for direct contact with residents, and PPE would be readily available, and specific signage (to instruct staff on what PPE requirements were necessary) would be on the door. Resident 451 Observations on 04/21/2022 at 8:55 AM showed a Quarantine Precautions sign taped to the outside of the bedroom door of Resident 451. The sign directed only essential personnel to enter the room and directed staff who entered the room they must clean hands, wear an N95 respirator, protective eyewear, gown and gloves for providing personal care. The PPE cart outside the residents room contained no hand sanitizer, gowns, gloves, masks, eyewear or N95 respirators. In an observation and interview on 04/21/2022 at 8:55 AM, Resident 451 was observed at the doorway, not wearing a mask. Staff T (Certified Nursing Assistant) was walking by and was asked why Resident 451 was on quarantine precautions. Staff T stated they were not aware that Resident 451 was on quarantine precautions and would go ask the manager. Staff T did not return with the answer to why Resident 451 was on quarantine. On 04/21/2022 at 9:00 AM, Staff E (Infection Control Nurse) confirmed Resident 451 was on quarantine precautions because they recently had COVID-19 and did not receive the booster vaccine. Staff E stated all staff are required to follow the precautions listed on the door, including use of the N95 respirator when entering the room. Staff E looked in the isolation cart and confirmed there were no N95 respirators, gowns, gloves, or hand sanitizer in the cart. Staff E confirmed there were no PPE supplies at the door to enter the quarantined room. Resident 6 The 12/2021 facility policy WA State Policy for Preventing Transmission of [COVID-19] During Aerosol Generating Procedures showed N95 respirators would be used for any resident room where the resident used an aerosol generating procedures (AGP). Continuous positive airway pressure (CPAP) treatments were listed as an AGP with the requirement to keep door closed and continue N95 respirator use when entering the room for three hours after the treatment completion. Observations on 04/22/2022 at 10:57 AM showed room [ROOM NUMBER] with a AGP sign taped to the door. The sign directed only essential personnel to enter during the procedure, must clean hands, must wear an N95 respirator, protective eyewear, a gown, and gloves for providing personal care. There was no cart outside the door for PPE storage/availability. In an interview on 04/22/2022 at 10:57 AM outside of room [ROOM NUMBER], Staff N (Licensed Practical Nurse) was asked what PPE should be worn when entering room [ROOM NUMBER]. Staff N stated they did not know why the sign was on the door and would have to ask the manager. Staff N stated they did not notice the sign and was in the room giving medications without an N95 respirator or a gown. Staff N stated, they should have worn the PPE as the sign directed. In an interview on 04/22/2022 at 11:29 AM, Staff CC (Registered Nurse) stated they heard Resident 6 had a CPAP (breathing machine) used at night and that was why Resident 6 was on isolation. Staff CC looked at the physician orders (PO) and did not see any order for a CPAP. Staff CC looked in room [ROOM NUMBER] and Resident 6 did not have a CPAP machine that would require isolation. In an interview on 04/26/2022 at 10:26 AM, Staff E (Infection Control Nurse) stated if Resident 6 was not using a CPAP, then they would not need to be on isolation. Staff E stated they did not know why the AGP sign was on Resident 6's door. Staff E stated the protocol for isolation tracking was not being done and agreed that staff did not know or follow when to use the required PPE. Observation showed the AGP Sign was not removed from the door of room [ROOM NUMBER] until 04/28/2022, 2 days later. A PPE cart was not observed outside the room between 04/22/2022 through 04/28/2022. Hand Hygiene & PPE The 09/09/2021 facility policy titled Hand Hygiene directed staff to perform hand hygiene in the following situations: between resident contact, after handling contaminated objects, before applying and after removing PPE, including gloves, and before/after handling clean or soiled linens. Observation on 04/21/2022 at 10:52 AM showed Staff BB (Nurse Aide) and Staff T (Certified Nursing Assistant- CNA) walked in and out of room [ROOM NUMBER] without performing hand hygiene. Staff T walked down the hall, entered room [ROOM NUMBER] and put on gloves without performing hand hygiene. Observation on 04/21/2022 at 10:52 AM showed therapy staff with a gait belt, exited room [ROOM NUMBER], not wearing PPE, and did not perform hand hygiene. Observation on 04/21/2022 at 1:17 PM showed a CNA enter room [ROOM NUMBER] to assist Resident 7 with toileting. The CNA did not perform hand hygiene before assisting Resident 7. The CNA did not assist Resident 7 to wash their hands after using the commode. Resident 7 stated there was no way to wash their hands. [NAME] debris was noted under Resident 7's nails. The hand sanitizer on the wall inside room [ROOM NUMBER] was empty. Observation on 04/24/2022 at 10:22 AM showed a Physical Therapist (PT) enter room [ROOM NUMBER] with a posted Quarantine Precautions sign on the door, without wearing an isolation gown or an N95 respirator. The PT did not perform hand hygiene before assisting the resident or upon leaving the room. In an interview on 04/28/2022 at 2:13 PM, Staff E (Infection Control Nurse) stated all staff are expected to perform hand hygiene before and after resident care was provided. Staff E provided a copy of the 03/25/2022 All staff meeting sign in sheet which showed a topic handwashing/ hand hygiene. There were 25 staff signatures on the sign-in sheet, out of the total 157 staff. Staff BB and Staff T were not on the attendance list. Staff E was asked if the March 2022 verbal education on hand washing for 25 staff was effective for all staff training, Staff E stated no. The 08/04/2021 facility COVID-19 Plan showed the facility would provide and ensure that employees wear facemasks or a higher level of respiratory protection. Face masks must be worn by employees over the nose and mouth when indoors. Observation on 04/21/2022 at 12:59 PM, showed a housekeeper wearing an N95 respirator with their nose exposed. The housekeeper was not wearing gloves and reached into a mop bucket, then walked into resident room [ROOM NUMBER] without performing hand hygiene. On 04/21/2022 at 1:05 PM the same housekeeper walked into room [ROOM NUMBER] without hand hygiene and still wearing the same N95 respirator they used in room [ROOM NUMBER] with their nose exposed. Staff F (Registered Nurse) confirmed the improper use of the N95. COVID-19 Risk Assessments A sample of resident's records (Residents 36, 84, 81, 451, 6, 3, and 86) were reviewed for completed COVID-19 risk assessments as required for public outings from the facility. There were no risk assessments located in any of the resident records. Resident 36 stated they went on an outing for lunch on 04/23/2022. Residents 6 and 86 stated they went out of the building three times a week for dialysis using the public transportation wheelchair bus. In an interview on 04/28/2022 at 2:13 PM, Staff E (Infection Control Nurse) explained how the process of risk assessments worked. Staff E stated the nurse would complete the form before the resident left for an outing. When the resident returned from an outing. If the resident was vaccinated, they were at low risk for transmitting viruses. If the assessment said the resident was at high risk for transmitting viruses the nurse was to place the resident on quarantine for 14 days. When asked how Staff E ensured staff followed this process on quarantine status, Staff E replied they only followed up if the nurse told (Staff E) about the quarantine. When asked who supervised the quarantine status of residents, Staff E replied, the nurses do. Staff E stated the risk assessments were not in the resident charts or readily available for review. Staff E stated they were not aware that the risk assessment was part of the resident record. Staff E was not able to provide risk assessments for Residents 36, 6, or 86. In an interview on 04/28/2022 at 2:20 PM, Staff C (Chief Nursing Officer) corrected Staff E on their description of the risk assessment process and their answers to the questions. Staff E stated risk assessments are to be completed after the resident returns, if high risk for virus transmission, the resident was placed on quarantine and the Infection Control Nurse was responsible to track and ensure the quarantine and isolation processes were followed by all staff. Staff C confirmed the system of completing risk assessments was not intact. Fit Testing and N95 Respirator Use According to the Department of Labor and Industries Division of Occupational Safety and Health: Directive 11.80 (updated September 21, 2021) regarding Respiratory Protection and Face Coverings during the COVID-19 pandemic, fit tested NIOSH (National Institute for Occupational Safety and Health) approved N95 respirators were required when caring for residents with COVID-19 or suspected of having COVID-19, and when fit tested, a worker must select and wear the same make/model/size of the respirator they were fitted to. A review of the (undated) fit testing record provided by Staff E showed fit testing was completed on only 53 of the 157 total staff. The fit testing was completed on 08/12/2021 and 09/27/2021 and 09/28/2021 for only one type of N95 respirator (Makrite). In an interview on 04/25/2022 at 1:41 PM, Staff TT (Director of Central Supply) stated there were three types of N95 respirators in the central supply closet. On observation there was BYD and 3M respirators and an unknown brand of KN95 mask. There was no Makrite N95 respirators. In an interview on 04/26/2022 at 10:26 AM Staff E stated all staff were fit tested to a N95 respirator. Staff E was not aware there was no supply of Makrite N95 respirators in the facility. In an interview on 04/26/2022 at 2:25 PM, Staff C (Chief Nursing Officer) confirmed the facility did not have any supply of the Makrite N95 respirators. Staff C stated the process for N95 fit testing and ordering was not intact to keep the required respirators in stock. The undated facility Policy for PPE Contingency and Crisis use of N95 Respirators showed the Administrator was responsible for the inventory and supply chain of PPE. The policy showed the administrator was expected to have a calculated contingency supply of PPE supplies needed for a crisis. In an interview on 04/27/2022 at 1:25 PM, Staff A (Administrator) stated the facility ordered N95 respirators through the State Department of Health (DOH) and another private supplier. The facility used a set ordering system to keep PPE in stock. Staff A stated the facility asked DOH for the Makrite N95 respirators and the DOH did not send them. Staff A acknowledged the designated N95 respirator that staff were fit tested to use were not available in the facility. Staff A stated they were not aware that each brand of N95 respirator needed to be fit tested to each staff person. Staff A was not able to confirm the current facility supply, or if there was sufficient PPE if there was a facility infection outbreak. Staff A was not able to provide information on the facility's calculations for the PPE contingency supply for a crisis. Refer to F886 COVID-19 Testing Residents and Staff. Refer to F888 COVID-19 Vaccination Tracking/Reporting. REFERENCE: WAC 388-97-1320(1)(a-c)(2)(a-c). .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 35% turnover. Below Washington's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 2 life-threatening violation(s), 3 harm violation(s), $70,502 in fines. Review inspection reports carefully.
• 83 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $70,502 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
• Grade F (1/100). Below average facility with significant concerns.

Bottom line: Trust Score of 1/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Valley View Skilled Nursing And Rehabilitation's CMS Rating?

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

How is Valley View Skilled Nursing And Rehabilitation Staffed?

CMS rates VALLEY VIEW SKILLED NURSING AND REHABILITATION's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 35%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Valley View Skilled Nursing And Rehabilitation?

State health inspectors documented 83 deficiencies at VALLEY VIEW SKILLED NURSING AND REHABILITATION during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 78 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Valley View Skilled Nursing And Rehabilitation?

VALLEY VIEW SKILLED NURSING AND REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VERTICAL HEALTH SERVICES, a chain that manages multiple nursing homes. With 136 certified beds and approximately 98 residents (about 72% occupancy), it is a mid-sized facility located in RENTON, Washington.

How Does Valley View Skilled Nursing And Rehabilitation Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, VALLEY VIEW SKILLED NURSING AND REHABILITATION's overall rating (2 stars) is below the state average of 3.2, staff turnover (35%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Valley View Skilled Nursing And Rehabilitation?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Valley View Skilled Nursing And Rehabilitation Safe?

Based on CMS inspection data, VALLEY VIEW SKILLED NURSING AND REHABILITATION has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Valley View Skilled Nursing And Rehabilitation Stick Around?

VALLEY VIEW SKILLED NURSING AND REHABILITATION has a staff turnover rate of 35%, 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 Valley View Skilled Nursing And Rehabilitation Ever Fined?

VALLEY VIEW SKILLED NURSING AND REHABILITATION has been fined $70,502 across 1 penalty action. This is above the Washington average of $33,784. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Valley View Skilled Nursing And Rehabilitation on Any Federal Watch List?

VALLEY VIEW SKILLED NURSING AND REHABILITATION 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: 136
Avg. Residents: 98
Occupancy: 72.2%
Ownership: For profit - Corporation
Chain: VERTICAL HEALTH SERVICES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
2 Immediate Jeopardy citations: -24
3 Actual Harm citations: -15
83 Deficiencies: -10
Fines ($70,502): -10
Final Score: 1/100

Nearby Alternatives

REDMOND CARE AND REHABILITATIO... 5-star QUEEN ANNE HEALTHCARE 5-star SHORELINE HEALTH AND REHABILIT... 5-star

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505202